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Penetrating injury
Trauma ForumEditorial
remain the same and penetrating trauma is no different. However, it is optimal to have m place guidelines which may assist in the clinical decision making process when dealing with penetrating trauma. We have included an extract from the Westmead Hospital Guidelines for the Management of Trauma (2nd E&tion 1997) relating to the treatment of penetrating abdominal injuries.
by Trish McDougall & Andrea Delprado
The Incidence of penetrating tramna is undoubtedly on the rise. Difficulties encountered by Emergency Department staff and Trauma Team members are confounded by varying degrees of experience in dealing with this type of injury. Expertise in clinical decision making in penetrating trauma is very dependant on the volume of penetrating trauma treated. In some urban areas of Australia penetrating trauma now makes up a significant portion of trauma admissions, however on the whole, there has been a very uneven distribution of penetrating trauma cases treated. The principles of resuscitation
©
We hope this will assist you, as members of the resuscitation team, to participate in decisions which will lead to the best outcome for your patients.
RegardsTrish
& Andrea
PENETRATINGINJURY Stab Wounds Stab wounds associated with clear peritoneal penetration (peritoneal signs, evisceration or free gas on erect CXR) must be explored. Stab wounds penetrating the chest cavity below the plane of the 4th costal cartilages anteriorly and 7th ribs posteriorly carry a significant risk of having transgressed the diaphragm, and must be assessed as combined thoracic and abdominal injuries. Stab wounds penetrating the back where there is any doubt about retroperitoneal injury, should be explored by laparotomy. Stab wounds to the abdomen where peritoneal penetration is unclear, can be managed in four possible ways. Clinical Observation: This must be diligent and repeated frequently, but has been shown in U.S. studies to be rehable and safe. It does however necessitate admission to hospital. Expl, ,ration of wound under Local AnaEsthesia: Commonly performed in many U.S. Emergency Rooms, this procedure requires both a moderate level of surgical skdl and experience, and better surgical facilities than we can offer in our Resuscitation area. The best results are obtained by centres which see a lot of stab wounds (ie. 10-20 or more cases daily! !). Diagnostic Peritoneal Lavage (DPL): Picks up significant bleeding very reliably but visceral perforation not always detected in the early stages. Laparotomy: Remains the gold standard.
Laparoscopy can be useful to determine if there has been penetration of the peritoneum in anterior and lateral stab wounds. If laparoscopy shows no peritoneal breach no further action is required. However if a peritoneal breach is identified then laparotomy should be performed as there is good evidence showing a significant missed injury rate ( especially small bowel injuries) from laparoscopy alone.
Laparotomy may mean a substannal rate of "non-therapeutic" procedures if done routinely for all stab wounds. In hospitals such as Westmead where abdominal stab wounds are infrequent, a combination of careful clinical observation in apparently trivial wounds, with a low threshold for laparoscopy/laparotomy is the safest policy. If the patmnt presents with the weapon or -(Nipple
'3
"Abdominal S t a b s ,, ~li~etO buttock + geom'¢~'ease}' '
Clear penetration ofdeepf~ch (eg eviscera,tlO~, I transabdominat
I ?P e n e ~ | d~p ~ i a
]
]
t
L woune)
Clear penetration
/
object still in situ, it should be removed in the Operating Room, NOT the Resuscitation area.
GunshotWounds All gunshot wounds to the abdomen should be explored. Small bowel, colon and liver are the most commonly injured organs. This is one of the few situations where a plain abdominal X-Ray is indicated early in the Initial Assessment of a trauma patient, as it will help locate bullet fragments (and sometimes bone fragments which may act as secondary missiles). An assessment of the likely path of the bullet should be made using entry and exit sites as well as the radiograph. Be aware of the damage caused by shock waves and cavitation adjacent to the bullet's path. The higher the velocity, the greater the area of surrounding damage. High velocity rounds (ie. > 2000 ft/sec muzzle velocity) passing through the lower chest have been known to cause colonic damage and subsequent perforation by this mechanism, without actually entering the peritoneal cavity. Therefore patients with projectiles passing below the plane of 4th costal cartilages anteriorly and 7th ribs posteriorly, should have a laparotomy.
Equivocal No penetration penetration In the stable patient CT may provide additional information on trajectory and +re signs -re signs intraabdominal injuries. This investigation should only be undertaken at the express wish of the General Surgical consultant, and should never be contemplated in the unstable patient. J - Obse~e
/\
/
AENJ VOLUME 1 NO. 4 MAY 1998
17
remain the same and penetrating trauma is no different. However, it is optimal to have m place guidelines which may assist in the clinical decision making process when dealing with penetrating trauma. We have included an extract from the Westmead Hospital Guidelines for the Management of Trauma (2nd E&tion 1997) relating to the treatment of penetrating abdominal injuries.
by Trish McDougall & Andrea Delprado
The Incidence of penetrating tramna is undoubtedly on the rise. Difficulties encountered by Emergency Department staff and Trauma Team members are confounded by varying degrees of experience in dealing with this type of injury. Expertise in clinical decision making in penetrating trauma is very dependant on the volume of penetrating trauma treated. In some urban areas of Australia penetrating trauma now makes up a significant portion of trauma admissions, however on the whole, there has been a very uneven distribution of penetrating trauma cases treated. The principles of resuscitation
©
We hope this will assist you, as members of the resuscitation team, to participate in decisions which will lead to the best outcome for your patients.
RegardsTrish
& Andrea
PENETRATINGINJURY Stab Wounds Stab wounds associated with clear peritoneal penetration (peritoneal signs, evisceration or free gas on erect CXR) must be explored. Stab wounds penetrating the chest cavity below the plane of the 4th costal cartilages anteriorly and 7th ribs posteriorly carry a significant risk of having transgressed the diaphragm, and must be assessed as combined thoracic and abdominal injuries. Stab wounds penetrating the back where there is any doubt about retroperitoneal injury, should be explored by laparotomy. Stab wounds to the abdomen where peritoneal penetration is unclear, can be managed in four possible ways. Clinical Observation: This must be diligent and repeated frequently, but has been shown in U.S. studies to be rehable and safe. It does however necessitate admission to hospital. Expl, ,ration of wound under Local AnaEsthesia: Commonly performed in many U.S. Emergency Rooms, this procedure requires both a moderate level of surgical skdl and experience, and better surgical facilities than we can offer in our Resuscitation area. The best results are obtained by centres which see a lot of stab wounds (ie. 10-20 or more cases daily! !). Diagnostic Peritoneal Lavage (DPL): Picks up significant bleeding very reliably but visceral perforation not always detected in the early stages. Laparotomy: Remains the gold standard.
Laparoscopy can be useful to determine if there has been penetration of the peritoneum in anterior and lateral stab wounds. If laparoscopy shows no peritoneal breach no further action is required. However if a peritoneal breach is identified then laparotomy should be performed as there is good evidence showing a significant missed injury rate ( especially small bowel injuries) from laparoscopy alone.
Laparotomy may mean a substannal rate of "non-therapeutic" procedures if done routinely for all stab wounds. In hospitals such as Westmead where abdominal stab wounds are infrequent, a combination of careful clinical observation in apparently trivial wounds, with a low threshold for laparoscopy/laparotomy is the safest policy. If the patmnt presents with the weapon or -(Nipple
'3
"Abdominal S t a b s ,, ~li~etO buttock + geom'¢~'ease}' '
Clear penetration ofdeepf~ch (eg eviscera,tlO~, I transabdominat
I ?P e n e ~ | d~p ~ i a
]
]
t
L woune)
Clear penetration
/
object still in situ, it should be removed in the Operating Room, NOT the Resuscitation area.
GunshotWounds All gunshot wounds to the abdomen should be explored. Small bowel, colon and liver are the most commonly injured organs. This is one of the few situations where a plain abdominal X-Ray is indicated early in the Initial Assessment of a trauma patient, as it will help locate bullet fragments (and sometimes bone fragments which may act as secondary missiles). An assessment of the likely path of the bullet should be made using entry and exit sites as well as the radiograph. Be aware of the damage caused by shock waves and cavitation adjacent to the bullet's path. The higher the velocity, the greater the area of surrounding damage. High velocity rounds (ie. > 2000 ft/sec muzzle velocity) passing through the lower chest have been known to cause colonic damage and subsequent perforation by this mechanism, without actually entering the peritoneal cavity. Therefore patients with projectiles passing below the plane of 4th costal cartilages anteriorly and 7th ribs posteriorly, should have a laparotomy.
Equivocal No penetration penetration In the stable patient CT may provide additional information on trajectory and +re signs -re signs intraabdominal injuries. This investigation should only be undertaken at the express wish of the General Surgical consultant, and should never be contemplated in the unstable patient. J - Obse~e
/\
/
AENJ VOLUME 1 NO. 4 MAY 1998
17