ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Initial evaluation and management of abdominal gunshot wounds in adults

Initial evaluation and management of abdominal gunshot wounds in adults
Literature review current through: Jan 2024.
This topic last updated: Nov 10, 2021.

INTRODUCTION — 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".)

EPIDEMIOLOGY — Although encountered less frequently than stab 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 10 percent [3]. 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, 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.

Shotgun wounds (SGWs) have different characteristic patterns of injury given their use of pellets, rather than single bullets, and longer barrels. Typically, initial pellet velocity decreases quickly and spread increases with distance from the target. Most lethal SGWs occur at close range (<2.7 m; <3 yards). Management of abdominal SGWs does not differ significantly from that of GSWs.

SGWs are categorized into three types based on distance:

Type I (>6.4 m; >7 yards) wounds are typically limited to the subcutaneous tissue and deep fascial layers.

Type II (2.7 to 6.4 m; 3 to 7 yards) wounds occur when projectiles enter the abdominal cavity due to a tighter pellet spread and increased velocity.

Type III (<2.7 m; <3 yards) wounds result in massive tissue loss and destruction, in addition to added contaminants from debris.

ANATOMIC ZONES — The abdominal cavity is divided into four anatomic zones (figure 1):

Anterior abdomen – The anterior abdomen is bound by the anterior axillary lines extending from the costal margins to the groin creases.

Thoracoabdominal region – The nipple line (fourth intercostal space) anteriorly and the tips of the scapulae (seventh intercostal space) and the inferior costal margin posteriorly demarcate the cephalad portion of the thoracoabdominal area. The caudad portion is bound by the inferior costal margin. Wounds in this general region pose significant threat, as injury to the chest, mediastinum, and abdomen are all possible because of the path of the weapon and movement of the diaphragm.

Flank region – The flanks are separated on each side by the inferior costal margins and iliac crests, and the anterior and posterior axillary lines.

Back region – The back is defined as the area between the posterior axillary lines, the inferior scapular tips (seventh intercostals space), and the iliac crest.

HISTORY — History should be gathered from the patient if possible, available eye-witnesses, and emergency medical service (EMS) providers. In addition to standard information that may be helpful in the management of any trauma patient, the following items may be particularly useful when managing the patient with a GSW to the abdomen.

Prehospital vital signs – These are particularly helpful if they were abnormal at any point, suggesting significant injury.

Number of shots heard – The number can provide a warning of possible missed injuries.

Blood loss at the scene – This may be substantial and is not always obvious once the patient is in the emergency department.

Position of the patient when shot – This may provide clues to possible injuries.

The general trauma history is reviewed in detail separately. (See "Initial management of trauma in adults", section on 'History'.)

METHODS OF EVALUATION

Initial assessment — General evaluation and the initial management of the trauma patient is reviewed separately. Issues specifically related to the initial evaluation of patients with abdominal GSWs are discussed below. (See "Initial management of trauma in adults".)

Indications for immediate laparotomy include the following [1,4,5]:

Signs of peritonitis (eg, rigid abdominal wall, rebound tenderness)

Hypotension or hemodynamic instability

Evisceration of abdominal contents (bowel or omentum)

Hematemesis or gross blood per rectum

The management of patients whose abdomen cannot be examined reliably (eg, unresponsive, intoxicated, or intubated patient) will vary depending on local expertise and resources, and the preference of the attending trauma surgeon. Immediate laparotomy and diagnostic laparoscopy are both reasonable options. The stable patient with mild alteration in mental status (eg, mildly intoxicated) may be a candidate for nonoperative management based on computed tomography (CT) scanning [3]. GSWs to the right upper quadrant with isolated liver injuries are favorable candidates for observation.

All patients must be completely undressed and systematically examined. A patient with what appears to be an isolated abdominal GSW may have additional wounds in the axilla, groin, perineum, scalp, or skin folds. A rectal examination should be performed in all patients with a GSW involving the lower abdomen, and a genitourinary examination should be performed in all patients with a GSW involving the pelvis. All patients must be log-rolled to evaluate for exit wounds and wounds to the back. Depending on bullet trajectory, ricochets, and associated shrapnel, abdominal GSWs may raise concern for intrathoracic injury.

Local wound exploration — GSWs often destroy tissue making local wound exploration less effective for visualizing the extent of the missile tract. Occasionally, local wound exploration may be used to assess superficial tangential wounds, but the clinician must ensure that the entire tract is visualized. If the entire tract cannot be visualized, additional testing is required. In general, and in contrast to abdominal stab wounds, wound exploration is not performed in patients with GSWs because of the difficulty in following wound tracks.

Plain radiographs — Plain film radiographs are often employed and generally accurate for determining the path of a bullet and its location. Two planes must be imaged to determine the likelihood of the peritoneum being penetrated. In addition, plain radiographs may be helpful to identify a bullet "embolus" (eg, the absence of a projectile in the setting of only an entrance wound).

Radiographs are less helpful in patients with through-and-through wounds, wounds in which ricochet off of ribs or the pelvis may have occurred, and multiple bullets or pellets. Missiles may enter vessels or travel outside of the peritoneal cavity. In such cases, the number of wound sites may not correspond to the number of missiles found on plain films, compelling the clinician to extend the radiographic search [6]. This can be done using additional plain radiographs or CT, and the preferred approach will vary according to local expertise and resources.

Computed tomography — The advent of fast, high-resolution multi-detector computed tomography (CT) scanners has dramatically expanded the role of CT in the management of abdominal GSWs. Intravenous (IV) and oral contrast are often used in patients with GSWs to better visualize solid and hollow viscus injuries. Rectal contrast may be added for suspected colorectal injury, based on missile path or clinical findings such as rectal bleeding. In stable patients, this study can be completed expeditiously, making it an excellent test for those who do not need immediate exploratory laparotomy [7-9].

In one prospective observational study of 100 hemodynamically stable patients with non-tangential abdominal GSWs, researchers found that using abdominal CT with IV contrast alone to evaluate for intra-abdominal injury after an abdominal GSW yielded a sensitivity of 90.5 percent and specificity of 96 percent [10]. Only 26 of the 100 proceeded to exploratory laparotomy and of those five had a nontherapeutic laparotomy. This suggests that IV contrast-only CT coupled with serial physical examination for the evaluation of stable abdominal GSW patients has reasonable accuracy and may be safe and useful.

In another prospective observational study, 41 patients with abdominal GSWs were initially managed nonoperatively [8]. Of the 24 patients with negative CT findings, none required operation (one went to the OR based on physical exam findings but had a negative laparotomy). Of the remaining 17 with positive CT findings, 11 had a therapeutic laparotomy and one had a nontherapeutic laparotomy. The other positive CT scans showed five hepatic injuries, three of which were managed with angioembolization, and one diaphragmatic injury, which was repaired using video-assisted thoracoscopy.

Due to advances in CT imaging, selective nonoperative management of abdominal GSWs is gaining favor [11]. CT is helpful for elucidating the missile path, delineating organ and vascular injury, and identifying patients with injuries amenable to nonoperative management (eg, low-grade liver injuries) [6,8,10]. (See 'Selective nonoperative management' below.)

Ultrasound — Ultrasound (US) can be invaluable in the initial evaluation of the unstable trauma patient because it can rapidly determine the presence of fluid in the pericardial and peritoneal spaces. However, it cannot rule out intra-abdominal injury, especially injury to the diaphragm or hollow viscus organs, which may bleed minimally when injured. Minimal intra-abdominal fluid identified by US (or CT), without other findings, may be a harbinger of isolated hollow viscus or diaphragmatic injury [12]. The use of US to evaluate patients with abdominal trauma is discussed in detail separately. (See "Emergency ultrasound in adults with abdominal and thoracic trauma".)

Diagnostic peritoneal lavage — The role of diagnostic peritoneal lavage (DPL) in the assessment of abdominal GSWs is extremely limited. The latest generation of CT scanners provide high-resolution images with great speed, and has made DPL largely obsolete save for a few special circumstances. As one possible example, DPL might be used to assess a stable patient with an abdominal GSW and suspected internal injuries being evaluated in a small hospital without a CT scanner to determine whether urgent transfer and operative intervention is required. DPL is discussed in greater detail separately. (See "Initial evaluation and management of abdominal stab wounds in adults", section on 'Diagnostic peritoneal tap and diagnostic peritoneal lavage' and "Diagnostic peritoneal lavage (DPL) or aspiration (DPA)".)

DPL is a highly sensitive test for detecting injury following abdominal GSW [6,13,14]. Using 5000 to 10,000 red blood cells per high-powered field (RBC/HPF) as the threshold for a positive test, the sensitivity of DPL is reported to be 96 percent for GSWs [6] and 87.5 percent in shotgun wounds (SGWs) [14]. We use 5000 RBC/HPF as the threshold for injury. A retrospective review suggests that this positive criterion can be raised to 100,000 RBCs/HPF without missing any significant injuries, if coupled with other positive criteria such as the presence of >500 WBCs/HPF, bile, or amylase [15].

Drawbacks to its routine use in patients sustaining an abdominal GSW include its invasive nature, time needed to analyze the DPL effluent, and its lack of specificity for organ injuries that might be managed nonoperatively [6].

DPL may be useful in several other circumstances:

A grossly positive DPL aspirate can often determine that the intraperitoneal cavity is the sole or a contributing source of hemorrhagic shock.

In patients with injuries to the low chest, flank, and back, DPL can be used to determine whether the peritoneum has been violated.

In patients who cannot be evaluated clinically, DPL can be used to detect hollow viscus injury.

As an example of the last scenario, DPL might be used in a patient with a severe head injury whose initial abdominal CT shows no injury but who subsequently develops a fever without a clear source. DPL may also be useful for distinguishing between blood and ascites, for example, in a patient with known liver disease.

Diagnostic laparoscopy — The role for diagnostic laparoscopy (DL) in the management of abdominal GSWs continues to evolve. DL allows the surgeon to identify peritoneal violation and partially inspect the diaphragm. DL is also useful for assessing GSWs to the right upper quadrant when CT indicates an isolated hepatic injury but there is concern due to the proximity of the colon. However, DL does not enable adequate visualization of the posterior portion of the diaphragm, nor does it provide an effective means for detecting subtle hollow viscus or retroperitoneal injuries [6,16-18].

Other potential drawbacks to DL include the need for anesthesia and the inability to repair some injuries, requiring conversion to an open laparotomy. DL is best utilized in those patients without a clear indication for laparotomy or thoracotomy with a tangential abdominal GSW or low-left chest injury [16].

MANAGEMENT

Indications for laparotomy and general approach to management — The mainstay of the management of abdominal GSWs is detection of peritoneal violation and intra-abdominal injury. A management algorithm is provided (algorithm 1); general management of the adult trauma patient is discussed separately. (See "Initial management of trauma in adults".)

Indications for immediate laparotomy in the patient with an abdominal or pelvic GSW include the following [1,4,5,19]:

Signs of peritonitis (eg, rigid abdominal wall, rebound tenderness)

Hypotension or hemodynamic instability

According to a retrospective study of 303 patients with GSWs to the torso and hypotension at presentation, a delay in transfer to the operating room of more than 10 minutes increased the risk of mortality as much as threefold [20]. Abnormal prehospital vital signs, even if normalized on arrival, are highly specific (albeit not highly sensitive) for identifying serious injuries [21].

Evisceration of abdominal contents (bowel or omentum)

Hematemesis or gross blood per rectum

The management of patients whose abdomen cannot be examined reliably (eg, unresponsive, intoxicated, or intubated patient) varies depending on local expertise and resources, and the preference of the attending trauma surgeon. Immediate laparotomy and diagnostic laparoscopy are both reasonable options.

Of note, it is important not to overlook other, possibly extra-abdominal, causes of shock or hemodynamic instability, particularly those amenable to immediate intervention (eg, pericardial tamponade, tension pneumothorax). It may not be the most obvious injury that poses the greatest threat to life. (See "Initial management of trauma in adults" and "Approach to shock in the adult trauma patient".)

In the past, any patient with suspected peritoneal violation was taken to laparotomy, but for properly selected patients, nonoperative approaches can be safe and are gaining favor at some trauma centers [6,11,17,22-30]. (See 'Selective nonoperative management' below.)

If the patient with an abdominal GSW is hemodynamically stable with no indications for immediate laparotomy, but their ultrasound (FAST) examination reveals intraperitoneal fluid, a computed tomography (CT) scan should be performed. The CT may reveal significant intra-abdominal injury (eg, bowel perforation), in which case the patient is taken to the operating suite, or it may reveal an isolated solid organ injury (eg, isolated liver injury). In the latter case, depending upon hospital resources and protocols, the patient may be observed as an in-patient or taken for laparotomy. For patients who appear stable initially but whose CT scan is equivocal and who are at greater risk should they deteriorate subsequently (eg, older age, major comorbidities), it is reasonable for the trauma surgeon to take them for early laparotomy or laparoscopy. (See 'Selective nonoperative management' below.)

Otherwise, in most trauma centers and other hospitals, a CT is obtained to assess the stable patient with an abdominal GSW. While uncommon, in some cases a careful examination by a clinician experienced with the assessment of GSWs shows that the trajectory of the missile has not violated the peritoneal cavity, in which case a CT is not necessary. As this determination can be difficult, and as many of these patients ultimately require laparotomy, clinicians managing such patients in a rural emergency department (ED) or other resource-limited setting should transfer them expeditiously to a hospital with the resources necessary to provide definitive care, unless CT is performed and reveals no peritoneal violation. Basic diagnostic studies may be obtained, but transfer should not be delayed to obtain them.

In some instances, a CT scan performed in a hemodynamically stable patient shows that no peritoneal penetration has occurred following a GSW. Such patients may be discharged from the ED after six hours of observation, assuming that a thorough workup reveals no other signs of injury.

Neither a urinary (Foley) catheter nor a nasogastric tube is required for management, unless otherwise indicated. In stable patients, the authors prefer to avoid these interventions, unless there is a specific reason for them (eg, trajectory of the projectile raises concern for genitourinary injury). A plain chest radiograph should be obtained.

Laboratory studies — At a minimum, a type and screen should be obtained for all patients with an abdominal GSW in preparation for possible blood transfusion. A type and crossmatch should be obtained if there is evidence of significant hemorrhage or the patient manifests indications for immediate laparotomy. Other laboratory tests that are commonly obtained include:

Complete blood count

Coagulation studies

Thromboelastography, if available and if there is any evidence of hemorrhage (see "Etiology and diagnosis of coagulopathy in trauma patients")

Arterial blood gas for patients who are hypotensive or demonstrate hemodynamic instability

Selective nonoperative management — Selective nonoperative management of patients with abdominal GSWs may be appropriate for select patients. The following criteria are necessary for this strategy:

Patient remains hemodynamically stable throughout their care

No hollow visceral or major vascular injury exists

Frequent, careful patient reassessment can be performed and continued for a minimum of 24 hours

Rapid transport to the operating room can be accomplished if concerning clinical signs develop

Selective nonoperative management of patients with abdominal GSWs only works in facilities able to provide frequent patient reassessment, by the same clinician if possible, and to move the patient rapidly to the operating room if hemodynamic instability or peritoneal signs develop [1,22,31]. Even so, the evidence for nonoperative management of GSWs remains somewhat limited, and some trauma surgeons believe the safest course is laparotomy if there is evidence of peritoneal violation. In hemodynamically stable patients, CT has gained favor as a noninvasive, rapid, and accurate diagnostic tool that helps to identify patients who might benefit from selective nonoperative management after an abdominal GSW [2,19].

Typically, the patients amenable to nonoperative management have sustained an isolated solid organ injury, usually involving the liver, and there are no signs of bowel injury on CT [32]. The type of GSW may affect whether nonoperative management is successful. A retrospective review of a national trauma databank involving over 1400 patients with abdominal shotgun wounds (SGWs) found that while nonoperative management was more likely to fail in these patients compared with those with GSWs from a handgun, it was still a safe and beneficial management strategy in appropriately selected patients [33]. (See 'Computed tomography' above.)

Any stable patient with an abdominal GSW should be observed for a minimum of 24 hours before discharge unless there is clear evidence that no peritoneal penetration occurred [31,34]. In an observational study of 245 patients with GSWs to the torso, including 91 managed nonoperatively, all 8 patients initially managed with observation but who ultimately required laparotomy manifested signs of intra-abdominal injury within 24 hours [31]. Usually, patients managed nonoperatively are admitted and undergo serial abdominal examinations, even if all initial studies are negative. We suggest repeating the examination every four hours, or if there is any change in the patient’s condition. Re-examination should include careful assessment of vital signs and the abdomen and chest, and ideally is performed by the same clinician.

If the patient is hemodynamically stable, and no other significant injury, comorbidity, or other concerning factor (advanced age) is present, it is not necessary to admit the patient to an intensive care unit or to perform cardiac monitoring.

For the patient with an abdominal GSW but without evidence of peritoneal penetration based on a thorough evaluation (typically including abdominal CT), and without other concerning injuries, a six-hour observation period is reasonable prior to discharge from the ED. However, such cases are uncommon and the great majority of patients who are candidates for selective nonoperative management are observed for a minimum of 24 hours [31].

Some centers may try to avoid hospital admission, as suggested by a retrospective study performed at a major, urban trauma center of 107 patients with penetrating abdominal trauma who received a selective ED evaluation involving local wound exploration, CT, and serial examinations [29]. Of those patients discharged from the ED, 66 percent were available for follow-up and none experienced significant morbidity or mortality.

Prophylactic antibiotics — Broad spectrum antibiotics are generally given to patients with penetrating abdominal injury requiring surgical management; routine antibiotic administration is not warranted in most injured patients, including those with penetrating abdominal injury, who are managed nonoperatively. The use of prophylactic antibiotics in the setting of trauma is discussed in greater detail separately. (See "Overview of inpatient management of the adult trauma patient", section on 'Antibiotics'.)

SPECIAL CONSIDERATIONS

Flank and back — Patients with a GSW to the flank and back are difficult to evaluate due to the potential of injury to retroperitoneal structures. Neither diagnostic peritoneal lavage (DPL), ultrasound, nor diagnostic laparoscopy is able to provide definitive information regarding injury to these structures. Abdomen and pelvic computed tomography (CT) scans with intravenous (IV), oral, and rectal contrast ("triple contrast") to delineate the missile path and identify potential injuries, especially those of the colon and rectum, has been the standard approach [7,35]. With improved sensitivity of multidetector computed tomography (CT), however, it is generally possible to follow the wound tract and get an accurate assessment using IV contrast alone [36].

Thoracoabdominal — Wounds of the upper abdomen and lower chest are especially difficult to evaluate due to the potential for missiles to ricochet off ribs and the range of movement of the diaphragm during respiration. If there is concern for a possible thoracoabdominal injury, we suggest obtaining a CT in the hemodynamically stable patient. If the CT is equivocal, we suggest laparoscopy.

DPL is no longer commonly used for evaluation. When DPL is performed in this setting, some recommend lowering the threshold for a positive study to 5000 from 10,000 red blood cells per high powered field (RBCs/HPF) in order not to miss injuries. However, this approach has the potential to increase negative and nontherapeutic laparotomy rates. Other trauma surgeons use diagnostic laparoscopy to inspect the diaphragm and abdominal cavity in the hope of avoiding exploratory laparotomy, and potentially nontherapeutic and negative laparotomies [6]. (See 'Diagnostic peritoneal lavage' above.)

Airway management — For patients with abdominal GSWs who will need laparotomy but are initially hemodynamically stable and do not require immediate airway management, delay of tracheal intubation until the patient is in the operating room may be beneficial. Hypotension immediately following intubation is common, and delayed intubation can allow for more rapid control of the source of hemorrhage while minimizing any potential drop in blood pressure [37]. However, such decisions must be made clinically on a case by case basis. In some circumstances, it is prudent to obtain control of the airway rapidly, even with apparently stable patients who are to be taken to the operating room. (See "Rapid sequence intubation in adults for emergency medicine and critical care" and "Overview of advanced airway management in adults for emergency medicine and critical care".)

Gunshot wounds in pregnancy — Abdominal GSWs sustained during pregnancy are uncommon. The management of the pregnant trauma patient is reviewed separately. (See "Initial evaluation and management of major trauma in pregnancy".)

Patients on anticoagulants — Patients taking warfarin, heparin, or other anticoagulants are at higher risk of hemorrhage following an abdominal GSW and reversal of anticoagulation may be needed if bleeding becomes severe. This is discussed separately. (See "Management of warfarin-associated bleeding or supratherapeutic INR", section on 'Treatment of bleeding' and "Heparin and LMW heparin: Dosing and adverse effects", section on 'Bleeding' and "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Major bleeding'.)

ED thoracotomy — Emergency department thoracotomy with cross clamping of the descending aorta may temporarily prevent life-threatening exsanguination from an abdominal GSW, while shunting blood to the heart and brain, and providing a bridge to operative care. (See "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Role of emergency department thoracotomy'.)

In trauma centers with relevant expertise, resuscitative endovascular balloon occlusion of the aorta (REBOA) is a reasonable alternative to resuscitative thoracotomy. (See "Endovascular methods for aortic control in trauma".)

Law enforcement and social service issues — Many jurisdictions require emergency departments to notify local law enforcement of all GSWs. Law enforcement investigation may be necessary to ensure that no other victims are in need of assistance. Necessary steps should be taken to ensure that the emergency department and hospital are safe and secure, which may include communicating with hospital security or police personnel. Clothing removed from the patient should be placed in brown paper bags or other containers suitable for evidence collection. All wounds should be carefully documented in the medical chart.

Victims of assault may suffer emotionally as well as physically. Social services or mental health professionals should be consulted as needed during the hospital evaluation and as part of post-discharge follow-up. Victims of GSWs are often at risk for experiencing future traumatic injuries, and violence intervention programs should be used when available. (See "Acute stress disorder in adults: Epidemiology, clinical features, assessment, and diagnosis".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues of trauma management in adults" and "Society guideline links: Traumatic abdominal and non-genitourinary retroperitoneal injury".)

SUMMARY AND RECOMMENDATIONS

Mechanism of injury – Gunshot wounds (GSWs) most often injure the small bowel, followed by the colon and liver. The velocity of the missile and its distance from the patient can be important factors in determining the extent of injury. (See 'Mechanisms of injury' above.)

History – Important historical information includes: prehospital vital signs; number of shots heard; type of gun used; position of the patient when shot; blood loss at the scene; and, the distance of the patient from the gun. (See 'History' above.)

Examination – All patients must be completely undressed. Wounds in the axilla, groin, perineum, scalp, or skin folds can be obscured by clothing. All patients must be log-rolled to evaluate for wounds to the back. GSWs often destroy tissue making local wound exploration less effective for visualizing the entire extent of the missile tract. (See 'Initial assessment' above and 'Local wound exploration' above.)

GSWs to the back, flank, or upper abdomen are more difficult to evaluate. Back or flank wounds may involve injuries to retroperitoneal as well as intraperitoneal structures; upper abdominal or low chest wounds may involve injuries to both intra-abdominal and intrathoracic structures. (See 'Special Considerations' above.)

Indications for laparotomy – Evidence of hemodynamic instability, signs of peritonitis, or evisceration of bowel or omentum mandates immediate exploratory laparotomy (algorithm 1). The management of patients whose abdomen cannot be examined reliably (eg, unresponsive, intoxicated, or intubated) varies depending on local expertise and resources: immediate laparotomy and diagnostic laparoscopy are both reasonable options. Close observation may be a reasonable option in some circumstances. (See 'Indications for laparotomy and general approach to management' above.)

Diagnostic imaging – Plain film radiographs are often employed to define the path of the bullet. Two planes must be imaged to determine if the peritoneum was penetrated. Radiographs are less helpful in patients with through-and-through wounds, wounds close to ribs or pelvic bones, and multiple bullets or pellets.

Ultrasound can rapidly determine the presence or absence of fluid in the pericardial and peritoneal spaces but is poor at detecting diaphragmatic or hollow viscus injuries. (See 'Plain radiographs' above and 'Ultrasound' above.)

Computed tomography (CT) provides rapid, accurate imaging for patients with abdominal GSWs not in need of immediate laparotomy. Patients should proceed directly to exploratory laparotomy in cases of obvious peritoneal violation. (See 'Computed tomography' above.)

Blood typing and other laboratory studies – A type and screen should be obtained for all patients in preparation for possible blood transfusion. A type and crossmatch should be obtained if there is evidence of significant hemorrhage or the patient manifests indications for immediate laparotomy. (See 'Laboratory studies' above.)

Prophylactic antibiotics – Broad spectrum antibiotics are generally given to patients with penetrating abdominal injury requiring surgical management; routine antibiotic administration is not warranted in most patients with penetrating abdominal injury who are managed nonoperatively. (See "Overview of inpatient management of the adult trauma patient", section on 'Antibiotics'.)

Nonoperative approach – Facilities able to provide frequent, careful patient reassessment and to move patients rapidly to the operating room if peritoneal signs develop may use selective nonoperative management strategies for appropriate, hemodynamically stable patients. (See 'Selective nonoperative management' above.)

Patient transfer – Smaller hospitals without the resources necessary to provide definitive care for patients with abdominal GSWs should not delay transfer of these high-risk patients by performing lengthy work-ups or advanced imaging studies.

  1. 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.
  2. 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.
  3. Martin MJ, Brown CVR, Shatz DV, et al. Evaluation and management of abdominal gunshot wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2019; 87:1220.
  4. Jansen JO, Inaba K, Resnick S, et al. Selective non-operative management of abdominal gunshot wounds: survey of practise. Injury 2013; 44:639.
  5. 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.
  6. Pryor JP, Reilly PM, Dabrowski GP, et al. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med 2004; 43:344.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. Demetriades D, Hadjizacharia P, Constantinou C, et al. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg 2006; 244:620.
  12. Boulanger BR, Kearney PA, Tsuei B, Ochoa JB. The routine use of sonography in penetrating torso injury is beneficial. J Trauma 2001; 51:320.
  13. 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.
  14. 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.
  15. 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.
  16. Poole GV, Thomae KR, Hauser CJ. Laparoscopy in trauma. Surg Clin North Am 1996; 76:547.
  17. 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.
  18. Friese RS, Coln CE, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma 2005; 58:789.
  19. Como JJ, Bokhari F, Chiu WC, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma 2010; 68:721.
  20. Meizoso JP, Ray JJ, Karcutskie CA 4th, et al. Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes. J Trauma Acute Care Surg 2016; 81:685.
  21. Newgard CD, Cheney TP, Chou R, et al. Out-of-hospital Circulatory Measures to Identify Patients With Serious Injury: A Systematic Review. Acad Emerg Med 2020; 27:1323.
  22. 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.
  23. Leppäniemi AK, Voutilainen PE, Haapiainen RK. Indications for early mandatory laparotomy in abdominal stab wounds. Br J Surg 1999; 86:76.
  24. Nagy K, Roberts R, Joseph K, et al. Evisceration after abdominal stab wounds: is laparotomy required? J Trauma 1999; 47:622.
  25. 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.
  26. 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.
  27. 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.
  28. Alzamel HA, Cohn SM. When is it safe to discharge asymptomatic patients with abdominal stab wounds? J Trauma 2005; 58:523.
  29. 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.
  30. Peponis T, Kasotakis G, Yu J, et al. Selective Nonoperative Management of Abdominal Gunshot Wounds from Heresy to Adoption: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCoNECT). J Am Coll Surg 2017; 224:1036.
  31. 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.
  32. Navsaria P, Nicol A, Krige J, et al. Selective nonoperative management of liver gunshot injuries. Eur J Trauma Emerg Surg 2019; 45:323.
  33. Schellenberg M, Owattanapanich N, Switzer E, et al. Selective Nonoperative Management of Abdominal Shotgun Wounds. J Surg Res 2021; 259:79.
  34. 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.
  35. 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.
  36. Jawad H, Raptis C, Mintz A, et al. Single-Contrast CT for Detecting Bowel Injuries in Penetrating Abdominopelvic Trauma. AJR Am J Roentgenol 2018; 210:761.
  37. 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.
Topic 352 Version 31.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟