Chapter 166: Penetrating Trauma to The Flank and Buttocks

INTRODUCTION

Challenges in evaluating penetrating trauma to the flank and buttocks include recognizing peritoneal and retroperitoneal injuries and determining which patients need immediate surgery and which can be managed more conservatively. Trajectories and resultant severity and pattern of injury can vary widely with both stab and gunshot wounds. Hemodynamically unstable patients need immediate operative intervention. Mechanism and time of injury, weapon characteristics, and determining the bullet path or stab wound depth may also assist in determining the initial diagnostic approach if the patient is otherwise stable.

PENETRATING FLANK TRAUMA

Clinical Features

Presentation may vary from stable vital signs with an innocuous-appearing wound to hemodynamic shock and peritonitis. Gross blood on rectal examination suggests bowel injury. Blood at the urethral meatus or hematuria suggests genitourinary injury.

Diagnosis and Differential

CT imaging is the diagnostic modality of choice for hemodynamically stable patients. Protocols vary by institution, but may include PO or rectal contrast if there is suspicion for hollow viscous injury. Contrast-enhanced CT can also often help determine stab wound depth. Bedside ultrasound (eFAST exam) can be used to assess for intraabdominal free fluid and thus help predict the need for surgical intervention.

Emergency Department Care and Disposition

1. Follow standard trauma resuscitation protocols. Patients who require emergent exploratory laparotomy include those who are hemodynamically unstable, display peritonitis, and have sustained gunshot wounds to the flank.

2. If there is concern that the peritoneum is violated or the patient displays signs of peritonitis, administer broad-spectrum antibiotics, such as pipercillin/tazobactam 3.375 g IV.

3. Many patients with stab wounds can be managed conservatively. High-risk patients (stab wounds with penetration beyond deep fascia) require surgical consultation and admission. Low-risk patients (stab wounds superficial to deep fascia) may be discharged if serial examinations are unremarkable and the patient remains stable throughout an observation period.

PENETRATING BUTTOCK TRAUMA

Clinical Features

Gunshot wounds are much more likely to require laparotomy than stab wounds. Gunshot wounds above the level of the greater trochanter and gross hematuria predict the need for surgery. Rectal examination to assess for gross blood, evaluation of lower extremity pulses, and neurologic examination to assess for sciatic and femoral nerve injury should be performed.

Diagnosis and Differential

Hemodynamically stable patients should undergo CT with oral, IV, and rectal contrast (to avoid missed colon and rectal injuries). Cystourethrogram should be performed on patients with findings of hematuria or wounds near the genitourinary tract. CT angiography or traditional angiography and venography may be indicated if a pelvic hematoma is found on CT. Bedside ultrasound (eFAST exam) can also be used to assess for intraabdominal free fluid and thus help predict the need for surgical intervention.

Emergency Department Care ...