General Surgery · Year 3 · from General Surgery

Case 2: Penetrating Abdominal Trauma

Patient Demographics

  • Age: 24 years
  • Sex: Male
  • Occupation: Unknown

Chief Complaint

Brought by EMS with stab wound to the abdomen

History of Present Illness

The patient was found outside a bar with a single stab wound to the left upper quadrant. Bystanders report an altercation. The patient is awake but confused and complaining of abdominal pain. The weapon (a folding knife, 4-inch blade) was recovered at the scene.

Prehospital Information

  • GCS 14 (E4V4M6)
  • BP 82/54, HR 138
  • Wound covered with sterile dressing
  • Large-bore IV access, crystalloid running

Primary Survey

  • A: Airway intact, speaking
  • B: Bilateral breath sounds, tachypneic (RR 28)
  • C: BP 78/50, HR 142, weak thready pulses, cold and clammy
  • D: GCS 13 (confused)
  • E: Single stab wound in left upper quadrant, 2 cm in length

Assessment

  • Class III-IV hemorrhagic shock
  • Penetrating abdominal trauma

Immediate Management

  1. Massive transfusion protocol activated
  2. Permissive hypotension target (SBP 80-90) until OR
  3. Blood products administered
  4. Emergency department thoracotomy NOT indicated (has pulse)
  5. Direct to OR for exploratory laparotomy

Decision: OR vs. Further Workup

Indications for immediate laparotomy:

  • Hemodynamic instability
  • Peritonitis
  • Evisceration
  • Impalement (not this case)

Patient meets criteria → Emergent laparotomy

Operative Procedure

Exploratory Laparotomy (Damage Control):

Findings:

  • 1.5L hemoperitoneum
  • Splenic hilum laceration (actively bleeding)
  • Gastric perforation (anterior wall, near greater curvature)
  • Diaphragm laceration (left hemidiaphragm, 3 cm)
  • No other injuries on systematic exploration

Procedures:

  1. Splenectomy (hilum injury, unable to salvage)
  2. Primary repair of gastric perforation (two-layer closure)
  3. Repair of diaphragm laceration (primary suture)
  4. Thorough abdominal washout
  5. Primary fascial closure (patient physiologically stable)

Intraoperative Blood Products

  • 6 units PRBCs
  • 4 units FFP
  • 1 unit platelets
  • Ratio approximately 1:1:1

Postoperative Course

  • ICU admission
  • Extubated POD 1
  • Diet advanced POD 3
  • Ambulatory POD 4

Post-Splenectomy Prophylaxis

  • Vaccinations administered before discharge:
  • Pneumococcal (PCV13 and PPSV23)
  • Meningococcal (MenACWY and MenB)
  • Haemophilus influenzae type b
  • Patient education on OPSI risk
  • Medical alert identification recommended
  • Low threshold for antibiotics with febrile illness

Discharge

  • POD 5
  • Oral antibiotics not routinely needed
  • Follow-up with trauma surgery
  • Social work consulted regarding circumstances of injury

Teaching Points

  1. Penetrating abdominal trauma with shock = immediate laparotomy
  2. Stab wounds to the left upper quadrant can injure spleen, stomach, diaphragm, and colon
  3. Systematic exploration of all abdominal organs required
  4. Damage control principles when patient is physiologically compromised
  5. 1:1:1 blood product ratio in massive transfusion
  6. Post-splenectomy vaccination is critical (OPSI prevention)
  7. Left-sided penetrating trauma: Always rule out diaphragm injury

Clinical Image

Image Description: Intraoperative photograph during exploratory laparotomy for penetrating trauma demonstrating systematic exploration of the abdominal cavity. The surgeon performs a thorough evaluation of all organs following the established sequence to identify all injuries.

Attribution: Image from Wikimedia Commons, Category:Trauma surgery. Source: https://commons.wikimedia.org/wiki/Category:Trauma_surgery

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