A difficult case of penetrating abdominal trauma

Abstract text (incl. references and figure legends)

Case history: A 59-year-old male firefighter was a victim of penetrating abdominal trauma following an explosion.

Clinical findings: The patient was admitted to the ER and managed according to the ATLS approach. He was an obese patient (BMI 43Kg/m²) and presented with tachycardia, abdominal pain, and two penetrating wounds, one on the right iliac fossa with evisceration of the small bowel and one on the left flank with evisceration of the omentum.

Investigation: Chest radiography and E-FAST were performed, and laparotomy was proposed.

Diagnosis: The patient underwent midline laparotomy. Multiple small bowel lesions were identified. A segmental enterectomy was performed, and a gastric band, placed ten years earlier, was removed. The patient was left with a laparostomy, VacPac Barker style.

Therapy and Progressions: The patient underwent a total of eleven surgeries that involved laparostomy review, the construction of ileo-ileal anastomosis followed by resection of anastomosis due to anastomotic fistula, a terminal ileostomy, appendectomy for acute perforated appendicitis and debridement of fasciitis of the abdominal wall. He remained hospitalized for 100 days, 48 of which were in the ICU.

Comments: The initial approach to the patient, including the perception of the injury mechanism and primary and secondary surveys, help in triage and prioritization decision-making. In unstable patients, a damage control therapy, with stabilization of the patient in the ICU and early re-interventions, should be chosen as the patient's clinical condition improves. These decisions must be individualized and adapted to the patient and the trauma. This approach, although complex, is the best therapeutic option in major trauma.

References: Brenner M, Hicks C. Major Abdominal Trauma:Critical Decisions and New Frontiers in Management.Emerg Med Clin North Am.2018 Feb36(1):149-160.

Isenhour JL, Marx J. Advances in abdominal trauma. Emerg Med Clin North Am. 2007 Aug;25(3):713-33.

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