A 28-year-old woman is brought to the trauma bay after a stab wound to the left lower abdomen. She is alert, blood pressure 118/72 mmHg, heart rate 92/min, respiratory rate 18/min. Abdominal examination reveals a single stab wound with minimal surrounding erythema; no peritoneal signs are present. FAST examination is negative for free fluid in all four views (Morrison's pouch, perisplenic, pelvic, and pericardial). Local wound exploration under local anesthesia reveals penetration through the fascia. What is the most appropriate next step?

Explanation

## Clinical Scenario Analysis This patient has a **penetrating abdominal wound with fascial violation** but is **hemodynamically stable** with **no peritoneal signs** and **negative FAST**. The challenge is ruling out hollow viscus or solid organ injury without unnecessary surgery. ## Penetrating Abdominal Trauma — Selective Non-Operative Management **Key Point:** In a **hemodynamically stable patient with penetrating abdominal trauma**, the presence of fascial penetration mandates further investigation. However, a negative FAST does not exclude solid organ or hollow viscus injury. **High-Yield:** Modern ATLS guidelines favor **selective non-operative management (SNOM)** for stable patients with penetrating abdominal trauma: - Hemodynamically stable (SBP > 100, HR < 100) - No peritoneal signs - Reliable for serial examination - CT imaging ± diagnostic laparoscopy to assess for injury ## Why CT Over Laparotomy? | Approach | Indication | | --- | --- | | **Immediate Laparotomy** | Hemodynamic instability, peritoneal signs, positive FAST | | **CT + Serial Exam** | Stable, fascial penetration, negative FAST, need to exclude solid organ/hollow viscus injury | | **Observation Alone** | Superficial wound, no fascial penetration | **Clinical Pearl:** Stab wounds to the lower abdomen carry risk of small bowel perforation, which may not manifest immediately. CT with IV contrast can detect peritoneal fluid, solid organ injury, and sometimes hollow viscus injury (free air, contrast extravasation). Serial abdominal examinations over 24 hours help detect evolving peritonitis. **Warning:** Negative FAST does NOT rule out all intra-abdominal injury. FAST is most sensitive for free blood; it may miss solid organ injury without significant bleeding or small hollow viscus perforation. ## Mnemonic: SNOM Criteria **STABLE** — **S**ystolic BP > 100, **T**achycardia absent (HR < 100), **A**lert/reliable, **B**lunt or penetrating, **L**ocal wound explored, **E**xam repeated serially. [cite:ATLS 10th Edition, Chapter 5; Journal of Trauma 2015 (Selective Non-Operative Management)]