Initial evaluation and management of abdominal gunshot wounds in adults
- Christopher Colwell, MD
Christopher Colwell, MD
- Chief of Emergency Medicine
- Zuckerberg San Francisco General Hospital and Trauma Center
- Professor and Vice-Chair, Department of Emergency Medicine
- University of California at San Francisco School of Medicine
- Ernest E Moore, MD
Ernest E Moore, MD
- Vice Chairman for Research
- Professor of Surgery
- University of Colorado Denver
While in the past abdominal gunshot wounds (GSWs) often mandated exploratory laparotomy, with the advent of newer diagnostic and therapeutic modalities, and the ability for noninvasive critical care monitoring, fewer patients cross the operating room threshold.
This topic review will discuss the evaluation and management of abdominal GSWs. Abdominal stab wounds, blunt abdominal trauma, and other aspects of general trauma management are discussed separately. (See "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial management of trauma in adults".)
Although encountered less frequently than stab wounds, gunshot wounds (GSWs) carry higher mortality due in large part to the greater energy transmitted to tissues [1,2]. Abdominal injury from GSWs accounts for up to 90 percent of the mortality associated with penetrating abdominal injuries. Although data is limited, the mortality rate for isolated abdominal GSWs is reported to be approximately 7 percent. Approximately 25 percent of such injuries may be managed non-operatively in appropriate settings. The small bowel is the organ most frequently injured, followed by the colon and liver. (See 'Selective nonoperative management' below.)
MECHANISMS OF INJURY
Ballistic wounds can occur from a variety of missiles including bullets, grenades, flying glass, and objects launched by lawn mowers or severe weather. Among such injuries, gunshot wounds (GSWs) to the abdomen most often require operative intervention.
The velocity of the missile and its distance from the patient are important factors in determining the extent of injury. Medium and high-velocity weapons (such as AK 47s) also cause injury by opening and closing tissue with such force as to create a wave of energy that can damage intraperitoneal structures, despite entirely extraperitoneal tracking of the missile. Projectiles from medium velocity weapons travel 335 to 610 m/second, or 1100 to 2000 feet/second, while projectiles from high-velocity weapons travel >610 m/second, or >2000 feet/second.
- Lamb CM, Garner JP. Selective non-operative management of civilian gunshot wounds to the abdomen: a systematic review of the evidence. Injury 2014; 45:659.
- Navsaria PH, Nicol AJ, Edu S, et al. Selective nonoperative management in 1106 patients with abdominal gunshot wounds: conclusions on safety, efficacy, and the role of selective CT imaging in a prospective single-center study. Ann Surg 2015; 261:760.
- Jansen JO, Inaba K, Resnick S, et al. Selective non-operative management of abdominal gunshot wounds: survey of practise. Injury 2013; 44:639.
- Schellenberg M, Inaba K, Priestley EM, et al. The diagnostic yield of commonly used investigations in pelvic gunshot wounds. J Trauma Acute Care Surg 2016; 81:692.
- Pryor JP, Reilly PM, Dabrowski GP, et al. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med 2004; 43:344.
- Ginzburg E, Carrillo EH, Kopelman T, et al. The role of computed tomography in selective management of gunshot wounds to the abdomen and flank. J Trauma 1998; 45:1005.
- Chiu WC, Shanmuganathan K, Mirvis SE, Scalea TM. Determining the need for laparotomy in penetrating torso trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography. J Trauma 2001; 51:860.
- Melo EL, de Menezes MR, Cerri GG. Abdominal gunshot wounds: multi-detector-row CT findings compared with laparotomy: a prospective study. Emerg Radiol 2012; 19:35.
- Velmahos GC, Constantinou C, Tillou A, et al. Abdominal computed tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative management. J Trauma 2005; 59:1155.
- Demetriades D, Hadjizacharia P, Constantinou C, et al. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg 2006; 244:620.
- Boulanger BR, Kearney PA, Tsuei B, Ochoa JB. The routine use of sonography in penetrating torso injury is beneficial. J Trauma 2001; 51:320.
- Nagy KK, Krosner SM, Joseph KT, et al. A method of determining peritoneal penetration in gunshot wounds to the abdomen. J Trauma 1997; 43:242.
- Brakenridge SC, Nagy KK, Joseph KT, et al. Detection of intra-abdominal injury using diagnostic peritoneal lavage after shotgun wound to the abdomen. J Trauma 2003; 54:329.
- Thacker LK, Parks J, Thal ER. Diagnostic peritoneal lavage: is 100,000 RBCs a valid figure for penetrating abdominal trauma? J Trauma 2007; 62:853.
- Poole GV, Thomae KR, Hauser CJ. Laparoscopy in trauma. Surg Clin North Am 1996; 76:547.
- Ahmed N, Whelan J, Brownlee J, et al. The contribution of laparoscopy in evaluation of penetrating abdominal wounds. J Am Coll Surg 2005; 201:213.
- Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma 2005; 58:789.
- Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma 2010; 68:721.
- Velmahos GC, Demetriades D, Toutouzas KG, et al. Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg 2001; 234:395.
- Leppäniemi AK, Voutilainen PE, Haapiainen RK. Indications for early mandatory laparotomy in abdominal stab wounds. Br J Surg 1999; 86:76.
- Nagy K, Roberts R, Joseph K, et al. Evisceration after abdominal stab wounds: is laparotomy required? J Trauma 1999; 47:622.
- Arikan S, Kocakusak A, Yucel AF, Adas G. A prospective comparison of the selective observation and routine exploration methods for penetrating abdominal stab wounds with organ or omentum evisceration. J Trauma 2005; 58:526.
- 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; 179:639.
- Ertekin C, Yanar H, Taviloglu K, et al. Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds. Emerg Med J 2005; 22:790.
- Alzamel HA, Cohn SM. When is it safe to discharge asymptomatic patients with abdominal stab wounds? J Trauma 2005; 58:523.
- Conrad MF, Patton JH Jr, Parikshak M, Kralovich KA. Selective management of penetrating truncal injuries: is emergency department discharge a reasonable goal? Am Surg 2003; 69:266.
- Inaba K, Branco BC, Moe D, et al. Prospective evaluation of selective nonoperative management of torso gunshot wounds: when is it safe to discharge? J Trauma Acute Care Surg 2012; 72:884.
- Inaba K, Barmparas G, Foster A, et al. Selective nonoperative management of torso gunshot wounds: when is it safe to discharge? J Trauma 2010; 68:1301.
- Albrecht RM, Vigil A, Schermer CR, et al. Stab wounds to the back/flank in hemodynamically stable patients: evaluation using triple-contrast computed tomography. Am Surg 1999; 65:683.
- Heffner AC, Swords DS, Nussbaum ML, et al. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care 2012; 27:587.
- MECHANISMS OF INJURY
- ANATOMIC ZONES
- METHODS OF EVALUATION
- Initial assessment
- Local wound exploration
- Plain radiographs
- Computed tomography (CT)
- Diagnostic peritoneal lavage
- Diagnostic laparoscopy
- Indications for laparotomy and general approach to management
- Laboratory studies
- Selective nonoperative management
- Prophylactic antibiotics
- SPECIAL CONSIDERATIONS
- Flank and back
- Airway management
- Gunshot wounds in pregnancy
- Patients on anticoagulants
- ED thoracotomy
- Law enforcement and social service issues
- SUMMARY AND RECOMMENDATIONS