Tag Archives: abdomen

What Would You Do? Teensy Weensy Stab To The Abdomen – Part 2

Yesterday, I presented the case of a young man with a teensy weensy little stab to his abdomen, just above the umbilicus. There was a tiny bit of oddly colored fat that was visible in the wound. So now what should we do?

The first thing is to figure out what that bit of fat is. It doesn’t have the normal large pebbling and color of subcutaneous fat. Therefore, it must be a small piece of omentum protruding from the wound.

And what is the significance of that? This question has been addressed by papers with low numbers of subjects since the 1980s. It really depends on what country you are located in. Do you have readily available OR resources? Are there pressures to minimize hospital stays (US)?

One of the earliest papers originated from Parkland Hospital in Dallas TX. They reviewed 115 cases of omental evisceration over a 4 year period, and found that “serious” abdominal injuries were found in 75% of them. All went to laparotomy, and injuries to not one, but two organs were noted in about half of the positive cases. There was a 7% complication rate with negative laparotomy,

Contrast this with a study from Kingston, Jamaica where 66 patients with abdominal stabs and omental evisceration were treated. Of these, 14 were treated with observation because they had a normal abdominal exam. All were treated successfully without operation. But note the ratio here: 14/66 = 21%, which is the same as the negative laparotomy in the Parkland study (25%). So this study implies that if the patient can be watched and does not develop symptoms, the negative lap may be avoided.

Unfortunately, in many countries there are pressures to get people out of the hospital as soon as possible. Since small bowel content is relatively benign (at first), patients may not become symptomatic for several days. It would probably be difficult to convince your hospital to keep patients laying around for serial exams for days on end. Not to mention the logistical problems of doing good serial exams.

So most trauma professionals will be compelled to do something. And what should we do? Here are some possibilities. Pick your poison, and I’ll give you my choice tomorrow.

  • Local wound exploration
  • CT scan of the abdomen
  • Proceed to the operating room

As before, leave a comment to let me know what you would do. Or tweet it out!

References:

  1. Significance of omental evisceration in abdominal stab wounds. Am J Surg 152(6):670-673, 1986.
  2. Non-operative management of stab wounds to the abdomen with omental evisceration. J Royal Col Surg Edin 41(4):239-240, 1996.

How To: The Serial Abdominal Exam

How often have you seen this in an admitting history and physical exam note? “Admit for observation; serial abdominal exams.” We say it so often it almost doesn’t mean anything. And during your training, did anyone really teach you how to do it? For most trauma professionals, I believe the answer is no.

Yet the serial abdominal exam is a key part of the management of many clinical issues, for both trauma patients as well as those with acute care surgical problems.

Here are the key points:

  • Establish a baseline. As an examiner, you need to be able to determine if your patient is getting worse. So you need to do an initial exam as a basis for comparisons.
  • Pay attention to analgesics. Make sure you know what was given last, and when. You do not need to withhold pain medications. They will reduce pain, but not eliminate it. You just need enough information to determine if the exam is getting worse with the same amount of medication on board.
  • Perform regular exams. It’s one thing to write down that serial exams will be done, but someone actually has to do them. How often? Consider how quickly your patient’s status could change, given the clinical possibilities you have in mind. In general, every 4 hours should be sufficient. Every shift is not. And be thorough!
  • Document, document, document. A new progress note should be written, dated and timed, every time you see your patient. Leave a detailed description of how the patient looks, vital signs, pertinent labs, and of course, exact details of the physical exam.
  • Practice good handoffs. Yes, we understand that you won’t be able to see the patient shift after shift. So when it’s time to handoff, bring the person relieving you and do the exam with them. You can describe the pertinent history, the exam to date, the analgesic history, and allow them to establish a baseline that matches yours. And of course, make sure they can contact you if there are any questions.

EAST 2017 #2: CT Scan After Recent Operative Exploration for Penetrating Trauma

The general rule for penetrating trauma, especially gunshots to the abdomen, is that you don’t need to obtain a CT scan to help you decide to go to the OR. (Of course, there are a few exceptions.) And the corollary has always been that you don’t need to get a CT scan after you operate for penetrating trauma.

But the group at UCSF is questioning this. They retrospectively looked at 5 years of data on patients who underwent trauma laparotomy without preoperative imaging. They focused on new findings on CT that were not reported during the initial operation.

Here are the factoids:

  • 230 of 328 patients undergoing a trauma lap did not have preop imaging
  • 85 of the 230 patients (37%) underwent immediate postop CT scan. These patients tended to have a gunshot mechanism and higher injury severity score.
  • Unreported injuries were found in 45% (!) and tended to be GU and orthopedic in nature
  • 47% of those with unreported injuries found required some sort of intervention

Bottom line: This is a very interesting and potentially practice changing study. However, there is some opportunity for bias since only select patients underwent postop scanning. Nevertheless, one in five patients who did get a postop scan had an injury that required some sort of intervention. This study begs to be reworked to further support it, and to develop specific criteria for postop scanning.

Questions/comments for the authors/presenters:

  • Be sure to break down your results by gunshot vs stab. This will help formulate those criteria I mentioned above.
  • Specifically list the occult injuries and interventions required. In some studies, those “required interventions” are pretty weak (urology consult vs an actual procedure).
  • How exactly did the operating surgeons determine who to send to CT? Was it surgeon-specific (i.e. one surgeon always did, another never did)? Was it due to operative findings (hole near the kidney)? This is also needed when developing specific criteria for postop imaging.
  • Nice poster!

Click here to go the the EAST 2017 page to see comments on other abstracts.

Related posts:

Reference: Routine tomography after recent operative exploration for penetrating trauma: what injuries do we miss?  Poster #14, EAST 2017.

How To: The Serial Abdominal Exam

How often have you seen this in an admitting history and physical exam note? “Admit for observation; serial abdominal exams.” We say it so often it almost doesn’t mean anything. And during your training, did anyone really teach you how to do it? For most trauma professionals, I believe the answer is no.

Yet the serial abdominal exam is a key part of the management of many clinical issues, for both trauma patients as well as those with acute care surgical problems. 

Here are the key points:

  • Establish a baseline. As an examiner, you need to be able to determine if your patient is getting worse. So you need to do an initial exam as a basis for comparisons. 
  • Pay attention to analgesics. Make sure you know what was given last, and when. You do not need to withhold pain medications. They will reduce pain, but not eliminate it. You just need enough information to determine if the exam is getting worse with the same amount of medication on board.
  • Perform regular exams. It’s one thing to write down that serial exams will be done, but someone actually has to do them. How often? Consider how quickly your patient’s status could change, given the clinical possibilities you have in mind. In general, every 4 hours should be sufficient. Every shift is not. And be thorough!
  • Document, document, document. A new progress note should be written, dated and timed, every time you see your patient. Leave a detailed description of how the patient looks, vital signs, pertinent labs, and of course, exact details of the physical exam.
  • Practice good handoffs. Yes, we understand that you won’t be able to see the patient shift after shift. So when it’s time to handoff, bring the person relieving you and do the exam with them. You can describe the pertinent history, the exam to date, the analgesic history, and allow them to establish a baseline that matches yours. And of course, make sure they can contact you if there are any questions.