How should I assess and manage a 25-year-old male with cyclothymic disorder and attention‑deficit/hyperactivity disorder who presents after a self‑inflicted penetrating abdominal wound from a contaminated fork, stable vital signs, currently taking aripiprazole 10 mg daily and lamotrigine 100 mg daily, with no other medical comorbidities, allergic to seafood, and unknown tetanus immunization status?

Assessment and Plan: Self-Inflicted Abdominal Stab Wound in Patient with Cyclothymic Disorder and ADHD

Immediate Hemodynamic Assessment

This patient is hemodynamically stable (GCS 15, awake, not in distress, normal vital signs) and does not require immediate operative intervention. 1 The American College of Surgeons defines hemodynamic stability as systolic BP ≥90 mmHg and heart rate 50-110 bpm, which this patient meets. 2 However, stable appearance does not reliably exclude serious visceral injuries, mandating aggressive diagnostic work-up and serial clinical monitoring. 2

Wound Assessment and Imaging

• Obtain abdominal radiographs immediately to identify the fork tines and assess for pneumoperitoneum or retained foreign body. 3, 4
• Perform local wound exploration to determine if the peritoneum has been violated—this is the critical decision point for management. 4, 5
• If local wound exploration is positive for peritoneal violation, proceed directly to laparotomy without delay, as 65% of patients with positive exploration have intra-abdominal injuries requiring surgical repair. 4
• If local wound exploration is negative, admit for 48-hour observation with serial clinical examinations every 4-6 hours, as this is the gold standard for deciding operative versus non-operative management. 1, 2
• Do not obtain CT scan if peritoneal violation is confirmed on local exploration—proceed directly to surgery. 1

Infection Prevention

• Administer first-generation cephalosporin (cefazolin 2g IV) immediately for 48-72 hours, as all penetrating abdominal wounds require antibiotic prophylaxis. 1, 2
• Add penicillin if gross contamination is present to cover anaerobes (Clostridium species), though this is less likely with a fork injury. 2, 6
• Administer tetanus toxoid (Td or Tdap) immediately given unknown immunization status and contaminated wound. 1

Surgical Decision-Making

Indications for immediate laparotomy include: 1, 4

• Evidence of peritonitis on physical examination
• Evisceration of abdominal contents
• Signs of hollow viscus perforation (free air, peritoneal signs)
• Hemodynamic instability (systolic BP <90 mmHg, HR >120 bpm)
• Positive local wound exploration with peritoneal violation

Self-inflicted abdominal stab wounds typically cause 1.7 injuries per patient (most commonly stomach, duodenum, small bowel, colon, mesentery), but are rarely lethal. 4 The right upper quadrant (40%) and right lower quadrant (23%) are the most common injury sites in self-inflicted wounds. 4, 5

Non-Operative Management Protocol (If Peritoneum Not Violated)

Minimum 48-hour observation period is mandatory with the following resources: 1

• Serial clinical examinations every 4-6 hours
• Continuous vital signs monitoring
• Serial hemoglobin measurements (every 6-12 hours)
• Serial inflammatory markers (WBC, CRP) if available
• Immediate access to operating room
• ICU admission capability

Do not discharge based on negative initial assessment alone—clinical observation over 48 hours is required. 1, 2

Psychiatric Assessment and Safety

• Conduct immediate psychiatric evaluation by a clinician experienced in evaluating mental health conditions, as 74% of self-inflicted abdominal stab wound patients have previous psychiatric history. 4, 7
• Place patient on 1:1 observation with personal belongings search and hospital attire to prevent repeat self-harm. 7
• Interview patient and family separately to assess suicidal intent, as patients frequently minimize severity of symptoms. 7
• Screen for comorbid conditions including depression, anxiety, substance use (50% have positive admission drug/alcohol screen in self-inflicted wounds), and assess for continued suicidal ideation. 7, 4
• Plan for psychiatric ward transfer after medical clearance, as 70% of self-inflicted abdominal stab wound patients require psychiatric admission. 4

Comorbidity Considerations

Cyclothymic disorder and ADHD frequently co-occur (15% comorbidity rate) and show similar levels of emotional dysregulation. 8 Patients with both conditions demonstrate significantly higher affective instability and negative emotional dysregulation. 8 This patient's aripiprazole and lamotrigine should be continued throughout hospitalization to maintain mood stability. 7

Assess for increased suicide risk factors: 7

• Continued desire to die
• Severe hopelessness
• Inability to engage in safety planning
• Inadequate support system
• High-lethality attempt with clear expectation of death

Common Pitfalls to Avoid

• Do not rely on initial hemoglobin, as it takes hours to equilibrate and may be falsely reassuring. 1
• Do not discharge based on negative imaging alone—48-hour clinical observation is mandatory. 1, 2
• Do not assume low injury severity—self-inflicted wounds can cause significant intra-abdominal injuries including IVC and retroperitoneal injuries. 4
• Do not overlook psychiatric comorbidities—28% of assault victims also have psychological disorders, and all self-harm patients require psychiatric evaluation. 5, 7

Expected Clinical Course

Mean length of stay on surgical service is 8 days for self-inflicted abdominal stab wounds. 4 Wound infection is the most common post-operative complication (occurring in 13% of cases). 4 Mortality from self-inflicted abdominal stab wounds is rare (<5%), as these injuries are typically non-lethal despite potential for significant organ damage. 4