What is the management for a patient with a stab wound to the epigastrium, presenting with hypotension and hematemesis after the object (knife) was removed?

Emergency Management of Epigastric Stab Wound with Hemorrhagic Shock

This patient requires immediate surgical exploration (laparotomy) without delay—the combination of profound hypotension (BP 60/palpation) and hematemesis after an epigastric stab wound indicates Class IV hemorrhagic shock with likely major vascular or hollow viscus injury requiring urgent operative bleeding control. 1, 2

Immediate Resuscitation (Simultaneous with Surgical Preparation)

Airway and Breathing

• Secure the airway immediately and provide high-flow oxygen or intubate if the patient shows signs of altered mental status (expected with this degree of shock). 3
• Avoid hyperventilation—maintain normal ventilation rates as hyperventilation decreases cardiac output and worsens outcomes in hypovolemic trauma patients. 1

Circulation and Hemorrhage Control

• Establish large-bore IV access (two large-bore peripheral lines or central access) and begin aggressive crystalloid resuscitation immediately. 2, 3
• Target permissive hypotension with systolic BP 80-100 mmHg until surgical bleeding control is achieved—avoid aggressive fluid resuscitation to "normal" blood pressure as this worsens coagulopathy and increases bleeding. 2
• Initiate massive transfusion protocol immediately—this patient has Class IV shock (>40% blood volume loss, BP decreased, likely >2000 mL blood loss) and requires immediate blood product administration. 1, 2
• Administer emergency release blood products (O-negative or type-specific) without waiting for crossmatch. 1

Vasopressor Support

• Consider norepinephrine only if hypotension persists despite adequate fluid resuscitation, maintaining systolic BP 80-100 mmHg. 2, 4
• Critical caveat: Norepinephrine is contraindicated as primary therapy when blood volume depletion has not been addressed—it should only be used as a bridge while blood volume replacement continues. 4

Diagnostic Approach (DO NOT DELAY SURGERY)

Clinical Assessment

• This patient meets criteria for immediate laparotomy based on presentation alone: penetrating epigastric injury + profound shock (BP 60/palpation) + hematemesis indicating upper GI bleeding. 1, 2
• The hematemesis suggests injury to the stomach, duodenum, or major vessels (potentially celiac axis, superior mesenteric vessels, or aorta given the epigastric location). 5

Imaging Considerations

• Do NOT obtain CT imaging—this patient is hemodynamically unstable and requires immediate operative intervention. 1, 6
• Perform bedside FAST ultrasound only if it can be done within 1-2 minutes during resuscitation to confirm free intraperitoneal fluid, but do not delay surgery for this. 2, 6
• Obtain portable chest X-ray only if it does not delay transfer to the operating room, to assess for pneumothorax or hemothorax. 6

Surgical Management

Damage Control Surgery Approach

• Employ damage control surgery principles—this patient meets all criteria: deep hemorrhagic shock, signs of ongoing bleeding, and likely developing coagulopathy given the massive blood loss. 1, 2
• Damage control surgery indications present: profound shock, ongoing bleeding, hypothermia (likely developing), acidosis (likely developing), and potential for time-consuming procedures given epigastric location. 1

Operative Strategy

• Perform immediate exploratory laparotomy via midline incision for rapid access and ability to extend as needed. 1
• Epigastric stab wounds can injure: stomach, duodenum, pancreas, liver, transverse colon, major vessels (aorta, celiac axis, superior mesenteric artery/vein), and diaphragm. 5
• Control hemorrhage first with packing, direct pressure, or vascular control before definitive repair. 1
• Limit initial surgery to hemorrhage control and contamination control—plan for staged reconstruction after physiologic recovery. 1, 2

Critical Time Considerations

• Target <60 minutes from arrival to operating room for patients in hemorrhagic shock—delays significantly increase mortality. 1
• Minimize time in emergency department—resuscitation should continue en route to and in the operating room. 1, 2

Common Pitfalls to Avoid

• Never remove impaled objects in the field or ED—this has already occurred and likely worsened bleeding, but emphasizes the importance of leaving objects in place until surgical control is available. 7
• Do not delay surgery for "complete resuscitation"—surgery IS the resuscitation for this patient. 1, 2
• Avoid excessive crystalloid administration which worsens coagulopathy, hypothermia, and acidosis (the "lethal triad"). 1, 2
• Do not use diagnostic peritoneal lavage or wound exploration—these are only for stable patients without clear operative indications. 5, 8, 9

Classification of Shock Severity

This patient demonstrates Class IV hemorrhagic shock based on: 1, 2

• Blood loss >2000 mL (>40% blood volume)
• Heart rate likely >140 bpm
• Systolic BP 60 mmHg (severely decreased)
• Altered mental status expected (confused/lethargic)
• Negligible urine output expected

Response to resuscitation will be "minimal or no response" indicating need for immediate surgical intervention and emergency blood release. 1