Abdominal Stab Wound

ABDOMINAL STAB WOUNDS
INTRODUCTION — Emergency clinicians manage stab wound (SW) injuries now more than ever. While in the past surgical dictum mandated exploratory laparotomy for all patients with abdominal SWs, new diagnostic techniques and therapeutic modalities have rendered that dogmatic approach obsolete.
This topic review will discuss the evaluation and management of abdominal stabwounds. Initial trauma management, blunt abdominal trauma, abdominal gunshot wounds, and other aspects of trauma management are discussed separately. (See "Initial management of trauma in adults" and "General approach to blunt abdominal trauma in adults" and "Abdominal gunshot wounds".)
EPIDEMIOLOGY — While three times more prevalent than gunshot wounds, stab wounds (SW) are typically less invasivedue to their lower velocity, and therefore, associated morbidity and mortality is decreased [1]. In children and adults alike, the liver is the organ most often injured. Small bowel injuries follow close behind [2].
MECHANISM OF INJURY — Any instrument that can impale may inflict a stab wound (SW). Typically these are narrow and sharp, such as a knife, scissor, arrow, pen, fence post, ice pick,coat hanger, or an animal horn. The instrument's path and depth may injure any tissue it traverses, including skin, fascia, solid organ, hollow viscus, and even bone.
The area most often injured is the upper abdomen, left upper quadrant greater than right. Multiple SWs are present in up to 20 percent of patients and 10 percent of SWs may involve the chest [3-5]. If the wound is close to the lowerchest, clinicians must consider and evaluate diaphragmatic and intrathoracic injuries in addition to intraabdominal injury. Potential intrathoracic injuries include pneumothorax and pericardial tamponade. Peritoneal violation with intraabdominal injury occurs in greater than 40 percent of SWs to the flank and up to 15 percent of those to the back.
ANATOMIC ZONES — The abdominal cavity is dividedinto four anatomic zones (figure 1 and figure 2). The anterior abdomen is bound by the anterior axillary lines extending from the costal margins to the groin creases. The nipple line (4th intercostal space) anteriorly and the tips of the scapulae (7th intercostal space) and the inferior costal margin posteriorly demarcate the cephalad portion of the thoracoabdominal area. The caudad portion is boundby 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. The flanks are separated on each side by the inferior costal margins and iliac crests, and the anterior and posterior axillary lines. The back is defined as the area between theposterior axillary lines, the inferior scapular tips (7th intercostals space), and the iliac crest.
HISTORY — Answers to the following questions help to guide the clinician in assessing potential injuries:
* What instrument was used?
* How long and how wide was the instrument?
* How was the patient positioned during the stabbing?
* What path did the implement travel?
METHODS OFEVALUATION
Initial assessment — As with gunshot wounds (GSW), it is vitally important to completely undress any patient who sustains a stab wound (SW). SWs can often be obscured by body habitus, clothing, or bleeding, or be "hidden" in the axilla, scalp, or groin. The clinician should be wary of lacerations reported to be, or that appear to be, from blunt trauma. As an example, linear lacerations tothe face may be interpreted as superficial when caused by a blunt mechanism, but in fact represent stab wounds with intracranial penetration.
Local wound exploration — SWs are often amenable to local wound exploration (LWE) to evaluate their depth and tract [6]. This is quickly and safely performed at the bedside in patients with SWs to the abdomen, flank, or back. This procedure, better...