e-CASES: Injury of abdominal wall, Acute hemorrhage
Attempted suicide with anterior abdominal wound from a sharp instrument (knife).
Initial examination by emergency services:
- Blood pressure 150/80 mmHg, Heart rate = 60.- Abdomen supple, not in much pain.
- Symmetrical pulmonary auscultation.
Presence of 3 skin wounds, 2 superficial presternal wounds (blade stopped by rib cage) and 1 deeper wound with a bayonet trajectory to the abdominal cavity. Hematology revealed a significant reduction in cell count in a patient taking anti-platelet medication (Plavix and Kardegic).
Open abdominal trauma with left subcostal entry wound, with breach of the anterior parietal peritoneum. Active parietal arterial (collateral epigastric branch) and epiploic (greater omentum) bleeding causing moderately abundant hemoperitoneum.
Absence of pneumoperitoneum, no gastrointestinal parietal thickening but lack of segmental enhancement of the transverse colon suggestive of a gastrointestinal trauma until proven otherwise (perforation or ischemia).
Minor infiltration of the subcutaneous fat tissues in front of the 5th left costochondral junction associated with the known presternal skin wounds with no contact pleuro-pulmonary trauma.
Morphological integrity of the intra-abdominal solid organs (physiological indentation of the spleen).
Injury of abdominal wall, Acute hemorrhage
- Emergency gastrointestinal exploration via exploratory laparotomy: exploration of the trajectory of the blade, site of a layer of bleeding, which was contained by a full-thickness parietal resorbable suture, failing the option of elective hemostasis. The blade appears to have ended its trajectory in the greater omentum, where there was a hematoma with no active bleeding. No other lesions were detected in the exploration of the supra
- and submesocolic spaces including the omental bursa. No gastrointestinal perforation. Separate closure of each cutaneous layer.Favorable progression.
- Psychiatric care with antidepressant treatment.
- Entry and exit wounds must be sought in all cases of ballistic trauma to "imagine" the trajectory of the bullet and thus detect any traumatic lesions on the organs liable to have been affected.
- Pneumoperitoneum is of no pathological relevance in open abdominal trauma.