1. History
- Mechanism: Stab wound (SW) vs. gunshot wound (GSW) — GSW carry ~4× higher odds of mortality compared to SW. Determine weapon type, blade length, caliber, number of shots/stabs, distance, and angle of entry. [1-2]
- Timing: Time of injury, time to arrival, prehospital interventions (tourniquets, packing, fluids)
- Symptoms: Abdominal pain (location, severity, radiation), dyspnea, chest pain (thoracoabdominal wounds), hematuria, rectal bleeding, hematemesis
- Associated injuries: Assess for concomitant thoracic, pelvic, extremity, or spinal injuries — GSW have extra-abdominal injuries in ~49% of cases [3]
- Scene details: Blood loss at scene, loss of consciousness, intoxicants used
- Tetanus status: Confirm immunization history
2. Alarm Features
- Hemodynamic instability (SBP <90 mmHg, HR >110 bpm) [2]
- Peritonitis (diffuse guarding, rigidity, rebound tenderness)
- Evisceration of bowel or omentum
- Impalement with object in situ
- Blood per rectum, hematemesis, or frank blood on NG aspiration
- Enteric matter visible in the wound
- Any of the above are "hard signs" mandating immediate laparotomy [4-6]
- Unreliable clinical exam (intubated, intoxicated, psychiatric illness) — these patients are not candidates for nonoperative management [4]
3. Medications
Antibiotic Prophylaxis
- A single preoperative dose of broad-spectrum antibiotics with aerobic and anaerobic coverage is recommended for all penetrating abdominal trauma [7-8]
- Continue antibiotics for ≤24 hours if hollow viscus injury is found; no further antibiotics needed if no hollow viscus injury [7-8]
- Ertapenem (1 g IV) is suggested by the Surgical Infection Society as the prophylactic agent of choice for trauma laparotomy, based on evidence of reduced surgical site infections [9]
- Alternative: Cefazolin + metronidazole provides adequate aerobic and anaerobic coverage [10]
- No evidence supports antibiotic courses >24 hours for reducing SSI, mortality, or intra-abdominal infection [7][11]
Resuscitation Adjuncts
- Tranexamic acid (TXA): Administer within 3 hours of injury per CRASH-2 data [12-13]
- Calcium supplementation: Empiric replacement during massive transfusion to counteract citrate-induced hypocalcemia [12]
- Minimize crystalloid (<3 L in first 6 hours); prioritize balanced blood product resuscitation [14]
Medications to Avoid
- Avoid excessive crystalloid resuscitation (>5 L associated with increased mortality) [13]
- Avoid aminoglycosides when possible in abdominal trauma prophylaxis [7]
4. Diet
- NPO on arrival — all patients with penetrating abdominal trauma should be kept nil per os pending evaluation and potential operative intervention
- Patients managed nonoperatively may advance diet cautiously after clinical improvement and return of bowel function
- Failure to tolerate enteral feeding can indicate a missed bowel injury [15]
5. Review of Systems
- Respiratory: Dyspnea, pleuritic chest pain (diaphragmatic injury, hemopneumothorax — especially with thoracoabdominal wounds)
- GI: Nausea, vomiting, hematemesis, hematochezia, melena
- GU: Hematuria (renal/bladder/ureteral injury), flank pain
- Neurologic: Altered mental status, extremity weakness (spinal cord involvement)
- Vascular: Extremity pallor, pulselessness (associated vascular injury)
- Constitutional: Lightheadedness, syncope, diaphoresis (hemorrhagic shock)
6. Collateral History and Family History
- Collateral: EMS report (scene findings, estimated blood loss, vitals en route, interventions), bystander account of mechanism, law enforcement details on weapon
- Social context: Assault vs. self-inflicted — 35.7% of penetrating abdominal injuries in some series are due to suicide attempts; psychiatric evaluation may be needed [16]
- Substance use: Intoxication status is critical — intoxicated patients have unreliable exams and are not candidates for nonoperative management [4]
- Family history is generally not relevant in the acute setting
7. Risk Factors
- Demographics: Young males (83–95% of cases), mean age ~28–40 years [16-18]
- Mechanism: GSW associated with higher ISS, more hollow viscus injuries, more vascular injuries, and higher mortality than SW [1][3]
- Interpersonal violence: Most common etiology (~64%) [16]
- Anticoagulant/antiplatelet use: Increases hemorrhage risk
- Obesity: Independent risk factor for SSI post-laparotomy [11]
- Immunosuppression: Increases infection risk and may warrant broader antibiotic coverage [11]
8. Differential Diagnosis
The diagnosis is typically apparent from the mechanism. The clinical challenge is identifying which organs are injured:
- Hollow viscus injury (small bowel, colon, stomach) — most common in GSW: small bowel 60%, colon 42%, stomach 17% [19]
- Solid organ injury (liver 29%, kidney 17%, spleen) [19]
- Vascular injury (mesenteric, aorta, IVC, iliac vessels) — present in ~25% of abdominal GSW; 87% of intra-abdominal vascular injuries occur after GSW [3]
- Diaphragmatic injury — especially with thoracoabdominal wounds; easily missed on CT
- Retroperitoneal injury — duodenal, pancreatic, renal, ureteral injuries may present with delayed symptoms and are difficult to assess clinically [6]
- Tangential/superficial wound — no peritoneal violation; can be discharged if confirmed by local wound exploration [4]
Cannot-miss diagnoses
- Major vascular injury with hemorrhagic shock
- Cardiac tamponade (thoracoabdominal penetration)
- Tension pneumothorax
- Diaphragmatic rupture with herniation
9. Past Medical History
- Prior abdominal surgery: Adhesions may alter injury patterns and complicate operative exploration
- Coagulopathy/anticoagulant use: Increases hemorrhage risk; may require reversal
- Chronic liver disease/cirrhosis: Portal hypertension increases bleeding risk
- Splenectomy: Alters immune function and management considerations
- Immunosuppression: Lowers threshold for antibiotic therapy
- Allergies: Particularly to antibiotics (beta-lactams, carbapenems) and contrast dye
10. Physical Exam
Primary Survey (ATLS)
- Airway, Breathing, Circulation — address life threats first
- Vital signs: SBP <90 or HR >110 defines hemodynamic instability [2]
Focused Abdominal Exam
- Number, location, and characteristics of wounds (entry/exit)
- "Hilt mark" or bruising at entry site suggests full blade penetration [2]
- Peritoneal signs: guarding, rigidity, rebound tenderness
- Evisceration, impalement
- Distension
Complete Exam
- Log roll: Inspect back and flanks for additional wounds — posterior wounds rely more on CT than clinical exam [6]
- Rectal exam: Blood per rectum, rectal tone
- Perineal/genital exam: Assess for associated injuries
- Chest exam: Decreased breath sounds (hemopneumothorax), muffled heart sounds (tamponade)
- Mark all wounds with radiopaque markers prior to CT [2]
Clinical exam sensitivity for bowel injury: 99% specificity and 100% sensitivity — superior to CT (84% specificity, 31% sensitivity) in experienced hands [4]
11. Lab Studies
- Type and crossmatch — priority in all penetrating abdominal trauma
- CBC: Serial hemoglobin — a drop of ≥2 g/dL from baseline without other explanation should prompt surgical exploration [4]
- BMP/CMP: Baseline renal function, electrolytes, calcium (especially during massive transfusion)
- Coagulation studies: PT/INR, PTT, fibrinogen
- Lactate: Marker of tissue hypoperfusion and shock severity
- ABG/VBG: Assess for acidosis (part of the "lethal triad")
- Lipase: If pancreatic injury suspected
- Urinalysis: Hematuria suggests GU tract injury
- Serial procalcitonin: May help exclude bowel injury during observation, though not highly specific [4][15]
- Viscoelastic testing (TEG/ROTEM): Guide targeted blood product resuscitation once initial hemorrhage control is achieved [12]
12. Imaging
Bedside (Unstable Patients)
- E-FAST (Extended Focused Assessment with Sonography for Trauma): First-line triage tool — detects hemoperitoneum, hemopericardium, hemopneumothorax. A positive FAST with hemodynamic instability → immediate OR [20-21]
- Portable CXR and pelvic XR: Part of trauma series
- A hypotensive patient does not belong in the CT suite [20]
CT (Stable Patients)
- Contrast-enhanced CT of chest, abdomen, and pelvis is the gold standard for hemodynamically stable patients [2][22]
- Single-acquisition whole-torso imaging preferred over segmental imaging to follow wound tract [2]
- Dual-phase CT (arterial + venous) recommended by AAST for vascular and solid organ injury characterization [2]
- Delayed excretory phase if renal/ureteral injury suspected [2]
- CT trajectography: Identifies wound track and predicts injured organs [23]
Key CT findings warranting surgical exploration: Extraluminal air, extraluminal contrast, bowel-wall defects, metallic fragments within bowel wall/lumen [4]
CT limitations: Sensitivity for hollow viscus injury is only ~31% (vs. 100% for clinical exam); a negative CT alone should not determine discharge unless a tangential, extraperitoneal tract is confirmed [4][24]
When imaging is unnecessary: Patients with hard signs for immediate laparotomy should go directly to the OR without delay for imaging [5][20]
13. Special Tests
- Local Wound Exploration (LWE): Best studied for anterior abdominal stab wounds — determines if the wound breaches the anterior fascia. If fascia is intact → discharge. If peritoneum is violated → observation or further workup [4]
- Diagnostic Peritoneal Lavage (DPL): Limited role; can be used as adjunct to negative laparoscopy to exclude bowel injury. Useful when FAST is negative but clinical suspicion remains high [4][20]
- Diagnostic Laparoscopy: Increasingly used in hemodynamically stable patients to assess peritoneal violation and diaphragmatic injury; reduces nontherapeutic laparotomy rate. However, it misses up to 45% of bowel injuries, so observation is required after a negative laparoscopy [15][25-26]
14. ECG
- Indicated for: Thoracoabdominal wounds, suspected cardiac involvement, elderly patients, or those with cardiac history
- Findings to recognize:
- Electrical alternans, low voltage → pericardial tamponade
- ST changes → myocardial contusion or ischemia from hemorrhagic shock
- PEA → tension pneumothorax, tamponade, or exsanguination
- Dysrhythmias from electrolyte derangements (hypocalcemia, hyperkalemia during massive transfusion)
15. Assessment
Severity Stratification — the critical branch point is hemodynamic status:
- Hemodynamically unstable or hard signs present → Immediate laparotomy [5-6]
- Hemodynamically stable, GSW → Most require laparotomy (~70%); selective NOM possible in ~29% with 92.5% success rate at experienced centers [17][27]
- Hemodynamically stable, SW → ~61% can be managed nonoperatively with 93% success rate [17]
Commonly injured organs (GSW): Small bowel (54–60%), colon (42–50%), liver (29%), vascular structures (25%), stomach (17%), kidney (17%). [3][19] SW tend to cause fewer hollow viscus and vascular injuries. [3]
Complications to anticipate: Missed bowel injury (delayed peritonitis), intra-abdominal abscess (most common postoperative complication, ~3%), wound infection, fascial dehiscence, short bowel syndrome, adhesive bowel obstruction, fistula formation [19]
16. Treatment Plan
Initial Stabilization
- ATLS primary survey: Secure airway, bilateral large-bore IV access, hemorrhage control (direct pressure, wound packing)
- Activate massive transfusion protocol (MTP) early — each 1-minute delay in MTP activation is associated with a 5% increase in mortality [28]
- Balanced resuscitation: Plasma:platelets:RBCs in 1:1:1 ratio (or whole blood) [14][29]
- Permissive hypotension (target SBP ~80–90 mmHg) until hemorrhage control is achieved [30]
- Minimize crystalloid (<3 L in first 6 hours) [14]
- TXA within 3 hours of injury [12]
- Empiric calcium replacement during massive transfusion [12]
Operative Management
- Immediate laparotomy for: hemodynamic instability, peritonitis, evisceration, impalement, blood per rectum, hematemesis, enteric matter in wound [4-5]
- Damage control surgery in the unstable patient: Abbreviated laparotomy for hemorrhage control and contamination control → temporary abdominal closure → ICU resuscitation → planned return to OR for definitive repair [30]
- Primary bowel repair and anastomosis preferred when patient is stable; ostomy or damage control with delayed anastomosis when complication risk is high [15]
Nonoperative Management (NOM)
- Appropriate for hemodynamically stable, cooperative patients with reliable clinical exams at specialized trauma centers [4][27]
- Requires: serial clinical exams by experienced clinicians, vital sign monitoring, prompt OR access, ICU capability [4]
- Minimum 48 hours of observation [4]
- Serial hemoglobin monitoring — drop ≥2 g/dL should prompt exploration [4]
- NOM success rate: ~93% for SW, ~93% for GSW at experienced centers [17]
Antibiotic Prophylaxis
- Single preoperative dose of broad-spectrum coverage (ertapenem 1 g IV preferred) [8-9]
- Continue ≤24 hours only if hollow viscus injury found [7-8]
17. Disposition
Immediate Laparotomy (→ OR)
- Hemodynamic instability despite resuscitation
- Peritonitis, evisceration, impalement
- Hard signs of bowel/vascular injury [4-5]
Admission for Observation (NOM)
- Hemodynamically stable with no hard signs
- Reliable clinical exam (alert, cooperative, not intoxicated)
- Minimum 48-hour observation with serial exams, vitals, and labs [4]
- Patients managed with NOM can be discharged after 48 hours if clinically improving [4]
Discharge from ED
- Anterior abdominal stab wound with negative local wound exploration (fascia intact) — may be discharged with return precautions [4]
- Tangential wound with CT confirming extraperitoneal tract only [4]
Specialist Consultation Triggers
- Trauma surgery: All penetrating abdominal trauma
- Vascular surgery: Suspected major vascular injury
- Urology: Hematuria, suspected renal/ureteral/bladder injury
- Interventional radiology: Active contrast extravasation on CT in a stable patient amenable to angioembolization
18. Follow Up / Return Precautions
For patients discharged after negative LWE or successful NOM:
- Follow up with trauma surgery within 5–7 days
- Wound care instructions; watch for signs of wound infection
Return immediately for
- Increasing abdominal pain, distension, or rigidity
- Fever >38.3°C (101°F)
- Nausea/vomiting, inability to tolerate oral intake
- Blood in stool or urine
- Lightheadedness, syncope, or signs of hemorrhage
- Wound drainage (purulent, bilious, or enteric)
Expected recovery
- Patients discharged after negative LWE typically recover within days
- Post-laparotomy patients: 1–2 weeks hospitalization depending on injury severity; full recovery 4–8 weeks
- Delayed complications (adhesive bowel obstruction, incisional hernia) may present weeks to months later
References
1. Nationwide Analysis of Firearm Injury Versus Other Penetrating Trauma: It's Not All the Same Caliber. — Ramsey WA, O'Neil CF, Shatz CD, et al. The Journal of Surgical Research. 2024.
2. ACR Appropriateness Criteria® Penetrating Torso Trauma. — Lee JT, Sobieh A, Bonne S, et al. Journal of the American College of Radiology : JACR. 2024.
3. Hemodynamically “Stable” Patients With Peritonitis After Penetrating Abdominal Trauma: Identifying Those Who Are Bleeding. — Brown CV, Velmahos GC, Neville AL, et al. Archives of Surgery. 2005.
4. WSES Guidelines on Blunt and Penetrating Bowel Injury: Diagnosis, Investigations, and Treatment. — Smyth L, Bendinelli C, Lee N, et al. World Journal of Emergency Surgery : WJES. 2022.
5. Management Guidelines for Penetrating Abdominal Trauma. — Biffl WL, Leppaniemi A. World Journal of Surgery. 2015.
6. Management Guidelines for Penetrating Abdominal Trauma. — Biffl WL, Moore EE. Current Opinion in Critical Care. 2010.
7. Antibiotic Prophylaxis in Trauma: Global Alliance for Infection in Surgery, Surgical Infection Society Europe, World Surgical Infection Society, American Association for the Surgery of Trauma, and World Society of Emergency Surgery Guidelines. — Coccolini F, Sartelli M, Sawyer R, et al. The Journal of Trauma and Acute Care Surgery. 2024.
8. Prophylactic Antibiotic Use in Penetrating Abdominal Trauma: An Eastern Association for the Surgery of Trauma Practice Management Guideline. — Goldberg SR, Anand RJ, Como JJ, et al. The Journal of Trauma and Acute Care Surgery. 2012.
9. The Surgical Infection Society Guidelines on the Management of Intra-Abdominal Infection: 2024 Update. — Huston JM, Barie PS, Dellinger EP, et al. Surgical Infections. 2024.
10. Prophylactic Antibiotic Use for Penetrating Trauma in Prolonged Casualty Care: A Review of the Literature and Current Guidelines. — Causbie JM, Wisniewski P, Maves RC, Mount CA. The Journal of Trauma and Acute Care Surgery. 2024.
11. The 2023 WSES Guidelines on the Management of Trauma in Elderly and Frail Patients. — De Simone B, Chouillard E, Podda M, et al. World Journal of Emergency Surgery : WJES. 2024.
12. Resuscitation and Care in the Trauma Bay. — Van Gent JM, Clements TW, Cotton BA. The Surgical Clinics of North America. 2024.
13. The Importance of the "Damage Control" Strategy in Multiple Organ Injuries, Pathophysiology and Principles of Hemorrhage Control. — Klimek O, Dudek J, Czesyk A, et al. Journal of Clinical Medicine. 2026.
14. Hemorrhagic Shock. — Cannon JW. The New England Journal of Medicine. 2018.
15. Bowel Injury in Trauma: Guidelines for Diagnosis and Treatment From the World Society of Emergency Surgery. — Mentler E, Vietor R, Maddox J. American Family Physician. 2023.
16. Penetrating Abdominal Injuries: A 10-Year Retrospective Analysis of 49 Patients at a German Trauma Center. — Beck S, Bieler D, Kuchmann-Nowak S, et al. Medical Science Monitor : International Medical Journal of Experimental and Clinical Research. 2026.
17. A Prospective Audit of 805 Consecutive Patients With Penetrating Abdominal Trauma: Evolving Beyond Injury Mechanism Dictating Management. — Sander A, Spence RT, McPherson D, et al. Annals of Surgery. 2022.
18. Penetrating Abdominal Trauma in the Era of Selective Conservatism: A Prospective Cohort Study in a Level 1 Trauma Center. — Sander A, Spence R, Ellsmere J, et al. European Journal of Trauma and Emergency Surgery : Official Publication of the European Trauma Society. 2022.
19. Abdominal Gunshot Wounds. An Urban Trauma Center's Experience With 300 Consecutive Patients. — Feliciano DV, Burch JM, Spjut-Patrinely V, Mattox KL, Jordan GL. Annals of Surgery. 1988.
20. Initial Care of the Severely Injured Patient. — King DR. The New England Journal of Medicine. 2019.
21. Focused Assessment With Sonography for Trauma (FAST). — Savoia P, Jayanthi SK, Chammas MC. Journal of Medical Ultrasound. 2023.
22. Liver Trauma: WSES 2020 Guidelines. — Coccolini F, Coimbra R, Ordonez C, et al. World Journal of Emergency Surgery : WJES. 2020.
23. CT of Penetrating Abdominopelvic Trauma. — Naeem M, Hoegger MJ, Petraglia FW, et al. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2021.
24. Accuracy of CT Scan for Detecting Hollow Viscus Injury in Penetrating Abdominal Trauma. — Wolmarans A, Fru PN, Moeng MS. World Journal of Surgery. 2023.
25. Cesena Guidelines: WSES Consensus Statement on Laparoscopic-First Approach to General Surgery Emergencies and Abdominal Trauma. — Sermonesi G, Tian BWCA, Vallicelli C, et al. World Journal of Emergency Surgery : WJES. 2023.
26. Evaluation of Diagnostic Laparoscopy for Penetrating Abdominal Injuries: About 131 Anterior Abdominal Stab Wound. — Buisset C, Mazeaud C, Postillon A, et al. Surgical Endoscopy. 2022.
27. Selective Nonoperative Management of Abdominal Gunshot Wounds: What You Need to Know. — Matsushima K, Inaba K. The Journal of Trauma and Acute Care Surgery. 2025.
28. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical Protocol for Damage-Control Resuscitation for the Adult Trauma Patient. — LaGrone LN, Stein D, Cribari C, et al. The Journal of Trauma and Acute Care Surgery. 2024.
29. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma: The PROPPR Randomized Clinical Trial. — Holcomb JB, Tilley BC, Baraniuk S, et al. The Journal of the American Medical Association. 2015.
30. Damage Control Resuscitation in Adult Trauma Patients: What You Need to Know. — Lammers DT, Holcomb JB. The Journal of Trauma and Acute Care Surgery. 2023.