Hemodynamically "Stable" patients with peritonitis after penetrating abdominal trauma - Identifying those who are bleeding

Hypothesis: Despite initial presentation, hemodynamically stable patients with penetrating abdominal trauma may have significant ongoing hemorrhage and major intra-abdominal injuries requiring emergent surgical intervention. Design: Cohort analytic study. Setting: Academic, level 1 trauma center. Patients: One hundred thirty-nine consecutive hemodynamically stable patients with penetrating abdominal trauma in whom peritonitis was the sole indication for laparotomy. Main Outome Measures: The primary outcome was the amount of blood initially found at laparotomy. Secondary outcomes included additional intraoperative blood loss, intraoperative hypotension, transfusion, fluid, and vasopressor requirement; need for admission to the intensive care unit and mechanical ventilation; complications; survivor length of stay in the hospital and intensive care unit; and mortality. Results: The admission systolic blood pressure (mean +/- SD, 131 +/- 22 mm Hg) and heart rate (mean +/- SD, 91 +/- 22 beats/min) were normal. Median time from peritonitis to incision was 40 minutes. Ninety-seven percent of patients had intra-abdominal injury, including 81%, hollow visceral; 36%, solid organ; and 11%, vascular injury. Though most patients had less than 750 mL(3) of blood found initially at laparotomy, there were 11% with 750 to 1500 mL(3) and 7% with 1500 mL(3) or more. Intraoperative hypotension (25%) and blood transfusion (39%) were common. Postoperatively, 40% of patients required intensive care (78% of them requiring mechanical ventilation) and 19% required additional transfusion within 24 hours. Complications occurred in 25% of patients, with intra-abdominal abscess (12%) and wound infection (7%) being the most common. Three patients died, 2 of exsanguination and 1 of multisystem organ failure. Conclusions: Following penetrating abdominal trauma, peritonitis should be a trigger for emergent operation regardless of vital signs, because hemodynamic "stability" does not reliably exclude significant hemorrhage. Vascular injury, subsequent hypotension, blood transfusion, and complicated postoperative course are common in this population.