Penetrating Abdominal Trauma

Quick Answer

One-liner: Penetrating abdominal trauma requires rapid assessment of haemodynamic stability, judicious use of FAST and imaging, and immediate laparotomy for hypotension, peritonitis, or evisceration.

Penetrating abdominal trauma is a surgical emergency with mortality 15-25% for major vascular injuries. Immediate priorities: ABCDE assessment, establish two large-bore IVs, type and cross, FAST (limited for hollow viscus), and expeditious transfer to operating theatre for hypotensive or peritonitic patients. Selective non-operative management may be considered for haemodynamically stable patients with anterior abdominal stab wounds (Zone II). Key surgical indications: hypotension, peritonitis, evisceration, gunshots crossing midline, and positive FAST in unstable patient. Local wound exploration may obviate laparotomy in 25-30% of anterior abdominal stab wounds that do not penetrate peritoneum. ATLS principles apply: airway with cervical spine protection if indicated, breathing with chest decompression for tension pneumothorax, circulation with blood product resuscitation, disability assessment, and full exposure with log roll to assess for back wounds.

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ACEM Exam Focus

Primary Exam Relevance

Anatomy:

• Abdominal wall layers: Skin, Camper's fascia, Scarpa's fascia, external oblique, internal oblique, transversus abdominis, transversalis fascia, extraperitoneal fat, parietal peritoneum
• Retroperitoneal structures: Aorta, IVC, kidneys, ureters, pancreas, duodenum (2nd and 3rd parts), ascending and descending colon
• Solid organs: Liver (Couinaud segments), spleen (segments), kidneys (retroperitoneal, protected by ribs 11-12)
• Vascular anatomy: Celiac trunk, superior mesenteric artery, inferior mesenteric artery, renal arteries, portal vein, hepatic veins

Physiology:

• Compensatory mechanisms: Tachycardia, vasoconstriction, fluid shift to maintain perfusion pressure
• Third spacing: Fluid loss into peritoneal cavity, retroperitoneum
• Mesenteric ischaemia: Bowel viability dependent on mesenteric perfusion pressure above 60 mmHg
• Haemodynamic thresholds: Class III shock (30-40% blood loss, SBP below 100, HR 120-140)

Pharmacology:

• Resuscitation fluids: Balanced crystalloids (Plasma-Lyte, Hartmann's) vs normal saline, blood product ratios (1:1:1)
• Antibiotics: Cefazolin 2g IV or ceftriaxone 2g IV + metronidazole 500mg IV for hollow viscus injury
• Analgesia: IV opioids (fentanyl 25-50mcg increments) titrated to effect, caution in hypotension

Fellowship Exam Relevance

Written:

• Management algorithms: ATLS approach, selective non-operative management criteria
• FAST interpretation: Sensitivity/specificity for different injury patterns
• Laparotomy indications: Absolute vs relative criteria
• Organ-specific injuries: Liver (AAST grades), spleen (grades), kidney (grades), bowel (primary repair vs resection)

OSCE:

• Primary survey: ABCDE management of hypotensive trauma patient
• Team leadership: Closed-loop communication, role allocation in trauma team
• FAST examination: Systematic approach to trauma ultrasound
• Procedures: Tube thoracostomy, diagnostic peritoneal lavage (historical), central line placement

Key domains tested: Medical Expert (clinical decision-making), Communicator (family liaison), Leader (trauma team coordination), Collaborator (surgical consultation)

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Key Points

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Epidemiology

Australian/NZ Specific

• Urban trauma centres: Major penetrating abdominal trauma clusters in Melbourne, Sydney, Brisbane, Perth
• Indigenous representation: 3-4 times higher incidence of penetrating trauma in Aboriginal populations compared to non-Indigenous | [10]
• Rural distribution: Higher proportion of stab wounds in remote/very remote areas (often alcohol-related)
• NSW Trauma Registry: 200-250 major abdominal penetrating injuries annually | [11]
• Victorian State Trauma Registry: Gunshot injuries increased 45% from 2015-2025 | [12]

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Pathophysiology

Mechanism

Stab Wounds:

• Low velocity: Limited tissue cavitation, injury follows track of blade
• Depth unpredictable: Can reach deep structures despite small external wound
• Multiple injuries possible: Single stab may traverse multiple organs
• Self-inflicted: Higher intra-abdominal injury rate (more aggressive, deeper)

Gunshot Wounds:

• High velocity: Cavitation and kinetic energy transfer
• Yaw and tumble: Bullet destabilisation increases tissue destruction
• Fragmentation: Increased tissue damage
• Range dependence: Close-range (below 3m) = higher energy transfer

Pathological Progression

Penetration → Haemorrhage (solid organ, vascular) → Hypovolaemic shock → Multi-organ failure
                ↓
         Hollow viscus injury → Bacterial peritonitis → Sepsis → MODS
                ↓
         Retroperitoneal injury → Concealed bleeding → Delayed recognition

Time Course

Immediate (0-30 min): Haemorrhage, acute blood loss Early (30 min-6 hr): Peritonitis develops (hollow viscus), ongoing bleeding Delayed (6-24 hr): Sepsis from bacterial translocation, organ failure Late (24+ hr): Complications: abscess, fistula, bowel obstruction

Why It Matters Clinically

Solid organ injury → Massive haemorrhage → Rapid decompensation Hollow viscus injury → Peritonitis → Sepsis → Mortality delayed but high Vascular injury → Catastrophic bleeding → Highest mortality Retroperitoneal injury → Concealed → Diagnostic challenge, delayed presentation

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Clinical Approach

Recognition

Trigger Features:

• Visible abdominal wound (stab or GSW)
• History of abdominal trauma
• Hypotension without obvious external bleeding
• Abdominal tenderness or rigidity
• Wound location: anterior abdomen, flank, back, thoracoabdominal

Red Flag Presentations:

• SBP below 90 mmHg with abdominal wound
• Peritonitis (board-like abdomen, guarding)
• Evisceration
• Blood at urethral meatus or rectal vault
• Gunshot crossing midline or thoracoabdominal location

Initial Assessment

Primary Survey (ABCDE)

A - Airway with Cervical Spine Protection

• Indicated for: GSW to neck/thoracoabdominal, altered GCS, associated injuries
• Manual in-line immobilisation if indicated
• Rapid sequence intubation for GCS below 8, severe respiratory distress, or need for operative control of bleeding

B - Breathing

• Assess for: Tension pneumothorax, open pneumothorax, haemothorax, diaphragmatic injury
• Thoracoabdominal wounds (wounds below 4th intercostal anterior, 6th posterior): Assess diaphragm
• Chest X-ray (supine) may miss small pneumothorax
• Tube thoracostomy for: Tension pneumothorax (needle decompression first), haemothorax (drain below 100-150mL initially, then output below 100-200mL/4hr)

C - Circulation

• Establish: Two large-bore peripheral IVs (14G or 16G)
• Immediate: 1L balanced crystalloid bolus if SBP below 90
• Blood products: Activate massive transfusion protocol if ABC score ≥ 2
• FAST examination: Focused Assessment with Sonography for Trauma
• Pelvic binder if pelvic fracture suspected
• Tourniquet for active limb arterial bleeding

D - Disability

• GCS: Baseline, reassess after resuscitation
• Pupils: Assess for brain injury
• Glucose: Check if altered mental status

E - Exposure/Environment

• Full exposure: Remove clothing, log roll to examine back
• Log roll: Essential to assess for posterior wounds (missed in up to 10% initially)
• Cover: Prevent hypothermia (warm blankets, active warming)
• Rectal examination: Blood, high-riding prostate, sphincter tone

Secondary Survey

Detailed History:

Examination:

Inspection:

• Number and location of wounds
• Evisceration (omental, bowel)
• Contusions (seatbelt sign, may indicate underlying injury)
• Distension (suggests significant haemoperitoneum or ileus)

Palpation:

• Local tenderness: May predict injury location (limited accuracy)
• Generalised tenderness/rigidity: Peritonitis (hollow viscus injury)
• Abdominal distension: Haemoperitoneum (1,000-1,500mL before clinically apparent)
• Pulse: Tachycardia (class I-III shock)
• Blood pressure: Hypotension (class III-IV shock)

Auscultation:

• Bowel sounds: Absent in peritonitis
• Arterial bruits: Arteriovenous fistula (rare, delayed presentation)

Special Tests:

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Investigations

Immediate (Resus Bay)

FAST Interpretation:

FAST Limitations in Penetrating Trauma:

• Hollow viscus injury: Sensitivity only 50-67% (air, minimal fluid) | [22]
• Retroperitoneal injury: Poor visualisation (duodenum, kidneys, pancreas, great vessels) | [23]
• Operator dependence: Requires training
• Time: Should be completed within 5-7 minutes

Indications for Immediate Laparotomy (bypass FAST):

• Hypotension (SBP below 90 mmHg) with abdominal wound
• Peritonitis
• Evisceration
• Gunshot wound crossing midline
• Thoracoabdominal wound with abdominal signs

Standard ED Workup

Laboratory Tests:

Urine Analysis:

• Microscopic haematuria: Renal, ureter, or bladder injury
• Gross haematuria: Higher likelihood of significant injury (70-80%) | [24]

Imaging:

CT Abdomen with Intravenous Contrast:

Indications:

• Haemodynamically stable patient (SBP ≥ 90)
• Anterior abdominal stab wound in Zone II
• Equivocal FAST or clinical examination
• Gunshot wound with uncertain trajectory (non-haemorrhagic)

Protocol:

• Arterial phase: Vascular injury assessment
• Portal venous phase: Solid organ injury, bowel enhancement
• Delayed phase: Urinary tract assessment (if indicated)

Findings:

Contra-indications to CT:

• Haemodynamic instability (SBP below 90)
• Peritonitis (immediate laparotomy)
• Evisceration (immediate laparotomy)
• Allergy to iodinated contrast (consider non-contrast or MRI if stable)

Advanced/Specialist

Diagnostic Peritoneal Lavage (DPL) - Historical context:

• Sensitivity: 95-98% for haemoperitoneum
• Specificity: 90-95%
• False positives: Retroperitoneal bleeding, pelvic fracture
• Limitations: Does not identify specific organ injury
• Current role: Largely replaced by FAST and CT, limited utility in penetrating trauma | [29]

Diagnostic Laparoscopy:

• Indications: Uncertain peritoneal penetration, diaphragm evaluation (thoracoabdominal), selected stable patients
• Sensitivity: 85-90% for peritoneal penetration
• Specificity: 95-100%
• Benefits: Therapeutic potential (diaphragmatic repair, haemostasis)
• Risks: Missed hollow viscus injury, pneumoperitoneum interference with subsequent open laparotomy | [30]

Point-of-Care Ultrasound

FAST Examination:

Technique:

1. Subxiphoid: Probe indicator to patient's right, fanning to assess pericardium
2. Right upper quadrant: Probe in mid-axillary line at 10-11th intercostal space, indicator to head
3. Left upper quadrant: Probe in posterior axillary line at 8-9th intercostal space, indicator to head
4. Suprapubic: Probe transverse suprapubic, indicator to patient's right

Positive Findings:

• Morison's pouch: Fluid stripe greater than 1cm
• Splenorenal: Fluid between spleen and kidney
• Pouch of Douglas: Fluid in rectovesical/rectouterine pouch
• Pericardium: Fluid greater than 5mm in diastole

Limitations:

• Obesity: Poor acoustic window
• Subcutaneous emphysema: Air obscures view
• Bowel gas: Interferes with visualisation
• Operator experience: Affects accuracy

Extended FAST (E-FAST):

• Pneumothorax assessment: Absence of lung sliding, absent B-lines, lung point
• Sensitivity: 88-98% for pneumothorax
• Specificity: 97-99%

Trauma in Pelvic Ultrasound:

• Indication: Blunt pelvic trauma (less useful for penetrating)
• Haemoperitoneum detection: Less sensitive than FAST for suprapubic view

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Management

Immediate Management (First 10 minutes)

1. PRIMARY SURVEY (ABCDE) with simultaneous team member interventions
2. Establish TWO large-bore IVs (14G or 16G) - draw bloods
3. Administer 1L balanced crystalloid if hypotensive (SBP below 90)
4. Activate trauma team and OR
5. Order: FAST, portable chest X-ray, pelvic X-ray
6. Group and hold or type and crossmatch blood
7. Administer broad-spectrum antibiotics: Cefazolin 2g IV or Ceftriaxone 2g IV + Metronidazole 500mg IV
8. Insert urinary catheter (if no urethral injury suspected)
9. Insert gastric tube (decompression)
10. Reassess haemodynamics, prepare for immediate laparotomy if indicated

Resuscitation

Airway

Indications for Intubation:

• GCS below 8
• Severe respiratory distress (RR above 30, SpO2 below 90% on oxygen)
• Need for operative intervention (general anaesthesia)
• Inability to protect airway (vomiting, haematemesis)

Rapid Sequence Intubation (RSI):

• Pre-oxygenation: 100% oxygen for 3-5 minutes, head up 20-30°
• Induction: Ketamine 1.5-2 mg/kg IV or Etomidate 0.3 mg/kg IV
• Paralysis: Rocuronium 1.2 mg/kg IV or Suxamethonium 1-1.5 mg/kg IV
• Cervical spine: Manual in-line immobilisation if indicated

Adjuncts:

• Nasogastric tube: After intubation (contraindicated if base of skull fracture suspected)
• Oropharyngeal airway: During bag-mask ventilation
• Suction: Aspiration prophylaxis

Breathing

Oxygenation Targets:

• SpO2: 94-98%
• PaO2: Above 80 mmHg on ABG

Ventilation:

• Tidal volume: 6-8 mL/kg (ideal body weight)
• Respiratory rate: 12-16 breaths/min
• PEEP: 5 cmH2O (higher if ARDS develops)

Thoracic Injury Management:

• Tension pneumothorax: Needle decompression (2nd intercostal space, midclavicular, 14G cannula), then tube thoracostomy (5th intercostal space, anterior axillary line, size 28-32 Fr)
• Open pneumothorax: Three-sided dressing, then tube thoracostomy
• Haemothorax: Tube thoracostomy, if initial output exceeds 1,000mL or ongoing above 200mL/hr for 4 hours = thoracotomy
• Diaphragmatic injury: Suspect in thoracoabdominal wounds, elevated hemidiaphragm on CXR, confirmed on CT or laparoscopy

Circulation

Haemodynamic Goals:

• SBP: 90-100 mmHg (permissive hypotension if not head injury) | [31]
• MAP: Above 65 mmHg
• Urine output: Above 0.5 mL/kg/hr

Fluid Resuscitation:

• Initial: 1L balanced crystalloid (Hartmann's or Plasma-Lyte) if hypotensive
• Blood products: If hypotension persists or significant bleeding suspected
• Massive Transfusion Protocol: Activate if ABC score ≥ 2
  • "A: Assessment (SBP below 90)"
  • "B: Base excess (below -3 mmol/L)"
  • "C: CT FAST positive"
  • Score ≥ 2 = activate MTP

Massive Transfusion Protocol (1:1:1 ratio):

• RBCs: 1 unit (300mL)
• FFP: 1 unit (300mL)
• Platelets: 1 unit (300mL)
• Repeat: Continue until bleeding controlled
• Cryoprecipitate: If fibrinogen below 1.5 g/L (10 units)

Calcium Replacement:

• Calcium gluconate 1g IV after every 4 units of blood products
• Rationale: Citrate toxicity from stored blood → hypocalcaemia → coagulopathy, myocardial depression
• Target ionised calcium: Above 1.0 mmol/L

Tranexamic Acid (TXA):

• Loading dose: 1g IV over 10 minutes
• Maintenance: 1g IV over 8 hours
• Window: Must be administered within 3 hours of injury | [32]
• Mechanism: Inhibits fibrinolysis
• Evidence: CRASH-2 trial - reduced mortality when administered early | [33]

Damage Control Resuscitation:

• Permissive hypotension: SBP 80-90 mmHg until bleeding controlled (exceptions: TBI, spinal cord injury, pregnancy)
• Balanced blood products: Minimise crystalloids
• Goal-directed therapy: ROTEM/TEG guided
• Hypothermia prevention: Warm blankets, fluid warmer, ambient temperature 24-26°C

Medications

Paediatric Dosing

Ongoing Management

Haemodynamic Monitoring:

• Arterial line: If unstable or requiring vasopressors
• Central venous catheter: For massive transfusion, vasopressor administration
• CVP: 8-12 cmH2O goal (guided, not absolute)
• Serial FAST: Every 30-60 min in borderline cases
• Serial lactate: Trending to assess response to resuscitation

Ventilatory Support:

• Intubated: Lung-protective ventilation, ARDS prevention
• Spontaneous breathing: Maintain if adequate airway, oxygenation, ventilation

Surgical Consultation:

• General surgery: Immediate consultation for all penetrating abdominal trauma
• Vascular surgery: For major vessel injury
• Urology: For renal, ureteral, bladder injury
• Thoracic surgery: For thoracoabdominal wounds, diaphragmatic injury

Definitive Care

Laparotomy Indications

Absolute Indications (immediate, no further imaging):

1. Hypotension (SBP below 90 mmHg) with abdominal wound | [34]
2. Peritonitis (generalised tenderness, guarding, rigidity) | [35]
3. Evisceration (omental or bowel) | [36]
4. Gunshot wound crossing midline | [37]
5. Positive FAST in haemodynamically unstable patient | [38]
6. Thoracoabdominal wound with abdominal signs (diaphragm, upper abdominal injury)

Relative Indications (individualised decision):

1. Anterior abdominal stab wound (Zone II) with equivocal FAST or examination | [39]
2. Gunshot wound in haemodynamically stable patient with uncertain trajectory | [40]
3. Back/flank wounds with haematuria or haemodynamic instability | [41]
4. Persistent acidosis (pH below 7.35, lactate above 4) despite resuscitation | [42]
5. Diagnostic peritoneal lavage positive (WBC above 500/μL, RBC above 100,000/μL, amylase elevated) - historical

Selective Non-Operative Management (SNOM):

Criteria:

1. Haemodynamically stable (SBP ≥ 90, HR below 100)
2. Anterior abdominal stab wound in Zone II
3. No peritonitis
4. No evisceration
5. No FAST evidence of significant haemoperitoneum
6. No associated injuries requiring laparotomy

Success rate: 75-85% in appropriately selected patients | [43]

Protocol:

1. Admission to monitored bed (HDU or ICU)
2. Serial abdominal examinations: Hourly for 6 hours, then 2-4 hourly for 24 hours
3. Repeat FAST: At 4-6 hours if clinical concern
4. CT abdomen: If examination becomes equivocal or delayed presentation of peritonitis
5. Immediate laparotomy: If signs of peritonitis or haemodynamic instability develop

Failed SNOM rate: 15-25% (delayed laparotomy)

• Delay: Mean 6-12 hours from admission
• Complication rate: Higher than immediate laparotomy (mortality 10-15% vs 5-8%)
• Risk factors: Missed hollow viscus injury, delayed presentation, inadequate serial examinations

Local Wound Exploration

Indications:

• Anterior abdominal stab wounds in Zone II
• Haemodynamically stable
• No peritonitis
• Equivocal FAST or clinical examination

Technique:

1. Local anaesthesia: 1% lidocaine with epinephrine (if not contraindicated)
2. Extension of wound: Sufficient length for visualisation
3. Visualisation: Assess for fascial and peritoneal penetration
4. If peritoneum intact: May avoid laparotomy (25-30% of cases) | [44]
5. If peritoneum breached: Laparotomy indicated

Limitations:

• Inability to definitively assess retroperitoneal structures
• Operator dependence
• Not applicable to gunshots or thoracoabdominal wounds

Operative Management

Exploratory Laparotomy:

Incision: Midline (most versatile, allows extension to sternotomy) Approach: Systematic exploration (all quadrants, retroperitoneum) Injury control: Control bleeding first, then contamination control

Damage Control Surgery:

1. Abbreviated laparotomy (30-60 min): Control bleeding, prevent contamination
2. ICU resuscitation: Rewarm, correct coagulopathy, optimise haemodynamics
3. Relook laparotomy (24-48 hours): Definitive repair

Indications for Damage Control:

• Hypothermia (temperature below 35°C)
• Acidosis (pH below 7.25)
• Coagulopathy (INR above 1.5, aPTT above 60)
• Massive transfusion (≥10 units RBC)
• Prolonged operative time (≥2 hours) with ongoing bleeding

Organ-Specific Management:

Liver:

• AAST Grades I-II: Observation, packing, topical haemostatics
• AAST Grades III: Parenchymal suturing, fibrin glue, arterial ligation
• AAST Grades IV-V: Resection, shunting, anatomic resection
• Non-operative management: Grades I-III (80% success rate in stable patients) | [45]

Spleen:

• AAST Grades I-II: Observation
• AAST Grades III: Splenorrhaphy (repair), partial splenectomy
• AAST Grades IV-V: Splenectomy
• Non-operative management: Grades I-III (90% success rate in stable patients) | [46]
• Post-splenectomy vaccinations: Pneumococcal, meningococcal, H. influenzae type B

Kidney:

• AAST Grades I-III: Observation, nephrostomy if ureteral injury
• AAST Grades IV: Repair (if viable tissue), nephrectomy if shattered
• AAST Grade V: Nephrectomy
• Renal vascular injury: Repair if feasible, nephrectomy if extensive damage | [47]

Bowel:

• Stomach: Primary repair (2-layer), resection if extensive damage
• Small intestine: Primary repair (transverse closure), resection with anastomosis if multiple injuries, devascularised segment
• Colon: Primary repair if short delay, minimal contamination, haemodynamically stable; resection with end colostomy (Hartmann's) if unstable, extensive contamination
• Rectum: Diverting colostomy, presacral drainage | [48]

Pancreas:

• Proximal: Pancreaticoduodenectomy (Whipple) for severe head injury
• Distal: Distal pancreatectomy with splenectomy (or spleen-preserving)
• Drainage: Essential for fistula prevention

Vascular:

• Aorta: Primary repair (lateral arteriorrhaphy) if feasible, aorto-iliac graft for extensive injury | [49]
• IVC: Lateral venorrhaphyny, ligation (survival 50-70%) if extensive injury | [50]
• Mesenteric vessels: Primary repair, ligation (bowel resection may be required)

Post-operative Care:

• ICU admission: For major injuries, damage control surgery, or ongoing instability
• Antibiotics: Continue for 24-48 hours (no benefit beyond this) | [51]
• Nutrition: Early enteral nutrition (within 24-48 hours) reduces complications | [52]
• Pain management: Multimodal (IV opioids, NSAIDs if appropriate, regional anaesthesia)
• Thromboprophylaxis: LMWH or unfractionated heparin (DVT prophylaxis)

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Disposition

Admission Criteria

All patients with penetrating abdominal trauma require admission:

• ICU/HDU: Unstable, requiring vasopressors, mechanical ventilation, massive transfusion
• General surgical ward: Stable, post-laparotomy, or undergoing SNOM
• Observation unit: Selected stable patients with anterior abdominal stab wounds (Zone II)

ICU/HDU Indications:

• SBP below 90 or requiring vasopressors
• Mechanical ventilation
• Massive transfusion (≥10 units RBC)
• Severe acidosis (pH below 7.30), lactate above 4 mmol/L
• Significant coagulopathy (INR above 1.5)
• Damage control surgery
• Renal failure (creatinine above 200 μmol/L)
• Need for close monitoring (renal injury, vascular injury)

Discharge Criteria

Rapid discharge possible ONLY if:

• Anterior abdominal stab wound in Zone II
• Haemodynamically stable (SBP ≥ 90, HR below 100)
• NO peritonitis
• NO evisceration
• Negative FAST (or minimal fluid)
• Wound exploration negative for peritoneal penetration
• Normal CT abdomen (if performed)
• 24-hour observation period completed

Discharge instructions:

• Return immediately for: Abdominal pain, distension, vomiting, fever, or fainting
• Wound care: Keep clean and dry, sutures or staples removed in 7-14 days
• Follow-up: Review in surgical clinic in 1-2 weeks
• Activity restriction: No heavy lifting or strenuous activity for 4-6 weeks

Red flags for return:

• Progressive abdominal pain or distension
• Vomiting (especially bilious)
• Fever (temperature above 38°C)
• Passage of blood per rectum or melena
• Dizziness or fainting

Follow-up

Post-discharge:

• Surgical clinic review: 1-2 weeks
• Wound review: At suture/staple removal
• Imaging: If persistent pain, fever, or other concerning symptoms
• Psychological support: PTSD assessment (up to 30% of trauma patients develop PTSD) | [53]

Long-term complications:

• Adhesions: Small bowel obstruction (2-5% at 5 years)
• Incisional hernia: 5-10% at midline laparotomy
• Chronic pain: 10-15%
• Organ dysfunction: Splenectomy (infection risk), nephrectomy (chronic kidney disease)

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Special Populations

Paediatric Considerations

Anatomical differences:

• Less protective fat: More susceptible to solid organ injury
• More pliable ribs: Less protection for liver and spleen
• Smaller blood volume: Dehydrates faster with haemorrhage

Management modifications:

• Permissive hypotension: NOT recommended (maintain age-appropriate SBP)
• Blood products: Type-specific or O-negative for massive transfusion
• Non-operative management: Higher success rate (85-90% for liver/spleen injuries) | [54]
• Antibiotics: Weight-based dosing
• Radiation: Minimise CT when possible (long-term cancer risk)

Age-specific vitals:

• Neonate: SBP 60-90, HR 100-180
• Infant (0-12 mo): SBP 70-100, HR 100-160
• Toddler (1-3 yr): SBP 80-110, HR 90-150
• Preschool (4-5 yr): SBP 90-110, HR 80-140

Pregnancy

Anatomical changes:

• Uterus elevation: Above umbilicus at 20 weeks, displaces bowel
• Increased blood volume: 40-50% increase (initially compensates for blood loss)
• Supine hypotension: Aortocaval compression in third trimester

Management modifications:

• Permissive hypotension: CONTRAINDICATED (maintain SBP above 90, placental perfusion)
• Imaging: CT abdomen with abdominal shielding, MRI if indicated
• Fetal monitoring: Continuous if gestation ≥ 24 weeks
• Obstetrics consultation: Immediate involvement
• Rh immunoglobulin: 300 μg IM if Rh-negative and Rh-positive blood exposure

Priority: Maternal stability = fetal stability

Maternal mortality: 5-10% for major penetrating abdominal trauma Fetal mortality: 30-50% for major penetrating abdominal trauma | [55]

Elderly

Physiological changes:

• Reduced physiological reserve: Less compensatory tachycardia
• Comorbidities: Cardiovascular disease, anticoagulant use, renal impairment
• Medications: Antiplatelets, anticoagulants (increase bleeding risk)

Management modifications:

• Lower threshold for laparotomy: Less reliable physical examination
• Earlier imaging: CT abdomen even if equivocal examination
• Higher suspicion for retroperitoneal injury: Aortic/IVC injury more common
• Medication review: Reversal of warfarin (Vitamin K, PCC), antiplatelet agents

Mortality: 2-3 times higher than younger patients with similar injuries | [56]

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Health Disparities:

• Aboriginal and Torres Strait Islander Australians have 3-4 times higher incidence of penetrating trauma | [10]
• Māori in New Zealand have 2-3 times higher trauma-related mortality | [57]
• Higher proportion of alcohol-related injuries in Indigenous populations
• Increased prevalence of comorbidities (diabetes, cardiovascular disease, renal disease)

Cultural Safety:

• Acknowledge Country and cultural protocols early in encounter
• Use Aboriginal Health Workers, Aboriginal Liaison Officers, or Māori health providers
• Explain procedures and investigations clearly (avoid medical jargon)
• Involve family and community in decision-making where appropriate
• Respect traditional healing practices alongside western medicine

Communication Considerations:

• Language barriers: Use interpreters (NOT family members)
• Time constraints: Allow sufficient time for discussions
• Eye contact: May be culturally inappropriate in some communities
• Touch: Obtain permission before physical examination
• Decision-making: May involve elders or family groups

Access Barriers:

• Remote residence: Delayed presentation, limited specialist services
• Transport challenges: Ambulance availability, road conditions
• Cultural mistrust: Historical trauma affecting healthcare engagement
• Financial constraints: Cost of travel, accommodation

Specific Recommendations:

• Early involvement of Aboriginal/Torres Strait Islander health services
• Cultural liaison for family communication and support
• Consider transfer to metropolitan trauma centre if indicated (RFDS, retrieval services)
• Post-discharge support through Aboriginal Medical Services or Iwi providers
• Psychosocial support addressing trauma-specific needs

Remote/Rural Management:

• Establish relationship with local Aboriginal Health Workers or Māori providers
• Telemedicine consultation with specialist centres when transfer delayed
• Consider community-based follow-up post-discharge
• Provide culturally appropriate discharge information

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Primary Survey and Resuscitation

Format: Resuscitation Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

A 38-year-old male has just arrived by ambulance following a stab wound to the abdomen. You are the team leader. Please manage this patient according to ATLS principles. You may request investigations and interventions as required. The nurse, registrar, and anaesthetist are available to assist you.

Examiner Instructions: Scenario: Patient is 38-year-old male with single stab wound to left upper quadrant. On initial presentation: GCS 15, HR 135, BP 80/50, RR 26, SpO2 96% on 15L via face mask. Single stab wound in left upper quadrant, bleeding controlled with gauze. Abdomen distended, diffusely tender, guarding present. No other obvious injuries.

Expected progression:

• Candidate performs systematic primary survey (ABCDE)
• Identifies hypotension as critical finding
• Initiates fluid resuscitation and activates massive transfusion protocol
• Orders FAST examination
• Recognises immediate laparotomy indication
• Communicates effectively with team using closed-loop communication
• Maintains situational awareness

Actor/Patient Brief: Simulated patient: Mannequin or simulated patient with abdominal wound Nurse: Responsive to commands, can establish IVs, administer medications, assist with FAST Registrar: Can assist with procedures, provide clinical updates Anaesthetist: Available for airway management if required

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • "Pass: Recognises need for immediate laparotomy, activates MTP, communicates clearly"
  • "Fail: Orders CT in hypotensive patient, does not activate massive transfusion, poor communication"

Critical actions:

1. ABC approach: Airway patent, breathing adequate (assess for tension pneumothorax), circulation compromised with hypotension
2. Establish access: Two large-bore IVs (14G or 16G)
3. Fluid resuscitation: 1L balanced crystalloid bolus
4. Massive transfusion protocol: Activate immediately
5. FAST: Perform rapidly (within 5 minutes)
6. Surgical consultation: Immediate involvement of general surgery
7. Antibiotics: Cefazolin 2g IV (add Metronidazole if hollow viscus suspected)
8. Do not delay for imaging: Immediate laparotomy is indicated

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Station 2: FAST Examination

Format: Skills/Procedure Time: 11 minutes Setting: ED resuscitation bay with ultrasound machine

Candidate Instructions:

Please perform and interpret a FAST (Focused Assessment with Sonography for Trauma) examination on this simulated patient. State your findings and their clinical significance. You have 11 minutes.

Examiner Instructions: Scenario: Candidate performs FAST on a simulated patient (mannequin or standardized patient) with abdominal penetrating trauma. The ultrasound machine is set up with pre-recorded clips or simulated findings.

Findings (simulated):

• Subxiphoid: Normal (no pericardial fluid)
• Right upper quadrant (Morison's): Positive - fluid between liver and kidney, greater than 1cm
• Left upper quadrant (splenorenal): Positive - fluid between spleen and kidney
• Suprapubic: Positive - fluid in pelvis

Expected progression:

• Candidate prepares equipment (gel, patient positioning)
• Performs systematic FAST in correct order
• Identifies normal vs abnormal findings
• Interprets findings correctly
• States clinical significance and next steps

Equipment:

• Ultrasound machine
• Ultrasound gel
• Curtains for patient privacy (if using simulated patient)

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • "Pass: Systematic approach, correct interpretation, appropriate clinical action"
  • "Fail: Misses positive findings, incorrect order, inappropriate clinical decisions"

Expected Findings:

• Subxiphoid: Normal - no pericardial fluid (assess for pericardial effusion, cardiac tamponade)
• Morison's pouch: Positive - fluid between liver and right kidney, greater than 1cm (indicating haemoperitoneum)
• Splenorenal: Positive - fluid between spleen and left kidney (indicating haemoperitoneum)
• Suprapubic: Positive - fluid in pelvis (indicating pelvic haemorrhage)

Clinical significance:

• Positive FAST in 3 views = significant haemoperitoneum
• In a haemodynamically stable patient: Prepare for laparotomy, consider CT to identify specific organ injuries
• In a haemodynamically unstable patient: Immediate laparotomy

Limitations of FAST:

• Sensitivity for haemoperitoneum: 79-85%
• Sensitivity for hollow viscus injury: Only 50-67% (air, minimal fluid)
• Sensitivity for retroperitoneal injury: Poor (duodenum, pancreas, kidneys, great vessels)

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Station 3: Communication - Breaking Bad News to Family

Format: Communication Time: 11 minutes Setting: Relatives room in ED

Candidate Instructions:

You are the emergency physician managing a 35-year-old male with severe penetrating abdominal trauma. The patient has just been taken to the operating theatre for emergency laparotomy. His sister has arrived at the ED. Please inform her about her brother's condition and prognosis. The nurse is present to support you.

Examiner Instructions: Scenario: Patient is 35-year-old male with multiple stab wounds to abdomen. Hypotensive on arrival (BP 75/45), positive FAST, immediate laparotomy. Injuries include liver laceration and small bowel injury. Estimated mortality 15-25%.

Sister (actor): 30-year-old female, anxious, seeking information about her brother's condition. May ask questions about prognosis, cause of injury, time course, and next steps.

Expected progression:

• Candidate establishes rapport and sets appropriate environment
• Uses SPIKES framework or similar structured approach
• Provides clear, accurate information at appropriate pace
• Assesses understanding and addresses concerns
• Provides support and follow-up plan
• Maintains empathy while being realistic about prognosis

Actor/Patient Brief (Sister): Name: Sarah Age: 30 Emotional state: Anxious, upset Information to reveal: "I just got a call that my brother John is here. What happened? Is he going to be okay?" Questions to ask:

• "What happened to him?"
• "Is the surgery going to save him?"
• "Can I see him?"
• "How long will he be in the operating theatre?"
• "Who did this to him?"

Marking Criteria:

Expected Standard:

• Pass: ≥6/10
• Key discriminators:
  • "Pass: Uses structured approach, demonstrates empathy, provides clear information, manages expectations"
  • "Fail: Uses medical jargon, no empathy, unrealistic promises, dismisses concerns"

Key communication strategies:

• SPIKES framework: Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary
• What we know: Patient has abdominal stab wounds, underwent immediate surgery for liver and bowel injury
• What we don't know: Exact extent of injuries, surgical outcome
• Prognosis: 15-25% mortality for major abdominal vascular/solid organ injury, individual prognosis uncertain
• Next steps: Surgery in progress, will provide updates, ICU care likely post-operatively
• Support: Offer social worker, chaplaincy, counselling services

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SAQ Practice

Question 1 (8 marks)

Stem: A 42-year-old male presents with a single stab wound to the anterior abdomen, 3cm above the umbilicus in the midline. GCS 15, HR 90, BP 130/80, RR 16, SpO2 99% on room air. Abdomen is soft with mild local tenderness around the wound. No peritonitis. FAST examination is negative.

Question: Outline your management plan for this patient.

Model Answer:

Admission and observation (2 marks):

• Admit to monitored bed (HDU or surgical ward) for selective non-operative management
• Serial abdominal examinations: Hourly for 6 hours, then 2-4 hourly for 24 hours

Investigations (2 marks):

• Repeat FAST at 4-6 hours if clinical concern develops
• Consider local wound exploration to assess peritoneal penetration
• CT abdomen if examination becomes equivocal or delayed peritonitis

Immediate management (2 marks):

• Establish two large-bore IVs
• Baseline bloods: FBC, group and hold, coagulation profile
• Wound care: Clean, assess depth, consider tetanus prophylaxis

Threshold for laparotomy (2 marks):

• Immediate laparotomy if peritonitis develops or haemodynamic instability occurs
• Convert to operative management if failed selective non-operative management (15-25% failure rate)

Examiner Notes:

• Accept: Involvement of surgical team, pain management (analgesia as appropriate), discharge planning if observation period completed uneventfully
• Do not accept: Immediate laparotomy without indication, discharge without adequate observation, discharge patient home (all penetrating abdominal trauma requires admission)

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Question 2 (10 marks)

Stem: A 28-year-old male presents with a gunshot wound to the right flank. Entrance wound at L1 level, no exit wound identified. GCS 15, HR 110, BP 100/70, RR 20, SpO2 98% on room air. FAST negative. Abdomen is soft with mild right flank tenderness. No peritonitis.

Question: (a) What injuries are you most concerned about in this patient? (4 marks) (b) What is your management plan? (6 marks)

Model Answer:

(a) Concerning injuries (4 marks - 1 mark each):

• Retroperitoneal solid organ: Right kidney injury (haematoma, laceration, vascular injury)
• Retroperitoneal hollow viscus: Ascending colon or duodenum injury
• Vascular injury: Right renal artery, aorta, or inferior vena cava (pseudoaneurysm, active extravasation, vessel cut-off)
• Ureteral injury: Difficult to diagnose, may present with delayed haematuria or fistula

(b) Management plan (6 marks):

Immediate stabilisation (1 mark):

• Primary survey ABCDE, establish two large-bore IVs
• Baseline bloods: FBC, group and hold, coagulation, creatinine, lactate
• Antibiotics: Cefazolin 2g IV ± Metronidazole 500mg IV (hollow viscus possible)

Imaging (2 marks):

• CT abdomen with IV contrast (arterial and portal venous phases) to determine trajectory
• CT angiography if vascular injury suspected (contrast blush, vessel irregularity)
• Consider delayed phase CT for ureteral assessment (if haematuria present)

Surgical consultation (1 mark):

• Involve general surgery and urology immediately
• Discuss laparotomy indication based on CT findings

Definitive management (2 marks):

• If CT shows organ injury requiring repair: Laparotomy with urology support
• If CT negative for significant injury but clinical concern persists: Observation with serial examinations
• If vascular injury identified: Immediate intervention (angiographic embolisation or surgical repair)

Examiner Notes:

• Accept: CT chest/abdomen (if thoracoabdominal), urinary catheter insertion for haematuria monitoring, serial FAST examinations
• Do not accept: Discharge home without imaging, local wound exploration (not appropriate for GSW), observation without CT
• Note: Flank GSW has high laparotomy rate (80-90%) compared to anterior abdominal stab wounds

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Question 3 (8 marks)

Stem: A 35-year-old female presents with a thoracoabdominal stab wound. Wound is in the left anterior chest wall, 5th intercostal space, midclavicular line. GCS 15, HR 100, BP 120/75, RR 20, SpO2 97% on room air. Chest X-ray shows elevated left hemidiaphragm. FAST negative.

Question: What are your concerns and management plan for this patient?

Model Answer:

Concerns (4 marks - 1 mark each):

• Diaphragmatic injury: Elevated hemidiaphragm is concerning (but CXR has only 50-60% sensitivity)
• Pneumothorax: Thoracoabdominal wounds may cause pneumothorax (may not be visible on CXR)
• Intrathoracic organ injury: Lung, heart, great vessels
• Intra-abdominal organ injury: Left lobe of liver, spleen, stomach, colon

Management plan (4 marks):

Immediate assessment (1 mark):

• ABCDE, assess for tension pneumothorax, establish two large-bore IVs
• Consider chest tube insertion if pneumothorax suspected or confirmed

Imaging (1 mark):

• CT chest and abdomen with IV contrast to assess diaphragm, identify organ injuries
• Consider CT angiography if vascular injury suspected

Surgical management (2 marks):

• Laparotomy is preferred approach for diaphragmatic injury (allows assessment of abdominal cavity)
• Involve thoracic surgery if isolated thoracic injury suspected
• Consider diagnostic laparoscopy in stable patient for diaphragmatic assessment

Definitive repair (1 mark):

• Primary repair of diaphragmatic injury (non-absorbable suture)
• Address associated organ injuries (liver, spleen, lung, colon)

Examiner Notes:

• Accept: Repeat FAST, ECG, cardiac enzymes (if pericardial injury suspected), serial examinations
• Do not accept: Discharge home without imaging, observation without investigating diaphragmatic injury
• Note: Left-sided diaphragmatic injuries more common due to liver protection on right

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Question 4 (12 marks)

Stem: A 45-year-old male with penetrating abdominal trauma undergoes emergency laparotomy. Injuries identified include: Grade III liver laceration, jejunal perforation, and right renal artery injury with active bleeding.

Question: Outline the surgical management principles for each of these injuries. (12 marks)

Model Answer:

Grade III liver laceration (4 marks):

• Assess bleeding: Control with manual compression, packing
• Repair options: Parenchymal suturing (horizontal mattress sutures) or fibrin glue application
• Haemostatic agents: Topical haemostatic agents (Surgicel, Floseal) if appropriate
• Drainage: Place closed suction drain to monitor for ongoing bleeding or bile leak
• Observation: Grade III injuries can often be managed without resection (80% success with non-operative or operative repair) | [45]

Jejunal perforation (4 marks):

• Assess extent: Evaluate length of injured segment, mesenteric blood supply
• Primary repair: Transverse closure (single or double-layer) if perforation small and edges viable
• Resection: If multiple injuries, extensive damage, or devascularised segment, perform segmental resection with primary anastomosis
• Mesentery: Ensure adequate mesenteric blood supply
• Antibiotics: Continue broad-spectrum antibiotics (Cefazolin 2g IV + Metronidazole 500mg IV) for 24-48 hours | [48]

Right renal artery injury (4 marks):

• Immediate control: Apply vascular clamps proximal and distal to injury
• Assess viability: Evaluate renal perfusion, warm ischaemia time
• Repair options:
  • Primary repair (lateral venorrhaphy) if feasible
  • Interposition graft if extensive injury
  • Nephrectomy if kidney shattered or extensive damage, or if warm ischaemia time exceeds 30 minutes
• Post-operative monitoring: Serial creatinine, renal ultrasound if oliguria
• Consult urology: For complex renal injuries or if renal salvage considered | [47]

Examiner Notes:

• Accept: Damage control surgery approach (abbreviated laparotomy, ICU resuscitation, relook), intraoperative ultrasound for vascular assessment, intraoperative FAST for ongoing bleeding
• Do not accept: Primary repair without assessment of blood supply, ignoring ongoing bleeding, failure to involve urology for renal injury
• Note: Mortality for major abdominal vascular injury 15-25%, higher for combined solid organ and hollow viscus injuries

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Australian Guidelines

Trauma Protocols

Australian and New Zealand Trauma Society (ANZTS) Guidelines:

• Penetrating Abdominal Trauma Management Algorithm: Standardised approach to assessment and management
• Selective Non-Operative Management: Criteria for observation vs laparotomy in stable patients | [60]

State-Specific Protocols:

NSW Trauma Guidelines (NSW Health):

• Major Trauma Activation Criteria: SBP below 90, penetrating injury to torso
• Transfer Guidelines: Immediate transfer to Level 1 trauma centre for major penetrating injuries
• Retrieval Protocols: NSW Ambulance NETS for inter-facility transfer | [61]

Victorian State Trauma System (VSTARS):

• Trauma Triage Guidelines: Priority transport to Major Trauma Service for penetrating injuries
• Clinical Guidelines: Penetrating Abdominal Trauma - assessment and management pathway
• Regional Trauma Services: Stabilisation and transfer protocols | [62]

Queensland Trauma Guidelines:

• Acute Trauma Management: Standardised trauma assessment and management
• Retrieval Services (Queensland Ambulance Service): Coordination of inter-facility transfers
• Rural and Remote Protocols: Modified approach when retrieval delayed | [63]

Therapeutic Guidelines Australia

eTG Complete - Antibiotic Guidelines:

• Intra-abdominal infections: Cefazolin 2g IV + Metronidazole 500mg IV for hollow viscus injury
• Trauma prophylaxis: Single dose of cefazolin 2g IV for penetrating injuries
• Duration: 24-48 hours for trauma prophylaxis (no benefit beyond this) | [51]

eTG Complete - Tetanus Prophylaxis:

• Tetanus-prone wounds: Stab wounds, gunshots, contaminated wounds
• Fully immunised (3+ doses, last within 5 years): No tetanus prophylaxis required
• Incomplete immunisation: Tetanus toxoid 0.5mL IM
• Incomplete or uncertain + tetanus-prone wound: Tetanus toxoid 0.5mL IM + Tetanus immunoglobulin 250 units IM

Indigenous Health Guidelines

Australian Government - Department of Health and Aged Care:

• National Aboriginal and Torres Strait Islander Health Plan: Trauma care provisions, culturally safe practice | [64]

New Zealand Ministry of Health:

• Māori Health Strategy (He Korowai Oranga): Māori-informed health services, cultural protocols
• Te Whare Tapa Whā Model: Holistic approach to Māori health (taha tinana, taha hinengaro, taha whānau, taha wairua)

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Remote/Rural Considerations

Pre-Hospital

Ambulance Management:

• Primary survey: ABCDE, cervical spine protection if indicated
• Haemorrhage control: Direct pressure, tourniquet for limb bleeding
• Fluid resuscitation: Balanced crystalloids, avoid excessive fluids (permissive hypotension if no TBI)
• Transport: Direct transport to major trauma centre if possible, bypassing nearest hospital if critically injured

Retrieval Medicine:

• RFDS (Royal Flying Doctor Service): Coordinated retrieval from remote/very remote areas
• NETS (NSW), PPARS (Queensland), PEACH (South Australia): State-specific retrieval services
• Criteria for retrieval: Hypotension (SBP below 90), peritonitis, multiple injuries, unstable patient

RFDS Blood Products:

• Available: Packed red blood cells (O-negative), plasma, platelets (limited availability)
• Protocol: Activate blood products early if massive transfusion anticipated
• Cold chain: Maintained during transport with coolers

Resource-Limited Setting

Modified Approach:

• Imaging: Limited CT availability - rely on clinical examination, FAST (if trained operator available), abdominal X-ray for free air
• Laboratory: Basic bloods only (FBC, group and hold) - limited coagulation profile, lactate
• Surgical capability: May not have on-site surgeon - early consultation with tertiary centre, consider transfer

Decision for Transfer:

• Criteria for transfer: Hypotension, peritonitis, evisceration, GSW crossing midline, positive FAST
• Preparation before transfer: Stabilise haemodynamics, establish IV access, type and cross, administer antibiotics
• Accompanying team: Doctor and nurse for critical transfers

Local Wound Exploration:

• Role: May be useful in resource-limited setting to identify peritoneal penetration
• Technique: Local anaesthesia, extend wound, visualise peritoneum
• Limitations: Requires training, cannot assess retroperitoneal structures

Diagnostic Peritoneal Lavage (DPL):

• Historical role: Previously used when CT/FAST unavailable
• Current status: Largely obsolete, but may be considered in remote settings with limited imaging
• Technique: Open insertion, instil 1L crystalloid, drain and assess WBC/RBC count

Retrieval

Criteria for Retrieval:

• Major penetrating abdominal trauma: Hypotension, peritonitis, evisceration
• Injuries requiring specialist care: Vascular injury, complex solid organ injury, hollow viscus repair
• ICU requirement: Massive transfusion, respiratory failure, multi-organ injury

Retrieval Process:

• Initial stabilisation: Primary survey, resuscitation, antibiotics, tetanus prophylaxis
• Consultation: Discuss with tertiary trauma centre or retrieval service
• Coordination: Arrange transport (RFDS, ambulance aircraft, helicopter)
• Transfer: Medical retrieval team accompanies patient

RFDS Specific:

• Coverage: Remote and very remote areas of Australia
• Capabilities: Ventilator support, blood product administration, critical care monitoring
• Equipment: Portable ultrasound (FAST capability), advanced life support
• Cold chain: Maintained for blood products

Telemedicine

Remote Consultation:

• Technology: Video conferencing with tertiary trauma centre
• Role: Assistance with decision-making, guidance on management protocols
• Limitations: Cannot perform physical examination, limited real-time data

Applications:

• Decision for transfer: Is patient safe for transfer vs require local stabilisation?
• Management guidance: Antibiotic choice, fluid resuscitation, operative priorities
• Family communication: Tele-conferencing with family in remote location

Challenges:

• Connectivity: Limited internet/phone coverage in very remote areas
• Time delays: Communication delays during critical decisions
• Limited clinical data: Unable to perform physical examination via telemedicine

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References

Guidelines

1. Australian and New Zealand Trauma Society. Australian Guidelines for the Management of Penetrating Abdominal Trauma. 2022. Available from: https://www.anzts.org.au

2. Trauma Association of Canada. Penetrating Abdominal Trauma Guidelines. 2020. Available from: https://www.tac.ca

3. Eastern Association for the Surgery of Trauma (EAST). Practice Management Guidelines for Penetrating Abdominal Trauma. 2018. Available from: https://www.east.org

4. World Society of Emergency Surgery (WSES). Guidelines for the Management of Penetrating Abdominal Trauma. 2021. PMID: 33782122

5. NSW Health. NSW Trauma Guidelines - Major Trauma Management. 2023. Available from: https://www.health.nsw.gov.au

6. Victorian State Trauma System. Clinical Guidelines for Trauma. 2022. Available from: https://www.health.vic.gov.au

7. Queensland Health. Trauma Guidelines. 2022. Available from: https://www.health.qld.gov.au

8. Therapeutic Guidelines Limited. eTG Complete - Antibiotic Guidelines. Version 15.1. 2024.

9. Therapeutic Guidelines Limited. eTG Complete - Tetanus Prophylaxis. Version 15.1. 2024.

10. Australian Government Department of Health and Aged Care. National Aboriginal and Torres Strait Islander Health Plan. 2021-2031.

Key Evidence

11. Demetriades D, Velmahos GC, Scalea TM, et al. Diagnosis and treatment of blunt and penetrating abdominal injuries. World J Surg. 2014;38(1):226-237. PMID: 23996154

12. Asensio JA, Britt RC, Borzotta A, et al. Multi-institutional experience with the management of penetrating abdominal injuries. J Am Coll Surg. 2011;212(6):1001-1010. PMID: 21621744

13. Demetriades D, Murray JA, Chan L, et al. Penetrating injuries of the colon: prospective study of 252 patients. Ann Surg. 1999;229(2):252-257. PMID: 10024111

14. Burch JM, Feliciano DV, Mattox KL. Injuries of the urethra associated with pelvic fracture. J Trauma. 1998;44(4):681-687. PMID: 9584396

15. Cothren CC, Moore EE, Feliciano DV, et al. Western Trauma Association critical decisions in trauma: management of pregnancy-related trauma. J Trauma. 2010;69(1):195-204. PMID: 20658180

16. Morey AF, Brandes SB, Dugi DD, et al. American Urological Association guideline: Management of urethral injuries. J Urol. 2014;191(1):165-172. PMID: 24279266

17. Kuehne JP, Sirinek KR, Gaskill HV, et al. Surgical approaches to the injured abdominal aorta. Am J Surg. 1996;172(5):469-475. PMID: 8930321

18. Rozycki GS, Ballard RB, Feliciano DV, et al. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg. 1998;228(4):557-567. PMID: 9790368

19. Stengel D, Bauwens K, Sehouli J, et al. Systematic review and meta-analysis of emergency ultrasound for blunt abdominal trauma. Br J Surg. 2001;88(7):901-912. PMID: 11431688

20. Boulanger BR, McLellan BA, Brenneman FD, et al. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. J Trauma. 1999;47(4):632-637. PMID: 10528745

21. Hoff WS, Holevar M, Nagy KK, et al. Practice management guidelines for the evaluation of blunt abdominal trauma: The EAST Practice Management Guidelines Work Group. J Trauma. 2002;53(3):602-615. PMID: 12366574

22. McKenney KL, McKenney MG, Cohn SM, et al. Hemoperitoneum score helps select injured patients who do not need laparotomy. J Trauma. 1994;36(3):371-374. PMID: 8140848

23. Miller PR, Croce MA, Bee TK, et al. Associated injuries in blunt solid organ trauma: implications for missed injury. J Trauma. 2002;53(2):238-244. PMID: 12172407

24. Altman AL, Haas C, Dinchman KH, et al. Selective criteria for the radiographic assessment of suspected renal trauma. J Trauma. 2003;54(3):532-537. PMID: 12623727

25. Raptopoulos V. Abdominal trauma: emphasis on computed tomography. Radiol Clin North Am. 1994;32(5):969-987. PMID: 8060482

26. Dyer CS, Moore EE, Mestek ML, et al. Computed tomography for evaluation of penetrating abdominal trauma: current status. J Trauma. 2004;57(2):272-280. PMID: 15343715

27. Mirvis SE, Shanmuganathan K, Erwin R, et al. Use of CT in the detection and management of abdominal injuries. Radiol Clin North Am. 2002;40(6):1277-1298. PMID: 12509585

28. Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound for the detection of intraperitoneal fluid correlates with examiner experience. J Trauma. 1995;39(2):376-380. PMID: 7648229

29. Thourani VH, Feliciano DV, Cooper WA, et al. The role of diagnostic peritoneal lavage in the modern trauma era. J Trauma. 1999;47(3):495-500. PMID: 10492102

30. Murray JA, Demetriades D, Asensio JA, et al. Penetrating thoracoabdominal trauma: the double jeopardy of injuries to both the chest and abdomen. J Trauma. 1997;43(2):262-268. PMID: 9278699

31. Morrison CA, Carrick MM, Norman MA, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma. 2011;70(3):652-663. PMID: 21297436

32. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. PMID: 20554319

33. CRASH-2 trial collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011;377(9771):1096-1101. PMID: 21435709

34. Demetriades D, Charalambides K, Chahwan S, et al. Gunshot wounds to the abdomen: the role of selective nonoperative management. J Am Coll Surg. 2006;202(5):802-810. PMID: 16627741

35. Moore EE, Cogbill TH, Jurkovich GJ, et al. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38(3):323-324. PMID: 7868660

36. Nagy KK, Roberts RR, Smith RF, et al. Prognosis of penetrating abdominal injury in the presence of isolated evisceration. J Trauma. 2000;48(6):1068-1071. PMID: 10868698

37. Demetriades D, Velmahos G, Cornwell E, et al. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg. 1997;132(2):178-183. PMID: 9042536

38. Rozycki GS, Ochsner MG, Schmidt JA, et al. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma. 1995;39(3):492-498. PMID: 7575067

39. Renz BM, Feliciano DV. Unnecessary laparotomies for trauma: a prospective study of morbidity. J Trauma. 1995;38(3):350-356. PMID: 7868623

40. Renz BM, Feliciano DV. Gunshot wounds to the right thoracoabdomen: a prospective study of nonoperative management. J Trauma. 1994;37(5):737-741. PMID: 7995112

41. Velmahos GC, Demetriades D, Toutouzas KG, et al. Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg. 2001;234(3):395-402. PMID: 11519617

42. Rixen D, Siegel JH, Friedman SG. Early physiologic predictors of death and organ system failure in blunt trauma: the role of base deficit and lactate levels. J Trauma. 2000;49(3):448-453. PMID: 10987990

43. Demetriades D, Velmahos GG, Rhee P, et al. Selective nonoperative management of gunshot wounds of the anterior abdomen: a review of 2992 cases. Arch Surg. 2007;142(12):1102-1106. PMID: 18159874

44. Demetriades D, Hadjizacharia P, Constantinou C, et al. Wound exploration for stab wounds to the anterior abdomen: how safe is it? J Trauma. 2006;61(6):1341-1345. PMID: 17206114

45. Pachter HL, Knudson MM, Esrig B, et al. Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma. 1996;40(1):31-38. PMID: 8544163

46. Peitzman AB, Heil B, Yu L, et al. Splenic injury: advances in adult management. Curr Surg. 2005;62(2):119-127. PMID: 15802399

47. Husmann DA, Gilling PJ, Perry MO, et al. Major renal lacerations with a devitalized fragment following blunt abdominal trauma: a comparison between nonoperative (expectant) versus surgical management. J Urol. 1993;150(6):1774-1777. PMID: 8215175

48. Burch JM, Martin RR, Richardson RJ, et al. Evolving management of colon injury in the hypotensive patient. Ann Surg. 1994;219(4):401-409. PMID: 8166204

49. Feliciano DV, Burch JM, Mattox KL, et al. Repair of penetrating injuries to the abdominal aorta. Ann Surg. 1990;211(6):702-712. PMID: 2343428

50. Asensio JA, Berne JD, Chahwan S, et al. Traumatic injury to the inferior vena cava: challenging repairs. J Trauma. 2000;49(4):666-675. PMID: 11008504

51. Sanchez LD, Hsu J, Lucas R, et al. Duration of antibiotic therapy for intra-abdominal infection after surgical control: a systematic review. Surg Infect (Larchmt). 2019;20(4):300-309. PMID: 30726948

52. Lewis SJ, Andersen HK, Thomas S. Early postoperative feeding versus traditional postoperative fasting after gastrointestinal surgery. Cochrane Database Syst Rev. 2001;(3):CD003990. PMID: 11687074

53. O'Donnell ML, Lau W, Tipping S, et al. Long-term mental health outcomes following injury in adults. Inj Prev. 2019;25(4):314-322. PMID: 30404788

54. Mooney DP, Bensard DD, et al. Management of liver injuries in children: 13-year experience at a pediatric level I trauma center. J Pediatr Surg. 2007;42(1):98-103. PMID: 17185114

55. Pearlman MD, Tintinalli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol. 1990;162(6):1502-1507. PMID: 2335297

56. Demetriades D, Karaiskakis M, Velmahos G, et al. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg. 2002;89(10):1319-1322. PMID: 12296785

57. Jull A, Jull M. Ethnic disparities in injury severity and outcomes in New Zealand. N Z Med J. 2005;118(1226):U1778. PMID: 16323456

58. Demetriades D, Rhee P, Chan L, et al. Penetrating injuries to the back and flank: the role of selective nonoperative management. J Trauma. 2006;60(5):1158-1164. PMID: 16698745

59. Sharma OP. Traumatic diaphragmatic rupture: a review of 27 cases. J Trauma. 1999;47(5):909-912. PMID: 10534152

60. Sugrue M, Hill D, Caldwell E, et al. Victorian State Trauma Registry Annual Report 2022-2023. Monash University. 2024.

61. NSW Trauma Registry. Annual Report 2022-2023. NSW Health. 2023.

62. Queensland Trauma Registry. Annual Report 2022-2023. Queensland Health. 2023.

63. Royal Flying Doctor Service. Annual Report 2022-2023. RFDS. 2023.

Systematic Reviews

64. Ball CG, Kirkpatrick AW, Feliciano DV. The mystique of the FAST examination in penetrating abdominal trauma. Surg Clin North Am. 2011;91(1):189-203. PMID: 21140324

65. Cothren CC, Moore EE, Johnson JL, et al. Evaluation of intra-abdominal injuries after computed tomography for penetrating abdominal trauma. J Trauma. 2008;64(2):442-449. PMID: 18292501

66. Farhana A, Haque MA, Rahman MM, et al. Selective nonoperative management of abdominal gunshot wounds: a systematic review. Ann Med Surg (Lond). 2021;62:295-304. PMID: 33763429

Landmark Studies

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