Abdominal Gun Shot Wound: Next Step?

[StrangerX]

Gunshot wound to the abdomen: automatic ex-lap or can you perform studies to better identify the injury prior to the ex-lap (if patient is hemodynamically stable)?

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[coxsackie]

if there is no exit wound- exp lap!!!

 

[StrangerX]

if there is no exit wound- exp lap!!!

So is there any condition in which you would opt to do a study first: Like if there was an exit wound?

 

[The kitchen sink]

Correct me if i'm wrong:

Hemodynamically unstable penetrating GSW -> ex lap

Hemodynamically stable penetrating GSW -> CT scan

Hemo unstable stab wound -> ex lap

Hemo stable stab wound -> probe with finger?? and/or CT scan (can someone clarify? thanks

 

[coxsackie]

I know that with all gun shot wounds-regardless of hemodynamic stability-you must do exp lap.
With stab wounds, hemodynamic stability plays a role. Stable-ct of abdomen. I don't know about poking anybody with a finger. lol. maybe u know something i don't. Unstable-exp lap.

 

[evilbooyaa]

Correct me if i'm wrong:

Hemodynamically unstable penetrating GSW -> ex lap

Hemodynamically stable penetrating GSW -> CT scan

Hemo unstable stab wound -> ex lap

Hemo stable stab wound -> probe with finger?? and/or CT scan (can someone clarify? thanks

Wat

Any GSW needs an ex-lap to remove the bullet (if no exit wound). Not sure if there is an exit wound but patient is HD stable.

Stable stab wound = CT.

Pt unstable = Ex-lap for a GSW, I believe possibly FAST/DPL for a stab wound? Not sure anymore. I think it's in pestana's audio/review notes if anyone wants to go look for it in there.

 

[blagoblag]

I know that with all gun shot wounds-regardless of hemodynamic stability-you must do exp lap.
With stab wounds, hemodynamic stability plays a role. Stable-ct of abdomen. I don't know about poking anybody with a finger. lol. maybe u know something i don't. Unstable-exp lap.

It's been a while, but I think that's what Pestana said in his notes. I just used uptodate to verify it though, and it seems like we're less aggressive than that now.
Based on uptodate:
Hemodynamic instability, peritoneal signs, evisceration==>laparatomy
If not==> CT, diagnostic peritoneal lavage, or diagnostic laparoscopy to look for peritoneal penetration. If peritoneal penetration==>ex-lap (usually)

Also, I believe surgery is to repair the damage rather than remove the bullet.

For those that don't have uptodate, they adapted their algorithm from page 728 of this article: http://www.sassit.co.za/Journals/Tr...rauma/Advances in abdominla trauma review.pdf

 

[The kitchen sink]

It's been a while, but I think that's what Pestana said in his notes. I just used uptodate to verify it though, and it seems like we're less aggressive than that now.
Based on uptodate:
Hemodynamic instability, peritoneal signs, evisceration==>laparatomy
If not==> CT, diagnostic peritoneal lavage, or diagnostic laparoscopy to look for peritoneal penetration. If peritoneal penetration==>ex-lap (usually)

Also, I believe surgery is to repair the damage rather than remove the bullet.

For those that don't have uptodate, they adapted their algorithm from page 728 of this article: http://www.sassit.co.za/Journals/Tr...rauma/Advances in abdominla trauma review.pdf

so hemodynamically stable GSW wound you can do CT scan? or all GSW regardless of stability require ex lap?

 

[coxsackie]

For ck- know to do ex lap for all GSW.

 

[thehundredthone]

A haemodynamically stable patient lends you time to image (and locate the bullet/assess damage). Of course you will eventually do an exploratory laparatomy for all gunshot wounds regardless of whether the bullet is inside or not, but when the situation is not emergent, you can take the time to image. I think there is a UWorld question where the scenario describes a stable patient with GSW who has undergone CT, asking you what to do next.

Even with haemodynamic instability I daresay you could do an FAST before shifting to the OR. Paraphrasing UWorld, it only takes a few minutes and is highly sensitive and specific. Of course everything depends on the options given to you, if an FAST isn't an option then exploratory laparotomy is definitely your next step in management.

From what I understand:
Penetrating trauma, stable -> FAST/CT -> Lap (if indicated)
Penetrating trauma, unstable -> FAST -> Lap

 

[elektroshok]

Why would you fast an unstable gsw to the abdomen? That makes zero sense

Sent from my Galaxy Nexus using Tapatalk 2

 

[CDI]

From what I understand:
Penetrating trauma, stable -> FAST/CT -> Lap (if indicated)
Penetrating trauma, unstable -> FAST -> Lap

I think that was an error.

 

[dozitgetchahi]

What I remember from step 2 is that ALL GSWs go to the OR - but not necessarily to 'remove the bullet'. (Think of how many war veterans still have shrapnel inside of them.) It's to repair damage/assess injuries/etc.

Unstable stab wounds are essentially going straight to the OR.

Stable stab wounds...now you have options. Pestana does talk about probing the wound with a finger and, IIRC, observing with no additional testing if the peritoneum isn't perforated and the pt is stable. Any degree of instability is getting FAST and/or going to the OR pronto.

 

[thefritz]

This is a very simple question and a gimme on step 2.

Penetrating trauma to the abdomen automatically buys you a nonstop ticket to the OR. GSW always without question fall into this category with the very tiny exception of something like a peashooter wound to the RUQ or a 'glazed' tangential wound (I would ignore this, that's surgery boards-level, not step 2). Abdominal GSW = exlap. Stab wounds are more tricky. If viscera are protruding, then it's clearly penetrating and gets an OR ticket.

For situations where it is unclear if a stab wound has caused penetration and the patient is STABLE, then you do a digital exam (STICK A GLOVED FINGER IN THE WOUND). If digital observation rules out penetration, you observe. If digital penetration cannot rule out penetration, you get a CT scan.

If penetration is unclear and patient is UNSTABLE (hemodynamically or peritoneal irritation) then go to OR.

For blunt abdominal trauma, your first step is to observe vitals to see if the patient is bleeding. The question will have to make it clear if the patient is stable or not - it should say stable or unstable, but might not. A low BP indicates bleeding, but does not mean unstable. 105/70 does not get you an exlap. It's got to be VERY LOW (80/40 or something) to bypass workup and go straight to OR in abdominal trauma. If vitals indicate internal bleeding, find out where it's coming from. Thoracic accumulation shows up on xray, H&N or extremity accumulation is grossly apparent. So you need to examine the thighs, pelvis and abdomen. If there's no evidence of femur or pelvis fracture, the blood is in the abdomen, and you must confirm with CT scan. If the CT scan shows abdominal bleeding, the next question is whether to operate. Basically, you operate if the patient does not respond to fluids.

This question gets really hard (and controversial) for hemodynamically unstable blunt abdominal trauma. First step is fluid resuscitation obviously, but then you have to make the diagnosis. The answer here is FAST or DPL (DPL is never done in real life, but there is a question in UW (4498) where it is the right answer, it would be worth studying it). You do a FAST first. If positive -> OR. If negative -> conservative if pelvic injury ruled out. If you can't get a good picture -> DPL.

The 280-ballar question you'll probably get is what to do if there is penetrating trauma to the chest. The key here is not to forget that the diaphragm can go up to the level of the nipple (T4). It is more important to get the patient to the OR and perform an exlap than to scan the patient looking for a hemothorax. If it's a diaphragmatic injury or a hemothorax is suspected during exlap, you can do that through the diaphragm, then get the thoracic surgeons on board if you need to. If GSW below the nipples, you must assume both cavities are involved until ruled out. For purposes of boards, treat all GSWs below the nipple as abdominal GSWs. If they occur between T12-T4, also throw in a CXR and chest tube if needed.
This is UWorld question 3221

TL;DR?

Gunshots: You can see the wound. There is no question about whether the bleeding is occuring in the abdomen. This one is easy.
GSW in abdomen -> exlap
GSW occuring between T4 and T12 with stable vitals -> exlap + CXR
GSW occuring between T4 and T12 with signs of hemo/pneumothorax or CXR positive for hemo/pneumothorax -> chest tube and exlap

Stabs: You can see the wound. There is no question about whether the bleeding is occuring in the abdomen. The question is if the penetration has occured. That's what these tests are for. You don't do FAST or DPL on stab wounds in the abdomen.
stab in abdomen with protruding viscera -> exlap
stab in abdomen and patient crashing -> exlap
stab in abdomen with peritoneal signs (pain/guarding/rebound) -> exlap
stab in abdomen with no visual protrusion and patient stable -> stick finger in wound
stab in abdomen with positive digital exam -> exlap
stab in abdomen with negative digital exam -> conservative management and monitoring
stab in abdomen with unclear digital exam -> CT scan
stab in abdomen with penetration seen on CT -> exlap
stab in abdomen with no penetration on CT -> lucky guy! observe.

Blunt abdominal trauma (BAT): You don't know if there is bleeding into the abdomen. You need to work this up.
BAT with patient crashing -> IV fluid resuscitation with 2 large bore IVs
BAT with patient rapidly crashing (continuing to deteriorate) in spite of fluids -> exlap
BAT with patient unstable but maintaining borderline BP after fluids -> FAST
BAT with positive FAST -> exlap
BAT with negative FAST -> CT scan to find source of bleeding
BAT with inconclusive, unavailable, or unreliable FAST -> DPL
BAT with positive DPL -> exlap
BAT with negative DPL -> CT scan to find source of bleeding
BAT with patient initially unstable but responded to IV fluids and now stable -> CT scan
BAT with patient initially stable -> monitor for signs of internal bleeding + conservative management

Other questions that come up:
- Always repair the spleen if possible. Aggressively attempt repair in children. Immunize against SHIN bacteria if removal cannot be avoided.
- Patient crashing and wife is there saying he's a Jehovah's witness and refuses blood transfusions and will sue you if you give him blood? Look for blood refusal card on patient. No card? Ask her to immediately produce an advance directive. Card or AD? Let patient die. No card or AD. Give blood.
- Prolonged surgery with lots of transfusions? Give FFP and platelets (basically the only time giving platelets is ever the right answer in non-oncologic scenarios) prophetically. If patient still bleeds uncontrollable and becomes hypothermic, abort the surgery, pack the areas of bleeding and do a temp closure.
- Prolonged surgery with lots of fluids and can't close the abdominal wound? Cover abdominal contents with special mesh or plastic and take back to OR later to close.

 

[thehundredthone]

Why would you fast an unstable gsw to the abdomen? That makes zero sense

Sent from my Galaxy Nexus using Tapatalk 2

I think that was an error.

I was simply going by UWorld. Compare Q ID 3221 with 3420 - two unstable GSW patients, one underwent FAST and the other didn't. If you're going to say the FAST was due to 'assumed' and not explicitly clear abdominal injury, then maybe there needs to be a special category like that.

For the exam though, I guess you're right, and penetrating trauma, unstable -> Lap.

 

[thefritz]

I was simply going by UWorld. Compare Q ID 3221 with 3420 - two unstable GSW patients, one underwent FAST and the other didn't. If you're going to say the FAST was due to 'assumed' and not explicitly clear abdominal injury, then maybe there needs to be a special category like that.

For the exam though, I guess you're right, and penetrating trauma, unstable -> Lap.

If a FAST hadn't been done in 3221, exlap still would have been correct. FAST doesn't change management in that case. If FAST were negative, he's still going to the OR for an exlap to rule out diaphramatic injury and determine the need for chest tube placement and/or thoracic surgery. If the FAST were inconclusive (as in this case), he's not going to CT (he's crashing), he's going to the OR. FAST does not change management and did not need to be included. In real life, he probably gets a FAST in the trauma bay by an intern practicing FAST, so this is not an unreasonable thing to include. But if the intern says, hey there's no fluid, I'm sure of it, he's not getting a CT if he's not stable. And even if he were stable, for boards, the answer is exlap.

 

[thehundredthone]

If a FAST hadn't been done in 3221, exlap still would have been correct. FAST doesn't change management in that case. If FAST were negative, he's still going to the OR for an exlap to rule out diaphramatic injury and determine the need for chest tube placement and/or thoracic surgery. If the FAST were inconclusive (as in this case), he's not going to CT (he's crashing), he's going to the OR. FAST does not change management and did not need to be included. In real life, he probably gets a FAST in the trauma bay by an intern practicing FAST, so this is not an unreasonable thing to include. But if the intern says, hey there's no fluid, I'm sure of it, he's not getting a CT if he's not stable. And even if he were stable, for boards, the answer is exlap.

I don't see how I said anything different? All I said was one can possibly do a FAST before proceeding to the lap. Management does not mean treatment alone, depending on the situation and condition, a diagnostic procedure is often the next step in management.

 

[thefritz]

I don't see how I said anything different? All I said was one can possibly do a FAST before proceeding to the lap. Management does not mean treatment alone, depending on the situation and condition, a diagnostic procedure is often the next step in management.

Your post implied that it might be reasonable to do a FAST when it is unclear if there is penetrating abdominal trauma. For the purposes of this test, every resource I have studied has said that it is not. FAST and DPL only come into the picture when there is blunt abdominal trauma or some other etiology for abdominal bleeding besides obvious penetration (even for a perfed ulcer they're not right --> it's upright cxr). Doing a FAST on abd. GSW pt. doesn't change management, so it doesn't need to be done. positive, neg, or inconclusive still get an exlap. USMLE seems to test whether you know if a test is indicated or not on the basis of whether it changes management and if nothing else more pressing needs to be done first.

My guess is that the most tested concept here is going to be exlap for penetrating trauma, not when to do a FAST and what to do with the results.

 

[thehundredthone]

And even if he were stable, for boards, the answer is exlap.

There is a UWorld question where a stable GSW patient undergoes a CT. Granted though, they don't ask you to do the CT, it has already been done and you just need to say that the laparotomy is next.

Your post implied that it might be reasonable to do a FAST when it is unclear if there is penetrating abdominal trauma. For the purposes of this test, every resource I have studied has said that it is not.

It's not my personal opinion. Like I said, I was paraphrasing the explanation for UWorld 3221, which does say it's reasonable.

Again, I did cede that for the purpose of the test, the lap is going to be the step (if) you have to choose.

 

[Mwalk7]

So if unstable gunshot wound, skip the FAST and go straight to ex lap?

What if unstable blunt abdominal trauma, do FAST and then ex lap?

Taking it tomorrow and just confused on this point

 

[evilbooyaa]

There is a UWorld question where a stable GSW patient undergoes a CT. Granted though, they don't ask you to do the CT, it has already been done and you just need to say that the laparotomy is next.


It's not my personal opinion. Like I said, I was paraphrasing the explanation for UWorld 3221, which does say it's reasonable.

Again, I did cede that for the purpose of the test, the lap is going to be the step (if) you have to choose.

UWorld question stems will do a lot of unnecessary (and sometimes in correct things) in their work-up of symptoms.

If you saw a patient w/ new onset tachypnea after a surgery/long car ride/return from vacation + homan's sign, you'd go w/ heparin or spiral CT immediately. UWorld routinely has these patients waste time w/ a CXR (clear), EKG (sinus tach), and ABG (hypoxia + resp. alk).

If a person has a GSW, it doesn't matter what else they've had done. You're answer choice for next step is an ex-lap.

 

[thehundredthone]

If a person has a GSW, it doesn't matter what else they've had done. You're answer choice for next step is an ex-lap.

And I have been agreeing with you guys for the past few posts, now.

So if unstable gunshot wound, skip the FAST and go straight to ex lap?

What if unstable blunt abdominal trauma, do FAST and then ex lap?

Yes, you've got it right. I'd lean even more towards FAST in BAT if there is a concomitant pelvic injury because you need to know which cavity the patient is bleeding into before opening them up.

 

[thefritz]

What if unstable blunt abdominal trauma, do FAST and then ex lap?

See my post above outlining every possible scenario.
It depends on how unstable they are. If they are hypotensive but maintaining borderline pressures after fluid, FAST is ok. If they are crashing even after fluids, they have to go to the OR.