What is the next step in managing a patient with a thoracoabdominal stab wound to the anterior left flank, normal vital signs, no peritonitis, and a computed tomography (CT) scan of the chest, abdomen, and pelvis showing gas in the anterior abdominal wall?

Management of Thoracoabdominal Stab Wound with Normal Vitals, No Peritonitis, and CT Showing Gas in Anterior Abdominal Wall

The next step in management for this patient with a thoracoabdominal stab wound to the anterior left flank, normal vital signs, no peritonitis, and CT showing only gas in the anterior abdominal wall is observation with serial clinical assessments. 1

Rationale for Observation

• The patient meets criteria for non-operative management (NOM) based on hemodynamic stability, absence of peritonitis, and negative CT findings except for subcutaneous emphysema 1
• In hemodynamically stable patients with penetrating abdominal trauma without peritonitis or evidence of hollow viscus injury, NOM is considered the standard of care 1
• The presence of gas limited to the anterior abdominal wall (subcutaneous emphysema) without intraperitoneal air suggests the wound may not have penetrated the peritoneum 1

Components of Observation

• Serial clinical assessments should be performed to detect any change in clinical status during the observation period 1
• Monitoring should include:
  • Repeated physical examinations focusing on development of peritoneal signs 1
  • Serial vital sign measurements to detect early hemodynamic changes 1
  • Laboratory testing including serial hemoglobin measurements 1

Duration of Observation

• Observation should continue for at least 24 hours, as delayed presentation of hollow viscus injuries can occur 2
• A negative CT scan alone without an observation period is inadequate to exclude significant intraabdominal injuries, particularly small bowel injuries 2

Special Considerations

• The location of the wound (anterior left flank) requires careful assessment for potential diaphragmatic injury, which can be missed on initial imaging 1, 3
• If the patient develops any signs of peritonitis, hemodynamic instability, or worsening symptoms during observation, immediate surgical intervention is indicated 1

Evidence Supporting This Approach

• Non-operative management has evolved to become standard of care for stable patients without peritonitis, with success rates exceeding 80% in properly selected patients 1
• The presence of gas limited to the anterior abdominal wall on CT likely represents air introduced at the time of injury rather than hollow viscus perforation 1
• Studies have shown that mandatory laparotomy for all penetrating abdominal wounds leads to unnecessary operations with associated morbidity 4

Common Pitfalls to Avoid

• Discharging the patient immediately after a negative CT scan without a period of observation, as CT has limited sensitivity for hollow viscus injuries (particularly small bowel) 2, 5
• Performing unnecessary laparotomy based solely on wound location without clinical indications, which increases hospital length of stay and carries significant risk of complications 1, 4
• Failing to recognize that CT may miss diaphragmatic injuries, which are more common with left-sided thoracoabdominal wounds 1, 3

Alternative Approaches to Consider

• If there is uncertainty about peritoneal violation, diagnostic laparoscopy may be considered to definitively rule out peritoneal penetration 1
• In some institutions, local wound exploration (LWE) may be used to determine if fascial penetration has occurred, though this approach has higher rates of non-therapeutic laparotomy (57%) compared to observation or CT-guided decision making 4