Penetrating Injury

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.