Guideline sources The following summarized guidelines for the evaluation and management of penetrating abdominal trauma are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2022), the World Society of Emergency Surgery (WSES 2022), the World Society of Emergency Surgery (WSES/AAST 2020; 2019), the American College of Radiology (ACR 2019), the Eastern Association for the Surgery of Trauma (EAST 2018; 2012), and the American Urological Association (AUA 2014). 1 2 3 4 5 6 7 8 Guidelines 1. Diagnostic investigations Diagnostic imaging: as per WSES 2022 guidelines, obtain IV contrast-enhancing CT for detecting bowel injury. B Show 2 more 2. Diagnostic procedures https://web.pathway.md/diseases/rectTO1S7aJBHhpam 1/5 6/29/23, 11:02 PM Penetrating abdominal trauma Pathway Diagnostic laparoscopy: perform local wound exploration or screening laparoscopy to investigate for peritoneal violation, when CT does not identify hard signs of bowel injury, to guide toward a laparotomy or nonoperative management. Discharge patients without peritoneal violation. B Show 2 more Diagnostic peritoneal lavage: consider performing diagnostic peritoneal lavage as an adjunct to a negative laparoscopy to definitively exclude bowel injury, particularly in conjunction with the use of biomarkers. C 3. Medical management Non-operative management: as per WSES 2022 guidelines, consider offering nonoperative management at specialized centers in patients with penetrating abdominal trauma if the patient is hemodynamically compensated and cooperative. Recognize that nonoperative management might be more suitable for stab wounds when compared to gunshot wounds. C 4. Inpatient care Serial clinical examinations: As per WSES 2022 guidelines: Obtain at least 48 hours of serial clinical examinations, performed by consistent specialists or consultants, vital sign monitoring, and serial inflammatory markers testing during nonoperative management. B Perform serial clinical examinations as complementary to CT in guiding surgical management in trauma centers practicing nonoperative management approach. B 5. Perioperative care Perioperative prophylactic antibiotics: administer a single preoperative dose of prophylactic antibiotics with broad-spectrum aerobic and anaerobic coverage in all patients with penetrating abdominal trauma. A Show 3 more 6. Surgical interventions Local wound exploration: perform local wound exploration or screening laparoscopy to investigate for peritoneal violation, when CT does not identify hard signs of bowel injury, to guide toward a laparotomy or nonoperative management. Discharge patients without peritoneal violation. B Bowel injury repair: recognize that the delay in the diagnosis of bowel injury is linked to increased morbidity and mortality. B Show 6 more https://web.pathway.md/diseases/rectTO1S7aJBHhpam 2/5 6/29/23, 11:02 PM Penetrating abdominal trauma Pathway 7. Specific circumstances Patients with diaphragmatic injury: consider performing diagnostic laparoscopy rather than obtaining CT to decrease the incidence of missed diaphragmatic injury in hemodynamically stable patients with left thoracoabdominal stab wounds without peritonitis. C Show 4 more Patients with kidney injury: As per EAU 2022 guidelines, obtain multiphase CT in patients with penetrating abdominal trauma and suspected renal injury. A As per WSES 2019 guidelines: Obtain extended FAST to detect intra-abdominal free fluid. A Recognize that extended FAST has low sensitivity and specificity in kidney trauma. B Obtain contrast-enhanced CT with delayed urographic phase as the gold standard in hemodynamically stable or stabilized adult patients after penetrating trauma with suspected kidney or urinary tract injury. A As per AUA 2014 guidelines, obtain IV contrast-enhanced abdominal/pelvic CT with immediate and delayed images in patients with suspected renal injury. B Show 4 more Patients with ureteral injury: As per EAU 2022 guidelines, suspect ureteral injury in all cases of abdominal penetrating trauma. A As per WSES 2019 guidelines: Suspect ureteral injury in all patients with penetrating abdominal trauma. B Obtain IV contrast-enhanced CT with delayed phase in hemodynamically stable or stabilized patients with suspected ureteral injury. B As per AUA 2014 guidelines, obtain IV contrast-enhanced abdominal/pelvic CT with delayed imaging (urogram) in stable patients with trauma with suspected ureteral injuries. B Patients with bladder injury: As per ACR 2019 guidelines, obtain fluoroscopy retrograde cystography or pelvic CT with bladder contrast (CT cystography) for initial evaluation of patients with lower abdominal/pelvic penetrating trauma with suspected penetrating trauma to the lower urinary tract. B As per WSES 2019 guidelines, recognize that IV contrast-enhanced CT with delayed phase is less sensitive and specific than retrograde cystography in detecting bladder injuries. B Show 9 more As per AUA 2014 guidelines, obtain retrograde cystography in stable patients with gross hematuria and a mechanism concerning for bladder injury. B Show 4 more Clinical findings Symptoms Vital signs https://web.pathway.md/diseases/rectTO1S7aJBHhpam 3/5 6/29/23, 11:02 PM Penetrating abdominal trauma Pathway Abdominal pain Hypotension Dizziness Signs of shock Hematemesis Tachycardia Hematochezia Abdominal exam Hematuria Lightheadedness Cullen's sign Nausea Grey Turner's sign Neck pain Ileus Shortness of breath Peritoneal findings Shoulder pain Hematological findings Testicular pain Vomiting hematocrit Neurological exam Altered mental status Lab findings serum ALT serum AST Imaging findings Free intraperitoneal fluid Pneumoperitoneum References 1. Morey AF, Brandes S, Dugi DD rd et al. Urotrauma: AUA guideline. J Urol. 2014 Aug;192 2 327 35. Open 2. Federico Coccolini, Ernest E Moore, Yoram Kluger et al. Kidney and uro-trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 2;14 54. Open 3. N.D. Kitrey Chair), F. Campos-Juanatey, P. Hallscheidt et al. EAU Guidelines on Urological Trauma. EAU. 2022. Open 4. Leslie Kobayashi, Raul Coimbra, Adenauer M O Goes Jr et al. American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries. J Trauma Acute Care Surg. 2020 Dec;89 6 1197 1211. Open 5. Luke Smyth, Cino Bendinelli, Nicholas Lee et al. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. 10.1186/s13017 022 00418-y. Open 6. Expert Panel on Urological Imaging, Matthew T Heller, Aytekin Oto et al. ACR Appropriateness Criteria Penetrating Trauma-Lower Abdomen and Pelvis. J Am Coll Radiol. 2019 Nov;16 11S S392 S398. Open 7. Amy A McDonald, Bryce R H Robinson, Louis Alarcon et al. Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2018 Jul;85 1 198 207. Open https://web.pathway.md/diseases/rectTO1S7aJBHhpam 4/5 6/29/23, 11:02 PM Penetrating abdominal trauma Pathway 8. Goldberg SR, Anand RJ, Como JJ et al. Prophylactic antibiotic use in penetrating abdominal trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73 5 Suppl 4 S321 5. Open https://web.pathway.md/diseases/rectTO1S7aJBHhpam 5/5