Penetrating injury

Tj Kevin Doctor
 General Data
This is a case of F.T, 34 y/o, female, Filipino, single, currently unemployed,
Roman Catholic, born on April 28 17, 1983 in Leyte. Currently residing at
Maysan Rd, Malinta, Val. Admitted for the 1st time in our institution on Aug
12,2017.
 Chief complaint

Stab wound
 History of Present Illness
Few hrs prior to admission, patient self inflicted stabbed wound @ epigastric
area
 Past Medical History
+ asthma- unrecalled last attack
- htn
-dm
-accidents
- previous surgery
- blood trnsfusion
 Family History
Denies heredofamilial disease such as hypertension, diabetes, asthma,
pulmonary tuberculosis, thyroid diseases , cancer, cardiac diseases
 Personal and Social History
nonsmoker
Ocassional alcoholic drinker
 Obstetrical and Gyne History
G7P7 (5-2-0-5)
+Implanon- left upper arm
 Review of Systems
General: (-) weight loss, (-) fever, (-) chills, (-) fatigue, (-) insomnia, (-) loss of appetite, (-) night sweats

Skin: (-) lesions, (-) bleeding

Eyes: (-) corrective lenses, (-) diplopia, (-) itch, (-) redness

Ears: (-) pain, (-) tinnitus

Nose: (-) nasal stuffiness, (-) bleeding, (-) discharge

Mouth: (-) bleeding gums, (-) sores, (-) hoarsebess, (-) pain

Respiratory: (-) cough, (-) hemoptysis, (-) dyspnea

Cardiovascular: (-) chest pain, (-) palpitations, (-) orthopnea

Gastrointestinal: (-) anorexia, (-) dysphagia, (-) hematemesis, (-) diarrhea, (-) constipation

Endocrine: (-) polyuria, (-) polyphagia, (-) heat intolerance, (-) warm intolerance

Hematology: (-) pallor, (-) easy bruising

Nervous: (-) syncope, (-) tremors, (-) seizures

Psychiatric: (-) depression, (-) hallucination

 Physical Examination
Patient is conscious, coherent, not in cardiorespiratory distress

Skin: pale, cool, good skin turgor, no lesions, capillary refill <2 seconds

HEENT: anicteric sclerae, pink palpebral conjunctiva, no nasoaural discharge, no

tonsillopharyngeal congestion, no cervical lymphadenopathy

Chest and Lungs: symmetrical chest expansion, no retractions, no lagging, clear breath sounds

Heart: adynamic precordium, normal rate, regular rhythm, no murmur

Abdomen: + stabbed wound at epigastric area

Extremities: grossly normal extremities, no cyanosis, no edema, full equal pulses

 Physical Examination
Genitalia: essentially normal at the time of exam

Rectum: essentially normal

Neurologic: GCS15
 Assessment
Stab wound epigastric area, self-inflicted
 Plan
NPO
IVF: PLR 1L to run for 8 hrs
Labs: CBC with blood typing, UA, CXR-PA
Meds: Cefuroxime 1.5g TIV (-)ANST, then 750mg TIV q8
For E Exploratomy Laparotomy
 CBC
WBC: 17.2 ;N:5-10 RBC: 3.19; N:4.5-5.5
Neutrophils: 78.3, Hb: 62; N:125-160
N:40-60
Hct: 0.203; N:.380-.5
Lymphocytes: 12.5
Monocytes: 7.1
Platelet: 446
Eosinophils: 1.8
Basophils: 0.3
 UA
unremarkable
 Operation Record
Pre-operative diagnosis: acute surgical abdomen secondary to selinflicted stab
wound, epigastric area
Post- operative diagnosis: acute surgical abdomen secondary to stab wound,
penetrating, perforating stomach, lesser curvature and segment 3 and 4 of the liver
(grade 2), and hematoma, pancreatic body (grade 1)
Operation: Explore Lap, peritoneal lavage, gastrorrhaphy, s/p drain
Intra-operative findings: approximately 500cc hemoperitoneum, 1 cm laceration at
the segment 3 and 4 of the liver, 1cm perforation at the lesser curvature of the
stomach, and hematoma, pancreatic body
Abdomen
 Abdominal trauma is responsible for about 10% of all deaths related to
trauma. Abdominal trauma may involve penetrating or blunt injuries.

Penetrating injuries often result in injury to hollow organs, such as the

intestines. The liver is the most commonly injured solid organ. Gunshot
wounds are classified as high energy and may result in extensive damage,
especially if the bullet ricochets off of bone. Patients are at increased risk
for both hemorrhage and peritonitis, especially with intestinal injury.
The most common injuries from gunshot wounds include:
o Small intestines: 50%.
o Colon: 40%.
o Liver: 30%.
o Vascular structures: 25%.

The most common injuries from stab wounds include:

o Liver: 40%.
o Small bowel: 30%.
o Diaphragm: 20%.
o Colon: 15%.
Initial assessment
Primary survey: ABCs

As with all trauma patients, assessment should begin with the primary survey,
during which the patient is at least partially disrobed for examination,
placed on monitors (BP, cardiac, pulse oximeter) as indicated, and two
large-bore intravenous lines placed.
Airway, breathing, and circulation (ABCs) are checked immediately,
often while resuscitation efforts are occurring. The patient must be
assessed for blood loss.

Any impaled items, such as a knife stuck into the abdomen, should be
stabilized with bulky dressings until scans are completed and/or the
patient is taken for surgical removal. Protruding organs or
eviscerations should be covered with sterile saline dressings

Oxygen is usually administered with a non-rebreather mask, and NG

tube inserted (if there is no facial trauma), and blood samples (type and
crossmatch and CBC) and urine specimen obtained per indwelling
catheter.
Physical signs of internal bleeding include:
Abdominal pain.
Guarding, rigidity.
Bruising, crepitus, swelling (especially across chest and pelvis
from seat belt and or shoulder harness).
Abdominal distention, deformity.
Tachycardia, hypotension.
Pallor.
Evisceration.
Cullens sign: Bruising about the umbilicus (may indicate
hemoperitoneum or retroperitoneal bleeding but may take 12
hours to develop).
Grey Turners sign: Bruising over flank (may indicate
retroperitoneal bleeding but may take 12 hours to develop).
Hematuria.
Blood or semen at urethral meatus (from injury to prostate).
Inability to urinate.
Hemorrhagic shock classificat
Geriatric patients must be observed carefully as they may have less
obvious signs of shock for a variety of reasons. Cardiac response to
hypovolemia is often lessened because of myocardial pathology or
medications, such as -blockers and calcium channel blockers.

Metabolic acidosis (decreased serum bicarbonate and increased base

deficit (> -6) or increased serum lactate) may result from hemorrhage
and hypovolemia.
Neurological status (D for disability) is assessed. A quick assessment may
be done using the AVPU method:
A: Is the patient alert?
V: Is the patient verbal?
P: Is the patient responding only to verbal stimuli?
U: Is the patient completely unresponsive

?
HEAD INJURY
Eye opening
Glasgow Coma Scale (GCS)
4 spontaneous opening
Motor
3 opens to command
6 follows commands
2 opens to pain
5 localizes pain
1 no response
4 withdraws from pain
GCS score 14: head CT; 10: intubation; 8: ICP
3 flexion with pain (decorticate)
monitor
2 extension with pain (decerebrate)
1 no response
Verbal
5 oriented
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no response
If the patient is alert (A) and verbal (V), then the AMPLE method may be used to ask a series of basic
informational questions:
A: Do you have any allergies?
M: Are you taking any medications?
P: What is your past medical history and (if applicable) are you pregnant?
L: When did you last eat?
E. What events led to the trauma, and when did you have your last tetanus vaccination
E ( for exposure): The patient is completely disrobed, if possible. If
there is any danger of cervical trauma or the patient cannot be moved,
the clothing should be cut off. If forensics are involved (as in
shootings and knifings), care must be used to avoid cutting through or
damaging areas of clothing that may provide evidence, such as where
a bullet has entered clothing. Protocols for collection of evidence
should be carefully followed.
If time is not a critical factor, the CT
scan is the best tool for assessing all
types of abdominal injuries, including bleeding. CT is usually done with
contrast. Fast-scanning and image-reconstructing helical CT scanners
have reduced the turnaround time for CTs to as little as 10 minutes,
but older scanners may require more time.

X-rays, while often done, provide little useful information as they may
not identify free air and fluid collections must be large (>800 mL) to
be detected by standard x-ray. Angiograms are indicated if injury to
vessels is suspected in order to identify the site of bleeding.
However, if the patient is unstable or severe bleeding is suspected, then focused
abdominal sonography in trauma (FAST)examination should be done.
FAST is able to identify intra-abdominal fluid in about 98% of [Link], its
important to remember that while FAST will identify intra-abdominal fluid or
bleeding, it is not sufficiently sensitive to show disruption of an internal organ.

Additionally, a single negative finding by FAST does not preclude bleeding or other
injury as it is sensitive to >300 mL of blood. For example, a bowel perforation may
result in limited intraabdominal fluid in the initial period. Additionally, intracapsular
bleeding or delayed organ rupture may not be captured at the time of FAST but may
be identified on later examination or CT scan. Additionally, a positive FAST finding
does not necessarily indicate a need for surgical intervention.
Diagnostic peritoneal lavage (DPL) may also be used, but FAST is preferred and has
generally replaced DPL, as it is relatively fast andless invasive. DPL is especially insensitive
to colonic wounds, which require early diagnosis and treatment

DPL is done by inserting an abdominal catheter under local anesthetic. Aspiration is done
to
determine if free blood is present. If aspirate contains <10 mL of blood and no evidence of
intestinal contents, the aspirate is usually reinjected and 1 L of NSinfused with the fluid
recollected through gravity drainage.
Injuries to the Neck
The neck can be one of the more overwhelming regions when
confronted with severe injury, likely because of the presence of
multiple vital structures in close proximity to one another.

Penetrating mechanisms are the most common ,with

gunshot and stab wounds accounting for most neck injuries.
Penetrating injuries can result in direct laceration of vascular and
aerodigestive structures, resulting in substantial bleeding or
contamination, respectively.
primary concern is establishment of a secure airway, especially
given the rapidity with which deterioration can occur in the
setting of a neck injury. Airway compromise can occur secondary to direct
injury to the larynx or trachea, as well as blood or
debris within the upper airway.

Expanding neck hematomas can

quickly compress the upper airway, leading to cessation of adequate
ventilation. The presence of an expanding neck hematoma
mandates immediate intubation by experienced personnel before
complete airway obstruction occurs
Hemorrhage is the other major concern in the immediate
period after neck injuries. Hemorrhage through a penetrating wound
should be immediately treated with digital pressure in the wound until
operative exposure can be achieved.
Resuscitation with blood products should be initiated in the
setting of substantial bleeding from the neck because large quantities of
blood can be lost quickly.
In the setting of penetrating trauma, evaluation and management
of the neck have typically depended on the anatomic location
of the injury.
Zone I extends from the thoracic
inlet to the cricoid cartilage and contains large vascular structures, as well as the
trachea and esophagus.
Zone II is bordered
inferiorly by the cricoid cartilage and superiorly by the angle of
the mandible.
Zone II is the most accessible surgically and contains the carotid and vertebral
arteries, jugular veins, and structures of the aerodigestive tract. Zone III
includes the neck
between the angle of the mandible and the base of the skull.
Traditionally, injuries to zone II mandated operative
exploration whereas zones I and III were evaluated with diagnostic
studies to determine the presence of injury.

It has since
been recognized that only patients with evidence of active bleeding
or an obvious aerodigestive injury require mandatory neck
exploration. Others, regardless of anatomic location, can be
evaluated with diagnostic studies
CT angiography, which can delineate
the vascular anatomy of the neck with great accuracy. CT angiography
can be performed quickly in the emergency department
and is effective at revealing vascular injuries to the neck.

Shock, active bleeding, expanding neck hematoma, and/or

obvious aerodigestive injuries require immediate neck exploration. Neck
exploration is most commonly performed using an
incision along the anterior border of the sternocleidomastoid
muscle on the side of the injury.
Injuries to the Chest
Thoracic injuries are common, with up to one of five patients
presenting with trauma involving the chest
Chest radiography is performed on all significantly injured
patients at risk for thoracic injuries. This study can be obtained
rapidly in the trauma bay, with the results quickly revealed. The
chest radiograph easily identifies the presence of a pneumothorax or
hemothorax, as well as rib and sternal fractures.

The
appearance of the mediastinum may suggest a thoracic aortic
injury. An ultrasound of the pericardium is a component of the
FAST examination, which may reveal pericardial blood
Penetrating injuries to the chest that cross the mediastinum
or are in the vicinity of the heart and mediastinal structures
require a methodical evaluation. Penetrating wounds in an area
defined by the sternal notch superiorly, the costal margin inferiorly, and the
nipples laterally are in this group requiring further
evaluation. This includes an assessment of the cardiovascular and
aerodigestive structures of the mediastinum. Immediate ultrasound is
performed to evaluate the pericardium for effusion. If
the pericardium is communicating with one of the hemithoraces, ultrasound
may yield false-negative results. Further evaluation has historically included
an angiogram of the chest, which
has now been replaced by CT angiography in most situations.
The heart and great vessels are evaluated for injury, although this
can be impeded by the presence of retained missile fragments
that cause scatter on CT. Standard angiography can be valuable
in this setting. Depending on the trajectory of the penetrating
object, the trachea and proximal airways may require evaluation
with bronchoscopy. If injury is suspected, the esophagus should
be assessed with a combination of esophagoscopy and contrast
esophagography. In isolation, these studies have an approximate
20% false-negative rate, although their combined sensitivity
approaches 100%. Frequently, thoracic CT will accurately identify the trajectory
of the wound and thus guide the need for
further evaluation.
Injuries involving the chest wall or
pleural space can frequently be identified on chest radiographs.
Figure 18-15 demonstrates a large left pneumothorax on chest
radiograph. Chest CT is a common part of the evaluation for
thoracic injuries at many centers.

Pneumothorax or a large hemothorax on a chest radiograph

requires placement of a tube thoracostomy. Chest tube drainage
should continue until any pulmonary air leak has resolved and
drainage is not excessive.
Patients who demonstrate an occult pneumothorax
by chest CT and have no respiratory compromise can be
managed with observation and a repeat chest radiograph the
following day. Enlargement of the pneumothorax on follow-up
imaging necessitates a chest tube.
Penetrating trauma in the thoracoabdominal region may create injuries in
both the chest and the abdomen, including the
diaphragm

The chest X-ray and focused abdominal

sonographic examination for trauma (FAST) will elucidate
the presence of blood in the thoracic cavity, pericardial sac, or
abdominal cavity
Back/flank
Penetrating trauma to the back or flank is associated with a
lower likelihood of significant injury compared with anterior
abdominal or thoracoabdominal wounds.

However,
these injuries can pose a special problem because of the
difficulty in clinically evaluating the retroperitoneal organs
with physical exam and FAST. In a stable asymptomatic
patient, CT scanning is reliable for excluding significant injury.
Hepatic trauma

The liver is especially vulnerable to trauma because of its anterior

position in the abdomen. It may be lacerated or avulsed by either
blunt or penetrating injuries. Liver injury should be suspected if a
patient has rib fractures on the right side or has abdominal pain,
especially in the right upper quadrant.

After the spleen, hepatic injury is the second most common abdominal
injury, with injury to the posterior segment of the right lobe occurring
most frequently. Because of this, bleeding may occur into the
retroperitoneal area rather than the peritoneal.
Injury of the left lobe is less common and most often associated
with
direct blow to the epigastric area and is associated with injury to the
duodenum, pancreas, and transverse colon.

Mortality rates with hepatic injury are high (8% to 25%), and it is
the
most common cause of death related to abdominal trauma. With
severe injuries, death can occur within minutes. Hepatic injuries can
include lacerations, contusions, subcapsular hematoma, and
intrahepatic hematoma.
While in the past, surgical management of liver injury was common, it
was found that those undergoing surgery tended to have more
complications and required more transfusions than those treated more
conservatively, so presently only about 20% are treated surgically. In
about 70% of cases, bleeding stops spontaneously. Even grade IV
injuries may be treated non-surgically if there is no bleeding into the
peritoneal or retroperitoneal cavities.

However, patients must be carefully monitored as delayed

complications, including hemorrhage, abscess, and biloma
(encapsulated collection of bile in the peritoneal cavity), may occur.
Additionally, patients may require replacement fluids and blood
products, such as plasma and platelets for coagulopathy.
In the setting of more severe bleeding, a Pringle maneuver
is a valuable adjunct. The hepatoduodenal ligament is encircled
with a vessel loop or vascular clamp to occlude hepatic blood
flow from the hepatic artery and portal vein. This maneuver
helps distinguish hepatic venous bleeding, which persists from
a portal vein, and hepatic artery bleeding that slows, allowing
identification of sources of hemorrhage
Gastric Trauma
Because the stomach has 3 muscle layers, blunt trauma perforations
are rare although risk increases if a person suffers a severe blunt force
trauma with a full stomach. Forceful blunt trauma may result in
rupture of the left hemidiaphragm, causing the stomach to herniate
into the left hemithorax. The areas most prone to rupture include:
Anterior wall: 40%.
Greater curvature: 23%.
Lesser curvature: 15%.
Posterior wall: 15%.
Penetrating trauma of the stomach, such as from a knife or gunshot
wound, is more common and should be suspected when penetration is
inferior to the nipples or 4th intercostal space anteriorly or inferior to
the tips of the scapulae posteriorly.

Symptoms of perforation include severe abdominal pain, abdominal

rigidity, hematemesis and bloody nasogastric drainage. While the
stomach usually contains few bacteria, with perforation, stomach acids
begin to pour into the peritoneal cavity, resulting in chemical
peritonitis. Most patients present with shock and pain in the abdomen,
but some patients may have no signs of an acute abdomen in the
initial period.
Gastric injuries will often be identified on physical examination by the presence
of peritonitis. Some gastric injuries are
identified by CT or DPL but the value of these modalities is
limited.
Repair of gastric injuries is based on severity and injury
location. Large intramural hematomas should be evacuated to
ensure the absence of perforation, followed by control of bleeding and closure of
the seromusculature with nonabsorbable
suture. Full-thickness perforations should be dbrided to remove
nonviable gastric tissue and then closed with one or two layers.
The perforation is generally closed with an absorbable suture.
followed by inversion of the suture line with nonabsorbable
seromuscular stitches. Because of the size and redundancy of the
stomach, this can also be repaired with a stapling device.
Upright x-rays may show free air in the abdomen, but only
about 50% to 66% develop enough free air in the abdomen to
be detected by
upright x-ray. DPL may show food particles or bilious fluids in
the abdomen. However, if the patient is hemodynamically
stable, CT with contrast provides a definitive diagnosis.
Intestinal trauma

Intestinal trauma may occur as the result of blunt or penetrating

trauma, such as from gunshot wounds or knifings. Penetrating trauma
may result in evisceration of the small intestines through the
abdominal wall.

Falls from great heights or crush injuries may result

in evisceration through the rectum or perineum. The small intestines
are especially vulnerable to penetrating wounds as they cover the abdominal
surface. Motor vehicle accidents also frequently result in
injury to the small intestines.
As with other abdominal injuries, the CT is the best diagnostic tool
and
is about 97% accurate in providing evidence of bowel injury;
however,
CT findings may be compromised if a patient first has DPL, as this
procedure may introduce intraperitoneal fluid and air. CT is not
always
effective in identifying the exact location of an injury to the bowel,
and
CT in general is less effective in identifying injuries to hollow organs
than to solid organs.
According to some studies, the
most commonly perforated areas of the small intestine are the
proximal jejunum and the distal ileum.

Treatment of mild intestinal injury may be conservative, but with

perforation, surgical intervention with peritoneal lavage is indicated
as
well as antibiotics. In some cases, primary closure is avoided and the
wound left open to heal by secondary intention
The mainstay of evaluation for duodenal injury has become abdominal CT,
with a low threshold for operative exploration. Findings
on CT that reflect possible duodenal injury include thickened duodenal wall,
air or fluid outside the bowel lumen, and contrast
extravasation if oral contrast was administered. Any
indication of duodenal perforation on examination or imaging
should prompt operative exploration
Management of duodenal injuries depends on the severity
and location of the injury. Hematomas of the duodenal wall
typically require no treatment unless they are large and result in
a gastric outlet obstruction.
Treatment of obstructing hematomas consists of gastric decompression and
initiation of total
parenteral nutrition, with reevaluation of gastric emptying with
a contrast study after 5 to 7 days. If after 2 weeks of upper GI
bowel rest the obstruction persists, exploration is warranted to
evaluate for perforation, stricture, or associated pancreatic injury.

Duodenal hematomas identified at the time of laparotomy for

another indication require careful evaluation for perforation.
Pancreatic trauma

The pancreas is located in a fairly protected part of the abdomen, high

in the retroperitoneum, so when it is injured as the result of blunt
trauma, then 90% to 95% of the time, there are injuries to other
organs as well. Because of this, injury to the pancreas may be
Overlooked.
While injury to the pancreas occurs in fewer than 10% of all cases of
blunt abdominal trauma, the pancreas is injured in 20% to 30% of
cases of penetrating trauma.
Because vascular
structures, such as
the aorta and the
superior mesenteric
artery lie close to
the head of the
pancreas, injury to
that area may
include adjacent
vascular injury and
life-threatening
hemorrhage
The diagnosis of pancreatic injuries can be extremely challenging and
no single imaging modality has been found to be
highly effective. As with the duodenum, the retroperitoneal
location of the pancreas makes physical examination less helpful
for diagnosis. Abdominal imaging with IV-enhanced CT can
indicate the pancreatic injury but the sensitivity is limited for
parenchymal injury and pancreatic duct disruption, as identified
recently in a large multicenter trials.

Findings on CT that suggest pancreatic injury include malperfusion of

the pancreatic parenchyma indicating disruption, surrounding fluid, or
hematoma and stranding in the adjacent soft
tissue
As with other injuries, the CT scan provides the most definitive
diagnosis as the scan may show lacerations or peripancreatic fluids.
Blunt trauma may result in retroperitoneal hematoma and fluid, free
abdominal fluid and pancreatic edema. In the early phases after
injury, CT scans may not detect injury, so ongoing evaluation is
necessary. If the CT scan is inconclusive, then magnetic resonance
cholangiopancreatography may be indicated, as it more clearly outlines
damage to the ducts.
Standard x-rays are not effective for diagnosis of pancreatic injury but
findings of fractures of the lower thoracic or upper lumbar vertebrae
should raise suspicion of pancreatic or duodenal injury. FAST may
show free abdominal fluid but the position of the pancreas and the
overlying of the pancreas by the colonic gas make visualization
difficult. DPL has not been found useful because of the retroperitoneal
Location.
Serum amylase levels have been used to help diagnose pancreatic
injury, but studies show that levels dont elevate for about 3 hours,
so
serum amylase levels prior to 3 hours are not diagnostic. Serum
amylase levels may be sensitive but little is
known about their specificity; therefore, the use of this indicator
is limited and should not be routinely used
Pancreatic enzymes
(amylase and lipase) may be abnormal because of shock rather than
direct pancreatic injury, but they may remain normal even with
severe
pancreatic injury.
The mainstay of therapy for pancreatic injuries is surgical.
Exposure of the entire gland to evaluate the pancreas comprehensively is
required to exclude injury or select appropriate
management.
Most injuries to the pancreas are relatively minor and can be treated
by inserting external drains until healing occurs. Distal pancreatectomy
may be necessary with traum to the body, neck and/or tail with duct
disruption. Trauma to the head of the pancreas is usually treated with
external drainage even in the presence of ductal damage.
Pancreaticoduodenectomy is usually done only when the head of the
pancreas has been severely damaged and devitalized.
Spleen
Identification of splenic injuries may occur during laparotomy in patients who are
unstable and taken emergently to
the operating room. As noted, unstable patients with intraabdominal fluid on FAST
require exploration, with the spleen
commonly being the bleeding intra-abdominal organ. In stable
patients, abdominal CT performed with IV contrast is the mainstay for diagnosing
and characterizing splenic injuries
Angiography can identify specific sites of bleeding from the
splenic parenchyma and underlying segmental or trabecular vessels;
however, it cannot characterize the splenic parenchymal injury but
can be complementary to CT

Postsplenectomy vaccines must be

provided to ensure protection from encapsulated bacteria,
including Streptococcus pneumoniae, Neisseria meningitidis, and
Haemophilus influenzae. S
Our preference is to reserve nonoperative management for grades I and II injuries,
as well as grade III injuries that
are isolated
Splenic injury secondary to penetrating abdominal trauma is usually identified
during laparotomy and should be addressed based on the presence or absence
of ongoing bleeding. In the setting of damage control, the
splenic injury can be packed but, more commonly, splenectomy
is performed because of the rapidity at which the spleen can be
removed and managed definitively
Abdominal Great Vessel Injuries The great vessels
of the abdomen
are located within the retroperitoneum and
abdominal mesenteries. Injuries to these vessels can
be challenging to manage
given the amount of blood loss that can be present
when these
structures are injured.
Vascular injuries in the abdomen are often first recognized
at the time of laparotomy for penetrating abdominal trauma.
Frequently, these injuries are associated with significant ongoing
blood loss and hemodynamic instability. Exploration of penetrating
injuries to the retroperitoneum results in a definitive
diagnosis. Penetrating injuries to the back frequently benefit
from three-dimensional imaging, given that most do not enter
the peritoneal cavity. Current CT can often identify the path of
the injury and therefore suggest possible injury to adjacent
structures.
Zone 1 hematomas require exploration
because these frequently involve the aorta, proximal visceral
vessels, or inferior vena cava. An exception may be the dark
hematoma behind the liver, which suggests a retrohepatic vena
cava injury. These injuries may be best served by not exposing
the contained low-pressure injury or by gently packing the surrounding
area; heroic management techniques can be extremely
challenging. A hematoma in the region of zone 2 should only
be explored if it appears that the hematoma is expanding and
continuing to lose blood. Finally, a hematoma in zone 3 is
usually secondary to pelvic fracture bleeding and should not be
explored unless exsanguinating hemorrhage is present