A 35-year-old woman is admitted following a stab wound to the right lower abdomen. On examination, blood pressure is 110/70 mmHg, heart rate 92 bpm, and the abdomen is soft with mild right lower quadrant tenderness but no peritoneal signs. FAST examination shows no free fluid. Focused abdominal CT with IV contrast reveals a small laceration of the right colon with minimal perivisceral fat stranding and no active contrast extravasation. What is the most appropriate next step in management?

Explanation

## Selective Non-Operative Management (NOM) in Penetrating Abdominal Trauma **Key Point:** Not all penetrating abdominal injuries require immediate laparotomy. Hemodynamically stable patients without peritonitis and with imaging evidence of isolated, non-expanding injuries can be managed non-operatively with strict monitoring. ### Criteria for Selective Non-Operative Management | Criterion | Present in This Case? | Significance | |---|---|---| | Hemodynamic stability | Yes (BP 110/70) | Essential for NOM | | No peritoneal signs | Yes (soft abdomen, mild tenderness) | No evidence of diffuse peritonitis | | Negative or minimal FAST findings | Yes (no free fluid) | No massive bleeding | | Imaging shows isolated injury | Yes (small colon laceration) | No active extravasation | | No active contrast extravasation | Yes | Suggests contained injury | | Reliable patient for follow-up | Assumed | Must be able to return if deteriorates | **High-Yield:** The paradigm shift in penetrating abdominal trauma is that **hemodynamically stable patients with isolated injuries on imaging and no peritonitis can be observed**. This reduces unnecessary laparotomies and associated morbidity. ### NOM Protocol for Penetrating Abdominal Trauma 1. **Admission to ICU or high-dependency unit** for continuous monitoring 2. **Serial abdominal examinations** every 1–2 hours initially, then every 4–6 hours 3. **Serial laboratory studies** (CBC, lactate) to detect occult bleeding or peritonitis 4. **Repeat imaging** (CT or ultrasound) if clinical deterioration or persistent symptoms 5. **Immediate laparotomy** if: - Peritoneal signs develop - Hemodynamic instability - Rising lactate or falling hemoglobin - Imaging shows progression (expanding hematoma, new free fluid) **Clinical Pearl:** Colon injuries from penetrating trauma can be managed non-operatively if there is no peritonitis, no fecal contamination, and no other injuries requiring laparotomy. Primary repair or diversion depends on the degree of contamination and patient stability at the time of laparotomy (if it becomes necessary). **Warning:** NOM is NOT appropriate if: - Patient is hemodynamically unstable - Peritoneal signs are present - Imaging shows active extravasation or expanding hematoma - Patient cannot be reliably monitored ### Why Immediate Laparotomy Is NOT Indicated Here - Hemodynamically stable - No peritonitis - Imaging shows isolated, non-expanding injury - No active bleeding This patient meets criteria for selective NOM with close observation. [cite:ATLS 10th Edition Ch 5, Trauma Surgery: Core Principles]