Introduction:
Penetrating abdominal trauma is caused by various factors like gunshot injury or stabbed wound. Any trauma that enters through the peritoneal cavity or retroperitoneum causes harm to the intra-abdominal contents. Usually, injured regions are the liver, vasculature of the intra-abdominal area, and bowel. In the past few years, the treatment of these types of injuries has changed a lot. Initially, laparotomy is done in intra-abdominal trauma.
Treating penetrating intra-abdominal trauma requires understanding pathophysiology, the extent of the lesion, and multiple factors. Thus, the management of penetrating abdominal trauma requires an interprofessional team effort. Using radiographic techniques, understanding trajectories and potential damage to organs allow control without surgeries in certain patient cases.
The entry wound of abdominal trauma may be mostly from the fifth intercostal space to the perineum. When an injury occurs, more kinetic energy is there for it than the injury occurring at a distance. Gunshot injury has a linear projection; high-energy trauma causes destruction that is not predictable. There is also a chance of secondary missile injury from small bones or bullet pieces. Wound by stab can penetrate deep into the abdomen and is not easy to evaluate. Occult injuries are not easily visible and can easily be missed in diagnosis. Thus it can lead to serious delayed complications and even morbidity.
What Are the Causes of Penetrating Abdominal Trauma?
Penetrating trauma means when an object hits the tissue and penetrates it by cutting the skin and plunging it into the body. In non-penetrating trauma, the skin would be intact, and the foreign object does not enter the body. In perforating trauma, the object will enter the body part and remain there or pass through the body and come out through another site.
Thus, there will be two wounds for perforating trauma: an entry wound and an exit wound. In penetrating trauma, it does not cause the foreign object to pass through the body or tissue; it is caused mainly by violence. It occurs mainly by gunshot, a piece of a broken bone, and injury by knife. Penetrating trauma may cause harm to internal organs. It may lead to infection or shock depending on factors like which body organ is affected, how much energy is transmitted, and the type of object which causes injury. A puncture wound is caused by an injury like stepping on a nail. It does not have any exit wounds.
What Is the Epidemiology of Penetrating Abdominal Trauma?
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Sex- The male predominates in abdominal penetrating trauma, approximately ninety percent.
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Race- Non-Hispanic black males have increased age-adjusted firearm-related homicide.
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International- The frequency of these types of trauma increases when weapons are more available.
Injury caused by trauma is the most important cause of death in people aged one to forty-four years of age. The penetrating injury affects thirty-five percent of patients in urban areas and twelve percent of suburban and rural areas.
What Is the Pathophysiology of Penetrating Abdominal Trauma?
A penetrating injury can rupture the intra-abdominal structures. As the object passes through the skin, it slows down and spreads kinetic energy to the body tissue. High velocity causes more destruction than mass; kinetic energy increases with the square of velocity. The area left by tissue damaged by the penetrating thing forms a cavity known as a permanent cavity.
The penetrating object will cause injury to the tissues with which it comes in contact; its increased velocity projectile will cause secondary cavitation. As the thing penetrates the body, it produces a pressure wave forcing tissue out of the way, forming the cavity. Slowly the tissue will move to the cavity site and fill it, but it could have caused enough harm. The features of injured tissue depend on multiple factors like severity of tissue damage, type of injury, amount of penetration, and the amount of energy transmitted.
How Is Evaluation Done in Wounds of Penetrating Abdominal Trauma?
The injury is internal assessment cannot be done grossly. Each patient should undergo a physical examination, followed by CT scanning, X-ray, or ultrasound. Before the X-ray, the entry and exit wounds are sometimes tapped with a paperclip. The patient is treated with IV fluids or blood. Surgery is required in most cases. The object should be immobile in place so it can be removed easily. If the object removal is more harmful or dangerous to the patient, it is left in its place only. Also, the tissues that cannot be regenerated should be removed to avoid infection.
How To Manage Penetrating Abdominal Trauma?
Initially, fluid resuscitation was done mainly with crystalloid fluid, 0.9percent saline, or ringer lactate solution. Damage control resuscitation is needed for patients with hemorrhagic shock until hemorrhage is controlled. In damage control resuscitation, blood products are used in approximately 1:1:1 ratio of plasma to platelets to packed red blood cells. This is done to control the crystalloid solution usage. In a few cases, hemodynamically unstable patients were taken for urgent exploratory laparotomy.
In most cases of patients who don't want surgical treatment, intra-abdominal injury patients are identified by an imaging technique. Treatment includes observation, angiographic embolization, and in very few cases, if the needed operation is done. In patients whose surgery is not intended, antibiotic prophylaxis is not indicated. Antibiotics are only given before surgery. Observation begins at the ICU itself. During the observation period, the patient is evaluated, and a complete blood count is checked every four to six hours. This is done to prevent hemorrhage or peritonitis. Diagnostic peritonitis requires diagnostic peritoneal lavage, CT, or exploratory laparotomy.
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Laparotomy- This procedure is selected due to the nature of the beginning injury and hemodynamic instability. So in a single procedure, bleeding can be controlled, and tissue damage can be repaired too.
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Angiographic Embolization- A percutaneous angiographic procedure can stop bleeding. This is done by injection of hemostatic substances (thrombogenic).
Conclusion:
Penetrating abdominal trauma is becoming common nowadays. The availability of guns is a common cause of this issue. The rate of mortality in penetrating abdominal trauma depends on the type of injury, the organ involved, and the time taken to start treatment. Superficial injury has less mortality rate than deeply penetrated injury. The mortality rate is more if a patient has a vascular injury in the abdominal vessels. In most cases, high-risk death occurs in the first 24 hours.
