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Abdominal Stab Wounds: A Decision

Algorithm
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/ Abdominal Stab Wounds: A Decision Algorithm
 F E AT U R E D

September 12, 2019

Abdominal Stab Wounds: A Decision Algorithm

If you work at a trauma center, then you’re bound to see your fair share of abdominal stab
wounds. Though civilian penetrating trauma has declined over recent decades and is less
common than blunt trauma, penetrating trauma represents ~10% of all trauma evaluations in
the U.S. and of those, ~50% are caused by stab wounds.

In 2018, the Western Trauma Association (WTA) published a clinical decision algorithm
outlining the diagnosis, investigation, and management of abdominal penetrating injuries
from stab wounds. This algorithm focuses on adult patients with abdominal stab wounds and
acknowledges the relative paucity of prospective randomized clinical trials, and thus,
recommendations were based primarily on observational studies and expert opinion. The
algorithm, instead of prescribing rigid recommendations, provides several equally acceptable
management pathways that can be selected based on the details of the case, setting,
resources, and local expertise/preference. The WTA encourages the algorithm as a general
framework to be customized/adapted to each center.

In this post, we will summarize these recommendations using both visual and text formats
followed by a more detailed description of the steps involved.
For other topics related to Military Medicine, please see our posts on Damage Control
Resuscitation (https://emottawablog.com/2019/03/damage-control-resuscitation-dcr-a-
summary-of-the-joint-trauma-system-clinical-practice-guideline/), TCCC
(https://emottawablog.com/2018/07/introduction-to-tactical-combat-casualty-
care/)and Recent Updates (https://emottawablog.com/2019/04/tactical-combat-casualty-care-
tccc-recent-updates/), Prolonged Field Care (https://emottawablog.com/2019/06/prolonged-
field-care/), Blast Injuries (https://emottawablog.com/2019/08/blast-injuries-what-you-need-
to-know/), Inhalation Injuries (https://emottawablog.com/2019/08/inhalation-injuries-and-
toxic-industrial-chemicals/), and Resuscitative Thoracotomy
(https://emottawablog.com/2019/08/emergency-resuscitative-thoracotomy-in-the-civilian-and-
military-environments/).

The Algorithm: Abdominal Stab Wounds

(https://emottawablog.com/wp-content/uploads/2019/08/Algorithm.png)

Diagnostic Questions to Ask in Abdominal

Stab Wounds
Let’s break down the algorithm in text format.

First, consider thoracic injuries if indicated and investigate/manage concurrently if

appropriate…

1. Does this patient require immediate abdominal exploration

exploration?? Yes, if:
Hemodynamically unstable

Evisceration
Impalement / Implement in situ

Peritonitis

Hematemesis

Gross blood NG/PR

2. Does the stab wound penetrate the peritoneum?

a. If alert and examinable – is there free air on CXR?

Yes – abdominal exploration or Serial Clinical Examinations (SCE) if low

suspicion for hollow viscus injury

No – assess location (below)

b. If not alert or examinable – perform Local Wound Exploration (LWE) , PoCUS,

Diagnostic Imaging (DI) , Diagnostic Peritoneal Lavage/Aspirate, or Diagnostic

Laparoscopy

Positive – abdominal exploration

Negative – SCE once patient is examinable

Equivocal – abdominal exploration or SCE if patient becomes examinable

3. Where is the stab wound?

Flank / Back – requires DI

Anterior – LWE , SCE , or DI depending on local resources / preference

Thoracoabdominal / Upper Abdominal – CXR, PoCUS for pericardial effusion, manage any

thoracic injury, evaluate for diaphragm injury

Possible Management Pathways in

Abdominal Stab Wounds
1. Abdominal Exploration

Gold standard is laparotomy, though laparoscopy may be performed in select stable patients
2. Local Wound Exploration

Is the anterior fascia penetrated?

Yes – SCE or DI , can consider Diagnostic Laparoscopy

No – DC home if no other issues

3. Serial clinical exams / Observation for ~24h

Peritonitis or instability?

Yes – abdominal exploration

No – Active bleeding?

Yes – DI

No – DC Home

4. Diagnostic Imaging

CT scan shows signs of operative injury?

Yes – abdominal exploration

No – Any solid organ injury or active bleeding?

Yes – SCE or Angiography

No – DC home or observation

A Deeper Dive into the Abdominal Stab

Wound Algorithm
A. Initial Evaluation and Indications for Immediate Operation
The initial evaluation focuses on identifying immediate life-threats and injuries requiring
prompt surgical repair (e.g. massive hemorrhage, hollow viscus perforation with intra-
abdominal contamination). The following indications portend a high likelihood of life-threat or
injury requiring surgical repair:

1. Hemodynamic instability with signs of shock

Clear warning sign for ongoing massive hemorrhage; initiate immediate exploratory

laparotomy, damage control resuscitation

No consensus for “unstable”, though majority of studies use sBP <90-100
2. Evisceration – high predictor of operative injuries

3. Impalement – requires removal of object under operative conditions

4. Peritonitis
5. Hematemesis or gross blood in the gastric aspirate / per rectum
The above factors together are 80-90% predictive of the need for therapeutic laparotomy. The
factors with the best PPVs for need for laparotomy were:

Development of hypotension after initial normotension (86%),

Shock on presentation (83%), and
Generalized peritonitis (81%)

For thoracoabdominal or upper abdominal stab wounds, perform

immediate:

1. CXR (upright or reverse trendelenburg)

Can determine presence of intraperitoneal air, PTX/HTX

Free air under the diaphragm should prompt consideration for immediate surgical exploration
(vs. imaging or close observation if stable)

2. PoCUS for pericardial effusion to r/o cardiac injury

Diagnostic Peritoneal Lavage

Though relatively sensitive for hollow viscus perforation, it has been shown to add little to the
management of abdominal stab wounds in modern algorithms. Though primarily of historic
interest, likely still a role for selective DPL in resource-constrained settings.

B. The Unreliable or Unexaminable Patient

Multiple factors interfere with clinical examination (e.g. intoxication, psychiatric illness, spinal cord

injury, intubated, etc.) and there is little scientific evidence for this specific cohort
 Though, routine surgical exploration in these patients is acceptable and preferable to significant

diagnosis delays, the WTA (who’ve previously shown that selective radiologic imaging was safe and
effective) recommend liberal use of diagnostic studies to identify peritoneal penetration and/or
operative abdominal injury (e.g. FAST, LWE, CT, diagnostic laparoscopy)in these patients

Positive findings lead to surgical exploration

For equivocal or positive LWE (to evaluate the anterior rectus fascia for penetration), the

decision for operative exploration vs serial clinical exams must be based on degree of patient
impairment, duration of impairment, available resources
In general, GCS <13 should be considered unexaminable

C. Assessing Injury Location and Location-Specific Management

Anatomic divides are:

Anterior
Thoracoabdominal / Upper abdominal
Flank / Back

Anterior
Costal margins to groin crease, anterior axillary lines laterally
If no indications for immediate surgical exploration, then depending on the case, can perform

LWE, SCE, or DI
Flank / Back
Though more subtle initial findings, there is potential for major morbidity/mortality as there is

risk to retroperitoneal structures (vessels, solid organs, bowel, etc.) and colon/duodenum
Recommend diagnostic imaging with CT abdo/pelvis
In regards to Triple-contrast (PO, PR, IV) vs Double-contrast – final consensus was that this

decision should be made at the discretion of the surgeon and radiologist

Thoracoabdominal / Upper abdominal

Thoracoabdominal – nipple line to costal margins

Upper abdomen – costal margins to umbilicus
In addition to evaluation for abdominal injuries, these also require evaluation for thoracic

injuries (e.g. PTX, HTX, cardiac injury)

pCXR, eFAST, CT Chest
Positive findings should be managed appropriately in the context of other ongoing injuries

and priorities
Evaluation for diaphragmatic injury
Any upper abdominal stab wound with associated PTX/HTX should be assumed to have a
 diaphragm injury and managed appropriately
If another indication for surgical exploration exists, then inspect the diaphragm at that time,

if not, then diagnostic laparoscopy should be performed to r/o diaphragm injury (delayed 8-
12 h to allow serial examinations to ensure no other operative injury presents, requiring
OR)

D. Local Wound Exploration

Exploration to determine if the anterior fascia was penetrated; fascial penetration is a proxy for

peritoneal penetration
Important points:
Clearly negative LWE can rule out intra-abdominal injury; safely DC home

Positive LWE in an examinable patient should NOT be considered an immediate indication for
laparotomy

Positive LWE should prompt further diagnostic imaging or admission for serial clinical
examinations
30–50% incidence of non-therapeutic laparotomy even with positive LWE; significantly

higher false positive rates with a benign abdo exam

Know when the patient/wound is NOT amenable to LWE:
Small puncture wounds (i.e., ice pick)

Long tangential stab wounds

Flank / Back wounds – difficult to predict or follow tract due to musculature
Significant obesity with very deep subcutaneous fat layer

Thoracoabdominal wounds – high risk of iatrogenic PTX

Multiple stab wounds
Patient cooperation is required, can be difficult if intoxicated, combative, etc.

E. Serial Clinical Examinations

SCE is: serial abdominal exams, VS monitoring, and laboratory assessments

Focused on identifying peritonitis (hollow viscus perforation), serious hemorrhage, or other

operative injury
Best performed in a well-resourced setting where frequent reassessments are possible

If not, can perform routine CT imaging or diagnostic laparoscopy

SCE is safe and reduces rates of non-therapeutic laparotomy

When can SCE be applied:

Abdominal stab wound
Examinable (can consider if only short term impairment of examination)
 No indication for immediate laparotomy OR positive LWE but no immediate indications for
abdominal exploration
Though SCE is well validated, the optimal duration of observation remains unclear

Majority of published protocols are 24-48h

WTA recommends minimum 24h observation

F. Diagnostic Imaging
CT scan lower chest, abdomen, and pelvis
High resolution, 3D multiplanar reconstructions, experienced trauma radiologist

Direct signs of operative injury = immediate surgery

Secondary signs of possible operative injury = operative exploration vs admission for close SCE
Any positive finding related to the stab wound, no matter how minor, should prompt

admission and observation

Negative CT scan = may allow for safe DC if examinable, reliable, low-risk vs. admission for SCE
Considerations:

CT can be helpful to identify signs of intra-abdominal injury, but 10-20% of injuries can be
missed
CT should not be used as the sole determinant of disposition, it should be combined with

other modalities, most often SCE

G. Traumatic Diaphragm Injury (TDI) Evaluation

TDI secondary to stab wounds is most commonly diagnosed on the left side (75% of cases)
Right-sided TDI is diagnosed less frequently and associated with lower morbidity and mortality

Some have recommended evaluation only for left-sided wounds. However, the liver should not be
considered as reliable protection against a diaphragm injury
These injuries are typically small and not easily identified on standard CT scan in the absence of

herniated contents, therefore it is critical to adequately evaluate all patients at risk of TDI
Some series have reported up to a 40% incidence of TDI with penetrating trauma to the left
thoracoabdominal region, many of which are clinically silent

There is some data suggesting that high resolution CT may provide adequate imaging to r/o
diaphragm injury
Focused, fine cut CT with experienced trauma radiologist should be performed

Repeat delayed imaging to ensure no missed injury should be considered

TDI can be diagnosed and repaired via laparoscopy; there is a role for thoracoscopy as an
alternative; VATS has been used as well
 References
 Bio  Twitter

Richard Hoang

Dr. Richard Hoang is a 4th year Emergency Medicine Resident at the University of
Ottawa with a variety of academic interests including military medicine, trauma,
simulation, and FOAMed.

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