Official reprint from UpToDate

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Initial evaluation and management of abdominal stab wounds in adults

Authors: Christopher Colwell, MD, Ernest E Moore, MD

Section Editor: Maria E Moreira, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2017. | This topic last updated: Oct 03, 2016.

INTRODUCTION Until the 20th century, nearly all penetrating injuries to the abdomen were managed
nonoperatively. Beginning with World War I, surgeons noted lower mortality among soldiers with penetrating
abdominal wounds who were managed with laparotomy. Ultimately, laparotomy became the mandatory
treatment for such wounds. It gradually became clear that penetrating abdominal trauma sustained during
warfare (mostly higher velocity gunshot wounds and incendiary devices) was different than penetrating
abdominal trauma sustained by civilians (mostly stab wounds and lower velocity gunshot wounds) [1]. In
1960, Shaftan questioned the dogma of mandatory laparotomy for all penetrating abdominal injuries, and
laparotomy rates for abdominal stab wounds have declined steadily over the ensuing decades [2].

This topic review will discuss the initial evaluation and management of abdominal stab wounds in adults.
General trauma resuscitation in adults and children, blunt abdominal trauma, abdominal gunshot wounds,
and other aspects of trauma care are reviewed separately. (See "Initial management of trauma in adults" and
"Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and
management of abdominal gunshot wounds in adults" and "Trauma management: Approach to the unstable
child" and "Approach to the initially stable child with blunt or penetrating injury".)

EPIDEMIOLOGY Although there is regional variability in the mechanism of injury producing abdominal
trauma, most studies indicate that blunt abdominal trauma is more common than abdominal stab wounds,
and that abdominal stab wounds are more common than abdominal gunshot wounds in the civilian population
[3]. Abdominal gunshot wounds, due to their higher kinetic energy, are associated with mortality rates
approximately eight times higher than abdominal stab wounds [4].

In children and adults alike, hollow viscus organs (intestines) are injured most often with abdominal stab
wounds [3,5,6]. The next most common sites of injury are the great vessels, diaphragm, mesentery, spleen,
liver, kidney, pancreas, gallbladder, and adrenal glands. The specific organs at greatest risk from a stab
wound depend upon the location of the injury.

MECHANISM OF INJURY Any instrument that can impale may inflict a stab wound. Typically these are
narrow, sharp, knife-like implements, but items that can inflict stab wounds range from scissors to coat
hangers to animal horns. The given instrument can injure any tissue it traverses, including skin, fascia, solid
organ, hollow viscus, blood vessel, nerve, muscle, and bone.

According to one series, the majority of abdominal stab wounds with evisceration occurred in the left upper
quadrant of the abdomen, followed by the left lower, the right upper, and the right lower [6]. Posterior (ie,
back) and flank stab wounds have a greater risk of injury to retroperitoneal structures, including the colon,
kidneys, and adrenals. Multiple stab wounds are present in 18 to 34 percent of patients, and as many as 30
percent of penetrating chest injuries may traverse the diaphragm, potentially harming abdominal tissues and
organs [7]. Accordingly, anterior stab wounds that are inferior to the nipple line (fourth intercostal space) and
posterior stab wounds that are inferior to the tip of the scapula (seventh intercostal space) should be
considered to involve potential diaphragm and intra-abdominal injuries in addition to chest injuries. (See
"Initial evaluation and management of penetrating thoracic trauma in adults" and "Recognition and
management of diaphragmatic injury in adults".)

ANATOMIC ZONES The abdominal cavity is divided into four anatomic zones (figure 1 and figure 2 and
figure 3 and figure 4 and figure 5). The anterior abdomen is bound by the anterior axillary lines extending
from the costal margins to the groin creases. Due to diaphragmatic excursion while breathing, the nipple line
(fourth intercostal space) anteriorly, and the tips of the scapulae (seventh intercostal space) and the inferior
costal margin posteriorly, should be used to define the cephalad portion of the abdomen. Wounds in the
upper abdominal region pose a significant threat of injury to the chest and abdomen depending upon the path
of the weapon and the position of the diaphragm at the time of injury.

The flanks are separated on each side by the inferior costal margins and iliac crests, and the anterior and
posterior axillary lines. The back is defined as the area between the posterior axillary lines, the inferior
scapular tips (seventh intercostal space), and the iliac crest. Back and flank stab wounds have a greater risk
of injury to retroperitoneal structures, including the colon, kidneys, and adrenals.

HISTORY Answers to the following questions help to guide the clinician in assessing potential injuries from
abdominal stab wounds:

What instrument was used?

How long and how wide was the instrument?
How was the patient positioned during the stabbing?
What path (or paths in the event of multiple wounds) did the implement travel?
Was there substantial blood loss at the scene?

METHODS OF EVALUATION

Initial assessment General evaluation and the initial management of the trauma patient is reviewed
separately. Issues specifically related to the initial evaluation of adult patients with stab wounds are discussed
below. (See "Initial management of trauma in adults".) An algorithm to help guide the management of patients
with an anterior abdominal stab wounds is provided (algorithm 1).

It is important to completely undress any patient who sustains a stab wound. Stab wounds can often be
obscured by body habitus, clothing, or bleeding, or be "hidden" in the axilla, scalp, perineum, or groin.
Examine the patient carefully for evidence of more than one stab wound. Clinicians should be wary of
lacerations reported to be, or that appear to be, from blunt trauma; such wounds may represent penetrating
trauma associated with significant internal injury.

The options for assessment and management of patients with abdominal stab wounds are determined by
their clinical presentation. Patients presenting in extremis may require resuscitative thoracotomy and
emergent laparotomy to control hemorrhage or manage other injuries. Emergency thoracotomy is discussed
in detail separately. (See "Initial evaluation and management of penetrating thoracic trauma in adults",
section on 'Emergency department thoracotomy (EDT)' and "Resuscitative thoracotomy: Technique".)

Patients with any of the following typically go immediately to the operating theater for laparotomy:

Hemodynamic instability
Peritonitis
Impalement
Evisceration
Frank blood from a nasogastric tube or on rectal examination

In patients without apparent indications for immediate laparotomy, physical examination is both sensitive and
specific for detecting significant intra-abdominal injury. A prospective observational study involving 249
consecutive abdominal stab wound patients treated at a major trauma center found physical examination to
be 100 percent sensitive and 98.7 percent specific compared with CT for detecting intra-abdominal injury
necessitating laparotomy, and concluded that a physical examination based diagnostic algorithm was
effective and decreased radiation exposure for such patients [8].

Patients without apparent indications for laparotomy may be evaluated by one or more of the following
techniques:

Local wound exploration (LWE)

Plain radiograph
Computed tomography (CT)
Serial physical examinations (SPE)
Diagnostic peritoneal lavage (DPL)
Ultrasonography
Laparoscopy

Local wound exploration Since the entire abdominal wall is encased in a layer of fascia, the first
question in asymptomatic patients is to determine whether the stab wound violated the peritoneum. Stab
wounds are amenable to local wound exploration (LWE) to evaluate their depth and tract [9]. LWE is safely
performed at the bedside in patients with stab wounds to the anterior abdomen, but requires appropriate
patient sedation and local anesthesia. The procedure, best undertaken by two individuals, should be done
with sterile technique, good lighting and both sharp and blunt dissection until the bottom of the wound is
clearly visualized. Blunt probing with fingers or cotton swabs is unreliable and not recommended. Adequate
analgesia and appropriate sedation must be provided when performing LWE. In some cases, local infiltration
of tissues with anesthetic is sufficient, but standard procedural sedation and analgesia (PSA) is required in
other cases. The performance of PSA is discussed separately. (See "Procedural sedation in adults outside
the operating room".)

For anterior stab wounds, if the exploration to the deepest extent of the wound demonstrates that anterior
rectus fascia is not violated, then patients may be discharged after appropriate wound care, assuming no
additional or extra-abdominal injuries are present [9-11]. Obesity, heavy muscle, or the presence of multiple
wounds or other injuries can compromise LWE [12,13]. If the anterior fascia is not clearly and completely
seen, peritoneal injury cannot be ruled out and further evaluation is required. For clinicians with limited
experience performing LWE, or those who have not performed one in some time, the safest policy is to
presume peritoneal violation unless all edges of the wound are visualized clearly.

Plain radiographs Plain radiographs typically add little to the management of abdominal stab wounds. If
free intraperitoneal air is seen on an upright chest or lateral decubitus radiograph, then the peritoneal cavity
has been violated, but this does not confirm hollow viscus injury. Thus, plain radiographs lack sensitivity and
specificity for significant injuries and are rarely employed in this setting.

An exception is the use of plain radiographs to evaluate foreign bodies. These include cases of impalement
where the foreign object remains in the patient and cases where there is concern for a retained foreign body
not visible in the wound, such as a broken knife blade.

Serial physical examination and observation It is well accepted that serial physical examination (SPE)
is a safe and reliable means to detect significant intra-abdominal injuries after stab wounds to the abdomen, if
performed by experienced clinicians on appropriate patients. Ideally, the same clinician should perform each
examination.

Patients not appropriate for SPE include those with an unreliable examination due to head injury, spinal cord
injury, altered mental status (eg, from intoxication), or the need for anesthesia. In addition to careful
reassessment of the abdomen, the physical examination should include assessment of the neurologic and
vascular status of the lower extremities as stab wounds may damage nerves and vessels in the abdomen
and pelvis. Ideally, serial examinations are performed at least every six hours.
The requisite duration of observation after a stab wound to the abdomen that penetrates the anterior rectus
fascia is at least 12 hours [14]. Patients in the following categories should be observed for at least 24 hours:

Older than 65 years

Taking anticoagulants or antiplatelet medications at the time of injury
Have significant medical comorbidities that may affect detection of internal injury (eg, diabetes)
Have other significant injuries warranting observation

Mildly intoxicated patients should be observed until the effects of the intoxicating substance have resolved.
Assuming no signs of significant injury are detected, such patients may be discharged following a final
reassessment and reexamination.

Some basic criteria that the patient with an abdominal stab wound should meet to be considered appropriate
for discharge after brief observation (12 hours) include the following:

Mentally capable of making appropriate, informed decisions about medical care

Physical examination including careful abdominal examination is unremarkable, with the lone
exception of some reasonable discomfort at the stab wound site only
Vital signs stable and without concerning trends (eg, heart rate has not risen from 55 to 89): Heart rate
less than 90; respiratory rate less than 14/minute; temperature less than 38C (100.4F)
Spontaneous urination
Tolerating oral fluids
Able to ambulate safely
Not taking anticoagulants
Safe discharge environment

Ultrasound Bedside extended Focused Abdominal Sonography for Trauma (eFAST) examination is
frequently used to determine the presence of hemopericardium, hemoperitoneum, pneumo- or hemothorax,
or some combination thereof. Overall, the specificity of the FAST examination for identifying signs of internal
injury from a stab wound appears to be high, but sensitivity is limited. The use of ultrasound (US) in
evaluating patients with abdominal trauma is described in detail separately. (See "Emergency ultrasound in
adults with abdominal and thoracic trauma".)

The eFAST examination is particularly valuable in the initial assessment of a patient with a low chest or upper
abdominal stab wound who is hemodynamically unstable, as rapid identification of hemopericardium or
hemoperitoneum can help to determine the priorities of management. Hemopericardium causing
hemodynamic compromise (ie, pericardial tamponade) must be drained immediately. Unstable patients with
hemoperitoneum and no sign of hemopericardium or another immediately treatable cause of hypotension
(eg, pneumothorax) should proceed to immediate laparotomy. (See "Initial evaluation and management of
penetrating thoracic trauma in adults", section on 'Pericardial tamponade' and "Emergency
pericardiocentesis" and 'General approach and indications for laparotomy' below.)

In hemodynamically stable patients with a positive eFAST, other diagnostic modalities, such as computed
tomography (CT) or diagnostic laparoscopy, can identify specific injuries and guide management. In those
with a negative eFAST, injury cannot be excluded and other diagnostic modalities must be employed.

Other applications of US in penetrating abdominal trauma continue to evolve. While it is not routinely used to
diagnose peritoneal penetration, a small preliminary study using the US transducer to assess fascial violation
deep to the stab wound demonstrated excellent specificity but suboptimal sensitivity [15].

Diagnostic peritoneal tap and diagnostic peritoneal lavage Although invasive, diagnostic peritoneal
tap and lavage is a rapid and easily performed bedside procedure that offers information about peritoneal
penetration and injury to solid organs, bowel, and the diaphragm [16,17]. However, diagnostic peritoneal
lavage (DPL) does not assess the retroperitoneum. The procedure entails inserting a catheter into the
peritoneal cavity, initially to aspirate blood or fluid, and subsequently to infuse fluid and lavage the cavity, if
necessary. The initial portion of the procedure is often referred to as a diagnostic peritoneal tap or aspirate;
the latter portion is a DPL.

In the setting of abdominal stab wounds, diagnostic peritoneal tap and lavage is generally used for one of the
following indications:

Need to rapidly determine the presence of hemoperitoneum in unstable patients when ultrasound is not
diagnostic

Need to diagnose diaphragm injury (eg, unclear if a stab wound to the lower chest has penetrated the
peritoneum)

The only absolute contraindication to DPL is the presence of a clear indication for immediate laparotomy.

In the hemodynamically unstable patient, DPL has been used to identify hemoperitoneum when the physical
examination is equivocal or ultrasound is technically inadequate. DPL may be particularly important for
guiding management in the patient with multiple stab wounds and other potential causes for hypotension,
such as hemothorax, pericardial tamponade, spinal cord injury, and retroperitoneal hemorrhage.

In patients with stab wounds of the anterior abdomen who are hemodynamically stable and without
indications for immediate laparotomy, the clinician should determine whether peritoneal violation has
occurred. If the peritoneum has been violated or the clinician is uncertain whether it has, serial physical
examination is the most cost effective means of assessing for significant intraperitoneal injury [18]. DPL may
be a useful procedure when intraperitoneal injury must be assessed in patients who will become difficult to
reevaluate, such as the patient who will be under general anesthesia for a procedure other than laparotomy.
However, in most circumstances ultrasound or CT scan is used to evaluate stable patients rather than DPL.

Although previous abdominal surgery has been considered by some to be a potential cause of complications
(eg, catheter malplacement, fluid sequestration, bowel perforation), according to a retrospective review the
accuracy and complication rate of DPL in patients with previous abdominal surgery are similar to those
without [19]. Consequently, previous abdominal surgery should be considered a relative contraindication to
DPL and the decision to proceed in such cases should be made based on clinical judgment of, or in
consultation with, the trauma surgeon. Other relative contraindications include preexisting coagulopathy,
advanced cirrhosis, morbid obesity, and pregnancy beyond the first trimester. The supraumbilical approach to
the DPL is advised in patients with a pelvic fracture or females beyond the first trimester of pregnancy.

We and most experts agree that the aspiration of 10 mL of gross blood in a patient with penetrating
abdominal wounds indicates visceral injury [16,17]. However, debate continues over the appropriate red
blood cell count threshold for determining visceral injury if the initial aspirate is negative or inconclusive and
lavage is performed. A commonly used threshold is the presence of greater than 10,000 red blood cells per
high-powered field (RBCs/HPF). A range of 5000 to 10,000 RBCs/HPF is often used to determine the
presence of injury in thoracoabdominal (low chest) wounds, as this lowered threshold allows greater
sensitivity for detecting isolated diaphragmatic or small bowel injury [16,20]. This degree of RBC
concentration in the DPL effluent should not be attributed to the procedure itself. We believe these are
reasonable thresholds to use.

Not all trauma surgeons agree with these thresholds, and several alternative approaches have been
proposed, including higher thresholds that result in lower rates of nontherapeutic laparotomy but may lead to
delays in diagnosis. Undoubtedly, approaches will vary by institution and available resources. Emergency
clinicians performing a DPL should interpret the results in the context of the clinical scenario and in close
consultation with the trauma surgeons, who must ultimately decide whether laparotomy is necessary. In
patients selected for initial nonoperative management, DPL may be best employed in combination with serial
physical examinations [13,14,21].
Studies supporting alternative thresholds for determining a positive DPL include the following:

A retrospective study performed at a single level one trauma center reported that of 280 patients with an
abdominal stab wound who had a negative DPL only 15 (5 percent) went on to have a therapeutic
laparotomy within 24 hours of admission [22]. Initial aspiration of 10 mL gross blood or specific lavage
fluid values, including >100,000 RBCs/HPF, was used to determine a positive DPL.

The authors of a similar study involving 195 patients with stab wounds to the anterior chest or abdomen
confirmed the lower nontherapeutic laparotomy rates associated with these higher thresholds [23]. In this
study, a threshold of >100,000 RBCs/HPF, along with the presence of >500 white blood cells
(WBCs)/HPF, bile, or amylase, was used to determine a positive DPL.

A review of 388 hemodynamically stable patients with stab wounds who underwent DPL reported that
thresholds of >100,000 RBCs/HPF for abdominal wounds and >10,000 RBCs/HPF for thoracoabdominal
wounds had an overall sensitivity and specificity of 90 and 84 percent, respectively, for injuries that
required surgical intervention, while thresholds of >15,000 RBCs/HPF for abdominal wounds and
>25,000 RBCs/HPF for thoracoabdominal wounds improved sensitivity and specificity to 94 and 96
percent respectively [24].

Of note, diagnosis can be delayed using some of these thresholds, as white blood cell counts do not become
positive until approximately six hours from injury and laboratory analysis would be required to detect bile or
amylase. Additional prospective studies are needed to validate these proposed thresholds. The performance
of DPL is reviewed separately. (See "Diagnostic peritoneal lavage".)

Computed tomography and magnetic resonance imaging Multidetector computed tomography

(MDCT) is a noninvasive and rapidly performed imaging study that enables clinicians to delineate visceral
injury [7,25,26]. A systematic review and observational studies cite a sensitivity of up to 97 percent coupled
with a specificity of up to 98 percent for identification of peritoneal violation [7], and a sensitivity of 94 percent
and specificity of 95 percent for detecting significant intra-abdominal injuries possibly requiring operative
management [27]. Another advantage of MDCT is that it enables the identification of intraperitoneal injuries,
such as hepatic lacerations, that may be amenable to nonoperative management [7].

Although previous studies of CT involved triple contrast (intravenous, oral, and rectal), the advent of high-
resolution, multidetector scanners makes this approach unnecessary in most cases of isolated anterior
abdominal stab wounds [26]. However, rectal contrast may be needed to assess possible retroperitoneal
injury from back or flank wounds [8]. The preferred approach to imaging is best determined in consultation
with the trauma surgeon and radiologist.

Even with a negative initial CT scan, patients with a high likelihood of diaphragmatic or bowel injury should
have further testing, or observation and serial examinations, as these injuries are the ones most frequently
missed [28]. Although, the accuracy of multidetector CT scans for detecting these conditions is improving
[29], magnetic resonance imaging (MRI) has greater sensitivity for some injuries and may play a useful role in
evaluating the stable pregnant patient in need of intra-abdominal or thoracoabdominal imaging following
penetrating injury [29,30]. (See "Recognition and management of diaphragmatic injury in adults" and
"Management of duodenal and pancreatic trauma in adults", section on 'Diagnosis' and "Traumatic
gastrointestinal injury in the adult patient".)

Diagnostic laparoscopy Diagnostic laparoscopy (DL) is most useful for inspecting the diaphragm in
thoracoabdominal wounds and determining the feasibility of nonoperative management of isolated liver
injuries [31-33]. DL is used more commonly in Europe and South America where there is greater enthusiasm
for laparoscopic repair of hollow viscous injuries. The accuracy of DL in identifying injuries varies according to
the location and type of injury [32]. In general, laparoscopy or thoracoscopy is useful for identifying
diaphragmatic wounds and facilitates minimally invasive repair [34]. However, complete assessment of
hollow organs can be challenging and the retroperitoneum cannot be evaluated.
INITIAL MANAGEMENT

General approach and indications for laparotomy The initial evaluation and resuscitation of the patient
with an abdominal stab wound are identical to that for any acutely injured patient and are discussed in detail
separately (see "Initial management of trauma in adults"). An algorithm to help guide the management of
patients with an anterior abdominal stab wounds is provided (algorithm 1).

After necessary resuscitation, patients with any of the following typically go immediately to the operating
theater for laparotomy:

Hemodynamic instability
Peritonitis
Impalement
Evisceration
Frank blood from a nasogastric tube or on rectal examination

In the remaining patients, the first management decision is whether there is violation of the peritoneum or
retroperitoneum. For anterior abdominal stab wounds, peritoneal penetration is the key decision point. This
can often be determined by local wound exploration (LWE), but advanced imaging studies are sensitive and
specific when necessary. Omental or visceral evisceration represents peritoneal violation and most believe
this warrants laparotomy because of the high risk of gastrointestinal perforation [35]. For flank and back
wounds, there is a risk of retroperitoneal as well as peritoneal penetration (figure 2). In addition, there is
concern for peritoneal violation with anterior lower thoracic stab wounds, and retroperitoneum injury with
lower posterior chest wounds. Hemodynamically stable patients with these potentially more complex wounds
(flank, back, thoracoabdominal) warrant careful evaluation, often including CT imaging and a period of
observation. (See 'Flank and back stab wounds' below and 'Thoracoabdominal stab wounds' below and
'Right upper quadrant stab wound' below.)

Signs of gastrointestinal hemorrhage (eg, hematemesis, hematochezia) suggest gastroduodenal or colorectal

injury and generally warrant laparotomy without further investigation by imaging study. An implement in situ
(ie, a weapon protruding from the patient's body) ordinarily prompts laparotomy, even in stable patients, in
case the implement rests inside an intraperitoneal vessel, such that removal would lead to hemorrhage.
Therefore, high risk surgical candidates and pregnant patients, for whom laparotomy puts the fetus at risk,
may undergo removal of the implement without general anesthesia but in the operating suite in case they
deteriorate.

Peritoneal violation Peritoneal violation occurs in up to 50 to 70 percent of abdominal stab wounds, but
only half of those with peritoneal violation sustain an intra-abdominal injury requiring operative intervention
[35]. Thus, only 25 to 33 percent of patients with abdominal stab wounds require laparotomy. In most major
trauma centers, local wound exploration (LWE) is performed to determine peritoneal penetration for anterior
abdominal stab wounds. If no violation of the anterior rectus fascia has occurred, the patient may be
discharged safely after local wound care, assuming there are no other injuries of concern. (See 'Local wound
exploration' above.)

In centers without extensive experience with abdominal stab wounds, the alternative tests to evaluate for
peritoneal penetration are DPL or CT scanning. Patients with a negative DPL or CT scan require at least
another 12 hours of observation because of the risk of missing a gastrointestinal perforation or, in the case of
DPL, the risk of intestinal injury due to the procedure. (See 'Diagnostic peritoneal tap and diagnostic
peritoneal lavage' above and 'Computed tomography and magnetic resonance imaging' above.)

Selective nonoperative management With increased use of sophisticated diagnostic modalities, more
trauma centers are managing nonoperatively those patients without indications for immediate laparotomy.
Nontherapeutic and negative laparotomy rates, as well as overall lengths of hospital stay and cost, are
reduced using this approach [11,18,36-38]. A systematic review of two studies including 114 patients with
penetrating abdominal injury concluded that there is no evidence to support the use of surgery over an
observation protocol for patients with penetrating abdominal trauma who are stable with no signs of peritonitis
[39]. The approach to selective nonoperative management varies by injury and is discussed in greater detail
separately. (See "Overview of inpatient management in the adult trauma patient", section on 'Nonoperative
management' and "Traumatic gastrointestinal injury in the adult patient", section on 'Approach to
management' and "Overview of the diagnosis and initial management of traumatic retroperitoneal injury",
section on 'Nonoperative management'.)

Prophylactic antibiotics Broad spectrum antibiotics are given to patients with penetrating abdominal
injury requiring surgical management; however, antibiotic administration is not warranted in injured patients
who are managed nonoperatively. The use of prophylactic antibiotics in the setting of trauma is discussed
separately. Tetanus prophylaxis should be given as indicated. (See "Overview of inpatient management in the
adult trauma patient", section on 'Antibiotics' and "Infectious complications of puncture wounds", section on
'Tetanus immunization'.)

Observation in resource-limited settings Clinicians in rural emergency departments or other resource-

limited settings must decide whether to observe patients with an abdominal stab wound who are
hemodynamically stable and without obvious signs of intra-abdominal injury (including unconcerning
abdominal examination) at their institution or to transfer them to a hospital with the resources necessary to
provide definitive care should the patients condition deteriorate. There is no single best answer to this
question and the decision will vary depending upon such factors as patient characteristics (eg, major
comorbidities, advanced age) and distance from the closest hospital capable of providing definitive care. In
general, we believe it is reasonable in most cases to keep such patients at a resource-limited facility for
observation, even if LWE cannot be performed or is equivocal and CT cannot be obtained or is negative
initially. Should the patient begin to manifest signs of intra-abdominal injury (eg, worsening abdominal pain) or
vital signs show a concerning trend (eg, increase in heart rate or respiratory rate, decline in blood pressure),
the patient should be transferred immediately. One exception to this general approach would be if the time
needed to reach definitive care is prolonged (longer than approximately six hours) due to distance or
weather. In such cases, it makes sense to transfer the patient early.

SPECIAL CONSIDERATIONS

Flank and back stab wounds Identifying structures injured from penetrating wounds to the flank and
back can be difficult. Stab wounds to these regions can injure both retroperitoneal and intraperitoneal
structures. Several reports indicate that up to 40 percent of penetrating flank wounds result in significant
internal injury [8,40]. Triple contrast CT (3CT) has been the diagnostic modality of choice for stable patients
with such wounds, but with advanced, high-resolution, multidetector CT scanners, rectal contrast alone may
be needed to assess possible retroperitoneal injury from back or flank wounds [8,40,41]. Advanced imaging
often allows for safe triage to nonoperative management. Local wound exploration (LWE), ultrasound (US),
and diagnostic peritoneal lavage (DPL) do not assess retroperitoneal structures.

Thoracoabdominal stab wounds Thoracoabdominal wounds present a diagnostic challenge as

movement of the diaphragm makes prediction of the stab wound tract difficult [42]. If the wound is close to the
lower chest, intrathoracic and diaphragmatic injuries must be considered and evaluated in addition to intra-
abdominal injury. Pericardial tamponade is particularly important to consider in stab wounds near the xyphoid
process.

The morbidity and mortality associated with missed diaphragmatic injury on the left side is high (the liver
generally prevents small bowel herniation on the right side). However, controversy continues about how best
to evaluate possible diaphragm injuries. If diaphragmatic injury is a concern, diagnostic laparoscopy (DL) or
thoracoscopy are the preferred tests because CT scanning is relatively insensitive [21,43]. Some experts use
diagnostic peritoneal lavage with the lower threshold of 5000 red blood cells per high powered field
(RBCs/HPF) as the criterion for exploratory laparotomy. Diaphragmatic injury is discussed in detail
separately. (See 'Diagnostic laparoscopy' above and 'Computed tomography and magnetic resonance
imaging' above and 'Diagnostic peritoneal tap and diagnostic peritoneal lavage' above and "Recognition and
management of diaphragmatic injury in adults".)

Right upper quadrant stab wound Patients with a right upper quadrant stab wound who remain
hemodynamically stable and free of abdominal tenderness, and who are reliable (eg, not intoxicated and
remain alert) may be managed without laparotomy [28]. Most patients with injuries of this nature have
sustained grade I or grade II hepatic injuries that do not require operative intervention. However, these
patients should be admitted for a period of observation of at least 48 hours. Many centers perform CT
scanning to confirm and determine the extent of any hepatic wounds and to assess for potential colonic
injury. If the severity of liver injury cannot be determined with certainty by CT scan, most trauma surgeons
perform diagnostic laparoscopy. The physical examination cannot be considered reliable in patients with a
brain injury, spinal cord injury, heavy intoxication, or who require sedation or anesthesia, and serial physical
examination is not an appropriate means of evaluation in these circumstances.

Stab wounds in pregnancy Abdominal stab wounds sustained during pregnancy are uncommon. The
management of the pregnant trauma patient is reviewed separately. (See "Initial evaluation and management
of pregnant women with major trauma".)

Patients on anticoagulants Patients taking warfarin, heparin, or other anticoagulants are at higher risk of
hemorrhage following an abdominal stab wound and reversal of anticoagulation may be needed if bleeding
becomes severe. This is discussed separately. (See "Management of warfarin-associated bleeding or
supratherapeutic INR", section on 'Treatment' and "Heparin and LMW heparin: Dosing and adverse effects",
section on 'Bleeding' and "Management of bleeding in patients receiving direct oral anticoagulants", section
on 'Major bleeding'.)

Law enforcement and social service issues Many jurisdictions require emergency departments to notify
local law enforcement of all stab wounds. Law enforcement investigation may be necessary to ensure that no
other stab victims are in need of assistance. Necessary steps should be taken to ensure that the emergency
department and hospital are safe and secure, which may include communicating with hospital security or
police personnel. Clothing removed from the patient should be placed in brown paper bags or other
containers suitable for evidence collection, and care should be taken to avoid cutting through rips or knife
cuts in garments whenever possible. All wounds should be carefully documented in the medical chart.

Victims of assault may suffer emotionally as well as physically. Social services or mental health professionals
should be consulted as needed during the hospital evaluation and as part of post-discharge follow-up. (See
"Acute stress disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis".)

SUMMARY AND RECOMMENDATIONS

Whenever possible, obtain a history of the abdominal stab wound from the patient and emergency
medical services personnel or other witnesses. Important questions include: what instrument was used,
how long and how wide it was, how the patient was positioned during the stabbing, what path the
implement traveled, and whether there was substantial blood at the scene. Undress completely any
patient who sustains a stab wound. Stab wounds can often be obscured by body habitus, clothing, or
bleeding, or be "hidden" in the axilla, scalp, or groin. (See 'History' above and 'Initial assessment' above.)

Indications for emergent laparotomy include: hemodynamic instability, unequivocal peritoneal signs on
physical examination, signs of gastrointestinal hemorrhage, and implement in situ. Evisceration of intra-
abdominal organs or omentum is an indication for immediate laparotomy at most trauma centers. Broad
spectrum antibiotics are generally given to patients with penetrating abdominal injury requiring surgical
management, but otherwise are not administered. An algorithm to help guide the management of
patients with an anterior abdominal stab wounds is provided (algorithm 1). (See 'General approach and
indications for laparotomy' above.)
 Stab wounds to the abdomen, or flank are often amenable to local wound exploration (LWE) to evaluate
their depth and tract. If a properly performed exploration to the deepest extent of the wound
demonstrates that anterior rectus fascia is not violated, the patient may be discharged after appropriate
wound care, assuming no additional or extra-abdominal injuries are present. If body habitus, multiple
wounds, other injuries, or difficulty in performing LWE impedes visualization of the complete depth of the
wound and all its margins, then peritoneal injury cannot be ruled out and further testing or observation
must ensue. (See 'Local wound exploration' above.)

Plain radiographs are seldom useful for evaluating abdominal stab wounds, with the exception of
assessing foreign bodies such as impaled objects. (See 'Plain radiographs' above.)

Bedside extended Focused Abdominal Sonography for Trauma (eFAST) examination is frequently used
to determine the presence of hemopericardium, hemoperitoneum, pneumothorax, hemothorax, or some
combination thereof. Overall, the specificity of the FAST examination for identifying signs of internal
injury from a stab wound appears to be high, but sensitivity is limited. The use of ultrasound in evaluating
patients with abdominal trauma is described in detail separately. (See "Emergency ultrasound in adults
with abdominal and thoracic trauma".)

Observation with serial physical examination is a reliable approach for detecting significant injuries after
stab wounds to the abdomen, assuming normal mental status and neurologic function, and the absence
of distracting injury or sedation. Ideally, serial examinations should be performed by the same clinicians.
The optimal time period for observation of uncomplicated stab wound patients in a nonoperative
management plan is at least 12 hours. Patients with complicating factors (eg, older age, diabetes, taking
anticoagulants) warrant a longer period of observation. (See 'Serial physical examination and
observation' above.)

Multidetector computed tomography (MDCT) is a noninvasive and fast imaging technique that enables
accurate identification of peritoneal penetration and delineation of solid visceral and vascular injury.
Patients with a high likelihood for diaphragmatic, bowel, or pancreatic injury should have further testing,
or observation and serial examinations, even with a negative initial CT scan, as these injuries are missed
most frequently. (See 'Computed tomography and magnetic resonance imaging' above.)

Flank, back, and thoracoabdominal injuries may involve more than one anatomic space and can be
difficult to evaluate. Stable patients with stab wounds to the flank or back are generally evaluated using
MDCT. The morbidity and mortality associated with missed diaphragmatic injury on the left side is high.
Patients with thoracoabdominal injury require thorough investigation, possibly with diagnostic
laparoscopy or thoracoscopy. Patients with an isolated stab wound to the right upper quadrant may be
managed without laparotomy if vital signs remain stable and the abdominal examination is reliable (eg,
no alteration of mental status), and there is minimal to no abdominal tenderness. (See 'Special
considerations' above.)

Clinicians should be aware of local legal requirements for reporting stab wounds and whenever possible
take the necessary steps for proper evidence collection. Consultation with social service or mental health
service personnel may be beneficial and appropriate outpatient referral to such services may be
warranted.

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Topic 356 Version 27.0

GRAPHICS

Anatomic zones of the abdominal cavity

Graphic 64644 Version 3.0

Adult abdominal anatomy

Graphic 51176 Version 2.0

Blood vessels of the anterior abdominal wall

The superior and inferior epigastric arteries provide a rich arcade, arising from the internal
thoracic artery superiorly and the external iliac artery inferiorly. The musculophrenic artery,
deep circumflex iliac artery, and subcostal arteries supply the lateral abdominal wall. The
superficial epigastric veins and the superficial iliac veins can arise from the great saphenous
vein.

Graphic 81343 Version 5.0

Muscles of the anterior abdominal wall

Graphic 72219 Version 2.0

Nerves of the anterior chest and abdomen

The chest and abdominal walls are supplied by the thoracic and thoracoabdominal intercostal
nerves, as well as nerves from the lumbar plexus. The intercostal nerves arise from the ventral
rami of the thoracic spinal nerves from T1 to T11. The corresponding nerve associated with T12
is the subcostal nerve.

n.: nerve; ns.: nerves.

Graphic 79068 Version 3.0

Management of anterior abdominal stab wound

eFAST: extended FAST ultrasound examination; LWE: local wound exploration; MDCT: multi-detector
computed tomography; WBC: white blood cell.
* The appropriate length of observation varies according to clinical circumstances. Such
characteristics as advanced age, important comorbidities, and medications that increase the risk of
bleeding warrant longer observation.
Appropriate discharge criteria are described in the topic discussing abdominal stab wounds.

Graphic 108065 Version 2.0

Contributor Disclosures
Christopher Colwell, MD Nothing to disclose Ernest E Moore, MD Grant/Research/Clinical Trial Support:
Haemonetics [Coagulopathy (Thromboelastography); TEM [Coagulopathy (Rotational thromboelastometry)].
Patent Holder: Haemonetics [Coagulopathy (Thromboelastography)]. Maria E Moreira, MD Nothing to
disclose Jonathan Grayzel, MD, FAAEM Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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