Thoracoabdominal stab wound

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.

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

Quote:

Originally Posted by Doc Dutch

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.

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

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-