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Question:

A 48-year-old man is brought to the emergency department after being stabbed once in the abdomen during a robbery.  The patient sustained no other injuries.  Blood pressure is 114/68 mm Hg and pulse is 118/min.  Bilateral breath sounds are clear and equal.  Heart sounds are normal without murmur.  Abdominal examination shows a nonbleeding puncture wound to the left upper quadrant measuring approximately 2.5×1 cm.  The abdomen is rigid and diffusely tender.  Rectal examination reveals no blood.  Resuscitation with intravenous crystalloid is ongoing.  Which of the following is the best next step in management of this patient?

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Explanation:

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This patient has penetrating abdominal trauma (PAT) (ie, stab wound) to the left upper quadrant with possible injury to underlying organs (eg, stomach, small bowel, spleen).  In addition to tachycardia (ie, possible early hemorrhagic shock), the patient has peritonitis (rigidity, diffuse tenderness).  This presentation is highly concerning for intraabdominal injury with ongoing hemorrhage and warrants immediate exploratory laparotomy.

For patients with PAT, any of the following is an indication for immediate exploratory laparotomy:

  • Evidence of ongoing hemorrhage: hemodynamic instability (systolic blood pressure <90 mm Hg) or frank blood in the nasogastric tube or rectum
  • Peritonitis (eg, rigidity, rebound tenderness)
  • Evisceration (ie, externally exposed intestines)
  • Impalement (ie, penetrating object still in situ)

In contrast, patients without an indication for immediate laparotomy should undergo further evaluation to determine whether peritoneal penetration occurred (eg, CT scan [Choice A], local wound exploration for anterior stab wounds) and/or whether intraabdominal injuries are present (eg, Focused Assessment with Sonography for Trauma, CT scan).  The presence of either typically warrants surgical exploration.

(Choice B)  Diagnostic peritoneal lavage is not commonly performed, but it can help rule out intraabdominal injuries in patients with PAT who have no indication (eg, peritonitis) for immediate laparotomy.

(Choice D)  In patients with isolated anterior stab wounds, an experienced surgeon may perform local wound exploration under local anesthetic to look for violation of the peritoneum (eg, visualization of intraabdominal contents), which usually prompts definitive surgical exploration.  However, this patient's peritonitis implies peritoneal penetration with intraabdominal injury and warrants immediate surgical intervention.

(Choice E)  In some patients, a stab wound may violate the peritoneum but miss important intraabdominal organs.  When this is suspected (eg, small wound with otherwise benign abdominal examination, normal vital signs, nonconcerning imaging), serial abdominal examinations may be performed to rule out progression of an occult injury.  In contrast, this patient has peritonitis and requires immediate surgical intervention.

Educational objective:
Patients with penetrating abdominal trauma and hemodynamic instability, peritonitis, evisceration, or impalement should undergo immediate exploratory laparotomy.