Initial evaluation and management of abdominal stab wounds in adults

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Initial evaluation and management of abdominal stab wounds in adults
Authors:
Christopher Colwell, MD
Ernest E Moore, MD

Section Editor:
Maria E Moreira, MD
Deputy Editor:
Jonathan Grayzel, MD, FAAEM

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Feb 2018. | This topic last updated: Oct 03, 2016.

INTRODUCTION — Until the 20th century, nearly all penetrating injuries to the abdomen
were managed nonoperatively. Beginning with World War I, surgeons noted lower
mortality among soldiers with penetrating abdominal wounds who were managed with
laparotomy. Ultimately, laparotomy became the mandatory treatment for such wounds. It
gradually became clear that penetrating abdominal trauma sustained during warfare
(mostly higher velocity gunshot wounds and incendiary devices) was different than
penetrating abdominal trauma sustained by civilians (mostly stab wounds and lower
velocity gunshot wounds) [1]. In 1960, Shaftan questioned the dogma of mandatory
laparotomy for all penetrating abdominal injuries, and laparotomy rates for abdominal
stab wounds have declined steadily over the ensuing decades [2].

This topic review will discuss the initial evaluation and management of abdominal stab
wounds in adults. General trauma resuscitation in adults and children, blunt abdominal
trauma, abdominal gunshot wounds, and other aspects of trauma care are reviewed
separately. (See "Initial management of trauma in adults" and "Initial evaluation and
management of blunt abdominal trauma in adults" and "Initial evaluation and
management of abdominal gunshot wounds in adults" and "Trauma management:
Approach to the unstable child" and "Approach to the initially stable child with blunt or
penetrating injury".)

EPIDEMIOLOGY — Although there is regional variability in the mechanism of injury

producing abdominal trauma, most studies indicate that blunt abdominal trauma is more
common than abdominal stab wounds, and that abdominal stab wounds are more
common than abdominal gunshot wounds in the civilian population [3]. Abdominal
gunshot wounds, due to their higher kinetic energy, are associated with mortality rates
approximately eight times higher than abdominal stab wounds [4].

In children and adults alike, hollow viscus organs (intestines) are injured most often with
abdominal stab wounds [3,5,6]. The next most common sites of injury are the great
vessels, diaphragm, mesentery, spleen, liver, kidney, pancreas, gallbladder, and adrenal
glands. The specific organs at greatest risk from a stab wound depend upon the location
of the injury.

MECHANISM OF INJURY — Any instrument that can impale may inflict a stab wound.
Typically these are narrow, sharp, knife-like implements, but items that can inflict stab
wounds range from scissors to coat hangers to animal horns. The given instrument can
injure any tissue it traverses, including skin, fascia, solid organ, hollow viscus, blood
vessel, nerve, muscle, and bone.

According to one series, the majority of abdominal stab wounds with evisceration
occurred in the left upper quadrant of the abdomen, followed by the left lower, the right
upper, and the right lower [6]. Posterior (ie, back) and flank stab wounds have a greater
risk of injury to retroperitoneal structures, including the colon, kidneys, and adrenals.
Multiple stab wounds are present in 18 to 34 percent of patients, and as many as 30
percent of penetrating chest injuries may traverse the diaphragm, potentially harming
abdominal tissues and organs [7]. Accordingly, anterior stab wounds that are inferior to
the nipple line (fourth intercostal space) and posterior stab wounds that are inferior to the
tip of the scapula (seventh intercostal space) should be considered to involve potential
diaphragm and intra-abdominal injuries in addition to chest injuries. (See "Initial
evaluation and management of penetrating thoracic trauma in adults" and "Recognition
and management of diaphragmatic injury in adults".)

ANATOMIC ZONES — The abdominal cavity is divided into four anatomic zones (figure
1 and figure 2 and figure 3 and figure 4 and figure 5). The anterior abdomen is bound
by the anterior axillary lines extending from the costal margins to the groin creases. Due
to diaphragmatic excursion while breathing, the nipple line (fourth intercostal space)
anteriorly, and the tips of the scapulae (seventh intercostal space) and the inferior costal
margin posteriorly, should be used to define the cephalad portion of the abdomen.
Wounds in the upper abdominal region pose a significant threat of injury to the chest and
abdomen depending upon the path of the weapon and the position of the diaphragm at
the time of injury.

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 the
posterior axillary lines, the inferior scapular tips (seventh intercostal space), and the iliac
crest. Back and flank stab wounds have a greater risk of injury to retroperitoneal
structures, including the colon, kidneys, and adrenals.

HISTORY — Answers to the following questions help to guide the clinician in assessing
potential injuries from abdominal stab wounds:

●What instrument was used?

●How long and how wide was the instrument?
●How was the patient positioned during the stabbing?
●What path (or paths in the event of multiple wounds) did the implement travel?
●Was there substantial blood loss at the scene?

METHODS OF EVALUATION

Initial assessment — General evaluation and the initial management of the trauma
patient is reviewed separately. Issues specifically related to the initial evaluation of adult
patients with stab wounds are discussed below. (See "Initial management of trauma in
adults".) An algorithm to help guide the management of patients with an anterior
abdominal stab wounds is provided (algorithm 1).
It is important to completely undress any patient who sustains a stab wound. Stab
wounds can often be obscured by body habitus, clothing, or bleeding, or be "hidden" in
the axilla, scalp, perineum, or groin. Examine the patient carefully for evidence of more
than one stab wound. Clinicians should be wary of lacerations reported to be, or that
appear to be, from blunt trauma; such wounds may represent penetrating trauma
associated with significant internal injury.

The options for assessment and management of patients with abdominal stab wounds
are determined by their clinical presentation. Patients presenting in extremis may require
resuscitative thoracotomy and emergent laparotomy to control hemorrhage or manage
other injuries. Emergency thoracotomy is discussed in detail separately. (See "Initial
evaluation and management of penetrating thoracic trauma in adults", section on
'Emergency department thoracotomy (EDT)' and "Resuscitative thoracotomy:
Technique".)

Patients with any of the following typically go immediately to the operating theater for
laparotomy:

●Hemodynamic instability
●Peritonitis

●Impalement

●Evisceration

●Frank blood from a nasogastric tube or on rectal examination

In patients without apparent indications for immediate laparotomy, physical examination

is both sensitive and specific for detecting significant intra-abdominal injury. A
prospective observational study involving 249 consecutive abdominal stab wound
patients treated at a major trauma center found physical examination to be 100 percent
sensitive and 98.7 percent specific compared with CT for detecting intra-abdominal injury
necessitating laparotomy, and concluded that a physical examination based diagnostic
algorithm was effective and decreased radiation exposure for such patients [8].

Patients without apparent indications for laparotomy may be evaluated by one or more of
the following techniques:

●Local wound exploration (LWE)

●Plain radiograph
●Computed tomography (CT)
●Serial physical examinations (SPE)
●Diagnostic peritoneal lavage (DPL)
 ●Ultrasonography

●Laparoscopy

Local wound exploration — Since the entire abdominal wall is encased in a layer of
fascia, the first question in asymptomatic patients is to determine whether the stab
wound violated the peritoneum. Stab wounds are amenable to local wound exploration
(LWE) to evaluate their depth and tract [9]. LWE is safely performed at the bedside in
patients with stab wounds to the anterior abdomen, but requires appropriate patient
sedation and local anesthesia. The procedure, best undertaken by two individuals,
should be done with sterile technique, good lighting and both sharp and blunt dissection
until the bottom of the wound is clearly visualized. Blunt probing with fingers or cotton
swabs is unreliable and not recommended. Adequate analgesia and appropriate
sedation must be provided when performing LWE. In some cases, local infiltration of
tissues with anesthetic is sufficient, but standard procedural sedation and analgesia
(PSA) is required in other cases. The performance of PSA is discussed separately.
(See "Procedural sedation in adults outside the operating room".)

For anterior stab wounds, if the exploration to the deepest extent of the wound
demonstrates that anterior rectus fascia is not violated, then patients may be discharged
after appropriate wound care, assuming no additional or extra-abdominal injuries are
present [9-11]. Obesity, heavy muscle, or the presence of multiple wounds or other
injuries can compromise LWE [12,13]. If the anterior fascia is not clearly and completely
seen, peritoneal injury cannot be ruled out and further evaluation is required. For
clinicians with limited experience performing LWE, or those who have not performed one
in some time, the safest policy is to presume peritoneal violation unless all edges of the
wound are visualized clearly.

Plain radiographs — Plain radiographs typically add little to the management of

abdominal stab wounds. If free intraperitoneal air is seen on an upright chest or lateral
decubitus radiograph, then the peritoneal cavity has been violated, but this does not
confirm hollow viscus injury. Thus, plain radiographs lack sensitivity and specificity for
significant injuries and are rarely employed in this setting.

An exception is the use of plain radiographs to evaluate foreign bodies. These include
cases of impalement where the foreign object remains in the patient and cases where
there is concern for a retained foreign body not visible in the wound, such as a broken
knife blade.

Serial physical examination and observation — It is well accepted that serial physical
examination (SPE) is a safe and reliable means to detect significant intra-abdominal
injuries after stab wounds to the abdomen, if performed by experienced clinicians on
appropriate patients. Ideally, the same clinician should perform each examination.

Patients not appropriate for SPE include those with an unreliable examination due to
head injury, spinal cord injury, altered mental status (eg, from intoxication), or the need
for anesthesia. In addition to careful reassessment of the abdomen, the physical
examination should include assessment of the neurologic and vascular status of the
lower extremities as stab wounds may damage nerves and vessels in the abdomen and
pelvis. Ideally, serial examinations are performed at least every six hours.

The requisite duration of observation after a stab wound to the abdomen that penetrates
the anterior rectus fascia is at least 12 hours [14]. Patients in the following categories
should be observed for at least 24 hours:

●Older than 65 years

●Taking anticoagulants or antiplatelet medications at the time of injury
●Have significant medical comorbidities that may affect detection of internal injury
(eg, diabetes)
●Have other significant injuries warranting observation

Mildly intoxicated patients should be observed until the effects of the intoxicating
substance have resolved. Assuming no signs of significant injury are detected, such
patients may be discharged following a final reassessment and reexamination.

Some basic criteria that the patient with an abdominal stab wound should meet to be
considered appropriate for discharge after brief observation (12 hours) include the
following:

●Mentally capable of making appropriate, informed decisions about medical care

●Physical examination – including careful abdominal examination – is unremarkable,
with the lone exception of some reasonable discomfort at the stab wound site only
●Vital signs stable and without concerning trends (eg, heart rate has not risen from
55 to 89): Heart rate less than 90; respiratory rate less than 14/minute; temperature
less than 38°C (100.4°F)
●Spontaneous urination
●Tolerating oral fluids
●Able to ambulate safely
●Not taking anticoagulants
●Safe discharge environment
Ultrasound — Bedside extended Focused Abdominal Sonography for Trauma (eFAST)
examination is frequently used to determine the presence of hemopericardium,
hemoperitoneum, pneumo- or hemothorax, or some combination thereof. Overall, the
specificity of the FAST examination for identifying signs of internal injury from a stab
wound appears to be high, but sensitivity is limited. The use of ultrasound (US) in
evaluating patients with abdominal trauma is described in detail separately.
(See "Emergency ultrasound in adults with abdominal and thoracic trauma".)

The eFAST examination is particularly valuable in the initial assessment of a patient with
a low chest or upper abdominal stab wound who is hemodynamically unstable, as rapid
identification of hemopericardium or hemoperitoneum can help to determine the priorities
of management. Hemopericardium causing hemodynamic compromise (ie, pericardial
tamponade) must be drained immediately. Unstable patients with hemoperitoneum and
no sign of hemopericardium or another immediately treatable cause of hypotension (eg,
pneumothorax) should proceed to immediate laparotomy. (See "Initial evaluation and
management of penetrating thoracic trauma in adults", section on 'Pericardial
tamponade' and "Emergency pericardiocentesis" and 'General approach and indications
for laparotomy' below.)

In hemodynamically stable patients with a positive eFAST, other diagnostic modalities,

such as computed tomography (CT) or diagnostic laparoscopy, can identify specific
injuries and guide management. In those with a negative eFAST, injury cannot be
excluded and other diagnostic modalities must be employed.

Other applications of US in penetrating abdominal trauma continue to evolve. While it is

not routinely used to diagnose peritoneal penetration, a small preliminary study using the
US transducer to assess fascial violation deep to the stab wound demonstrated excellent
specificity but suboptimal sensitivity [15].

Diagnostic peritoneal tap and diagnostic peritoneal lavage — Although invasive,

diagnostic peritoneal tap and lavage is a rapid and easily performed bedside procedure
that offers information about peritoneal penetration and injury to solid organs, bowel, and
the diaphragm [16,17]. However, diagnostic peritoneal lavage (DPL) does not assess the
retroperitoneum. The procedure entails inserting a catheter into the peritoneal cavity,
initially to aspirate blood or fluid, and subsequently to infuse fluid and lavage the cavity, if
necessary. The initial portion of the procedure is often referred to as a diagnostic
peritoneal tap or aspirate; the latter portion is a DPL.

In the setting of abdominal stab wounds, diagnostic peritoneal tap and lavage is
generally used for one of the following indications:
 ●Need to rapidly determine the presence of hemoperitoneum in unstable patients
when ultrasound is not diagnostic
●Need to diagnose diaphragm injury (eg, unclear if a stab wound to the lower chest
has penetrated the peritoneum)

The only absolute contraindication to DPL is the presence of a clear indication for
immediate laparotomy.

In the hemodynamically unstable patient, DPL has been used to identify

hemoperitoneum when the physical examination is equivocal or ultrasound is technically
inadequate. DPL may be particularly important for guiding management in the patient
with multiple stab wounds and other potential causes for hypotension, such as
hemothorax, pericardial tamponade, spinal cord injury, and retroperitoneal hemorrhage.

In patients with stab wounds of the anterior abdomen who are hemodynamically stable
and without indications for immediate laparotomy, the clinician should determine whether
peritoneal violation has occurred. If the peritoneum has been violated or the clinician is
uncertain whether it has, serial physical examination is the most cost effective means of
assessing for significant intraperitoneal injury [18]. DPL may be a useful procedure when
intraperitoneal injury must be assessed in patients who will become difficult to
reevaluate, such as the patient who will be under general anesthesia for a procedure
other than laparotomy. However, in most circumstances ultrasound or CT scan is used to
evaluate stable patients rather than DPL.

Although previous abdominal surgery has been considered by some to be a potential

cause of complications (eg, catheter malplacement, fluid sequestration, bowel
perforation), according to a retrospective review the accuracy and complication rate of
DPL in patients with previous abdominal surgery are similar to those without [19].
Consequently, previous abdominal surgery should be considered a relative
contraindication to DPL and the decision to proceed in such cases should be made
based on clinical judgment of, or in consultation with, the trauma surgeon. Other relative
contraindications include preexisting coagulopathy, advanced cirrhosis, morbid obesity,
and pregnancy beyond the first trimester. The supraumbilical approach to the DPL is
advised in patients with a pelvic fracture or females beyond the first trimester of
pregnancy.

We and most experts agree that the aspiration of 10 mL of gross blood in a patient with
penetrating abdominal wounds indicates visceral injury [16,17]. However, debate
continues over the appropriate red blood cell count threshold for determining visceral
injury if the initial aspirate is negative or inconclusive and lavage is performed. A
commonly used threshold is the presence of greater than 10,000 red blood cells per
high-powered field (RBCs/HPF). A range of 5000 to 10,000 RBCs/HPF is often used to
determine the presence of injury in thoracoabdominal (low chest) wounds, as this
lowered threshold allows greater sensitivity for detecting isolated diaphragmatic or small
bowel injury [16,20]. This degree of RBC concentration in the DPL effluent should not be
attributed to the procedure itself. We believe these are reasonable thresholds to use.

Not all trauma surgeons agree with these thresholds, and several alternative approaches
have been proposed, including higher thresholds that result in lower rates of
nontherapeutic laparotomy but may lead to delays in diagnosis. Undoubtedly,
approaches will vary by institution and available resources. Emergency clinicians
performing a DPL should interpret the results in the context of the clinical scenario and in
close consultation with the trauma surgeons, who must ultimately decide whether
laparotomy is necessary. In patients selected for initial nonoperative management, DPL
may be best employed in combination with serial physical examinations [13,14,21].

Studies supporting alternative thresholds for determining a positive DPL include the
following:

●A retrospective study performed at a single level one trauma center reported that of
280 patients with an abdominal stab wound who had a negative DPL only 15 (5
percent) went on to have a therapeutic laparotomy within 24 hours of admission
[22]. Initial aspiration of 10 mL gross blood or specific lavage fluid values, including
>100,000 RBCs/HPF, was used to determine a positive DPL.
●The authors of a similar study involving 195 patients with stab wounds to the
anterior chest or abdomen confirmed the lower nontherapeutic laparotomy rates
associated with these higher thresholds [23]. In this study, a threshold of
>100,000 RBCs/HPF, along with the presence of >500 white blood
cells (WBCs)/HPF, bile, or amylase, was used to determine a positive DPL.
●A review of 388 hemodynamically stable patients with stab wounds who underwent
DPL reported that thresholds of >100,000 RBCs/HPF for abdominal wounds and
>10,000 RBCs/HPF for thoracoabdominal wounds had an overall sensitivity and
specificity of 90 and 84 percent, respectively, for injuries that required surgical
intervention, while thresholds of >15,000 RBCs/HPF for abdominal wounds and
>25,000 RBCs/HPF for thoracoabdominal wounds improved sensitivity and
specificity to 94 and 96 percent respectively [24].

Of note, diagnosis can be delayed using some of these thresholds, as white blood cell
counts do not become positive until approximately six hours from injury and laboratory
analysis would be required to detect bile or amylase. Additional prospective studies are
needed to validate these proposed thresholds. The performance of DPL is reviewed
separately. (See "Diagnostic peritoneal lavage".)

Computed tomography and magnetic resonance imaging — Multidetector computed

tomography (MDCT) is a noninvasive and rapidly performed imaging study that enables
clinicians to delineate visceral injury [7,25,26]. A systematic review and observational
studies cite a sensitivity of up to 97 percent coupled with a specificity of up to 98 percent
for identification of peritoneal violation [7], and a sensitivity of 94 percent and specificity
of 95 percent for detecting significant intra-abdominal injuries possibly requiring
operative management [27]. Another advantage of MDCT is that it enables the
identification of intraperitoneal injuries, such as hepatic lacerations, that may be
amenable to nonoperative management [7].

Although previous studies of CT involved triple contrast (intravenous, oral, and rectal),
the advent of high-resolution, multidetector scanners makes this approach unnecessary
in most cases of isolated anterior abdominal stab wounds [26]. However, rectal contrast
may be needed to assess possible retroperitoneal injury from back or flank wounds [8].
The preferred approach to imaging is best determined in consultation with the trauma
surgeon and radiologist.

Even with a negative initial CT scan, patients with a high likelihood of diaphragmatic or
bowel injury should have further testing, or observation and serial examinations, as these
injuries are the ones most frequently missed [28]. Although, the accuracy of multidetector
CT scans for detecting these conditions is improving [29], magnetic resonance imaging
(MRI) has greater sensitivity for some injuries and may play a useful role in evaluating
the stable pregnant patient in need of intra-abdominal or thoracoabdominal imaging
following penetrating injury [29,30]. (See "Recognition and management of
diaphragmatic injury in adults"and "Management of duodenal and pancreatic trauma in
adults", section on 'Diagnosis' and "Traumatic gastrointestinal injury in the adult patient".)

Diagnostic laparoscopy — Diagnostic laparoscopy (DL) is most useful for inspecting

the diaphragm in thoracoabdominal wounds and determining the feasibility of
nonoperative management of isolated liver injuries [31-33]. DL is used more commonly
in Europe and South America where there is greater enthusiasm for laparoscopic repair
of hollow viscous injuries. The accuracy of DL in identifying injuries varies according to
the location and type of injury [32]. In general, laparoscopy or thoracoscopy is useful for
identifying diaphragmatic wounds and facilitates minimally invasive repair [34]. However,
complete assessment of hollow organs can be challenging and the retroperitoneum
cannot be evaluated.

INITIAL MANAGEMENT
General approach and indications for laparotomy — The initial evaluation and
resuscitation of the patient with an abdominal stab wound are identical to that for any
acutely injured patient and are discussed in detail separately (see "Initial management of
trauma in adults"). An algorithm to help guide the management of patients with an
anterior abdominal stab wounds is provided (algorithm 1).

After necessary resuscitation, patients with any of the following typically go immediately
to the operating theater for laparotomy:

●Hemodynamic instability
●Peritonitis

●Impalement

●Evisceration

●Frank blood from a nasogastric tube or on rectal examination

In the remaining patients, the first management decision is whether there is violation of
the peritoneum or retroperitoneum. For anterior abdominal stab wounds, peritoneal
penetration is the key decision point. This can often be determined by local wound
exploration (LWE), but advanced imaging studies are sensitive and specific when
necessary. Omental or visceral evisceration represents peritoneal violation and most
believe this warrants laparotomy because of the high risk of gastrointestinal perforation
[35]. For flank and back wounds, there is a risk of retroperitoneal as well as peritoneal
penetration (figure 2). In addition, there is concern for peritoneal violation with anterior
lower thoracic stab wounds, and retroperitoneum injury with lower posterior chest
wounds. Hemodynamically stable patients with these potentially more complex wounds
(flank, back, thoracoabdominal) warrant careful evaluation, often including CT imaging
and a period of observation. (See 'Flank and back stab wounds' below
and 'Thoracoabdominal stab wounds' below and 'Right upper quadrant stab
wound' below.)

Signs of gastrointestinal hemorrhage (eg, hematemesis, hematochezia) suggest

gastroduodenal or colorectal injury and generally warrant laparotomy without further
investigation by imaging study. An implement in situ (ie, a weapon protruding from the
patient's body) ordinarily prompts laparotomy, even in stable patients, in case the
implement rests inside an intraperitoneal vessel, such that removal would lead to
hemorrhage. Therefore, high risk surgical candidates and pregnant patients, for whom
laparotomy puts the fetus at risk, may undergo removal of the implement without general
anesthesia but in the operating suite in case they deteriorate.
Peritoneal violation — Peritoneal violation occurs in up to 50 to 70 percent of
abdominal stab wounds, but only half of those with peritoneal violation sustain an intra-
abdominal injury requiring operative intervention [35]. Thus, only 25 to 33 percent of
patients with abdominal stab wounds require laparotomy. In most major trauma centers,
local wound exploration (LWE) is performed to determine peritoneal penetration for
anterior abdominal stab wounds. If no violation of the anterior rectus fascia has occurred,
the patient may be discharged safely after local wound care, assuming there are no
other injuries of concern. (See 'Local wound exploration' above.)

In centers without extensive experience with abdominal stab wounds, the alternative
tests to evaluate for peritoneal penetration are DPL or CT scanning. Patients with a
negative DPL or CT scan require at least another 12 hours of observation because of the
risk of missing a gastrointestinal perforation or, in the case of DPL, the risk of intestinal
injury due to the procedure. (See 'Diagnostic peritoneal tap and diagnostic peritoneal
lavage' above and 'Computed tomography and magnetic resonance imaging' above.)

Selective nonoperative management — With increased use of sophisticated

diagnostic modalities, more trauma centers are managing nonoperatively those patients
without indications for immediate laparotomy. Nontherapeutic and negative laparotomy
rates, as well as overall lengths of hospital stay and cost, are reduced using this
approach [11,18,36-38]. A systematic review of two studies including 114 patients with
penetrating abdominal injury concluded that there is no evidence to support the use of
surgery over an observation protocol for patients with penetrating abdominal trauma who
are stable with no signs of peritonitis [39]. The approach to selective nonoperative
management varies by injury and is discussed in greater detail separately.
(See "Overview of inpatient management in the adult trauma patient", section on
'Nonoperative management' and "Traumatic gastrointestinal injury in the adult patient",
section on 'Approach to management' and "Overview of the diagnosis and initial
management of traumatic retroperitoneal injury", section on 'Nonoperative
management'.)

Prophylactic antibiotics — Broad spectrum antibiotics are given to patients with

penetrating abdominal injury requiring surgical management; however, antibiotic
administration is not warranted in injured patients who are managed nonoperatively. The
use of prophylactic antibiotics in the setting of trauma is discussed separately. Tetanus
prophylaxis should be given as indicated. (See "Overview of inpatient management in
the adult trauma patient", section on 'Antibiotics' and "Infectious complications of
puncture wounds", section on 'Tetanus immunization'.)
Observation in resource-limited settings — Clinicians in rural emergency
departments or other resource-limited settings must decide whether to observe patients
with an abdominal stab wound who are hemodynamically stable and without obvious
signs of intra-abdominal injury (including unconcerning abdominal examination) at their
institution or to transfer them to a hospital with the resources necessary to provide
definitive care should the patient’s condition deteriorate. There is no single best answer
to this question and the decision will vary depending upon such factors as patient
characteristics (eg, major comorbidities, advanced age) and distance from the closest
hospital capable of providing definitive care. In general, we believe it is reasonable in
most cases to keep such patients at a resource-limited facility for observation, even if
LWE cannot be performed or is equivocal and CT cannot be obtained or is negative
initially. Should the patient begin to manifest signs of intra-abdominal injury (eg,
worsening abdominal pain) or vital signs show a concerning trend (eg, increase in heart
rate or respiratory rate, decline in blood pressure), the patient should be transferred
immediately. One exception to this general approach would be if the time needed to
reach definitive care is prolonged (longer than approximately six hours) due to distance
or weather. In such cases, it makes sense to transfer the patient early.

SPECIAL CONSIDERATIONS

Flank and back stab wounds — Identifying structures injured from penetrating wounds
to the flank and back can be difficult. Stab wounds to these regions can injure both
retroperitoneal and intraperitoneal structures. Several reports indicate that up to 40
percent of penetrating flank wounds result in significant internal injury [8,40]. Triple
contrast CT (3CT) has been the diagnostic modality of choice for stable patients with
such wounds, but with advanced, high-resolution, multidetector CT scanners, rectal
contrast alone may be needed to assess possible retroperitoneal injury from back or
flank wounds [8,40,41]. Advanced imaging often allows for safe triage to nonoperative
management. Local wound exploration (LWE), ultrasound (US), and diagnostic
peritoneal lavage (DPL) do not assess retroperitoneal structures.

Thoracoabdominal stab wounds — Thoracoabdominal wounds present a diagnostic

challenge as movement of the diaphragm makes prediction of the stab wound tract
difficult [42]. If the wound is close to the lower chest, intrathoracic and diaphragmatic
injuries must be considered and evaluated in addition to intra-abdominal injury.
Pericardial tamponade is particularly important to consider in stab wounds near the
xyphoid process.

The morbidity and mortality associated with missed diaphragmatic injury on the left side
is high (the liver generally prevents small bowel herniation on the right side). However,
controversy continues about how best to evaluate possible diaphragm injuries. If
diaphragmatic injury is a concern, diagnostic laparoscopy (DL) or thoracoscopy are the
preferred tests because CT scanning is relatively insensitive [21,43]. Some experts use
diagnostic peritoneal lavage with the lower threshold of 5000 red blood cells per high
powered field (RBCs/HPF) as the criterion for exploratory laparotomy. Diaphragmatic
injury is discussed in detail separately. (See 'Diagnostic laparoscopy' above
and 'Computed tomography and magnetic resonance imaging' above and 'Diagnostic
peritoneal tap and diagnostic peritoneal lavage' above and "Recognition and
management of diaphragmatic injury in adults".)

Right upper quadrant stab wound — Patients with a right upper quadrant stab wound
who remain hemodynamically stable and free of abdominal tenderness, and who are
reliable (eg, not intoxicated and remain alert) may be managed without laparotomy [28].
Most patients with injuries of this nature have sustained grade I or grade II hepatic
injuries that do not require operative intervention. However, these patients should be
admitted for a period of observation of at least 48 hours. Many centers perform CT
scanning to confirm and determine the extent of any hepatic wounds and to assess for
potential colonic injury. If the severity of liver injury cannot be determined with certainty
by CT scan, most trauma surgeons perform diagnostic laparoscopy. The physical
examination cannot be considered reliable in patients with a brain injury, spinal cord
injury, heavy intoxication, or who require sedation or anesthesia, and serial physical
examination is not an appropriate means of evaluation in these circumstances.

Stab wounds in pregnancy — Abdominal stab wounds sustained during pregnancy are
uncommon. The management of the pregnant trauma patient is reviewed separately.
(See "Initial evaluation and management of pregnant women with major trauma".)

Patients on anticoagulants — Patients taking warfarin, heparin, or other anticoagulants

are at higher risk of hemorrhage following an abdominal stab wound and reversal of
anticoagulation may be needed if bleeding becomes severe. This is discussed
separately. (See "Management of warfarin-associated bleeding or supratherapeutic
INR", section on 'Treatment' and "Heparin and LMW heparin: Dosing and adverse
effects", section on 'Bleeding' and "Management of bleeding in patients receiving direct
oral anticoagulants", section on 'Major bleeding'.)

Law enforcement and social service issues — Many jurisdictions require emergency
departments to notify local law enforcement of all stab wounds. Law enforcement
investigation may be necessary to ensure that no other stab victims are in need of
assistance. Necessary steps should be taken to ensure that the emergency department
and hospital are safe and secure, which may include communicating with hospital
security or police personnel. Clothing removed from the patient should be placed in
brown paper bags or other containers suitable for evidence collection, and care should
be taken to avoid cutting through rips or knife cuts in garments whenever possible. All
wounds should be carefully documented in the medical chart.

Victims of assault may suffer emotionally as well as physically. Social services or mental
health professionals should be consulted as needed during the hospital evaluation and
as part of post-discharge follow-up. (See "Acute stress disorder in adults: Epidemiology,
pathogenesis, clinical manifestations, course, and diagnosis".)

SUMMARY AND RECOMMENDATIONS

●Whenever possible, obtain a history of the abdominal stab wound from the patient
and emergency medical services personnel or other witnesses. Important questions
include: what instrument was used, how long and how wide it was, how the patient
was positioned during the stabbing, what path the implement traveled, and whether
there was substantial blood at the scene. Undress completely any patient who
sustains a stab wound. Stab wounds can often be obscured by body habitus,
clothing, or bleeding, or be "hidden" in the axilla, scalp, or groin. (See 'History'above
and 'Initial assessment' above.)
●Indications for emergent laparotomy include: hemodynamic instability, unequivocal
peritoneal signs on physical examination, signs of gastrointestinal hemorrhage, and
implement in situ. Evisceration of intra-abdominal organs or omentum is an
indication for immediate laparotomy at most trauma centers. Broad spectrum
antibiotics are generally given to patients with penetrating abdominal injury requiring
surgical management, but otherwise are not administered. An algorithm to help
guide the management of patients with an anterior abdominal stab wounds is
provided (algorithm 1). (See 'General approach and indications for
laparotomy' above.)
●Stab wounds to the abdomen, or flank are often amenable to local wound
exploration (LWE) to evaluate their depth and tract. If a properly performed
exploration to the deepest extent of the wound demonstrates that anterior rectus
fascia is not violated, the patient may be discharged after appropriate wound care,
assuming no additional or extra-abdominal injuries are present. If body habitus,
multiple wounds, other injuries, or difficulty in performing LWE impedes visualization
of the complete depth of the wound and all its margins, then peritoneal injury cannot
be ruled out and further testing or observation must ensue. (See 'Local wound
exploration' above.)
●Plainradiographs are seldom useful for evaluating abdominal stab wounds, with
the exception of assessing foreign bodies such as impaled objects. (See 'Plain
radiographs' above.)
●Bedside extended Focused Abdominal Sonography for Trauma (eFAST)
examination is frequently used to determine the presence of hemopericardium,
hemoperitoneum, pneumothorax, hemothorax, or some combination thereof.
Overall, the specificity of the FAST examination for identifying signs of internal injury
from a stab wound appears to be high, but sensitivity is limited. The use of
ultrasound in evaluating patients with abdominal trauma is described in detail
separately. (See "Emergency ultrasound in adults with abdominal and thoracic
trauma".)
●Observation with serial physical examination is a reliable approach for detecting
significant injuries after stab wounds to the abdomen, assuming normal mental
status and neurologic function, and the absence of distracting injury or sedation.
Ideally, serial examinations should be performed by the same clinicians. The optimal
time period for observation of uncomplicated stab wound patients in a nonoperative
management plan is at least 12 hours. Patients with complicating factors (eg, older
age, diabetes, taking anticoagulants) warrant a longer period of observation.
(See 'Serial physical examination and observation' above.)
●Multidetector computed tomography (MDCT) is a noninvasive and fast imaging
technique that enables accurate identification of peritoneal penetration and
delineation of solid visceral and vascular injury. Patients with a high likelihood for
diaphragmatic, bowel, or pancreatic injury should have further testing, or
observation and serial examinations, even with a negative initial CT scan, as these
injuries are missed most frequently. (See 'Computed tomography and magnetic
resonance imaging' above.)
●Flank, back, and thoracoabdominal injuries may involve more than one anatomic
space and can be difficult to evaluate. Stable patients with stab wounds to the flank
or back are generally evaluated using MDCT. The morbidity and mortality
associated with missed diaphragmatic injury on the left side is high. Patients with
thoracoabdominal injury require thorough investigation, possibly with diagnostic
laparoscopy or thoracoscopy. Patients with an isolated stab wound to the right
upper quadrant may be managed without laparotomy if vital signs remain stable and
the abdominal examination is reliable (eg, no alteration of mental status), and there
is minimal to no abdominal tenderness. (See 'Special considerations' above.)
●Clinicians should be aware of local legal requirements for reporting stab wounds
and whenever possible take the necessary steps for proper evidence collection.
Consultation with social service or mental health service personnel may be
beneficial and appropriate outpatient referral to such services may be warranted.
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