Trauma Surgery

Treating Cupid’s Wounds

No matter how big the whale is, a tiny harpoon can kill him.

Malaysian Proverb

Introduction

The South African Republic is known around the world for suffering a constant violence epidemic. The amount of penetrating trauma is probably ten times higher when compared to the Western world.

Gangs and gangster crowded the streets, and their affiliation is stuck on their skin in a tattoo: 26… 27…28.

Recently moved here, you are on call on a Saturday night, and you have just been welcomed by your colleagues saying, “Get prepared, the weekend is going to be hectic”.

After one hour many ambulances arrived at the ED door taking patients with all sorts of injuries.

Who should be treated first? Who should be taken to the operating room (OR)? Is the conservative management an option? Could we leave a bullet inside the body? Should we leave the knife in, or should we take it out?

Penetrating traumas can be scary, mostly because we are not used to these kinds of injuries, and trust us, you are not.

Assessment

First, as the ATLS course teaches: ABCDE.

Don’t panic and start examining the patient following this vertical checklist: you cannot exclude that a patient who has been stabbed in the abdomen doesn’t have an airways issue!

Here is the first difference between stabs and gunshots.

In the case of sharp injuries, the range and the distance of the injuries will be more likely close to the tract, and depending on the area of the body we will pursue different investigations.

In the case of gunshot wounds, the distance and the grade of injury can change depending on the ballistic of the bullet, the weapon used, and the type of bullet. The extension of the injury can be massive with a single shot.

Stab Wounds

Knife wounds usually involve low-velocity penetration, and mortality is directly related to the organ injured.

If the patient is stable and the knife is retained, independently from the body region, secure it to the skin, with gauze and tape and organize the removal in a safe setting (usually the OR). The sharp most likely tamponade the bleeding and an uncontrolled hemorrhage may occur when removing the retained blade (Figure 1).

After the removal, if no active bleeding is recorded, the wound should be sutured.

In case of active bleeding from the wound, do not explore it or try to control the bleeding with clamps or blind deep sutures. Most likely you will not control the bleeding and ligate or damage some important structures.

A large bore Foley catheter can be inserted and inflated into the wound; this will create a tamponade effect from within the wound (the same as in the neck). Once inserted, inflate the Foley balloon with water and clamp the “urinary” end! If the bleeding does not stop put a second and even a third catheter in until the bleeding is controlled. Remember to knot the bottom of the catheter to not aspirate blood from the wound.

In the case of venous bleeding, the Foley compression is usually enough to stop the bleeding and the catheter can be safely removed in the operating room after 24-48 hours.

In the case of arterial bleeding, the catheter will control the hemorrhage gaining time to plan the surgery, involving arterial repair, intravascular stent placement, or embolization.

In the case of thoracoabdominal and abdominal wounds, it is almost impossible to control the bleeding with a Foley catheter. In this scenario, the hemodynamic stability of the patient will guide your management.

Figure1 – Retained blade in the cardiac box

Gunshot Wounds

Most gunshots cause high-velocity injuries: the nature and the extension of the damage are related to the ballistic of the bullet and the weapon used. Experienced surgeons can predict the grade of injury just by looking at the gunshot wound (GSW) and the X-rays. However, in this setting, considering our low rate of exposure to this kind of injury, we will try to be meticulous and schematic and follow an easy checklist.

As aforementioned, the trajectory is the most important aspect. In the case of GSW, the trajectory is unpredictable because the bullet could hit a bone and change direction, could be slowed down by soft tissues, and be retained inside the patient’s body.

To avoid missed injury, a good practice is to use external wound markers for all visible entry/exit sites (e.g. paper clips) to facilitate wound tracking and to enhance the speed of the reading of images (Figure 2). In the case of GSW, don’t try to identify if a wound is an entry or an exit (in 50% of the cases you’ll be wrong). Mark them and study the patient’s front and back!

If we have an odd number of holes, there must be some retained bullet… Or we are missing something…

Once we have completed the primary survey and marked all the wounds the patient can undergo a whole-body X-ray (in South Africa the Lodox machine is used, otherwise a portable X-ray machine will work) and we can estimate the trajectory of the bullet, identify shrapnel and fractures.

As for the stab wounds, the decision to perform a computed tomography (CT) scan is related to the stability of the patient.

Figure 2 – Multiple gunshot wounds marked with paper clips

Unstable Patients

The assessment of the stability of the patient must follow the ATLS criteria and particular attention should be reserved to the transient responders.

If the patient has a rebound abdominal tenderness and/or is hemodynamically/physiologically unstable and/or has a hollow viscus evisceration, emergency laparotomy is mandatory, and no futile investigation (e.g. CT scan) should delay the surgery. You would never be blamed for operating a patient with peritonism or not responsive to resuscitation. On the other hand, ignoring clinical signs and delaying an intervention to perform a futile investigation can be an unforgivable mistake.

Stable Patients

If the patient responds to the initial resuscitation and is hemodynamically/physiologically stable, further investigations can be performed to better assess the trajectory and the injuries.

A triple-phase CT scan is the gold standard. In case of a doubt bladder injury, a cystogram should be performed as well. Different protocols exist and hospital policy can be different; however, if frank hematuria and the pelvic trajectory support the suspicion of bladder injury, a cystogram is mandatory to confirm or rule out the injury.

 It can be extremely difficult to see a clear bowel injury. However, pneumoperitoneum and free fluid without parenchymal injuries are suspicious of bowel injury.

If evidence of hollow visceral injury, an immediate laparotomy should be performed.

If there is no injury to parenchymal organs, conservative management could be attempted. In the conservatism era, non-operative management (NOM) is an option also for penetrating trauma. This can be applied surely to stab injuries, whereas GSW violating the peritoneum should be explored in most cases… Many protocols have been proposed and validated, even if this practice is still at the beginning and needs further validation.

During abdominal observation, the patient should fast, antibiotics should be avoided, and good analgesia and hydration should be given, for at least 24 hours. The patient should be reevaluated every 6 hours, and each change should make the surgeon reconsider a surgical intervention. Temperature spikes, peritonism, and uncontrolled pain are all signs that should alarm the clinician.

If after 24 hours the patient is completely stable and the abdomen soft, we can progressively reintroduce the full diet. If the patient tolerates the full diet and the trajectory involves the right abdominal quadrant, we can discharge the patient. In the case of injuries in the left quadrants, a laparoscopy must be performed to identify, and possibly close, a diaphragmatic laceration to avoid future diaphragmatic hernias. If the trajectory involves the pelvis or the lower quadrants of the abdomen a rectal exploration and a sigmoidoscopy should be performed to exclude blood in the bowel. If during the sigmoidoscopy blood is recorded, an exploratory laparotomy should be planned to look for a rectal injury.

Below is a list of conditions that we can consider “stable”. As previously mentioned, “stability” is a dynamic condition and the attending clinician must be able to reassess and change his/her plan according to the patient’s conditions.

  • Hemodynamically/physiologically stable after max 2 L of crystalloids or one/two units of blood products;
  • TEG/Rotem normal and no signs of coagulopathy;
  • Soft and not painful abdomen;
  • Intercostal drain with an output of less than 1500 mL or less than 200 mL/h;
  • Reliable abdominal evaluation.*

*In stable patients, before deciding how to manage the abdominal injury, it’s mandatory to determine the patient’s neurological status. A GCS lower than 14, and alcohol or drug intoxication, do not allow a reliable abdominal evaluation. In this setting, it’s better not to trust our examination: opt for a CT abdomen if the patient is hemodynamically stable, or take the patient for an exploratory laparotomy if the penetrating injury trajectory suggests possible visceral injuries.

Flowchart – Penetrating management according to Groote Schuur Hospital Protocol

Surgery

Taking to the OR a penetrating trauma patient can be challenging both for a young and non-expert surgeon and a long-experienced sub-specialized surgeon.

The number of injuries you must deal with can be extended and wrong management can cause the patient to die or to have a serious complication.

First, it is essential to know if you need to open the abdomen, the chest, or both, and in which order.

To make it simple, there is a quote from the Definitive Trauma Surgery Course that says “Treat first what kills first”. This concept should guide you both in the decision-making and along the surgery (to read something).

Once you have decided which is most likely the source of bleeding, it is mandatory to control it before looking at the contamination, and before planning the reconstruction.

The trauma laparotomy is a team event, and a strict collaboration must exist between surgeons, anesthesiologists, and nurses.

Furthermore, a meticulous exploration of the abdomen must be performed, above all in the case of GSW (as told before, the trajectory is unpredictable, and the grade and number of injuries can be extended).

The damage control surgery criteria should be applied if the patient is unstable and requires inotropes support. The surgery should be as quick as possible, theoretically less than 1 hour.

How to treat penetrating intrabdominal injuries would require a further chapter and we will talk about it in the future.

For now, a good practice rule can be to stabilize the patient, to control first the bleeding and then the contamination. After that, resuscitate the patient in the ICU and come back for a relook laparotomy in 24-48 hours.

If the patient is hemodynamically stable during the intervention, a definitive surgery could be performed without concerns.

Postoperative Care

Patients who experience penetrating traumas are usually young and with a good physiological response. Nevertheless, the postoperative time and the complication rate are strictly connected to the number and grade of injuries.

Moreover, if conservative management is followed for parenchymal organ injuries, we must be ready to treat multiple and threatening complications or to run to the OR if the NOM fails and the patient becomes hemodynamically unstable.

Interventional radiology, percutaneous drainage, antibiotics therapy, early mobilization, and physiotherapy must be part of our plan when managing these patients.

In conclusion, always keep in mind the “recurrence rate” of these patients: most of them, due to the environment they are exposed to will experience new penetrating injuries and getting involved in accidents.

We hope this will be of some help in the future.

References

  1. Advanced Trauma Life Support: Student Course Manual. 10th Ed. Chicago, IL: American College of Surgeons; 2018.
  2. Boffard KD. Manual of Definitive Surgical Trauma Care. 5th Ed. Boca Raton, FL: CRC Press; 2019.
  3. Nicol AES. Handbook of Trauma for Southern Africa. 3rd Ed. Oxford; 2018.
  4. Navsaria P, et al. Foley catheter balloon tamponade for life‐threatening hemorrhage in penetrating neck trauma. World J Surg 2006;30:1265-8.
  5. Sander A, et al. Penetrating abdominal trauma in the era of selective conservatism: a prospective cohort study in a level 1 trauma center. Eur J Trauma Emerg Surg 2022;48:881-9.

How to Cite This Post

Bunino FM, Bellio G, Marrano E. Treating Cupid’s Wounds. Surgical Pizza. Published on March 2, 2024. Accessed on February 14, 2025. Available at [https://surgicalpizza.org/trauma/treating-cupids-wounds/].

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