Evaluation of different modalities of management of penetrating abdominal trauma in Kasr Alainy emergency department Our aim is to evaluate different modalities of management of penetrating abdominal trauma and to assess their effectiveness in the management of our patients. Furthermore, the validation of our current management strategy and recommendations for the future.

2. Evaluation of different modalities
of management of penetrating
abdominal trauma in Kasr Alainy
emergency department
Mohamed Mostafa Alasmar
MBBCh

3. Aim of work
• Our aim is to evaluate different modalities of
management of penetrating abdominal
trauma and to assess their effectiveness in the
management of our patients.
• Furthermore, the validation of our current
management strategy and recommendations
for the future.

4. Penetrating Abdominal Trauma

5. Anatomy

6. Mechanisms of penetrating trauma
• Low energy-knife (stabs)
• Medium energy-handguns (shotgun)
• High energy-military or hunting rifles
(gunshot)

7. Stab wounds
• Wound size and type of weapon are very
important although they do not necessarily
correlate with the depth of wound or
trajectory.

8. Gunshot
Missile with large cross-sectional front such as hollow-point
bullets that spread or "mushroom" on Impact, cause more injury
and cavitation

9. Gunshot
The AK-47 rifle is one of the most common weapons seen
throughout the world. For this particular bullet (full metal
jacketed or ball), there is a 25 centimeter path of relatively
minimal tissue disruption before the projectile begins to Yaw.
This explains why relatively minimal tissue disruption may be
seen with some wounds

10. Velocity
• The velocity of a missile is the most significant
determinant of its wounding potential.
• Kinetic Energy = mass x (V12 – V22)/2
Where V1, is impact velocity and V2, is exit or
remaining velocity

11. Shotgun
• Shotgun pellets separate after leaving the
barrel of the gun and their velocity rapidly
decreases. As the pellets spread with
increasing range, their area of distribution
increases and the energy in each pellet
decreases.
• Can carry clothing and deposit wadding into
the depth of the wound and become a source
of infection if not removed.

12. Blast injuries

13. Assessment and management of
trauma patient

14. • Resuscitation of the trauma patient requires
an organized, systematic approach utilizing a
well-rehearsed protocol.
• Advanced Trauma Life Support (ATLS®)
developed by the American College of
Surgeons – Committee on Trauma in 1978.

15. Assessment of patient’s
Abdomen

16. Clinical examination
• Inspection, palpation, percussion and
auscultation.
• Searching for evidence of bleeding, air or
peritoneal irritation.

17. Different modalities in management
of penetrating abdominal trauma

18. Aim of these modalities
• Diagnostic vs. therapeutic.
• Diagnostic:
– Imaging modalities including: Chest x-ray, FAST and CT scan.
– DPL
– Detection of the violation of peritoneum: LWE and Diagnostic
laparoscopy.
– Serial physical examination.
• Diagnostic and therapeutic:
– Formal exploration and laparoscopic exploration
• Innovations:
– Laparoscopic diagnostic peritoneal lavage.
– Awake laparoscopy (under LA).

19. Patients and methods

20. • This is a prospective study of 50 patients
presented to Kasr Alainy emergency room
with penetrating abdominal trauma in the
period from 1st of August 2012 to 1st of March
2013.
• Inclusion criteria: any penetrating wound that
may injure intraabdominal organs.
• There was no exclusion criteria.
• The management modalities chosen for each
patient were according to surgeon preference

21. Results

22. • The 50 patients included in this study were 48
males & 2 females, their age ranged between
16 and 54 years. The mean age was 27.5
years.
male
Female
Frequency
Age

23. • All patients suffered from penetrating
abdominal trauma in the form of stab wounds
(36 patients), shotgun (12 patients) and
gunshot (2 patients).
Gunshot
Stab
Shotgun

33. • Twenty one patients (42%) were found to be
positive for intraabdominal injuries either by
investigations or on exploration.
Yes
No

34. • All patients were subjected to clinical examination of
the abdomen.
• Seven patients presented with eviscerated omentum
(of which 5 cases were positive for injuries), 10 patients
presented with acute abdomen (all of them were
positive for injuries), 33 patients were asymptomatic
and had no signs of peritoneal irritation (of which 5
cases were positive for injuries)
No
Yes
NegativePositiveevisceration
ColumnsRows
3D view of the contingency table

35. • Radiological investigations in the form of chest
X-ray, FAST scan and CT abdomen were done
according the decision of the consultant.
• The chest x-ray was found to be positive in 2
cases with air under diaphragm.

37. • FAST scan was done in 39 patients( 78%). The scan was
negative in 29 patients (58%) and positive in 10 patients (
20%)
• From the 29 negative cases there were 7 patients positive
for intraabdominal injuries. All cases with positive FAST
had indeed intraabdominal injuries. Therefore, the
sensitivity of FAST in detecting intraabdominal injuries was
70.8%, while the specificity was 100%.
Not Done
Done - Negative
Done - Positive

38. • CT scan was done in (17 patients, 34%). The scan was
negative in (4 patients, 8%) and positive in (13
patients, 26%).
• All 4 negative cases had no intraabdominal injury.
There were intraabdominal pellets in 4 shotgun cases
without intraabdominal injury. The sensitivity of the CT
scan in detecting intra abdominal injuries was 100%
and the specificity was 50%.
Done - Positive
(mention in
comments
Not Done
Done - Negative

40. • Diagnostic laparoscopy was done in 8 patients (16%). The
DL was negative in 4 patients (8%) and positive in 4 patients
(8%)
• No intraabdominal injuries detected in patients with
negative laparoscopic exploration. Three cases out of the 4
cases with positive peritoneal penetration by diagnostic
laparoscopy were found to have no intraabdominal injuries.
That gives the diagnostic laparoscopy sensitivity of 100%
and specificity of 57.14%.
Not Done
Done - Positive
Done - Negative

41. • Local wound exploration was done in 6 patients (12%)
all of them were negative.
• All 6 negative cases have no intraabdominal injuries
and there were no positive cases. All case were low
energy stab wounds. LWE has 100% specificity.
Not Done
Done - Negative

42. • Exploratory laparotomy was done in 28 patients (56%).
eighteen of them (36%) were positive, eight of them
(16%) were negative. Two patients (4%) were explored
after more than 24 hours of injury and were positive.
Positive
36%
Negative
16%
Not Done -
Conservative
Delayed, Positive

44. • The mean hospital stay for the 50 patients was 2.66 days.
• The mean hospital stay on conservative management was
1.76
• In patients after exploratory laparotomy positive for
intraabdominal injuries it was 3.58 days
• After non-therapeutic laparotomy it was 2.57 days.
non-
therapeutic
laparotomy
Positive cases
with
Exploratory
laparotomy
conservative
management
mean hospital
stay
2.573.581.762.66

45. • Complications occurred in 12 patients (24%)
all of them in the exploratory laparotomy
group.
• No patient under conservative management
had any complication.
• There were no complications in the non-
therapeutic laparotomy group.
• Complications varied from surgical site
infection in 8 patients, ICU admission in 4
patients mortality in 4 patients.

46. Discussion

47. FAST scan
• Our study supports that the FAST scan is a
very specific tool in detecting intraabdominal
injuries (100% specificity) as all positive cases
detected by FAST scan had intraabdominal
injuries on exploration.
• But care must be taken in cases with negative
FAST scan as it has a relatively low sensitivity
(70.8%).
• "rule-in" not "rule-out"

48. CT scan
• Our results support the value of using CT scan
in detecting intraabdominal injuries in back
and flank stabs
• Limited accuracy in detecting intraabdominal
injuries in shotgun wounds even in the
presence of intraabdominal pellets.

49. CT scan in shotgun injuries
• The presence of intraabdominal pellets on CT scan
without obvious associated organ injury prompted us
to use the CT scan in conjunction with frequent clinical
examination in these cases to minimize the rate of
nontherapeutic laparotomies, hospital stay and
complications.
• However CT scan is a very good tool to rule out the
presence of intraabdominal injuries in negative cases
as its sensitivity was 100% in our study, which opens
the possibility of discharging these patients from ED
reaching a zero hospital stay.

50. Diagnostic laparoscopy
• Its use as the sole indication for laparotomy
resulted in a high rate of nontherapeutic
laparotomies.
• We think that this disadvantage could be
overcome by combining the laparoscope with
other diagnostic modalities. One such
suggestion would be LDL (laparoscopic
peritoneal lavage).

51. • Alternatively, the laparoscope could be
extended to formally explore all intra-
abdominal contents and even therapeutic
intervention if warranted and the experience
of the surgeon permits.
• Herewith, we can minimize the rate of
nontherapeutic laparotomies and
consequently, the hospital stay and rate
postoperative complications.

52. LWE
• In our study LWE was done in 6 patients (12%) all
of them were negative. This phenomenon seems
to be related to the fact that surgeons at Kasr
Alainy emergency department prefer the use of
LWE in cases that most likely have no peritoneal
penetration. This can be suggested by the history
of trauma and description of the offending tool.
• we believe that the use LWE in cases who most
likely have no peritoneal penetration as in low
velocity penetrating injuries can rule out a good
proportion of patients in a simple and low cost
way.

53. • Although, we could not determine the specificity
of LWE, we expect, that similarly to diagnostic
laparoscopy it will have a low specificity as again
it is used only to detect peritoneal penetration
• Unlike diagnostic laparoscopy, conservative
management and frequent clinical examination
after positive LWE is an option as LWE is
performed under local anesthesia and not under
general anesthesia like diagnostic laparoscopy
which makes the clinical examination unreliable.

54. Serial clinical examination
• In our study all positive cases had intra-
abdominal injuries. As for evisceration, it is
not always the case.
• Relying on evisceration alone as evidence of
presence of intraabdominal injury is not
sufficient, as it is mainly a marker of violation
of peritoneum like LWE and Diagnostic
laparoscopy.

55. Hospital stay and complications
• Non therapeutic laparotomies per se prolong
hospital stay.
• Not a single patient under conservative
management suffered any complication.
• Interestingly, there were also no complications
in the group of patients whose exploratory
laparotomy proved non-therapeutic.

56. • Taking these findings into consideration puts
forth that the most important determining
factor for the occurrence of complications is
the presence of intra-abdominal injuries
rather than the exploratory laparotomy.
• Even though evidence from our study
supports this on the short term, we can
certainly not deny the long-term effect of
exploratory laparotomies

57. Conclusion

58. • No single modality per se proved the ideal in
all cases

59. • A combined approach using different modalities
(clinical examination, FAST, CT scan, laparoscopic
exploration and local wound exploration) in
diagnosing intraabdominal injury, selected
according the mode and site of injury, has
significantly high sensitivity and specificity in the
diagnosis of intraabdominal injuries
• These modalities reduced rate of negative
laparotomies, mean hospital stay and
complications.

60. Thank you..