Diagnosis

PORTABLE ULTRASOUND In a patient with a penetrating wound to the flank, portable ultrasonography can be utilized to determine if there is fluid in the abdominal cavity. In the absence of a preexisting medical condition (such as cirrhosis with ascites), such information may be invaluable. Although the sensitivity and specificity varies with the type of equipment used and the experience of the operator, fluid collections of 600 cc should easily be detected by the emergency physician. 1 For a patient with a gunshot wound this may be sufficient to recommend an operative approach. For a patient with a stab wound, even if hemodynamically stable, this indicates a significant intra-abdominal injury. Operative intervention is sometimes delayed pending further adjunctive diagnostic measures.

WOUND EXPLORATION Although local wound exploration under adequate local anesthesia using sterile technique is of value in anterior abdominal wounds, it is only of limited value in wounds of the flank. If local exploration demonstrates that the injury does not penetrate beyond fascia or muscle, the wound may be safely closed and the patient discharged from the ED with appropriate follow-up instructions. With deeper penetrating injuries, it is difficult to determine the extent of injury with local wound exploration. More information can usually be obtained by CT scanning. Deep wound exploration often leads to further hemorrhage and tissue damage and is of limited value. It is difficult, if not impossible, to ascertain the exact depth of a stab wound from deep wound exploration.

DIAGNOSTIC PERITONEAL LAVAGE Appropriately performed, diagnostic peritoneal lavage (DPL) is highly accurate in determining the presence of intraperitoneal injury; it does not detect the presence of a retroperitoneal injury. (For details of the technique, see Chap 2.5.2 ) The criteria of what constitutes a positive diagnostic lavage in penetrating trauma are different from the criteria for blunt trauma. The exact criteria vary from hospital to hospital, but a guide is a red cell count of >10,000/mm3 as an indication to perform an exploratory laparotomy. Lavage fluid may also be analyzed for bowel content, white cells, or enzymes such as amylase; although criteria for what constitutes a positive lavage vary from center to center. In some hospitals, enzymatic assay and examination for bowel content have been abandoned. Others still advocate its use to ascertain if a bowel or pancreatic injury has occurred. In most institutions, the use of diagnostic peritoneal lavage for a stable patient has been replaced by CT scanning. In an unstable patient, DPL can be performed (especially if portable ultrasound is not immediately available) to rapidly detect the presence (or absence) of hemoperitoneum.

COMPUTED TOMOGRAPHY (CT) In many centers, computed tomography has become the diagnostic modality of choice in patients who present hemodynamically stable following a flank penetrating trauma.23 Double (oral gastrografin and intravenous contrast) or triple (oral, intravenous, and rectal contrast) are used; rectal contrast should be used if there is even a remote likelihood of a rectal or sigmoid injury. Cooperation with the radiologist is essential as fine "cuts" through the site of injury may be required to delineate the injury tract. Particular attention should be paid to the presence of intraperitoneal fluid and any edema of the bowel wall. The latter may represent bowel perforation, although no leak is visible by leakage of the contrast. 4

The majority of patients with identified injury will be found to have retroperitoneal hematoma, without bowel or solid organ damage. Rarely, a hematoma around one of the major blood vessels or the pancreas is evident, requiring further diagnostic testing such as angiography, venography, or endoscopic retrograde cholangiopancreatogram (ERCP). Occasionally, a gunshot wound may be observed to pass extraperitoneally, but concerns about blast effect may lead to the decision to perform laparoscopy.

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