Epigastric Stab Wounds

An 11-year old male is brought to the ER 30 minutes after sustaining a stab wound at the epigastric area during a street rumble.

Epigastric Stab Wounds At the Emergency Room: He is conversant, conscious, coherent, ambulatory, not in respiratory distress VS: BP 100/60, PR 82 bpm, RR 24 cpm, T 36.5 C Pale palpebral conjunctivae, anicteric sclerae Chest: symmetrical chest expansion with clear breath sounds Heart: normal Abdomen: flat, with a 1.5 x 1.5 cm stab wound at the epigastric area, hypoactive bowel sounds, soft, direct tenderness at the epigastric area Rectal exam is unremarkable

Presentation Assessment begins at the scene of the incident and on the way to the emergency department ABC’s of primary survey should be followed Upon arrival at the emergency department, incident history and the patient’s vital is important Patients who present with hypotension are already in class III shock (30-40% blood volume loss), and they should receive blood products as soon as possible Physical examination includes inspection of all body surfaces, with notation of all penetrating wounds

Presentation In the examination of the abdomen, if there is peritoneal signs, such as pain and guarding and rebound tenderness, exploration without delay is a necessity Presence of abdominal rigidity or gross abdominal distention is an indication for prompt surgical exploration Rectal examination, as blood per rectum and high-riding prostate can indicate bowel injury and genitourinary tract injury, respectively Notation of blood at the urethral meatus is also a sign of genitourinary tract injury

Management of penetrating abdominal trauma Management of penetrating abdominal trauma. CT = computed tomography; DPL = diagnostic peritoneal lavage; RBC = red blood cells.

Laboratory Studies Complete blood count (CBC) Basic chemistry profile (BMP) Coagulation studies (PT/INR + PTT) Arterial blood gas (ABG) Urine dipstick Blood Typing and Crossmatching Ethanol and drug screens

Imaging Studies Plain radiograph Ultrasound CT Scan

Diagnosis Nasogastric intubation - All patients undergoing endotracheal intubation require decompression of the stomach to decrease the risk of aspiration. Blood in the nasogastric tube can indicate upper gastrointestinal injury.

Diagnosis Foley catheterization - required to monitor the fluid resuscitation status of the patient with penetrating abdominal trauma. The presence of blood in the urine is a sign of genitourinary tract injury

Diagnosis Diagnostic peritoneal lavage - DPL sensitivity for detecting intraabdominal injury exceeds 95 % - Results of DPL: grossly (+) – if >10 mL of free blood can be aspirated if < 10 mL – a liter of normal saline is instilled and the effluent is sent to the laboratory for RBC count, amylase alkaline phosphatase, and bilirubin levels and red blood cell count greater than 100,000/μL is considered positive

Diagnosis CT Scan specificity for hepatic, splenic, and renal injuries indicated primarily for hemodynamically stable patients who are candidates for nonoperative therapy