Penetrating Injury

by Kevin Pei, MD

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    00:01 Now, we’ve discussed blunt injury, let’s talk about penetrating injury.

    00:06 Penetrating injury in the United States has decreased significantly.

    00:09 In fact, most trauma centers see 85% blunt injury patients.

    00:12 This is good for our patients.

    00:15 Now, penetrating abdominal injuries are a little bit different than blunt in the sense that they are more at risk for perforation and may require surgery.

    00:24 In fact, most penetrating abdominal surgeries require at least a diagnostic laparoscopy.

    00:30 That’s in the hope of avoiding a major exploratory laparotomy incision particularly if the exploratory laparotomy may turn out to be negative.

    00:41 Now, remember, if there is a question of peritoneal violation, which is the indication for surgery, you can always offer a diagnostic laparoscopy.

    00:49 Small little incisions take a look at it while the patient is asleep.

    00:52 Or alternatively, you can do what’s called a local wound exploration.

    00:56 I have to say particularly in obese patients, it’s easier said than done in the trauma bay but it can be done under local.

    01:03 If you notice that there is peritoneal violation or suspect it, the patient needs to have an exploration.

    01:09 Now, let me pose another clinical scenario.

    01:11 What if patient is stabbed from the left flank with a butcher’s knife? What are some potential injuries? I’ll give you a second to think about it.

    01:23 Let’s go over the potential injuries.

    01:25 I hope you kept these in mind.

    01:27 Clearly, anything on the left flank can injure the kidney, colon, small intestines, aorta, and the ureter.

    01:36 Now, in this image, you see a colon injury.

    01:41 What are your priorities? Well, in the operating room if done in a timely manner, there should be very little contamination or spillage of stool, but our main goal is actually controlling the contamination and maintain stability.

    01:55 If all those cases are in a relatively clean and controlled situation, there’s nothing wrong with just putting a suture and closing the hole depending on how big the hole is.

    02:05 In all penetrating colon surgeries prior to making incision, the patient should get pre-operative antibiotics.

    02:12 Remember, you can close the hole primarily if there is very minimal spillage.

    02:15 No drains are usually necessary.

    02:18 However, this is not the case if there’s a lot of contamination.

    02:22 In these situations with significant contamination either a blood or a stool, patient may need a temporizing ostomy.

    02:31 Here you see an ostomy.

    02:32 Remember, tell the patient it’s temporary.

    02:34 And with significant stool spillage, I recommend you leave some drains.

    About the Lecture

    The lecture Penetrating Injury by Kevin Pei, MD is from the course Surgery: Trauma.

    Included Quiz Questions

    1. Liver
    2. Colon
    3. Ureter
    4. Kidney
    5. Small intestine
    1. Exploratory laparotomy and creation of an ostomy
    2. Exploratory laparotomy with primary colon repair
    3. Exploratory laparotomy and irrigating the abdominal cavity with antiseptics alone
    4. Antibiotic treatment alone

    Author of lecture Penetrating Injury

     Kevin Pei, MD

    Kevin Pei, MD

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