Shanmuganathan et al developed an algorithm for evaluating a patient with penetrating trauma to the torso. The authors are from the University of Maryland in Baltimore.


Patient selection: penetrating torso injury


Indications for surgical management:

(1) hemodynamically unstable

(2) evidence of peritonitis (rigidity, rebound tenderness, tenderness at a site remote from injury site)

(3) blood on rectal examination

(4) positive FAST examination

(5) peritoneal violation on triple contrast CT with injuries identified that require surgery



• Triple contrast helical CT involves oral, rectal and intravenous contrast.

• Intraperitoneal free air or fluid was considered a sign of peritoneal violation but not necessarily of bowel injury.

• Signs of peritoneal violation included wound tract extending into peritoneum, intraperitoneal free air, intraperitoneal fluid, intraperitoneal bullet fragments and/or organ damage.


Findings on helical CT considered surgical injuries:

(1) injury to liver and/or spleen with bleeding

(2) extravasation of contrast material

(3) wound tract outlined by blood, air or debris leading to bowel wall

(4) focal thickening or discontinuity in the bowel wall

(5) thickening or infiltration of mesentery

(6) active bleeding from mesentery

(7) free blood associated with active bleeding

(8) pseudoaneurysm or arteriovenous fistula

(9) diaphragmatic injury

(10) injury to renal collecting system or bladder


Findings not considered surgical injuries:

(1) minor injuries to kidneys, liver or spleen

(2) small mesenteric, retroperitoneal or pelvic hematomas


If there is peritoneal violation but not surgical injury identified on triple contrast CT, then the patient is held for observation with repeated examinations.


If there is no peritoneal violation then the patient is interpreted as having minor injuries which are treated and the patient is then discharged.


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