Abdominal Injury

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In 2019, the Western Trauma Association proposed a stepwise approach to abdominal GSWs, based on prospective and retrospective cohort studies and expert opinion, which advised that patients who are hemodynamically unstable and/or with signs of evisceration, peritonitis, hematemesis, or bright-red blood per rectum should be taken to the operating room immediately for exploratory laparotomy.$^{75}$ If the injury is close to the mediastinum, evaluation for cardiac injury using ultrasound should be performed as well.

If one is working in a facility that does not have immediate access to a trauma surgeon or operating room, attempts at stabilization (according to ATLS® guidelines) should be performed and transfer of care initiated as soon as possible. In a stable patient without obvious free air on adjunct imaging, free fluid on ultrasound, or multiple GSWs, a CT scan with IV contrast should be performed to evaluate for injury requiring operative intervention.$^{75}$ The American College of Radiology recommends that patients with any penetrating injury to the genitourinary region where there is concern for lower urinary tract injury should undergo CT cystography or fluoroscopic retrograde cystography as the most appropriate initial imaging. CT abdomen and pelvis with IV contrast is what may typically be ordered first, but it is not the best study for identifying urethral injury.$^{77}$