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
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.
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- 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