Penetrating Abdominal Trauma, Selective Non-Operative Management of

Published 2010

Level 1

a. Patients who are hemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy

b. Patients who are hemodynamically stable with an unreliable clinical examination (i.e., brain injury, spinal cord injury, intoxication, or need for sedation or anesthesia) should have further diagnostic investigation done for intraperitoneal injury or undergo exploratory laparotomy

Level 2

c. A routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with surgical expertise.

d. A routine laparotomy is not indicated in hemodynamically stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs.

e. Serial physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team.

f. In patients selected for initial nonoperative management, abdominopelvic computed tomography should be strongly considered as a diagnostic tool to facilitate initial management decisions.

i. Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations as well as peritoneal penetration (Level 2). 

Level 3

g. Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination and minimal to no abdominal tenderness.

h. The vast majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after twenty-four hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness.