Anterior Abdominal Stab Wounds (AASW’s) · 2019-05-22 · Anterior Abdominal Stab Wounds: A Western Trauma Association Multicenter Trial. J of Trauma: Injury, Infection, and Critical

Anterior Abdominal Stab Wounds (AASW’s)

Jose Baez PGY-4KCHCJune 3 2010

www.downstatesurgery.org

Case Presentation

• CC: Pain to epigastrium

• HPI: 47 year-old female who presented to KCHC on 4/10/10 after sustaining a stab wound to the epigastrium

• PMHx: asthma

• PSHx: C-section

• Meds: albuterol inhaler

• NKDA

• Shx: etoh, drug use, + tobacco


Case Presentation

• Physical Exam:

– V/S: 102/70, HR: 92, RR: 22, T: 97.7

– GCS: 15

– CHEST: clear bilaterally

– ABD: 1.5 cm SW to epigastric region, + local tenderness, no bleeding or hematoma. No omental or intestinal evisceration


Case Presentation

• Labs/Diagnostic Modalities– Vbg: 7.33/42/39/70/21/-3.1

– Lactate 3.6, 1.2

– CBC: 19/14/44/370

– LFT’s-wnl, amylase/lipase-wnl

– UCG: negative

– Utox: cocaine

– Etoh: 40


Case Presentation

• Upright CXR: negative for free air, no acute cardiopulmonary disease

• FAST: negative

• Local wound exploration (LWE): + Fascial Defect

• Management:– Admitted to SICU for serial abd exams and serial labs

– Serial exams indicated persistent/worsening local peritonitis, rising leukocytosis ( 19 to 22), no hemodynamic instability (stable hct)


Operative Intervention

• Procedure: Exploratory laparotomy with repair of CBD injury

• Findings: pelvic adhesions, Grade I liver lac(segment 2) anterior surface, bile staining in area of portal triad and pylorus, 1-2mm CBD serosalinjury

• Drains: JP x 1

• Methylene blue given via NGT-no dye seen in upper GI tract


Hospital Course

• POD# 1: Extubated

• POD#2: Tolerated clears, JP output 30cc SSF

• POD#3:Regular diet

• POD#5: Discharged with JP

• LFT’s- wnl throughout hospital stay


AASW’s

• Abdomen is a diagnostic black box• In ED: need to identify if the fascia/peritoneum

has been violated– Positive: need further eval for intrabdominal organ

injury ~ with 50% need for laparotomy

• Anterior abdomen (boundaries): from costal margins to inguinal ligaments and bilateral ant axillary lines

• 1/3 of AASWs violate the peritoneal cavity; 1/3 of these cause injury requiring operative repair.


AASWs (Diagnositic Modalities)

• OR for laparotomy– Hemodynamic instability– Peritonitis– Omental or intestinal evisceration– Peritoneal or fascial penetration

• Non-operative approach – In pts with none of the above mentioned findings– Serial exams, LWE, DPL, DL, CT, US


Presenter

Presentation Notes

Omental/ bowel evisceration because 1 likelihood of associated injuries 2 risk of infx c reduction of exposed viscera 3 Need to repair ventral wall defect to prevent future hernia

Serial exams

• Serial exams with observation – According to a prospective study where 651 pts

with AASWs where followed: laparotomy vsobservation rate (53% vs 47%)

– Of the 47% only 2.9% required subsequent surgery, therefore it’s a safe modality

– Problems: need for experienced and frequent evals of pt; possibility of delayed dx of injury


Local wound exploration

• LWE– Need to ID violation of peritoneal cavity

– If negative: no risk for intrabdominal injury therefore discharge from ED

– If positive: OR for exploration


Presenter

Presentation Notes

In a study from annals of surgery 1983 prospective study 27% of 572 pts had negative LWE and none needed laparotomy at presentation or at 1 month follow up

Diagnostic Peritoneal Lavage (DPL)

• Why? It quickly determines presence of intraperitoneal injury/need for exploration

• Reduces number of negative laparotomieswithout increasing morbidity/mortality related to delays

• Useful if unable to perform serial exams• Accuracy 89-95%• Sensitivity varies depending on criteria for a

postive test


DPL

• KCHC criteria– RBC > 20k/mm3

– WBC > 500/mm3

– Bile or particulate matter on aspirate

• Absolute CI– Need for laparotomy

• Relative CI– Prior abd surgeries,

obesity, ascites


Presenter

Presentation Notes

DPL criteria at KCHC RBC of 20k/mm3 is associated with a 95% accuracy with a low rate of negative laparotomies For thoracoabdominal injuries since they rarely produce symptoms or imaging findings but morbidity from delayed herniation is significant u should lower DPL criteria from 20 k to 5-10 k RBCs

Diagnostic Laparoscopy (DL)

• Why? Detect peritoneal violation

• Proved to be most useful to rule out diaphragmatic injuries

• Associated with high rate of negative laparotomies (~20%)

• Cost-effectiveness is unclear ( OR costs, length of stay)


Computerized Tomography (CT)

• Poor sensitivity for AASWs due to inability to detect hollow viscus injury

• Better for evaluation of back and retroperitoneal injuries

• CT enema is highly sensitive for evaluating the retroperitoneum

• CT scan offers no advantage over serial exams or DPL for AASWs

• Adjunct to identify the wound tract, solid organs and retroperitoneum


Ultrasonography

• Identify free intraperitoneal fluid

• More defined role in blunt trauma with a sensitivity of 85-99% and specificity of 97%

• Not as reliable for penetrating with a sensitivity of 45% and specificity of 94%



Biffl, WL. Kaups KL, et al. Management of Patients With Anterior Abdominal Stab Wounds: A Western Trauma

Association Multicenter Trial. J of Trauma: Injury, Infection, and Critical Care. Volume 66(5), May 2009, pp 1294-1301

• Multicenter prospective study, 2 years, 11 institutions, 359 pts

• Purpose to compare different management strategies of asx AASW’s patients to treat and identify injuries in a safe and cost-effective manner

• Inclusion: Age > 16, AASW

• Exclusion: back, flank, thoracoabdominal stab wound

• Indications for Imed Laparatomy: hypotension, peritonitis, evisceration


Results/Discussion

• 81/359 pts had indication for immediate laparotomy of which 84% where therapeutic

• Used LWE, DPL and CT to facilitate ED discharge vs laparotomy– ED d/c : 23,21,16% respectively– Negative laparotomies based on abnormal

findings : 57, 24, 31% respectively– 26/359 were selected for SCA of which 12%

underwent laparotomy (33% neg lap)


Results

• If immediate indication for laparotomy: laparotomy is highly therapeutic 84%

• If other modalities are abnormal, there is a high yield of negative laparotomies

• Propose LWE as best method for facilitating ED discharge

• Bottom line: high yield of negative laparotomies with modalities, if no indication for immediate laparotomy, recommend SCA’s


2


References

1. .Hasaniya N, Demetriades D, Stephens A, et al. Early morbidity and mortality of non-therapeutic operations for penetrating trauma. Am Surg, 1994, 60 (10), 744-7

2. Nance FC, Wennar MH, Johnson LW, et al. Surgical judgment in the management of penetrating wounds of the abdomen: experience with 2212 patients. Ann Surg, 1974, 179 (5), 639-46

3. Demetriades D and Rabinowitz B, Indications for operation in abdominal stab wounds. A prospective study of 651 patients. Ann Surg, 1987, 205 (2), 129-32

4. Biffl, WL. Kaups KL, et al. Management of Patients With Anterior Abdominal Stab Wounds: A Western Trauma Association Multicenter Trial. J of Trauma: Injury, Infection, and Critical Care. Volume 66(5), May 2009, pp 1294-1301

5. Aaron Winnick, MD and Patricia A. O’Neill, MD. Trauma, Surgical Critical Care and Surgical Emergencies


Documents

Anterior Abdominal Stab Wounds (AASW’s) · 2019-05-22 · Anterior Abdominal Stab Wounds: A Western Trauma Association Multicenter Trial. J of Trauma: Injury, Infection, and Critical