When do we operate for Penetrating Abdominal Trauma?

When a patient presents with a gunshot or stab wound to the abdomen, we need to determine if there is a potential injury that will require repair.  The checklist to consider in these patients is:

• Is the patient in shock?  If the patient has a wound on the abdomen, and they are hemodynamically unstable - they go directly to the OR
• Does the patient have peritonitis?  Peritonitis = injury until proven otherwise (in OR)
• Did the bullet traverse the peritoneal cavity?  A trans-peritoneal trajectory has a 98.6% chance of causing an injury.
• Is there blood per orifice?  Gross blood on rectal exam or per NG tube indicates an injury to the GI tract.
• Is there free air on upright chest x-ray?  Again, this indicates an injury to the GI tract.
• Is anything eviscerating from the wound?  75% of patients with an evisceration (bowel or omentum) will have an injury that requires repair.  See previous post.
• Is there a retained stabbing implement?  This should be removed under direct vision.

If the answer to all of the above is "no", then we need to determine the need for additional work-up, such as DPL or CT.  This will be the subject of another post.

Note:  FAST is not proven for penetrating trauma.