Initial evaluation and management of abdominal stab 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
- Section Editor
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Until the 20th century, nearly all penetrating injuries to the abdomen were managed nonoperatively. Beginning with World War I, surgeons noted lower mortality among soldiers with penetrating abdominal wounds who were managed with laparotomy. Ultimately, laparotomy became the mandatory treatment for such wounds. It gradually became clear that penetrating abdominal trauma sustained during warfare (mostly higher velocity gunshot wounds and incendiary devices) was different than penetrating abdominal trauma sustained by civilians (mostly stab wounds and lower velocity gunshot wounds) . In 1960, Shaftan questioned the dogma of mandatory laparotomy for all penetrating abdominal injuries, and laparotomy rates for abdominal stab wounds have declined steadily over the ensuing decades .
This topic review will discuss the initial evaluation and management of abdominal stab wounds in adults. General trauma resuscitation in adults and children, blunt abdominal trauma, abdominal gunshot wounds, and other aspects of trauma care are reviewed separately. (See "Initial management of trauma in adults" and "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults" and "Trauma management: Approach to the unstable child" and "Approach to the initially stable child with blunt or penetrating injury".)
Although there is regional variability in the mechanism of injury producing abdominal trauma, most studies indicate that blunt abdominal trauma is more common than abdominal stab wounds, and that abdominal stab wounds are more common than abdominal gunshot wounds in the civilian population . Abdominal gunshot wounds, due to their higher kinetic energy, are associated with mortality rates approximately eight times higher than abdominal stab wounds .
In children and adults alike, hollow viscus organs (intestines) are injured most often with abdominal stab wounds [3,5,6]. The next most common sites of injury are the great vessels, diaphragm, mesentery, spleen, liver, kidney, pancreas, gallbladder, and adrenal glands. The specific organs at greatest risk from a stab wound depend upon the location of the injury.
MECHANISM OF INJURY
Any instrument that can impale may inflict a stab wound. Typically these are narrow, sharp, knife-like implements, but items that can inflict stab wounds range from scissors to coat hangers to animal horns. The given instrument can injure any tissue it traverses, including skin, fascia, solid organ, hollow viscus, blood vessel, nerve, muscle, and bone.
- SHAFTAN GW. Indications for operation in abdominal trauma. Am J Surg 1960; 99:657.
- Nicholas JM, Rix EP, Easley KA, et al. Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma 2003; 55:1095.
- Petrowsky H, Raeder S, Zuercher L, et al. A quarter century experience in liver trauma: a plea for early computed tomography and conservative management for all hemodynamically stable patients. World J Surg 2012; 36:247.
- Zafar SN, Rushing A, Haut ER, et al. Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database. Br J Surg 2012; 99 Suppl 1:155.
- 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.
- Cigdem MK, Onen A, Siga M, Otcu S. Selective nonoperative management of penetrating abdominal injuries in children. J Trauma 2009; 67:1284.
- Shanmuganathan K, Mirvis SE, Chiu WC, et al. Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury--a prospective study in 200 patients. Radiology 2004; 231:775.
- Inaba K, Okoye OT, Rosenheck R, et al. Prospective evaluation of the role of computed tomography in the assessment of abdominal stab wounds. JAMA Surg 2013; 148:810.
- Cothren CC, Moore EE, Warren FA, et al. Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds. Am J Surg 2009; 198:223.
- Biffl WL, Kaups KL, Cothren CC, et al. Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma 2009; 66:1294.
- Biffl WL, Kaups KL, Pham TN, et al. Validating the Western Trauma Association algorithm for managing patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma 2011; 71:1494.
- 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.
- Tsikitis V, Biffl WL, Majercik S, et al. Selective clinical management of anterior abdominal stab wounds. Am J Surg 2004; 188:807.
- Alzamel HA, Cohn SM. When is it safe to discharge asymptomatic patients with abdominal stab wounds? J Trauma 2005; 58:523.
- Murphy JT, Hall J, Provost D. Fascial ultrasound for evaluation of anterior abdominal stab wound injury. J Trauma 2005; 59:843.
- Nagy KK, Roberts RR, Joseph KT, et al. Experience with over 2500 diagnostic peritoneal lavages. Injury 2000; 31:479.
- Sriussadaporn S, Pak-art R, Pattaratiwanon M, et al. Clinical uses of diagnostic peritoneal lavage in stab wounds of the anterior abdomen: a prospective study. Eur J Surg 2002; 168:490.
- Boyle EM Jr, Maier RV, Salazar JD, et al. Diagnosis of injuries after stab wounds to the back and flank. J Trauma 1997; 42:260.
- Moore GP, Alden AW, Rodman GH. Is closed diagnostic peritoneal lavage contraindicated in patients with previous abdominal surgery? Acad Emerg Med 1997; 4:287.
- Henneman PL, Marx JA, Moore EE, et al. Diagnostic peritoneal lavage: accuracy in predicting necessary laparotomy following blunt and penetrating trauma. J Trauma 1990; 30:1345.
- 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.
- Cha JY, Kashuk JL, Sarin EL, et al. Diagnostic peritoneal lavage remains a valuable adjunct to modern imaging techniques. J Trauma 2009; 67:330.
- 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.
- Hashemzadeh S, Mameghani K, Fouladi RF, Ansari E. Diagnostic peritoneal lavage in hemodynamically stable patients with lower chest or anterior abdominal stab wounds. Ulus Travma Acil Cerrahi Derg 2012; 18:37.
- Soto JA, Morales C, Múnera F, et al. Penetrating stab wounds to the abdomen: use of serial US and contrast-enhanced CT in stable patients. Radiology 2001; 220:365.
- Salim A, Sangthong B, Martin M, et al. Use of computed tomography in anterior abdominal stab wounds: results of a prospective study. Arch Surg 2006; 141:745.
- Goodman CS, Hur JY, Adajar MA, Coulam CH. How well does CT predict the need for laparotomy in hemodynamically stable patients with penetrating abdominal injury? A review and meta-analysis. AJR Am J Roentgenol 2009; 193:432.
- Demetriades D, Hadjizacharia P, Constantinou C, et al. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg 2006; 244:620.
- Stein DM, York GB, Boswell S, et al. Accuracy of computed tomography (CT) scan in the detection of penetrating diaphragm injury. J Trauma 2007; 63:538.
- Barbiera F, Nicastro N, Finazzo M, et al. The role of MRI in traumatic rupture of the diaphragm. Our experience in three cases and review of the literature. Radiol Med 2003; 105:188.
- 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.
- O'Malley E, Boyle E, O'Callaghan A, et al. Role of laparoscopy in penetrating abdominal trauma: a systematic review. World J Surg 2013; 37:113.
- Chestovich PJ, Browder TD, Morrissey SL, et al. Minimally invasive is maximally effective: Diagnostic and therapeutic laparoscopy for penetrating abdominal injuries. J Trauma Acute Care Surg 2015; 78:1076.
- da Silva M, Navsaria PH, Edu S, Nicol AJ. Evisceration following abdominal stab wounds: analysis of 66 cases. World J Surg 2009; 33:215.
- Leppäniemi A, Haapiainen R. Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma 2003; 55:636.
- Kopelman TR, O'Neill PJ, Macias LH, et al. The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds. Am J Surg 2008; 196:871.
- Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma 2010; 68:721.
- Oyo-Ita A, Chinnock P, Ikpeme IA. Surgical versus non-surgical management of abdominal injury. Cochrane Database Syst Rev 2015; :CD007383.
- Rosenthal RE, Smith J, Walls RM, et al. Stab wounds to the abdomen: failure of blunt probing to predict peritoneal penetration. Ann Emerg Med 1987; 16:172.
- Plackett TP, Fleurat J, Putty B, et al. Selective nonoperative management of anterior abdominal stab wounds: 1992-2008. J Trauma 2011; 70:408.
- Berg RJ, Karamanos E, Inaba K, et al. The persistent diagnostic challenge of thoracoabdominal stab wounds. J Trauma Acute Care Surg 2014; 76:418.
- Leppäniemi A, Haapiainen R. Occult diaphragmatic injuries caused by stab wounds. J Trauma 2003; 55:646.
- MECHANISM OF INJURY
- ANATOMIC ZONES
- METHODS OF EVALUATION
- Initial assessment
- Local wound exploration
- Plain radiographs
- Serial physical examination and observation
- Diagnostic peritoneal tap and diagnostic peritoneal lavage
- Computed tomography and magnetic resonance imaging
- Diagnostic laparoscopy
- INITIAL MANAGEMENT
- General approach and indications for laparotomy
- Peritoneal violation
- Selective nonoperative management
- Prophylactic antibiotics
- Observation in resource-limited settings
- SPECIAL CONSIDERATIONS
- Flank and back stab wounds
- Thoracoabdominal stab wounds
- Right upper quadrant stab wound
- Stab wounds in pregnancy
- Patients on anticoagulants
- Law enforcement and social service issues
- SUMMARY AND RECOMMENDATIONS