Management of Penetrating Torso Trauma
Hemodynamic status determines the entire management pathway for penetrating torso trauma—hypotensive patients require immediate surgical intervention with FAST examination for triage, while stable patients undergo contrast-enhanced CT imaging to guide definitive management. 1
Initial Assessment and Hemodynamic Stratification
Hemodynamic stability is defined as systolic blood pressure ≥ 90 mm Hg and heart rate 50-110 beats per minute. 1 This single determination dictates all subsequent management decisions and must be assessed before any imaging is performed. 1
Key Clinical Distinctions by Mechanism
Gunshot wounds are high-energy injuries causing radial tissue damage beyond the missile track due to kinetic energy transfer, with mortality rates of 13.7 deaths per 100,000 people and overall survival after emergency thoracotomy of only 4.3%. 1
Stab wounds are low-energy injuries affecting only tissue along the wound tract, with significantly better outcomes (15.2% survival after emergency thoracotomy) and may not require advanced imaging depending on wound depth. 1
Penetrating injuries to head, neck, torso, and proximal extremities place vital cardiopulmonary, vascular, and neurologic systems at immediate risk for exsanguinating hemorrhage and permanent disability. 1
Management Algorithm for Hypotensive Patients (SBP < 90 mm Hg)
The priority is early and aggressive hemostatic resuscitation, prompt diagnosis of life-threatening injuries, and early control of ongoing bleeding—NOT imaging. 1
Immediate Bedside Assessment
FAST examination is the primary triage tool to identify hemopericardium, pneumothorax, and free intraperitoneal fluid, which have direct implications for immediate surgical intervention. 1
Portable chest and pelvic radiographs can identify life-threatening injuries at the bedside. 1
Patients with positive FAST and hemodynamic instability proceed directly to trauma laparotomy to stop major abdominal bleeding without CT imaging. 1
Critical Time Consideration
Every 3 minutes spent in the emergency department equates to a 1% increased death probability in hemodynamically unstable penetrating trauma. 1 This underscores why traditional practice mandates operative management without CT imaging for hypotensive patients. 1
Emerging Controversy: CT in Unstable Patients
Some centers now recommend whole-body CT while continuing resuscitation regardless of hemodynamic status, arguing that information gathered helps determine optimal surgical approach and prevents delay of definitive management. 1 However, the degree of hemodynamic instability and distance to the CT scanner must be carefully considered—this approach should only be attempted in select cases where the patient can be adequately resuscitated during transport. 1
Management Algorithm for Hemodynamically Stable Patients
Contrast-enhanced CT with multiplanar reformations is the standard imaging tool due to fast acquisition and excellent resolution. 1
Optimal CT Protocol
CT chest, abdomen, and pelvis WITH IV contrast is the primary modality for stable patients. 1
Portal venous phase is optimal for assessing solid organs in abdomen and pelvis. 1
Arterial phase (multiphasic protocol) may improve identification and characterization of vascular injuries but varies by institutional protocol and clinical presentation. 1
CT without IV contrast should NOT be performed—if CT is indicated, IV contrast must be administered. 1
Highly Specific CT Findings Requiring Immediate Surgery
The presence of extraluminal air, extraluminal oral contrast, or bowel-wall defects warrants prompt surgical exploration. 1 These findings are pathognomonic for injuries requiring operative intervention. 1
Additional High-Risk CT Findings
Free air, free fluid without solid organ injury, intra-mesenteric fluid, contrast extravasation (blush), bowel wall thickening, and mesenteric stranding—when four or more of these findings are present, they are pathognomonic for bowel injury requiring surgical treatment. 1
CT grading score ≥5 points (including findings like pneumoperitoneum) indicates an 11-fold increase in bowel injury requiring surgical exploration. 1
Selective Non-Operative Management (NOM) for Penetrating Abdominal Trauma
NOM can be performed at specialized centers ONLY when all resources are available: serial clinical examinations by experienced clinicians, continuous vital signs monitoring, prompt operating room access, and ICU admission capability. 1
Prerequisites for NOM
Local wound exploration (LWE) must be performed to rule out peritoneal violation—if injury does not breach anterior fascia, patient can be discharged (other injuries permitting). 1
If peritoneum is breached, NOM can still be utilized but requires higher clinical suspicion and lower threshold for intervention. 1
Indications for Immediate Surgical Conversion
Hemoglobin decrease > 2 g/dL from baseline without other explanation. 1
Worsening vital signs or clinical examination should prompt immediate surgical exploration. 1
Development of peritoneal signs, though these may take several hours to develop as small bowel contents have neutral pH and relatively low bacterial load. 1
Role of CT in NOM
Stab wounds to back or flank rely heavily on CT to determine retroperitoneal organ or colon damage where clinical assessment is challenging. 1
Anterior stab wounds may be more easily assessed clinically, with less reliance on CT. 1
A negative CT should NOT be used as sole determinant for discharge unless a tangential and extraperitoneal wound tract is confirmed. 1
Common Pitfalls and Critical Caveats
FAST examination requires approximately 620 mL of free fluid to be detected (400 mL in highly skilled operators), and intra-abdominal free fluid is non-specific for intestinal injury. 1
Bowel injury is missed on initial CT in 20% of cases—patients with equivocal or non-specific findings require admission for observation with serial clinical examinations. 1
Peritoneal signs may take many hours to develop due to delayed bowel perforation from vascular injury causing ischemia and necrosis. 1
Follow-up CT should be considered if clinical improvement is not apparent within 8 hours, though 24-hour delay is more diagnostic but linked to higher complication rates and mortality. 1