Clinical Challenges in Trauma Surgery: Approach to Stab Wounds of the Torso

The anterior abdominal stab wound! Who gets explored? When do you get imaging? Who gets serial abdominal exams? How does this change depending on the location of injury? Join Drs. Cobler-Lichter, Kwon, Meizoso, and Urréchaga in their first episode as the new Miami Trauma team  - as they discuss how to navigate the nuances of stab wounds to the torso!

Hosts:
- Michael Cobler-Lichter, MD, PGY2:
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@mdcobler (twitter)
- Eva Urrechaga, MD, PGY6/R4:
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@urrechisme (twitter)
- Eugenia Kwon, MD, Trauma/Surgical Critical Care Fellow:
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
- Jonathan Meizoso, MD, MSPH Assistant Professor of Surgery
University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
@jpmeizoso (twitter)

Learning Objectives:
- Identify the differences in management of abdominal/thoracoabdominal stab wounds depending on location of injury
- Identify who needs immediate operative intervention and who can undergo further evaluation
- Define the management pathways for patients with abdominal stab wounds without an immediate indication for the OR
- Define thoracoabdominal stab wound and when to evaluate for thoracic injuries
- Discuss the role of diagnostic imaging when evaluating a patient with a stab to the torso

Quick Hits:
1. Don’t forget about the blunt trauma that may be associated with an assault!
2.  Don't miss injuries- always start with the ABCs and do a thorough head to toe exam 
3. For stab wounds to the torso- hemodynamic instability, evisceration, peritonitis, impalement, or gross blood should go to the OR.
4. The three general clinical pathways for patients without a clear indication for the OR, include serial abdominal exams, local wound exploration, or diagnostic imaging.
5. Serial abdominal exams require frequent monitoring ideally by the same team member every time to detect changes early.
6. Local wound exploration requires adequate lighting and retraction to visualize the anterior rectus fascia. A negative LWE rules out an intra-abdominal injury, but a positive LWE does not necessarily rule it in.
7. Left thoracoabdominal stab wounds require evaluation of the diaphragm to rule out a traumatic diaphragm injury.
8. If there are no clear indications for the OR, diaphragm evaluation should be performed via laparoscopy after a period of 8 - 12 hours from injury.
9. A negative pericardial ultrasound does not rule out a cardiac injury in patients with a left-sided hemothorax.
10. Patients with flank and back stab wounds should be evaluated with CT scan to rule-out retroperitoneal injuries

References
1. Martin MJ, Brown CVR, Shatz DV, Alam HB, Brasel KJ, Hauser CJ, de Moya M, Moore EE, Rowell SE, Vercruysse GA, Baron BJ, Inaba K. Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2018 Nov;85(5):1007-1015. doi: 10.1097/TA.0000000000001930. PMID: 29659472.
2. Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA, Ivatury RR, Scalea TM. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010 Mar;68(3):721-33. doi: 10.1097/TA.0b013e3181cf7d07. PMID: 20220426.

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