A 28-year-old woman is admitted to the trauma unit following a stab wound to the left flank. On examination, she is haemodynamically stable (BP 128/82 mmHg, HR 88/min), with mild left-sided abdominal tenderness but no peritoneal signs. FAST examination is negative. Which of the following management approaches is NOT appropriate for this patient?

Explanation

## Management of Penetrating Abdominal Trauma (Stab Wound) in Haemodynamically Stable Patients ### Clinical Context: Stab Wound to Flank **Key Point:** Penetrating abdominal trauma (stab wounds) in haemodynamically stable patients with **equivocal peritoneal signs** requires a **selective non-operative management (NOM) approach** rather than mandatory laparotomy. ### Indications for Immediate Laparotomy vs. Selective Management | Clinical Scenario | Recommendation | Rationale | |-------------------|----------------|----------| | **Haemodynamic instability + peritoneal signs** | **Immediate laparotomy** | Life-threatening bleeding or peritonitis | | **Haemodynamic stability + clear peritoneal signs** | **Laparotomy** | Organ injury likely; operative exploration needed | | **Haemodynamic stability + equivocal/absent peritoneal signs + negative FAST** | **Selective NOM** | Serial examination, imaging, observation | | **Haemodynamic stability + no peritoneal signs + negative FAST** | **Conservative observation** | Serial exam, labs, imaging if indicated | ### Appropriate Management Options for This Patient **High-Yield:** In a **haemodynamically stable patient with a stab wound, mild tenderness, no peritoneal signs, and negative FAST**, the following are acceptable: 1. **Serial Clinical Examination** — Repeat abdominal examination at regular intervals (q2–4h) to detect evolving peritonitis or instability. 2. **Serial Haemoglobin** — Trend Hb to detect ongoing occult bleeding. 3. **Diagnostic Laparoscopy** — Minimally invasive evaluation of peritoneal penetration; if peritoneum is intact, laparotomy is avoided. 4. **Contrast-Enhanced CT Abdomen/Pelvis** — If available and patient remains stable, CT can identify solid organ injury, free fluid, and guide further management. **Clinical Pearl:** Modern trauma centres increasingly use **selective non-operative management (NOM)** for penetrating abdominal trauma in haemodynamically stable patients. This reduces unnecessary laparotomies and associated morbidity. ### Why Option 2 (Immediate Laparotomy) Is NOT Appropriate **Warning:** Immediate exploratory laparotomy **without further investigation** in a haemodynamically stable patient with: - Mild tenderness (not frank peritonitis) - No peritoneal signs - Negative FAST ...is **overly aggressive** and violates the principle of selective non-operative management. This approach increases unnecessary operative morbidity and mortality without improving outcomes. **Mnemonic for Penetrating Trauma Decision-Making: STAB** - **S** — Stable haemodynamically? - **T** — Tenderness and peritoneal signs present? - **A** — Abdominal imaging (FAST/CT) findings? - **B** — Bleeding trend (serial labs)? If stable, no clear peritonitis, and imaging negative → **Observe and reassess**, not immediate laparotomy. ### Why Options 1, 3, and 4 Are Appropriate - **Option 1 (Serial exam + serial Hb):** Gold standard for NOM; detects deterioration early. - **Option 3 (Diagnostic laparoscopy):** Minimally invasive; confirms peritoneal penetration and identifies injuries without full laparotomy. - **Option 4 (CT imaging):** Provides detailed anatomical assessment; helps guide NOM vs. operative decisions. [cite:ATLS 10th Edition; Trauma Surgery Textbooks]