Management of Abdominal Stab Wounds
Immediate Assessment: Determine Hemodynamic Status
Hemodynamically unstable patients (systolic BP <90 mmHg, heart rate >120 bpm, shock signs), those with evisceration, or signs of peritonitis require immediate laparotomy without delay for imaging. 1, 2, 3
- Approximately 84-92% of these emergency laparotomies will be therapeutic 4, 5
- Do not waste time on extensive diagnostic workup in unstable patients 3
Hemodynamically Stable Patients: Algorithmic Approach
Step 1: Local Wound Exploration (LWE) for Anterior Wounds
For anterior abdominal stab wounds, perform local wound exploration first to determine if the anterior fascia has been breached. 1, 2
- If fascia is NOT violated: Patient can be safely discharged from the emergency department (no peritoneal penetration) 1, 2, 5
- If fascia IS violated: Proceed to selective non-operative management (NOM) with heightened clinical suspicion 1
Step 2: Imaging Strategy Based on Wound Location
CT imaging decisions depend critically on anatomic location of the stab wound. 1, 2
- Posterior or flank wounds: CT scan is mandatory because clinical examination cannot adequately assess retroperitoneal organs and colon 1, 3
- Anterior wounds: Can be managed primarily with serial clinical examinations; CT is less essential 1
- CT has approximately 80% sensitivity for detecting bowel injury in stab wounds 1, 2
Hard signs on CT requiring immediate laparotomy include: 1, 3
- Extraluminal air
- Extraluminal contrast extravasation
- Bowel wall defects
- Active vascular extravasation
Step 3: Non-Operative Management (NOM) Requirements
NOM can only be performed at specialized centers with ALL of the following resources available: 1, 2, 3
- Serial clinical examinations by experienced/consistent specialists or consultants
- Continuous vital signs monitoring
- Immediate 24/7 access to operating room
- ICU admission capability if needed
- Serial hemoglobin and inflammatory marker testing
Minimum observation period is 48 hours. 1, 2, 3
Step 4: Triggers for Surgical Intervention During NOM
Any of the following findings mandate immediate surgical exploration: 1, 2
- Hemoglobin drop ≥2 g/dL from baseline (without alternative explanation) 1
- Worsening vital signs 1
- Development of peritoneal signs on examination 1
- Worsening abdominal examination 1
Role of Laparoscopy
When CT does not show hard signs of bowel injury, screening laparoscopy can investigate for peritoneal violation and guide decision between laparotomy versus NOM. 1, 2
- Patients without peritoneal violation confirmed by laparoscopy can be safely discharged 1, 2
- Laparoscopy is emerging as a safer alternative to CT for anterior penetrating trauma 1, 2
- Consider interval laparoscopy in obese patients or when wound trajectory is unclear 1
Critical Pitfalls to Avoid
Do not discharge patients based solely on negative CT scan unless a tangential extraperitoneal wound tract is definitively confirmed 1
Do not rely on initial hemoglobin values as they take hours to equilibrate and may be falsely reassuring 3
Do not attempt NOM without the full complement of required resources (experienced examiners, continuous monitoring, immediate OR access) 1, 2, 3
Even with organ or omental evisceration, selective NOM may be appropriate in carefully selected stable patients at experienced centers, though therapeutic laparotomy rates remain high (approximately 67-72%) 6