Open Wound of the Abdomen

Overview

An open wound of the abdomen is a serious injury that creates a break in the continuity of the abdominal wall, potentially exposing or damaging internal organs. These wounds range from superficial lacerations affecting only the skin and subcutaneous tissue to deep penetrating injuries that breach the peritoneum and involve intra-abdominal organs. Due to the vital organs housed within the abdominal cavity, including the liver, spleen, intestines, kidneys, and major blood vessels, open abdominal wounds constitute a medical emergency requiring immediate attention.

The abdomen, spanning from the lower edge of the rib cage to the pelvis, lacks the bony protection afforded to other body cavities. This vulnerability makes it susceptible to both blunt and penetrating trauma. Open abdominal wounds can result in life-threatening complications including hemorrhage, peritonitis, organ damage, and shock. The severity depends on the wound's depth, location, mechanism of injury, and which organs are involved.

Mortality rates for penetrating abdominal trauma vary widely, from 0-5% for stab wounds to 10-30% for gunshot wounds, depending on the organs injured and the speed of medical intervention. Modern trauma care has significantly improved outcomes, but these injuries still require expert surgical management and intensive care. Understanding the nature of abdominal wounds, their potential complications, and proper emergency response can be life-saving for both medical professionals and the general public.

Symptoms

The symptoms of an open abdominal wound vary depending on the severity, depth, and organs involved. Recognition of these symptoms is crucial for appropriate emergency response and medical management.

Immediate Visible Signs

Systemic Symptoms

• Signs of shock:
  • Rapid, weak pulse
  • Cold, clammy skin
  • Rapid, shallow breathing
  • Confusion or altered consciousness
  • Extreme thirst
• Abdominal rigidity: Board-like hardness indicating peritoneal irritation
• Distension: Swelling of the abdomen from internal bleeding or air
• Nausea and vomiting: Often containing blood if stomach is injured
• Fever: Developing hours after injury, suggesting infection

Specific Organ Injury Signs

• Liver injury: Right upper quadrant pain, referred right shoulder pain
• Spleen injury: Left upper quadrant pain, left shoulder pain (Kehr's sign)
• Intestinal perforation: Severe pain, rigid abdomen, absence of bowel sounds
• Kidney injury: Flank pain, blood in urine
• Bladder injury: Lower abdominal pain, inability to urinate, bloody urine

Complications Symptoms

Causes

Open abdominal wounds result from various mechanisms that breach the integrity of the abdominal wall. Understanding these causes helps in prevention and guides appropriate treatment approaches.

Penetrating Trauma

• Stab wounds:
  • Knife injuries (most common penetrating trauma)
  • Ice picks, screwdrivers, or other sharp objects
  • Glass shards from accidents
  • Typically cause less damage than gunshots
• Gunshot wounds:
  • High-velocity injuries causing extensive damage
  • Cavitation effect damages surrounding tissues
  • May have entrance and exit wounds
  • Bullet fragments can cause additional injury
• Impalement injuries:
  • Falls onto sharp objects
  • Industrial accidents with machinery
  • Motor vehicle accidents with intrusion

Blunt Trauma with Open Wounds

• Motor vehicle accidents:
  • Dashboard injuries
  • Seatbelt syndrome with skin breach
  • Ejection with abdominal trauma
• Falls from height:
  • Landing on sharp objects
  • Severe compression causing rupture
• Crush injuries:
  • Industrial accidents
  • Building collapses
  • Heavy machinery accidents

Iatrogenic Causes

• Surgical complications:
  • Wound dehiscence (surgical incision opening)
  • Evisceration (organs protruding through wound)
  • Infected surgical wounds breaking down
• Medical procedures:
  • Paracentesis complications
  • Drain or tube insertion injuries
  • Laparoscopy port site herniation

Other Causes

• Animal attacks: Bites or goring injuries
• Blast injuries: Explosions causing penetrating trauma
• Self-inflicted wounds: Intentional injuries
• Child abuse: Non-accidental trauma in children

Risk Factors

Several factors increase the risk of sustaining open abdominal wounds or experiencing worse outcomes:

Occupational and Environmental Risks

• High-risk occupations:
  • Law enforcement and military personnel
  • Construction and industrial workers
  • Agricultural workers (machinery injuries)
  • Emergency responders
• Environmental factors:
  • Living in high-crime areas
  • Participation in violent activities
  • Poor workplace safety standards
  • Inadequate protective equipment

Behavioral Risk Factors

• Alcohol and substance abuse (impaired judgment)
• Gang involvement or criminal activity
• Domestic violence situations
• Risk-taking behaviors
• Non-compliance with safety regulations

Medical Risk Factors for Complications

• Pre-existing conditions affecting healing:
  • Diabetes
  • Obesity
  • Malnutrition
  • Immunosuppression
  • Bleeding disorders
• Medications:
  • Anticoagulants increasing bleeding risk
  • Corticosteroids affecting healing

Demographic Factors

• Young males (highest risk group for trauma)
• Elderly (poorer outcomes, slower healing)
• Children (abuse considerations)
• Socioeconomic factors affecting access to care

Diagnosis

Diagnosis of open abdominal wounds requires rapid assessment to determine the extent of injury and guide immediate treatment. The approach varies between obvious penetrating trauma and complex cases requiring extensive evaluation.

Primary Survey (ATLS Protocol)

• Airway: Ensure patent airway
• Breathing: Assess respiratory status
• Circulation: Control hemorrhage, assess perfusion
• Disability: Neurological assessment
• Exposure: Full body examination

Physical Examination

• Wound assessment:
  • Location, size, and depth
  • Active bleeding
  • Visible organs or foreign bodies
  • Signs of evisceration
• Abdominal examination:
  • Tenderness and guarding
  • Rebound tenderness
  • Bowel sounds
  • Distension
• Rectal examination: Blood, high-riding prostate

Imaging Studies

• FAST (Focused Assessment with Sonography in Trauma):
  • Rapid bedside ultrasound
  • Detects free fluid (blood) in abdomen
  • Can be done during resuscitation
• CT scan with contrast:
  • Gold standard for stable patients
  • Identifies specific organ injuries
  • Detects active bleeding
  • Evaluates retroperitoneum
• Plain radiographs:
  • Free air under diaphragm
  • Foreign bodies (bullets, fragments)
  • Associated fractures

Laboratory Tests

• Initial labs:
  • Complete blood count
  • Type and crossmatch
  • Coagulation studies
  • Basic metabolic panel
  • Liver function tests
  • Amylase/lipase
  • Urinalysis
• Arterial blood gas: Assess acid-base status
• Lactate: Marker of tissue perfusion

Special Procedures

• Diagnostic peritoneal lavage (DPL): Rarely used now, replaced by FAST/CT
• Diagnostic laparoscopy: For equivocal cases
• Wound exploration: Under local anesthesia to assess depth

Treatment Options

Treatment of open abdominal wounds requires a systematic approach focusing on immediate life-saving interventions followed by definitive surgical management. The treatment strategy depends on the patient's hemodynamic status, wound characteristics, and organ involvement.

Pre-Hospital Emergency Care

• Scene safety and PPE
• Hemorrhage control:
  • Direct pressure on external bleeding
  • Do NOT remove impaled objects
  • Hemostatic agents for severe bleeding
• Evisceration management:
  • Do NOT attempt to replace organs
  • Cover with sterile saline-soaked gauze
  • Cover with occlusive dressing
• IV access and fluid resuscitation
• Rapid transport to trauma center

Emergency Department Management

• Trauma team activation
• Resuscitation:
  • Large-bore IV access
  • Balanced resuscitation with blood products
  • Massive transfusion protocol if needed
  • Avoid over-resuscitation before hemorrhage control
• Medications:
  • Broad-spectrum antibiotics
  • Tetanus prophylaxis
  • Pain management
  • Tranexamic acid for hemorrhage

Surgical Management

• Immediate surgery indications:
  • Hemodynamic instability
  • Peritonitis
  • Evisceration
  • Impalement
  • Free air on imaging
• Exploratory laparotomy:
  • Systematic exploration of all organs
  • Control hemorrhage
  • Repair organ injuries
  • Remove foreign bodies
  • Washout and drainage
• Damage control surgery:
  • For unstable patients
  • Control bleeding and contamination
  • Temporary abdominal closure
  • ICU resuscitation
  • Planned re-operation

Non-Operative Management

Selected stable patients with certain injuries may be managed conservatively:

• Hemodynamically stable
• No peritonitis
• Solid organ injuries without active bleeding
• Close monitoring in ICU
• Serial examinations and labs
• Ready access to OR if deterioration

Wound Care

• Primary closure: Clean wounds without contamination
• Delayed primary closure: Contaminated wounds
• Secondary intention: Heavily contaminated wounds
• Negative pressure therapy: Complex wounds
• Abdominal wall reconstruction: Large defects

Post-Operative Care

• ICU monitoring
• Ventilatory support as needed
• Nutritional support
• DVT prophylaxis
• Physical therapy
• Psychological support

Prevention

While not all abdominal wounds can be prevented, many strategies can reduce the risk of injury:

Personal Safety Measures

• Violence prevention:
  • Avoid high-crime areas when possible
  • Conflict resolution training
  • Domestic violence resources
  • Gang prevention programs
• Home safety:
  • Secure storage of sharp objects
  • Childproofing measures
  • Proper tool handling
  • Gun safety and storage

Occupational Safety

• Use of personal protective equipment
• Following safety protocols
• Regular safety training
• Machine guards and safety devices
• Reporting unsafe conditions

Vehicle Safety

• Seatbelt use
• Avoiding impaired driving
• Defensive driving techniques
• Vehicle maintenance
• Motorcycle protective gear

Medical Prevention

• Proper surgical technique to prevent dehiscence
• Appropriate post-operative care
• Management of conditions affecting healing
• Fall prevention in elderly

When to See a Doctor

Any open wound to the abdomen requires immediate emergency medical attention:

Call 911 Immediately For:

• Any penetrating injury to the abdomen
• Visible organs through a wound (evisceration)
• Impaled objects in the abdomen
• Severe abdominal pain after injury
• Signs of shock (rapid pulse, cold skin, confusion)
• Significant bleeding from abdominal wound
• Gunshot or stab wounds to trunk

While Waiting for Help:

• Keep the person still and calm
• Do NOT give food or water
• Do NOT remove impaled objects
• Cover eviscerated organs with moist, clean cloth
• Apply direct pressure to control bleeding
• Monitor breathing and consciousness

Post-Treatment Warning Signs:

• Increasing pain or swelling
• Fever or chills
• Wound drainage or odor
• Wound separation
• Nausea or vomiting
• Changes in bowel habits

Related Conditions

References

1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. Chicago: American College of Surgeons; 2018.
2. Biffl WL, et al. Management of patients with anterior abdominal stab wounds: A Western Trauma Association multicenter trial. Journal of Trauma and Acute Care Surgery. 2009;66(5):1294-1301.
3. Como JJ, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. Journal of Trauma. 2010;68(3):721-733.
4. Feliciano DV, et al. Trauma. 9th ed. New York: McGraw-Hill Education; 2020.
5. Martin MJ, et al. Emergency department thoracotomy: An updated approach for resuscitative thoracotomy and penetrating chest trauma. Trauma Surgery & Acute Care Open. 2021;6(1):e000734.
6. National Association of Emergency Medical Technicians. Prehospital Trauma Life Support. 9th ed. Burlington: Jones & Bartlett Learning; 2019.