Penetrating Abdominal Injury

Penetrating abdominal injuries are created by an object puncturing the abdominal wall. Injuries can be high velocity, like gunshot wounds, or low velocity, like stab wounds. Different structures can be injured, including the duodenum, spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen, liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver, kidneys Kidneys The kidneys are a pair of bean-shaped organs located retroperitoneally against the posterior wall of the abdomen on either side of the spine. As part of the urinary tract, the kidneys are responsible for blood filtration and excretion of water-soluble waste in the urine. Kidneys, and pelvic organs. The extent and specific type of abdominal traumatic injury can be identified by a proper history and physical exam and supported by appropriate imaging studies. Management, which can be laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy or a conservative approach, is dependent on the patient’s hemodynamic stability and specific type of injury.

Last update:

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Overview

Definition

A penetrating abdominal injury is the result of trauma from an object puncturing the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin, entering the body, and creating a wound. 

  • Can often cause damage that results in shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock and infection 
  • Severity depends on which body organs are involved, the characteristics of the object, and the amount of energy transmitted. 

Epidemiology

  • Demographics:
    • 90% of cases involve men.
    • While 20-to-24-year-old individuals make up 7% of the population, 22.5% of gunshot deaths affect this age group.
  • By settings:
    • 35% of trauma patients are admitted in urban trauma centers.
    • Up to 12% of those admitted are in suburban or rural centers.
  • 40% of homicides and 16% of suicides by gun involve injuries in the torso.
  • Common organs injured:
    • Small bowel (50%)
    • Large bowel (40%)
    • Liver (30%)
    • Intra-abdominal vascular (25%)

Etiology

  • Gunshot wounds (65% of cases)
  • Stab wounds
  • Foreign objects from motor vehicle collisions or other trauma
  • Fractured bones

Pathophysiology and Clinical Presentation

Mechanism of injury

  • The projectile passes through tissue and decelerates, transferring kinetic energy into the tissue. 
  • ↑ Velocity leads to more damage than mass, and kinetic energy increases with the velocity
  • A cavity in the tissue is formed by the penetrating object → permanent cavitation
  • Medium- and high-velocity projectiles create secondary cavitation injuries as the object enters the body:
    • A pressure wave pushes tissue out of the way.
    • The tissues move back, filling the cavity in, but considerable damage has been created by the cavitation.

Clinical manifestations

  • Lacerations
  • Abdominal bleeding
  • Bowel evisceration
  • Abdominal bruising
  • Signs of peritonitis (abdominal tenderness, distension, rigidity, guarding, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever)
  • Hemodynamic instability 

Related videos

Diagnosis

Because of the wide variety and severity of injuries associated with penetrating abdominal trauma, a prompt but careful history and physical exam are necessary to direct investigation with imaging studies.

History

  • Mechanism of trauma:
    • May suggest severity of injury
    • Gunshot wounds:
      • Caliber and type of ammunition used
      • Degree of fragmentation of the bullet
      • Distance from shooter (closer → higher kinetic energy)
    • Stab wounds:
      • More predictable patterns of injury than gunshot wounds
      • Type of knife and length of blade
      • Associated with lower incidence of intra-abdominal injuries
  • History of previous trauma
  • Drug (illicit and prescription) or alcohol use by patient 
  • Prior surgical history
  • Amount of blood loss (on scene per paramedics and in hospital)

Physical exam

  • Airway, breathing, circulation (ABC) assessment:
    • Airway:
      • Look for foreign objects blocking the airway.
      • Assess for injury to the trachea Trachea The trachea is a tubular structure that forms part of the lower respiratory tract. The trachea is continuous superiorly with the larynx and inferiorly becomes the bronchial tree within the lungs. The trachea consists of a support frame of semicircular, or C-shaped, rings made out of hyaline cartilage and reinforced by collagenous connective tissue. Trachea (tracheal injury means intubation will be complex).
      • Listen for unusual breathing sounds (stridor suggests narrowing by a foreign body or edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema).
    • Breathing:
      • Look at chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall movement for even and spontaneous breathing (uneven chest movement suggests flail chest Flail chest Flail chest is a life-threatening traumatic injury that occurs when 3 or more contiguous ribs are fractured in 2 or more different locations. Patients present with chest pain, tachypnea, hypoxia, and paradoxical chest wall movement. Flail Chest).
      • Listen to breath sounds (muffled or uneven breath sounds may suggest pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax or hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax).
    • Circulation:
      • Palpate pulses on all 4 extremities (tachycardia suggests hemodynamic instability or pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax).
      • Assess capillary refill on extremities.
  • Secondary survey: 
    • Examine the patient head to toe.
    • External injury should prompt investigation for corresponding internal injury:
      • Note entrance wounds (and exit wounds if present).
      • There is no exit wound in a puncture wound, only in a penetrating injury.
    • Base the imaging decision on exam findings.
    • Signs concerning for severe intra-abdominal injury:
      • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension (with or without abdominal distention)
      • Narrow pulse pressure
      • Tachycardia
      • Respiratory distress
      • Signs of inadequate perfusion
      • Peritoneal signs
      • Generalized abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain that fails to resolve
Large left thoraco-abdominal wound with epiplocele

Penetrating injury: large left thoracoabdominal wound with epiplocele

Image: “Large left thoraco-abdominal wound with epiplocele” by SpringerPlus. License: CC BY 4.0

Imaging studies

  • FAST: used in all patients (stable or unstable) to look for intraperitoneal blood and pericardial effusion Pericardial effusion Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade 
    • Hemodynamically unstable patients:
      • Positive FAST → emergent laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy
      • Negative FAST → search for extra-abdominal bleeding sources (e.g., femur fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures)
      • Equivocal FAST → diagnostic peritoneal lavage (DPL) or stabilize patient and obtain CT scan
    • Hemodynamically stable patients: 
      • Positive FAST → emergent laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy
      • Negative FAST, low risk for intra-abdominal injury → observation
      • Negative or equivocal FAST with high risk for intra-abdominal injury → CT scan
  • X-ray: directed by exam findings
    • Chest X-ray: can show free intraperitoneal air, herniation of abdominal contents
    • Pelvic X-ray: Pelvic bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones fractures can be a source of bleeding or bladder injury.
    • X-ray can help locate bullets and shrapnel left from a penetrating injury.
  • CT scan abdomen with contrast:
    • Imaging of choice for stable patients 
    • Provides information regarding retroperitoneal structures, diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm, and solid abdominal organs
    • Most sensitive and specific study in identifying liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver and spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen injury severity

Other diagnostic studies

  • Hct: 
    • < 30% suggestive of intra-abdominal injury
    • Normal Hct does not rule out severe injury.
  • Urinalysis: blood suggestive of serious renal injury
  • Liver function tests Liver function tests Liver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases. Liver Function Tests
  • DPL:
    • Invasive procedure used to evaluate presence of blood in abdominal cavity: A catheter is placed into the peritoneal cavity, and then fluid is aspirated and evaluated.
    • Not often used but can be an alternative when CT scan and FAST are not available

Injury considerations

Penetrating injuries may affect more than just the area that is obviously injured externally, and damage to the adjacent structures needs to be investigated.

  • Back and flank:
    • Check retroperitoneal and intraperitoneal structures.
    • Diaphragmatic injury is possible.
  • In thoracoabdominal area, need to check:
    • Intra-abdominal organs/structures
    • Diaphragmatic involvement
    • Cardiac structures (e.g., pericardial tamponade) especially if injury is near xiphoid process
  • In lower chest injuries (from the nipple line anteriorly—4th intercostal space (ICS)—or scapular tip), highly consider intraperitoneal injury.

Related videos

Management

Historical and standard management of penetrating abdominal trauma is laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy. Recent improvements in imaging and better understanding of injury patterns have resulted in more-conservative strategies.

Initial approach

Assessment of patient stability, correlation with diagnostic tests Diagnostic tests Diagnostic tests are important aspects in making a diagnosis. Some of the most important epidemiological values of diagnostic tests include sensitivity and specificity, false positives and false negatives, positive and negative predictive values, likelihood ratios, and pre-test and post-test probabilities. Epidemiological Values of Diagnostic Tests, and determination of the need for immediate surgery:

  • Fluid resuscitation:
    • Insertion of 2 large IV lines
    • IV fluid administration
    • Replenish blood
  • Leave any foreign objects in situ until definitive management (e.g., surgical removal) is established.
  • Broad-spectrum antibiotics:
    • For those requiring surgical management
    • Not warranted in cases requiring nonoperative management 
  • Tetanus Tetanus Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani produces a neurotoxin that blocks the release of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. Tetanus prophylaxis
  • Indications for immediate laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy:
    • Hemodynamic instability (systolic blood pressure < 90 mm Hg)
    • Signs of peritonitis
    • Bowel evisceration
    • Impalement
    • Frank blood on rectal exam or nasogastric (NG) tube
  • Emergent laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy:
    • The keys of laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy are to control bleeding and prevent GI contamination. 
    • All 4 quadrants of the abdomen are packed with laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy pads to identify localized bleeding and injuries and to prevent GI contents from spreading. 
    • Injured organs such as the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver can be manually compressed to tamponade bleeding. 
    • Severe cases of bleeding may require ligation of arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries.
Stab wound injury with multiple small bowel perforations on laparotomy

Stab wound injury: On laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy, multiple small bowel perforations (arrows) were evident.

Image: “Multiple small bowel perforations (indicated by arrows)” by Naidoo K, Mewa Kinoo S, Singh B. License: CC BY 3.0

Conservative strategies

  • In hemodynamically stable patients:
    • Secondary survey
    • FAST:
      • Recommended action dependent on the result
      • If there is a positive FAST, the patient is intoxicated, or unresponsive ➝ proceed with laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy.
    • Local wound exploration (LWE):
      • Preferably performed by 2 individuals
      • Requires sedation and local anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts
      • If wound in the anterior abdomen does not penetrate the anterior rectus fascia → wound care and consider discharge (depending on associated injuries).
    • CT scan and/or other indicated imaging
  • Alternatives to laparotomy Laparotomy Laparotomy is an open surgical exploration of the abdomen, usually through a single large incision. Laparotomy and Laparoscopy:
    • Regular rechecks in stable patients
    • Observation for at least 24 hours recommended in:
      • Age > 65 years
      • Those with medications that are anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants or antiplatelet therapy.
      • Other significant injuries
      • Medical comorbidities
    • Interventional radiology procedures for spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen and liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver lacerations with active bleeding
Management of penetrating abdominal injury

Algorithm of management of penetrating abdominal injury
Abbreviations: BP: blood pressure; FAST: Focused Assessment with Sonography for Trauma; LWE: local wound exploration; CT: computed tomography

Image by Lecturio.

Clinical Relevance

  • Blunt abdominal trauma: typically involves the violation of the abdominal cavity by deceleration, crushing, or external compression injuries. The most injured structures are the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver and spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen. Management depends on the patient’s hemodynamic stability and severity of the injury.
  • ABC assessment: airway, breathing, and circulation assessment is the mainstay approach used in managing critically ill patients. The ABCs are the essential first steps to perform in many situations, including unresponsive patients, cardiac arrests, and critical medical or trauma patients. For the trauma patient, ABC is included in the primary survey, the initial evaluation, and the management of injuries. 
  • Splenic injury: in blunt injuries, the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver and spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen are the most commonly injured organs. Usually, splenic injury is associated with lower left rib fractures. The features of splenic injury include hypotension, tachycardia, abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, left chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, and left shoulder pain Shoulder Pain Acute shoulder injuries are a common reason for visits to primary care physicians and EDs. Common acute shoulder injuries include acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Acute Shoulder Pain (referred pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain due to phrenic nerve irritation from splenic hemorrhage).
  • Pelvic injury: pelvic injuries and pelvic fractures Pelvic Fractures Pelvic fractures are a disruption in the cortex of a pelvic bone involving iliac wing fractures, acetabular fractures, or those causing loss of integrity of the pelvic ring (the sacrum and the 2 innominate bones). Patients often present with a history of trauma or a fall, limb length discrepancy, intense pain on palpation, and mechanical instability. Pelvic Fractures are among the worst complications of blunt abdominal injuries. Clinical features include hypotension, pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with movement, gross hematuria, and peripelvic ecchymoses. A digital rectal exam is important to identify injury to the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal and locate the prostate Prostate The prostate is a gland in the male reproductive system. The gland surrounds the bladder neck and a portion of the urethra. The prostate is an exocrine gland that produces a weakly acidic secretion, which accounts for roughly 20% of the seminal fluid. Prostate and other Male Reproductive Glands. Treatment is usually limited to supportive care, but surgical stabilization may sometimes be necessary. 

References

  1. Benjamin, E. (2020). Traumatic gastrointestinal injury in the adult patient. UpToDate. Retrieved January 8, 2021, from https://www.uptodate.com/contents/traumatic-gastrointestinal-injury-in-the-adult-patient
  2. Colwell, C, & Moore, E. (2020). Initial evaluation and management of abdominal stab wounds in adults. UpToDate. Retrieved January 7, 2021, from https://www.uptodate.com/contents/initial-evaluation-and-management-of-abdominal-stab-wounds-in-adults
  3. Lotfollahzadeh, S, & Burns, B. (2021). Penetrating abdominal trauma. StatPearls. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459123/
  4. Phillips, B, et al. (2017). Trauma to the bladder and ureter: A review of diagnosis, management, and prognosis. Eur J Trauma Emerg Surg. 43(6), 763–773. https://pubmed.ncbi.nlm.nih.gov/28730297/
  5. Sakamoto, R, et al. (2018). Nonoperative management of penetrating abdominal solid organ injuries in children. J Surg Res. 228, 188–193. https://pubmed.ncbi.nlm.nih.gov/29907210/

USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

User Reviews

0.0

()

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details