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Difficulty: MediumTrauma and Burns

Paramedics transport a 32-year-old man to the trauma resuscitation bay following an altercation outside a restaurant. The patient sustained a single stab wound to the left lower abdominal quadrant. He is awake, alert, and conversant. Vital signs show a temperature of 37.0∘C37.0^\circ\text{C} (98.6∘F98.6^\circ\text{F}), heart rate of 92/min92/\text{min}, respiratory rate of 16/min16/\text{min}, and blood pressure of 128/82 mm Hg128/82 \text{ mm Hg}. Physical examination reveals a 3-cm3\text{-cm} laceration in the left lower quadrant with a segment of omentum actively protruding through the defect. The remainder of the abdomen is soft and non-tender. Two large-bore intravenous lines are established. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Computed tomography of the abdomen and pelvis with intravenous contrast
  3. C
    Local wound exploration under local anesthesia
  4. D
    Focused assessment with sonography for trauma (FAST)
  5. E
    Intravenous administration of broad-spectrum antibiotics and serial abdominal examinations

Answer

Immediate exploratory laparotomy is required due to the presence of an evisceration.
The most appropriate next step in management is an immediate exploratory laparotomy. In the setting of penetrating abdominal trauma, there are three absolute 'hard signs' that mandate immediate surgical exploration: hemodynamic instability, generalized peritonitis (e.g., rebound tenderness, rigidity), and evisceration of intra-abdominal contents (such as bowel or omentum). Because this patient has an obvious evisceration, the peritoneal cavity has definitively been breached, and there is a high likelihood of underlying hollow viscus or solid organ injury. Proceeding directly to the operating room is required to assess for and repair internal injuries, regardless of the fact that the patient currently has normal vital signs and a soft abdomen.

Step-by-Step Solution

1
Evaluate the mechanism of injury and patient stability.
The patient has a penetrating abdominal injury (stab wound) but remains hemodynamically stable.
Initial trauma assessment dictates checking ABCs and vital signs to determine if the patient is in hemorrhagic shock.
2
Assess for 'hard signs' of penetrating abdominal trauma.
Physical examination reveals protruding omentum (evisceration).
Hard signs immediately dictate the management pathway, bypassing further diagnostic imaging.
3
Determine the appropriate clinical intervention based on the physical findings.
The patient is triaged directly to the operating room.
Evisceration, peritonitis, or hemodynamic instability in the setting of penetrating abdominal trauma are absolute indications for immediate exploratory laparotomy.

Key Concept

Patients with penetrating abdominal trauma who exhibit 'hard signs' (evisceration, peritonitis, or hemodynamic instability) require immediate exploratory laparotomy, regardless of normal vital signs.
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Topics

Trauma and Burns

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