Editing Penetrating abdo trauma (section)

=== '''Anterior stab wound''' ===

** Between costal margin and inguinal ligament anteriorly
** Try not to make treatment decisions based on reported length of knife etc - treat the patient not the weapon
** Stab wounds penetrate peritoneum 25% of the time, and 50% of those with peritoneal penetration will require laparotomy
** ''If unsure whether there has been a peritoneal breach, but the CT was normal and the patient is asymptomatic, Schein's suggests observation over 24 hours.''
*** In a patient of normal weight who is co-operative, local wound exploration is indicated (apparently do it in ED in USA but seems more likely to be done in OT here). Some centres would suggest terminating exploration once it is confirmed that the anterior muscular layer is breached, while others would suggest continuing to dissect down to posterior peritoneum or posterior aponeurosis. If no peritoneal access, the wound can be irrigated and closed in layers.
*** However, this can be difficult and inconclusive, so Schein's suggests going on other clinical signs to decide whether significant intra-peritoneal injury has occurred.
** An asymptomatic patient with penetration of muscle layer or peritoneum needs a diagnostic laparoscopy or at least 24 hours of serial examination. Almost all patients with bleeding or perforation will become symptomatic within 16 hours.
*** Another option is to perform DPL, with a red cell cut-off for indicating laparotomy of between 5,000 to 100,000, but this is old-fashioned.