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Doc Dutch
02-01-2009, 09:29
Okay, so a young 17 year old male comes in with a stab wound to his thoraco-abdominal region. He was a "drop off" at the ER's front doors and left by his "friends". I heard "Trauma Team to the emergency department NOW!" overhead and immediately went to see what was happening.

This is what I found on arrival. I took a picture. He only complained of left chest wall pain and slight SOB.

Thoughts on how you would handle this?

Oh . . . and yes, that is what you think it is hanging out!



Dutch

Warrior-Mentor
02-01-2009, 09:36
Can't tell by the photo... is that flesh or a blood soaked tampon hanging out?

Patriot007
02-01-2009, 09:53
I'll defer to those that have more experience. Just wanted to thank you Doc for sharing these cases.

Sdiver
02-01-2009, 09:58
From an EMT-B perspective, If we were called on this in the field, instead of it being a walk in.....

O2 15L via NRB

Bandage wound with sterile moist dressing, with possible occlusive dressing over it.

Start a large bore IV 14 or 16 g angio, with a fluid bolus.

Monitor vitals.

Transport Code 3 to a Level I trauma center and hand off to someone in a higher pay grade than me.

:munchin

Doc Dutch
02-01-2009, 11:04
Okay, then, this is an evisceration. That is omentum hanging out of the abdomen. Also called the "policeman of the abdomen" or the "watchdog of the abdomen". It will make its way to inflammation or an area of abnormalcy. It is a fatty apron with blood vessels.

At the site of the stab wound the omentum is hanging out of the thoracoabdominal laceration!

Sdiver said,

"O2 15L via NRB

Bandage wound with sterile moist dressing, with possible occlusive dressing over it.

Start a large bore IV 14 or 16 g angio, with a fluid bolus.

Monitor vitals.

Transport Code 3 to a Level I trauma center and hand off . . . "

That is a good start. If you use an occlusive dressing make it only three sides as this is a thoracoabdominal wound and the lung may be involved and could cause a tension pneuothorax."

Like the IV's, the fluid bolus, sterile dressing, and get the patient to the trauma center.

Now what . . . ?

D-

Sdiver
02-01-2009, 11:10
Okay, then, this is an evisceration. That is omentum hanging out of the abdomen. Also called the "policeman of the abdomen" or the "watchdog of the abdomen". It will make its way to inflammation or an area of abnormalcy. It is a fatty apron with blood vessels.

At the site of the stab wound the omentum is hanging out of the thoracoabdominal laceration!

Sdiver said,

"O2 15L via NRB

Bandage wound with sterile moist dressing, with possible occlusive dressing over it.

Start a large bore IV 14 or 16 g angio, with a fluid bolus.

Monitor vitals.

Transport Code 3 to a Level I trauma center and hand off . . . "

That is a good start. If you use an occlusive dressing make it only three sides as this is a thoracoabdominal wound and the lung may be involved and could cause a tension pneuothorax."

Like the IV's, the fluid bolus, sterile dressing, and get the patient to the trauma center.

Now what . . . ?

D-

Go to the EMS lounge and finish my paperwork. I've made my hand off. :p :D

I'd be interested to see where it goes next. :munchin

One thing I forgot to put was, attempt to find out the size and type of blade used (serrated v non-serrated), and include that in my hand off report.

Doc Dutch
02-02-2009, 14:48
Continuing on . . . Evisceration is a surgical emergency. The only place to be is in the OR. So, we went to the Trauma OR.

First, under anesthesia, I placed a chest tube for fear of pneumothorax. I opened up his abdomen. Here is a picture of the clamp holding up the omentumn with the chest tube in place in the left chest. Please notice the blue sterile drapes.

D-

Doc Dutch
02-02-2009, 16:14
Ok, so now what?

Well, with the evisceration in the thoracoabdominal region, I suspected that the diaphragm had been violated by the knife (lacerated the diaphragm) and that is why the omentum from the abdomen went through the lacerated muscle into the chest and then out of the chest wall to the outside.

This next photo (labelled) shows the omentum going through the diaphragm muscle and into the chest. See my hand holding back the small and large bowel and mesentry as a metal retractor lifts the abdominal wall up so we can take a photo. See the omentum going through the diaphragmatic laceration.

I repaired this by pulling the omentum back into the abdomen, closed the diaphragm laceration with suture, explored the rest of the abdomen for more injuries (none found) and closed the abdomen. I left the chest tube in until the lung sealed with no airleak in the pleuravac cannister and had a nomal chest x-ray.

Patient did fine and left a few days later.

Thoughts?

D-

RichL025
02-02-2009, 23:40
Beautiful pic, thanks DD.

Please tell me you have residents working with you!

Qs-
did you get CXR in the trauma bay or just empiric chest tube enroute to OR?

What did you close diaphragm with?

Let's change the scenario a little - same wound, except with a fair amount of EBL and a hypotensive patient. Maybe it's bleeding right now copiously. Chest or abdomen first?

Thanks,

RL

Doc Dutch
02-03-2009, 14:07
Beautiful pic, thanks DD.

Please tell me you have residents working with you!

Qs-
did you get CXR in the trauma bay or just empiric chest tube enroute to OR?

What did you close diaphragm with?

Let's change the scenario a little - same wound, except with a fair amount of EBL and a hypotensive patient. Maybe it's bleeding right now copiously. Chest or abdomen first?

Thanks,

RL

Great questions and yes we do have residents . . .

First, yes, I did get a chest x-ray in the trauma bay. A good rule of thumb is that no trauma patient should ever leave the trauma bay without a chest x-ray. It is critical that if you can only get one x-ray that it is the chest x-ray. In this patient you would be looking for a pneumo- or hemothorax or both potentially. His chest x-ray showed a moderate pneumothorax. So, I placed the chest tube at the time of intubation in the OR as he was hemodynamically stable.

Now, if he was hemodynamically unstable in the trauma bay, I would have placed it there. As it turned out, we only had about 50 to 60 cc's of blood come out of the chest tube in the OR. His pneumothorax resolved, I want to say in three or four days and then we pulled it out.

Second question: I used to use an O Ethibond or Number 1 Vicryl but now I use a number 1 PDS in an interrupted or a figure of eight suture.

Third question: If I have placed the chest tube in the ED, I look for how much is coming out of the chest tube into the pleuravac. If it is greater than 20cc/kg or greater than 1.5 liters immediately, I would go where the trouble is. So, it would be the chest, first. Now, if the chest tube is putting out minimal blood and he is hypotensive, then straight to the abdomen because the spleen is right there and may have been transected or the aorta that may have a hole lacerated in it. This is especially true with abdominal distension or peritonitis. If fluids stabilize him (he is a IV fluid responder and we buy some time, you might consider a CT of the abdomen with IV contrast).

If it is the wound pouring out blood and you do not know which cavity it is, I would stop, place the chest tube and examine the abdomen. Again, if the chest tube is pouring out blood, then go to the chest and if the chest tube made no difference and there is no blood coming out or very little, then go to the abdomen. If you have an ultrasound in the ED, do a FAST (Focused Assesment Sonography for Trauma) examination. You can see the abdomen, pelvis, retroperitoneum, pericardium, and chest as well.

Really good questions!

Dutch

Patriot007
02-03-2009, 16:13
Doc Dutch,

How does evaluation and treatment for peritonitis figure into your course of action? If the patient is hemodynamically stable and you are confident there are no significant bleeders is peritonitis the next big "killer" you should be worried/ evaluate for after ABC's? If so, how early can/ usually will it present in a low velocity penetrating wound such as a knife wound? Thanks for the education!

Doc Dutch
02-03-2009, 18:16
Doc Dutch,

How does evaluation and treatment for peritonitis figure into your course of action? If the patient is hemodynamically stable and you are confident there are no significant bleeders is peritonitis the next big "killer" you should be worried/ evaluate for after ABC's? If so, how early can/ usually will it present in a low velocity penetrating wound such as a knife wound? Thanks for the education!

Another good question:

Peritonitis in the face of pentrating trauma is ominous. Even if a patient is hemodynamically stable, a rigid abdomen needs prompt evaluation as the this usually means blood or enteric content and with abdominal penetration, watch out! So, I usually take them to the OR.

Honestly,one is never sure in the trauma bay that there are no "significant bleeders" as the patient may just be physiologically compensating, but if for the sake of argument, let us say that there is no significant bleeders, then peritonitis means bowel perforation and that is a killer if you delay or don't operate. Patients will eventually become septic and will die of multi-system organ failure which happened in WWI and prior as it was believed that to operate on the abdomen was foolish and heresy.

Knife wounds (low velocity) can obviously penetrate deeply and it is hard to know when the patient comes into the ED how deep the knife went. The wound could be superficial and just cut the skin and subcutaneous tissue and then it can go through and through from anterior to posterior and everything in between. Laparoscopy, DPL, CT scans, ultrasound, and local wound exploration are all modalities that can be used to evaluate the abdomen in general, but the bottom line is that penetrating trauma that goes through the fascia + peritonitis = surgical exploration.

Dutch

Doc Dutch
02-03-2009, 18:30
One last thing - ABCDE's and secondary survey are all inclusive in this. A complete physical examination is crucial. Peritonitis is huge and an acute abdomen should never be ignored in the face of the penetrating injury to the abdomen.

The timing for the development of peritonitis can be delayed or immediate, but maintaining a high index of suspicion and a detailed evaluation of the stab wound, even local wound exploration to see if the anterior stab wound passed the facia cannot be underestimated. So, a strong consideration for wound exploration is important in any anterior abdominal stab wound especially without peritonitis to prove you do not have fascial penetration.

Penetration of the thoracoabdominal region or chest can be fraught with danger and is not currently advised in the ED. Consider a chest X-ray and chest tubes, even chest CT scans for even more detailed examinations.

D-

AF Doc
02-07-2009, 12:25
Great case, thanks for sharing and the nice photos.