Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm

Abstract

This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with abdominal stab wounds. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

“…FAST scan improves as it is repeated, allowing for more time for fluid to accumulate. Intra-abdominal free fluid on FAST is non-specific for intestinal injury and should not be relied upon in these settings to diagnose bowel trauma [ 5 , 6 ]. Furthermore FAST scan can be utilised to detect free intraperitoneal air in the hands of an experienced sonographer, this free air may be an indication of bowel perforation [ 7 ].…”

“…Patients with penetrating abdominal trauma can be selected for nonoperative management (NOM) in certain civilian trauma centres. There is no standard generalizable classification; however there have been guidelines and algorithms proposed [ 6 , 45 , 46 ]. If there is no immediate indication for laparotomy a local wound exploration (LWE) is performed to rule out peritoneal violation.…”

“…NOM is an option only when all the resources are available for: serial clinical examinations performed by experienced clinicians, vital signs monitoring, prompt access to the operating theatre, and ICU admission if required. Any decrease in haemoglobin concentration < 2 g/dL from baseline, or presumed, without other explanation than the penetrating abdominal wound [ 48 ], worsening vital signs or clinical examination should prompt surgical exploration [ 6 , 49 ]. If NOM is elected, CT of chest, abdomen and pelvis can be a crucial adjunct.…”

“…Trauma patients with unreliable clinical examination (intubated, intoxicated, psychiatric illness) should not be candidates for NOM. [ 6 , 49 – 53 ]. Patients who are managed with NOM can potentially be discharged after 48 h if clinically improving.…”

Should the management approach to the anterior abdominal stab wound be different in patients with self-inflicted abdominal injury?

“…Anterior Abdominal stab wounds (AASW) is a common cause for admission to surgical Emergency Rooms. Only 28% of patients suffering from AASW will end up having internal abdominal injury [4,5].…”