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Biffl WL. Thinking like a freak in acute care surgery. J Trauma Acute Care Surg 2023; 95:615-620. [PMID: 37314399 DOI: 10.1097/ta.0000000000004076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Walter L Biffl
- From the Scripps Clinic/Scripps Clinic Medical Group, Department of Surgery, La Jolla, CA
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Corbitt M, Schmidt E, Swift K, O'Neill J, Brunott N. Overview of stab injuries in Far North Queensland: A new insight into the demographics, injury patterns and management. Injury 2022; 54:1386-1391. [PMID: 36604289 DOI: 10.1016/j.injury.2022.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/20/2022] [Accepted: 12/30/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Cairns Hospital is the northernmost tertiary referral hospital in Far North Queensland (FNQ) and manages trauma from a large catchment area. A large burden of stab injuries occurs in at-risk patient groups, such as Indigenous and mental health patients, in this region. This research aims to present an overview of the demographics, injury patterns, management and outcomes for stabbings injuries in FNQ. METHODS A five-year retrospective single-centre study of all patients treated for neck, torso or junctional stab wounds in Far North Queensland was performed searching for all patients with a coded diagnosis of stabbing or knife injury from 1 March 2016 to 31 March 2021. RESULTS 214 knife injuries were identified and 50.5% of those injured identified as Aboriginal and/or Torres Strait Islander. Stabbing injury locations were most commonly the abdomen/flank/pelvis (n = 81) and the chest/thorax (n = 77). Two-thirds of injuries that breached abdominal fascia had concurrent intra-abdominal injury. Hollow viscus injury commonly involved the small bowel (n = 8), colon (n = 5) and stomach (n = 2), whilst the liver was the most frequently injured solid organ (n = 6). There were 19 vascular injuries, excluding the extremities. 89.2% received diagnostic imaging in the emergency department. FAST scan had 76% sensitivity and 100% specificity for intra-abdominal injury at operation. Overall, 35% of patients required an operation. There were only two in-hospital deaths. CONCLUSION Stab injuries annually in FNQ are comparable to other centres in Australia. Overall injury severity was low, with excellent survival rates and outcomes for patients who reached hospital. Operative intervention rates for abdominal stab wounds were low in FNQ compared to available data and imaging again appears protective against negative laparotomy rate.
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Affiliation(s)
- Matthew Corbitt
- Department of Surgery, Cairns & Hinterland Hospital and Health Service, 165 Esplanade, Cairns, QLD, Australia; School of Medicine & Dentistry, Griffith University, Parklands Drive, Gold Coast, QLD, Australia.
| | - Emily Schmidt
- Department of Surgery, Cairns & Hinterland Hospital and Health Service, 165 Esplanade, Cairns, QLD, Australia
| | - Kate Swift
- Department of Surgery, Cairns & Hinterland Hospital and Health Service, 165 Esplanade, Cairns, QLD, Australia; Faculty of Medicine, University of Queensland, 288 Herston Road, St Lucia, QLD, Australia
| | - John O'Neill
- Department of Emergency Medicine, Cairns & Hinterland Hospital and Health Service, 165 Esplanade, Cairns, QLD, Australia
| | - Nathan Brunott
- Department of Surgery, Cairns & Hinterland Hospital and Health Service, 165 Esplanade, Cairns, QLD, Australia
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'The Armor Phenomenon' in Obese Patients with Penetrating Thoracoabdominal Injuries: A Systematic Review and Meta-Analysis. J Trauma Acute Care Surg 2022; 93:e101-e109. [PMID: 35195099 DOI: 10.1097/ta.0000000000003566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Obesity represents a growing global health threat, which generally portends increased morbidity and mortality in the context of traumatic injuries. We hypothesized that there may exist a protective effect related to increased weight and truncal girth provided for obese patients in penetrating torso injuries, although this may not exert a significant positive impact overall upon clinical outcomes. METHODS A comprehensive review of the literature was conducted across five databases up to March 2021 (Medline, Pubmed, Embase, Web of Science and the Cochrane library) to examine the effect of obesity on penetrating thoracoabdominal injuries. The primary outcome was to determine the rate of non-significant injury and injury patterns. Secondary outcomes examined were lengths of stay, complications, and mortality. Comparisons were drawn by meta-analysis. The study protocol was registered with PROSPERO under CRD42020216277. RESULTS 2,952 publications were assessed with twelve meeting the inclusion criteria for review. Nine studies were included for quantitative analysis including 5,013 patients sustaining penetrating thoracoabdominal injuries, of which 29.6% were obese. Obese patients that sustained stab injuries underwent more non-therapeutic operations. Obese patients that sustained gunshot injuries had longer intensive care and total hospital length of stay. Obese patients suffered more respiratory complications and were at an increased risk of death during their admission. CONCLUSION The 'armor phenomenon' does not truly protect obese patients, a population that experiences increased morbidity and mortality following penetrating thoracoabdominal injuries. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis, prognostic Level III.
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Sander A, Spence RT, McPherson D, Edu S, Nicol A, Navsaria P. A Prospective Audit of 805 Consecutive Patients With Penetrating Abdominal Trauma: Evolving Beyond Injury Mechanism Dictating Management. Ann Surg 2022; 275:e527-e533. [PMID: 32568748 DOI: 10.1097/sla.0000000000004045] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Global trends of penetrating abdominal trauma (PAT) have seen a shift toward a selectively conservative management strategy. However, its widespread adoption for gunshot injuries has been sluggish. The purpose of this study is to compare the injury mechanisms of gunshot (GSW) and stab wounds (SW) to the abdomen in presentation, management, and outcomes. METHODS Prospective cohort study, set in Cape Town, South Africa, over 2 years. All patients presenting to the center with PAT during this time were included. Presentation, management, and outcomes were compared by injury mechanism, with a focus on the operative strategy (operative vs nonoperative). RESULTS During the study period, 805 patients (SW 37.6%; GSW 62.4%) with PAT were managed. Immediate laparotomies were performed in 119 (39.3%) SW and 355 (70.7%) GSW, with a therapeutic laparotomy rate of 85.7% and 91.8% for SW and GSW, respectively. Nonoperative management (NOM) was implemented in 184 SW (60.7%) and 147 GSW (29.3%) (P < 0.001), with a 92.9% and 92.5% success rate for SW and GSW, respectively. The therapeutic laparotomy rate for the delayed laparotomies (DOM) was 69.2% for SW, and 90.9% for GSW. The accuracy of clinical assessment (with adjuncts) in determining the need for laparotomy was: GSW-92% and SW-91%. Univariate analysis revealed the mechanism not to be associated with DOM. The overall mortality rate was 7.2%, and nonfatal morbidities 22.2%. CONCLUSION Although GSW is a more morbid and often fatal injury, the general principles of selective conservatism hold true for both GSW and SW, equally.
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Affiliation(s)
- Anthony Sander
- Trauma Centre, Groote Schuur Hospital and University of Cape Town, Division of General Surgery: Trauma, Cape Town, South Africa
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Buisset C, Mazeaud C, Postillon A, Nominé-Criqui C, Fouquet T, Reibel N, Brunaud L, Perez M. Evaluation of diagnostic laparoscopy for penetrating abdominal injuries: About 131 anterior abdominal stab wound. Surg Endosc 2021; 36:2801-2808. [PMID: 34076764 DOI: 10.1007/s00464-021-08566-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 05/18/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The management of hemodynamically stable patients with anterior abdominal stab wounds (AASW) is debated. Mini-invasive techniques using laparoscopy and non-operative management (NOM) have reduced the rate of nontherapeutic laparotomies after AASW leading to unnecessary morbidity. The aim of this study was to determine with a systematic diagnostic laparoscopy of peritoneal penetration (PP), patients who do not require abdominal exploration in the management of stable patient with an AASW. METHODS All patients with AASW were retrospectively recorded from 2006 to 2018. Criteria of inclusion were AASW patients who underwent a systematic diagnostic laparoscopy. Criteria of exclusion were patients with an evisceration, impaling, clinical peritonitis, and hemodynamic instability. If no PP was detected, laparoscopy was terminated. If defects of peritoneum were found, a laparotomy was performed looking for diagnosis and treatment of intra-abdominal injuries. RESULTS On 131 AASW patients, 35 underwent immediate emergency laparotomy, 96 underwent diagnostic laparoscopy, 47 were positive (PP) and had an intra-abdominal exploration by laparotomy, 32 (68.1%) had intra-abdominal injuries which required treatment. All patients with an intra-abdominal injury had a positive diagnostic laparoscopy. For the 49 patients with a negative laparoscopy, the mean hospital stay was 1.6 days with ambulatory care for some patients. No patient presented a delayed injury. Non-therapeutic laparotomy rate was 15.6%. For patients who did not have an intra-abdominal injury the morbidity rate was low (3%). CONCLUSION Our study shows that diagnostic laparoscopy was safe, with a low duration of hospitalization, a possible ambulatory care and had an excellent ability to screen the patients who did not need a abdominal exploration. This management can avoid many unnecessary laparotomies with an acceptable rate of negative laparotomy, without any delayed diagnosis of intra-abdominal injuries and with a low morbidity rate.
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Affiliation(s)
- Cyrille Buisset
- Department of Digestive, Endocrine and Metabolic Surgery, Hôpital Robert Schuman - Groupe Hospitalier UNEOS, Rue du Champ Montoy, 57070, Metz, France.
| | - Charles Mazeaud
- Department of Urology, University Hospital Nancy Brabois, Rue du Morvan, 54511, Vandoeuvre-Les-Nancy, France
| | - Agathe Postillon
- Department of Gastrointestinal, Metabolic and Surgical Oncology, University Hospital Nancy Brabois, Rue du Morvan, 54511, Vandoeuvre-Les-Nancy, France
| | - Claire Nominé-Criqui
- Department of Gastrointestinal, Metabolic and Surgical Oncology, University Hospital Nancy Brabois, Rue du Morvan, 54511, Vandoeuvre-Les-Nancy, France
| | - Thibaut Fouquet
- Department of Gastrointestinal, Metabolic and Surgical Oncology, University Hospital Nancy Brabois, Rue du Morvan, 54511, Vandoeuvre-Les-Nancy, France
| | - Nicolas Reibel
- Department of Gastrointestinal, Metabolic and Surgical Oncology, University Hospital Nancy Brabois, Rue du Morvan, 54511, Vandoeuvre-Les-Nancy, France
| | - Laurent Brunaud
- Department of Gastrointestinal, Metabolic and Surgical Oncology, University Hospital Nancy Brabois, Rue du Morvan, 54511, Vandoeuvre-Les-Nancy, France
| | - Manuela Perez
- Department of Gastrointestinal, Metabolic and Surgical Oncology, University Hospital Nancy Brabois, Rue du Morvan, 54511, Vandoeuvre-Les-Nancy, France
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Sander A, Spence R, Ellsmere J, Hoogerboord M, Edu S, Nicol A, Navsaria P. Penetrating abdominal trauma in the era of selective conservatism: a prospective cohort study in a level 1 trauma center. Eur J Trauma Emerg Surg 2020; 48:881-889. [PMID: 32889613 DOI: 10.1007/s00068-020-01478-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 08/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Global trend has seen management shift towards selective conservatism in penetrating abdominal trauma (PAT). The purpose of this study is to compare the presentation; management; and outcomes of patients with PAT managed operatively versus non-operatively. METHODS Prospective cohort study of all patients Ùpresenting with PAT to Groote Schuur Hospital, Cape Town from 01 May 2015 to 30 April 2017. Presentation; management; and outcomes of patients were compared. Univariate predictors of delayed operative management (DOM) were explored. RESULTS Over the 2-year study period, 805 patients with PAT were managed. There were 502 (62.4%); and 303 (37.6%) patients with gunshot (GSW) and stab wounds (SW), respectively. The majority were young men (94.7%), with a mean age of 28.3 years (95% CI 27.7-28.9) and median ISS of 13 (IQR 9-22). Successful non-operative management was achieved in 304 (37.7%) patients, and 501 (62.5%) were managed operatively. Of the operative cases, 477 (59.3%) underwent immediate laparotomy and 24 (3.0%) DOM. On univariate analysis, number; location; and mechanism of injuries were not associated with DOM. Rates of therapeutic laparotomy were achieved in 90.3% in the immediate, and 80.3% in the DOM cohorts. The mortality rate was 1.3, 11.3 and 0% in the in the NOM, immediate laparotomy and DOM subgroups, respectively. The rate of complications was no different in the immediate and DOM cohorts (p > 0.05). CONCLUSION Patients with PAT in the absence of haemodynamic instability; peritonism; organ evisceration; positive radiological findings, or an unreliable clinical examination, can be managed expectantly without increased morbidity or mortality.
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Affiliation(s)
- Anthony Sander
- Trauma Center-C14, Department of General Surgery, Groote Schuur Hospital and University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Richard Spence
- Department of General Surgery, Dalhousie University, Halifax, Canada
| | - James Ellsmere
- Department of General Surgery, Dalhousie University, Halifax, Canada
| | | | - Sorin Edu
- Trauma Center-C14, Department of General Surgery, Groote Schuur Hospital and University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Andrew Nicol
- Trauma Center-C14, Department of General Surgery, Groote Schuur Hospital and University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Pradeep Navsaria
- Trauma Center-C14, Department of General Surgery, Groote Schuur Hospital and University of Cape Town, Observatory, Cape Town, 7925, South Africa.
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Hsiao V, Sim J, Zimmerman A, Stephen A. Obesity May Not be Protective in Abdominal Stab Wounds. J Emerg Trauma Shock 2019; 12:168-172. [PMID: 31543637 PMCID: PMC6735204 DOI: 10.4103/jets.jets_41_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Context: Current protocols for the management of abdominal stab wounds were established based on retrospective data from prior decades. Few have investigated whether higher body mass index (BMI) affects outcomes after these injuries. Aim: The aim was to determine the effects of obesity on outcomes in abdominal stab wound patients. Setting and Design: This was a retrospective cohort study at a Level I university-associated trauma center in the United States. Materials and Methods: We reviewed medical records of 100 adult patients admitted to our trauma center with abdominal stab wounds. Demographics, types of internal organ injury, gastrointestinal (GI) resection and repair, mortality, length of hospital stay (LOS), units of blood transfused within 24 h of admission, need and indications for exploratory laparotomy, surgical site infections (SSI), and need for re-operation were compared between obese and nonobese patients. Statistical Analysis: Categorical and continuous outcome variables were compared between the two groups using Chi-squared and independent-samples t-tests, respectively. BMI was evaluated as a predictor of outcomes using univariate and multivariate logistic regression. Results: Records of 100 adult abdominal stab wound patients were reviewed. Twenty-five patients were obese. The obese group was older (38.76 vs. 31.23, P = 0.018). Rates of therapeutic laparotomy were similar between obese and nonobese patients (20 [80.00%] vs. 64 [85.33%]). Obesity was associated with longer LOS (9.6 vs. 6.5, P = 0.026). In the multivariate analysis, increasing BMI was an independent predictor of need for GI resection (odds ratio: 1.10 [1.02–1.18], P = 0.018). One patient from the obese group died. Conclusions: Obese patients with abdominal stab wounds have longer LOS than nonobese patients. Increasing BMI was an independent predictor of need for GI resection.
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Affiliation(s)
- Vivian Hsiao
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - Jacob Sim
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - Asha Zimmerman
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - Andrew Stephen
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA
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Sarigoz T, Sevim Y. The use of computed tomography tractography in anterior abdominal stab wounds. Am J Emerg Med 2018; 36:2107. [PMID: 29571825 DOI: 10.1016/j.ajem.2018.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/13/2018] [Indexed: 11/27/2022] Open
Affiliation(s)
- Talha Sarigoz
- Batman Sason State Hospital, General Surgery, Batman, Turkey.
| | - Yusuf Sevim
- Ankara Numune Training and Research Hospital, Department of General Surgery, Division of Colorectal Surgery, Ankara, Turkey
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Herfatkar MR, Mobayen MR, Karimian M, Rahmanzade F, Baghernejad Monavar Gilani S, Baghi I. Serial Clinical Examinations of 100 Patients Treated for Anterior Abdominal Wall Stab Wounds: A Cross Sectional Study. Trauma Mon 2016; 20:e24844. [PMID: 26839861 PMCID: PMC4727469 DOI: 10.5812/traumamon.24844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 04/16/2015] [Accepted: 05/13/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The current approach in stab wounds of the anterior abdominal wall is still unclear. OBJECTIVES The goal of this study was to evaluate serial clinical examinations of patients with abdominal wall stab wounds referred to Poursina Hospital in Rasht. PATIENTS AND METHODS In a cross sectional study, 100 cases with stab wounds to the anterior abdominal wall were examined serially (admission time, 4, 8, 12, and 24 hours) after wound exploration. Serial hemoglobin test was performed every 8 hours. Laparotomy was performed in cases who were not hemodynamically stable or who showed symptoms of peritonitis. The results were analyzed with SPSS software version 21. RESULTS Ninety-one men (91%) and 9 women (9%) with mean age of 27 ± 10.7 years were included. Coexisting injuries were prevalent in 12 cases. The duration of hospitalization was 1 day in 31%, 2 days in 30%, 3 - 4 days in 32% and more than 5 days in 7%. Late laparotomy was performed 12 hours after admission in 8% of patients due to peritonitis. There was visceral damage in these cases. No mortality occurred. The cost and duration of hospitalization was significantly higher in cases with coexisting injuries and those who underwent laparotomy. CONCLUSIONS It seems serial clinical examinations are safe and decrease the cost and duration of hospitalization in stable patients with anterior abdominal wall stab wounds.
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Affiliation(s)
- Mohammad Rasool Herfatkar
- Department of Surgery, Guilan Surgery Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Mohammad Reza Mobayen
- Department of Surgery, Guilan Surgery Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Mehdi Karimian
- Department of Surgery, Guilan Surgery Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Fariba Rahmanzade
- Public Health Center of Guilan, Guilan Surgery Research Center, Rasht, IR Iran
| | | | - Iraj Baghi
- Department of Surgery, Guilan Surgery Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
- Corresponding author: Iraj Baghi, Department of Surgery, Guilan Surgery Research Center, Guilan University of Medical Sciences, Rasht, IR Iran. Tel: +98-9125139506, E-mail:
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Role of Laparoscopic Exploration Under Local Anesthesia in the Management of Hemodynamically Stable Patients with Penetrating Abdominal Injury. J Laparoendosc Adv Surg Tech A 2016; 26:27-31. [DOI: 10.1089/lap.2015.0420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Benefits of CT tractography in evaluation of anterior abdominal stab wounds. Am J Emerg Med 2015; 33:1188-90. [DOI: 10.1016/j.ajem.2015.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/27/2015] [Accepted: 05/18/2015] [Indexed: 11/23/2022] Open
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Ball CG. Current management of penetrating torso trauma: nontherapeutic is not good enough anymore. Can J Surg 2014; 57:E36-43. [PMID: 24666458 DOI: 10.1503/cjs.026012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
A highly organized approach to the evaluation and treatment of penetrating torso injuries based on regional anatomy provides rapid diagnostic and therapeutic consistency. It also minimizes delays in diagnosis, missed injuries and nontherapeutic laparotomies. This review discusses an optimal sequence of structured rapid assessments that allow the clinician to rapidly proceed to gold standard therapies with a minimal risk of associated morbidity.
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Affiliation(s)
- Chad G Ball
- From the University of Calgary, Calgary, Alta
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Diagnostic laparoscopy after anterior abdominal stab wounds: worth another look? J Trauma Acute Care Surg 2014; 75:1013-7; discussion 1017-8. [PMID: 24256675 DOI: 10.1097/ta.0b013e3182a1fde8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The National Institute of Medicine's report Hospital-Based Emergency Care: At the Breaking Point highlighted the critical issue of emergency department overcrowding. At our institution, patients with anterior abdominal stab wounds (AASW) have been managed with a protocol that uses diagnostic laparoscopy (DL) after positive result on local wound exploration. Patients with negative DL result are eligible for discharge directly from the recovery room. The purpose of this study was to evaluate the use of DL for AASWs in light of the recommendations that suggested serial abdominal examination (SAE) is preferred to determine the need for laparotomy. METHODS Patients admitted to a Level 1 trauma center from January 2010 through August 2012 with AASWs were included (contemporary period to Western Trauma Association study). Information regarding baseline characteristics, diagnostic workup, injury management, and outcomes were retrospectively reviewed and compared with the SAE AASW algorithm. RESULTS A total of 158 patients with AASWs were evaluated using our institutional algorithm. Thirty-eight patients (24%) went directly to the operating room for peritonitis, shock, or evisceration; 120 underwent local wound exploration; 99 had positive result (82%). Twenty-eight patients had immediate laparotomy owing to worsening clinical examination findings. Seventy had DL, and 19 of these patients were discharged home from the recovery room, with a mean length of stay of 6.4 hours. When comparing patients managed using the DL algorithm to those managed using the SAE-based algorithm, the nontherapeutic laparotomy rate was lower, although not statistically significant. However, the DL algorithm produced a significantly higher percentage of patients discharged directly home following local wound exploration. CONCLUSION With some trauma centers suffering from emergency department overcrowding and constrained resources, DL may offer an alternative to SAE to efficiently use available resources. Both SAE and DL are safe and offer similar therapeutic laparotomy rates. The method used to evaluate patients after AASW should be tailored to institutional needs and resources. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Abstract
PURPOSE OF REVIEW Patients with penetrating abdominal trauma are at risk of harboring life-threatening injuries. Many patients are in need of emergent operative intervention. However, there are clearly patients who can be safely managed nonoperatively. This review evaluates the literature to identify management guidelines for patients with penetrating abdominal trauma. RECENT FINDINGS Accumulating evidence supports nonoperative management of patients with stab wounds to the thoracoabdominal region, the back, flank, and anterior abdomen. Furthermore, select patients with gunshot wounds can be safely managed nonoperatively. SUMMARY Shock, evisceration, and peritonitis warrant immediate laparotomy following penetrating abdominal trauma. Thoracoabdominal stab wounds should be further evaluated with chest X-ray, ultrasonography, and laparoscopy or thoracoscopy. Wounds to the back and flank should be imaged with CT scanning. Anterior abdominal stab wound victims can be followed with serial clinical assessments. The majority of patients with gunshot wounds are best served by laparotomy; however, select patients may be managed expectantly.
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Omari A, Bani-Yaseen M, Khammash M, Qasaimeh G, Eqab F, Jaddou H. Patterns of anterior abdominal stab wounds and their management at Princess Basma teaching hospital, North of Jordan. World J Surg 2013; 37:1162-8. [PMID: 23400590 DOI: 10.1007/s00268-013-1931-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With the progressive use of new diagnostic techniques, the management of penetrating abdominal stab wounds is changing. Most studies have been conducted in well-equipped trauma centers in developed countries, and there is a paucity of reports from general teaching hospitals with limited resources. We reviewed the assessment of anterior abdominal stab wounds in patients presenting to our hospital hoping to establish an evidence-based algorithm for managing such patients in busy general hospitals. METHODS The medical records of all 393 patients treated at our hospital for anterior abdominal stab wounds over a 7-year period were reviewed. Information regarding age, gender, site of the stab wound, management, and complications were analyzed. RESULTS Twenty-six patients with hemodynamic instability at presentation underwent urgent laparotomy (LAP); 24 (92.3 %) of those procedures were therapeutic. Local wound exploration (LWE) proved that 114 (31 %) of all hemodynamically stable patients had no abdominal fascia penetration and consequently could be discharged home from the emergency department (ED). A total of 253 patients were found to have fascial penetration, and all were admitted for repeat clinical assessments (RCA) and imaging studies. A total of 121 (48 %) of the patients underwent abdominal exploration with 102 (84 %) therapeutic LAP procedures. CONCLUSIONS Hemodynamic instability and evisceration should continue to prompt urgent LAP. For stable patients, a sequence of LWE followed by focused abdominal sonography for trauma and computed tomography scanning for unclear cases primed by RCA was found to be efficient in limiting hospital admissions and reducing the rate of non-therapeutic LAP.
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Affiliation(s)
- Abdelkarim Omari
- Department of General Surgery, Faculty of Medicine Jordan University of Science and Technology (JUST), P.O. Box 3030, Irbid, Jordan.
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Martínez Casas I, Sancho Insenser J, Climent Agustín M, Membrilla Fernández E, Pons Fragero MJ, Guzmán Ahumada J, Grande Posa L. [A study of the predictive value of the primary review and complementary examinations in assessing the need for surgery in patients with stab wounds in the torso]. Cir Esp 2012; 91:450-6. [PMID: 23245991 DOI: 10.1016/j.ciresp.2012.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Revised: 07/26/2012] [Accepted: 08/29/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Observation is the gold standard for stable patients with stab wounds. The aim of the study was to analyse the value of the primary review and complementary examinations to predict the need for surgery in stab wound patients in order to decrease observation times. METHODS A retrospective study of stab wound patients recorded in a database. Clinical and diagnostic workup parameters were analysed. The main variable was the need for surgery. RESULTS A total of 198 patients were included between 2006 and 2009, with a mean injury severity score (ISS) of 7.8±7, and 0.5% mortality. More than half (52%) of the patients suffered multiple wounds. Wound distribution was 23% neck, 46% thorax and 31% abdomen. Surgery was required in 73 (37%) patients (59% immediate, 27% delayed and 14% delayed). The need for surgery was associated with a lower revised trauma score (RTS), evisceration, active bleeding, and fascial penetration. Initial and control haemoglobin levels were significantly lower in patients who required surgery. A positive computerised tomography (CT) scan was associated with surgery. There were complications in 18% of patients, and they were more frequent in those who underwent surgery. There was no difference in complication rates between immediate and delayed (P=.72). Surgery was finally required in 10% of the patients with no abnormalities in the primary review and diagnostic workup, and 6% of those developed complications. CONCLUSION None of the parameters studied could individually assess the need for surgery. Primary and secondary reviews were the most important diagnostic tool, but CT scan should be used more often. An observation period of 24 hours is recommended in torso penetrating wounds.
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Affiliation(s)
- Isidro Martínez Casas
- Unidad de Urgencias Quirúrgicas y Politrauma, Servicio de Cirugía General y Digestiva, Hospital Universitari del Mar, Barcelona, España.
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Validating the Western Trauma Association algorithm for managing patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. ACTA ACUST UNITED AC 2012; 71:1494-502. [PMID: 22182859 DOI: 10.1097/ta.0b013e31823ba1de] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED The optimal management of stable patients with anterior abdominal stab wounds (AASWs) remains a matter of debate. A recent Western Trauma Association (WTA) multicenter trial found that exclusion of peritoneal penetration by local wound exploration (LWE) allowed immediate discharge (D/C) of 41% of patients with AASWs. Performance of computed tomography (CT) scanning or diagnostic peritoneal lavage (DPL) did not improve the D/C rate; however, these tests led to nontherapeutic (NONTHER) laparotomy (LAP) in 24% and 31% of cases, respectively. An algorithm was proposed that included LWE, followed by either D/C or admission for serial clinical assessments, without further imaging or invasive testing. The purpose of this study was to evaluate the safety and efficacy of the algorithm in providing timely interventions for significant injuries. METHODS A multicenter, institutional review board-approved study enrolled patients with AASWs. Management was guided by the WTA AASW algorithm. Data on the presentation, evaluation, and clinical course were recorded prospectively. RESULTS Two hundred twenty-two patients (94% men, age, 34.7 years ± 0.3 years) were enrolled. Sixty-two (28%) had immediate LAP, of which 87% were therapeutic (THER). Three (1%) died and the mean length of stay (LOS) was 6.9 days. One hundred sixty patients were stable and asymptomatic, and 81 of them (51%) were managed entirely per protocol. Twenty (25%) were D/C'ed from the emergency department after (-) LWE, and 11 (14%) were taken to the operating room (OR) for LAP when their clinical condition changed. Two (2%) of the protocol group underwent NONTHER LAP, and no patient experienced morbidity or mortality related to delay in treatment. Seventy-nine (49%) patients had deviations from protocol. There were 47 CT scans, 11 DPLs, and 9 laparoscopic explorations performed. In addition to the laparoscopic procedures, 38 (48%) patients were taken to the OR based on test results rather than a change in the patient's clinical condition; 17 (45%) of these patients had a NONTHER LAP. Eighteen (23%) patients were D/C'ed from the emergency department. The LOS was no different among patients who had immediate or delayed LAP. Mean LOS after NONTHER LAP was 3.6 days ± 0.8 days. CONCLUSIONS The WTA proposed algorithm is designed for cost-effectiveness. Serial clinical assessments can be performed without the added expense of CT, DPL, or laparoscopy. Patients requiring LAP generally manifest early in their course, and there does not appear to be any morbidity related to a delay to OR. These data validate this approach and should be confirmed in a larger number of patients to more convincingly evaluate the algorithm's safety and cost-effectiveness compared with other approaches.
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Paydar S, Salahi R, Izadifard F, Jaafari Z, Abbasi HR, Eshraghian A, Hosseini SV, Farrokhnia F, Golshan Y, Bolandparvaz S. Comparison of conservative management and laparotomy in the management of stable patients with abdominal stab wound. Am J Emerg Med 2011; 30:1146-51. [PMID: 22100482 DOI: 10.1016/j.ajem.2011.08.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 08/15/2011] [Accepted: 08/16/2011] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The management of the hemodynamically stable patients with penetrating abdominal stab wounds is a problematic issue among trauma surgeons. METHODS In a retrospective study, we analyzed stable patients with anterior abdominal stab wound from August 2009 to 2010. The patients who were hemodynamically unstable or had developed peritonitis were excluded. In our center, the patients are treated through conservative or operative management depending on the protocol of management of the stable penetrating abdominal stab wound in our center. We compared the effectiveness, mean duration of hospital admission, and the time of starting diet in 2 groups. RESULTS There were 99 cases including 47 patients in the conservative group and 52 in the laparotomy group. The laparotomy was negative in 73% and positive in 27% of the patients. In the conservative group, all the patients remained asymptomatic and stable except for 6 patients who needed subsequent laparotomy. The maximum period between admission and delayed laparotomy in these 6 patients was 17 hours. The mean length of hospital stay and the time of starting diet were 70.4 vs 43 hours and 42.3 vs 30.6 hours in the operative group and conservative group, respectively. P < .05 was considered significant. CONCLUSION Our study showed that conservative management of asymptomatic and stable patients with anterior abdominal stab wound with physical examination can decrease the rate of normal laparotomy and the length of hospitalization and help to start diet earlier. This study made this hypothesis that after 17 hours of observation, diet can be started for the stable asymptomatic patients.
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Affiliation(s)
- Shahram Paydar
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Ohene-Yeboah M, Dakubo JCB, Boakye F, Naeeder SB. Penetrating abdominal injuries in adults seen at two teaching hospitals in ghana. Ghana Med J 2011; 44:103-8. [PMID: 21327014 DOI: 10.4314/gmj.v44i3.68893] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The incidence of penetrating abdominal injuries (PAI) has increased in the West African sub-region. OBJECTIVE To determine the pattern and management outcome of penetrating abdominal injuries (PAI) in the two main teaching hospitals in Ghana. STUDY DESIGN A prospective and retrospective descriptive study. SETTING Komfo Anokye Teaching Hospital (KATH), Kumasi and Korle-Bu Teaching Hospital (KBTH), Accra. METHODS Relevant details of all adult patients admitted with penetrating abdominal injuries over a 11-year period were recorded at KATH and KBTH in Accra. The study in KATH was prospective pro forma based and that in the KBTH was a retrospective case review of all penetrating abdominal injuries. RESULTS There were 411 patients, mostly men (M: F-8:1). The peak age of patients was 20-29 years, 164 patients (39.9%). Abdominal stab wound injuries accounted for 251 (61.1%). Three hundred and thirty - one patients (80.5%) had an emergency laparotomy. Twelve patients required 16 emergency thoracotomies. The small bowel (23.2%), stomach (12.9%), colon (10.2%), the liver (10.0%), were the most commonly injured organs. In 92 patients (29.0%) no significant intra-abdominal injury was detected at laparotomy CONCLUSION Stab wounds are the main penetrating abdominal injuries seen mostly among young male adults in Ghana. Management was by a mandatory laparotomy after clinical assessment. The overall mortality was 4.4%. Selective non-operative management of abdominal stab wounds is possible.
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Affiliation(s)
- M Ohene-Yeboah
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, University Post Office, PMB, Kumasi, Ghana and Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
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Clarke DL, Allorto NL, Thomson SR. An audit of failed non-operative management of abdominal stab wounds. Injury 2010; 41:488-91. [PMID: 19913226 DOI: 10.1016/j.injury.2009.10.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Revised: 10/13/2009] [Accepted: 10/13/2009] [Indexed: 02/02/2023]
Abstract
UNLABELLED Selective non-operative management based on clinical assessment has been shown to be a generally safe approach in the management of penetrating stab wounds of the torso. However there will be a subset of patients who fail selective non-operative management. This audit focuses on the failures. METHODS The metropolitan surgical service in Pietermaritzburg covers 3 hospitals. At the weekly metropolitan morbidity and mortality meeting all trauma patients are reviewed. All cases of failed selective non-operative management of penetrating abdominal stab wounds are discussed. Failed non-operative management is usually defined as any patient who ultimately requires surgical exploration. We do not subscribe to this as we feel as long as the need for surgical intervention is recognised within a short period of time (<12h) there is little additional morbidity. Recognition of the need for surgical intervention after 12h would be regarded by us as failed non-operative management as we feel the risk of delay associated morbidity begins to increase significantly after this time. RESULTS A total of 340 patients with a penetrating anterior abdominal stab wound were managed over the 2 year period under review. A total of 192 (56%) of these patients were subjected to mandatory laparotomy. Of these mandatory laparotomies 98% were positive. The remaining 148 (44%) patients were observed. Of the 148 observed patients a total of 30 (20%) subsequently underwent surgery. A total of 13 patients were only taken to surgery after 12h of observation. In this group of 13 patients the average delay between admission and recognition of injury was 40 h. There were six gastric injuries, one pyloric and pancreatic injury, two gallbladder injuries, one liver, one colon and two small bowel injuries. There were no deaths. 9 patients recovered with no additional morbidity. In the remainder, morbidity included, relaparotomy (1), open abdomen (1), renal failure (1) and prolonged stay in ICU (3). CONCLUSION Clinical assessment accurately predicts the need for mandatory laparotomy following a stab wound to the torso. In patients who do not meet the indications for mandatory laparotomy and who are subjected to non-operative management 20% will come to surgery. A subgroup may only be recognised as requiring surgery after more than 12h. These patients are at risk of delay associated morbidity. There are particular anatomical sites and structures which are prone to error.
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Affiliation(s)
- D L Clarke
- Pietermaritzburg Metropolitan Complex, Department of General Surgery, University of Kwa-Zulu Natal, Nelson R Mandela School of Medicine, South Africa.
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Local wound exploration remains a valuable triage tool for the evaluation of anterior abdominal stab wounds. Am J Surg 2009; 198:223-6. [DOI: 10.1016/j.amjsurg.2008.11.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 11/13/2008] [Accepted: 11/13/2008] [Indexed: 11/20/2022]
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Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. ACTA ACUST UNITED AC 2009; 66:1294-301. [PMID: 19430229 DOI: 10.1097/ta.0b013e31819dc688] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimal management of hemodynamically stable, asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe, cost-effective manner. Common evaluation strategies include local wound exploration (LWE)/diagnostic peritoneal lavage (DPL), serial clinical assessments (SCAs), and computed tomography (CT) imaging. The purpose of this multicenter study was to evaluate the clinical course of patients managed by the various strategies, to determine whether there are differences in associated nontherapeutic laparotomy (NONTHER LAP), emergency department (ED) discharge, or complication rates. METHODS A multicenter, Institutional Review Board-approved study enrolled patients with AASWs. Management was individualized according to surgeon/institutional protocols. Data on the presentation, evaluation, and clinical course were recorded prospectively. RESULTS Three hundred fifty-nine patients were studied. Eighty-one had indications for immediate LAP, of which 84% were therapeutic. ED D/C was facilitated by LWE, CT, and DPL in 23%, 21%, and 16% of patients, respectively. On the other hand, LAP based on abnormalities on LWE, CT, and DPL were NONTHER in 57%, 24%, and 31% of patients, respectively. Twelve percent of patients selected for SCA ultimately had LAP (33% were NONTHER); there was no apparent morbidity due to delay in intervention. CONCLUSIONS Shock, evisceration, and peritonitis warrant immediate LAP after AASW. Patients without these findings can be safely observed for signs or symptoms of bleeding or hollow viscus injury. To limit the number of hospital admissions, we propose a uniform strategy using LWE to ascertain the depth of penetration; the patient may be safely discharged in the absence of peritoneal violation. Peritoneal penetration, absent evidence of ongoing hemorrhage or hollow viscus injury, should not be considered an indication for LAP, but rather an indication for admission for SCAs. We suggest that a prospective multicenter trial be performed to document the safety and cost-effectiveness of such an approach.
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Abstract
BACKGROUND Abdominal stab wounds with evisceration remain an indication for emergency laparotomy. The purpose of this study was validate a policy of mandatory laparotomy for organ evisceration and a policy of selective nonoperative management with serial physical abdominal examination for omentum evisceration. METHODS The charts of 379 patients with abdominal stab wounds who presented to our Level I trauma center over a 3-year (January 2005 to December 2007) period were retrospectively reviewed. Altogether, 66 (17.4%) patients with evisceration were identified and included in the study. Indications for mandatory laparotomy were peritonitis, hemodynamic instability, organ evisceration, and a high spinal cord or severe head injury with an abdominal stab wound. Further data gathered included the organ eviscerated, intraabdominal organs injured, and complications. Injury severity was categorized using the revised trauma score (RTS), injury severity score (ISS), and penetrating abdominal index (PATI). RESULTS Organ and omentum evisceration occurred in 35 (53%) and 31 (47%) patients, respectively. Organs eviscerated were as follows (number of patients): small bowel in 27 (40.9%), stomach in 2 (3%), colon in 1 (1.5%), small bowel and stomach in 2 (3%), and small bowel and colon in 3 (4.5%). The mean RTS, ISS, and PATI scores were 7.71, 13.74, and 8.26, respectively. Only two (5.7%) patients with organ evisceration underwent a negative laparotomy. In total, 23 patients with omentum evisceration (21 with peritonitis, 1 with a head injury, 1 who failed abdominal observation) underwent therapeutic laparotomy. Six patients with omentum evisceration were managed successfully nonoperatively. Two patients with left thoracoabdominal omentum evisceration underwent delayed laparoscopy, which revealed a diaphragm injury in one patient. Overall, 57 (86.4%) patients with evisceration had an intraabdominal injury that required repair. CONCLUSIONS Evisceration should continue to prompt operative intervention. An exception can be made to a select few patients with omentum evisceration with benign abdominal findings.
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Pham TN, Heinberg E, Cuschieri J, Bulger EM, O'Keefe GE, Gross JA, Jurkovich GJ. The evolution of the diagnostic work-up for stab wounds to the back and flank. Injury 2009; 40:48-53. [PMID: 19117560 DOI: 10.1016/j.injury.2008.09.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 09/24/2008] [Accepted: 09/26/2008] [Indexed: 02/02/2023]
Abstract
BACKGROUND Stab wounds to the back and flank infrequently cause injuries requiring operative treatment. Triple-contrast CT scan (3CT) has essentially replaced diagnostic peritoneal lavage (DPL) as the primary means of identifying patients who require operative intervention. This study aims to review the evolution of the diagnostic work-up for stab wounds to the back and flank. METHODS We performed a retrospective review of haemodynamically stable patients with stab wound to the back or flank treated at a single Level 1 trauma centre over a 10-year period. Diagnostic accuracy of DPL and 3CT screening tests were evaluated against the patient's subsequent clinical course. The elapsed time between emergency department (ED) presentation and test results was recorded and compared. RESULTS A total of 177 patients were identified. 76 patients had stab wounds isolated to the back, 90 had stab wounds isolated to the flank and 11 had wounds in both locations. CT ultimately became the predominant initial diagnostic test during the study period. Although less frequently used over time, DPL retained good sensitivity and specificity for injuries requiring operative intervention (92% and 83%, respectively). 3CT identified all injuries requiring laparotomy (100% sensitivity) and had a specificity of 96%. 3CT was a more time-consuming process, with results available at a median of 3:31h after arrival to the ED, as compared to 1:03h for DPL (p<0.01). CONCLUSIONS 3CT diagnosed all injuries requiring operative intervention, and its use was associated with a lower rate of non-therapeutic laparotomies. However, average time to diagnosis by 3CT was prolonged compared to DPL. Although 3CT has become the predominant diagnostic test when evaluating patients with stab wounds to the back and flank at our institution, efforts to further expedite the diagnostic work-up are necessary.
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Affiliation(s)
- Tam N Pham
- Department of Surgery, University of Washington, Harborview Medical Centre, Seattle, WA 98104, United States.
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The comparison of characteristic and clinical features of self-inflicted abdominal stab wound patients in Japan: simple stab wounds versus Hara-kiri wounds. ACTA ACUST UNITED AC 2008; 64:786-9. [PMID: 18332824 DOI: 10.1097/ta.0b013e318165bb3a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The proportion of suicide attempts by infliction of abdominal stab wounds (ASWs) is higher in Japan than in other counties. There are few clinical reports on these wounds, especially hara-kiri wounds, which involve transversely cutting the abdomen. This study aimed to investigate Japanese patients with self-inflicted hara-kiri wounds and determine their characteristics and clinical features. METHODS We investigated 84 patients with self-inflicted ASWs who had been transferred to our hospital between April 1994 and March 2004. We recorded their characteristics and clinical features. They were then divided into two groups depending on their wound type, namely, simple stab wounds (SSWs) and hara-kiri wounds. The characteristics and clinical features of each group were then compared. RESULTS SSWs were frequently observed in the periumbilical and epigastric regions, whereas most hara-kiri wounds were observed in the middle abdomen. The rate of organ injury was 58.7% (44 of 75) for SSWs and 66.7% (6 of 9) for hara-kiri wounds; no significant difference was observed in this regard. SSWs resulted in injury to various organs, whereas hara-kiri wounds typically caused small bowel, mesenterium, omentum, and major vascular injuries. Small bowel and major vascular injuries had a significantly high incidence in hara-kiri wounds. The mortality rate caused by hara-kiri wounds was significantly higher than that caused by SSWs (1.3% vs. 22.2%). CONCLUSION The mortality rate caused by ASWs is relatively low. However, hara-kiri wounds might be a risk factor for death. Further, because hara-kiri wounds transversely cut the abdomen, they might be a risk factor for major vascular injury.
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Rozen WM, Jones IT, Judson RT. Re: Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen. ANZ J Surg 2008; 78:105-6; author reply 106-7. [PMID: 18199222 DOI: 10.1111/j.1445-2197.2007.04372.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Laparoscopy Offers Diagnosis and Treatment in Abdominal Stab Injuries. Surg Laparosc Endosc Percutan Tech 2007; 17:396-401. [DOI: 10.1097/sle.0b013e3181378e79] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rozen WM, Ma EH, Jones IT, Judson RT. Emerging epidemic in Australia: abdominal stab wounds. Twenty-four months at a major trauma centre. Emerg Med Australas 2007; 19:262-8. [PMID: 17564695 DOI: 10.1111/j.1742-6723.2007.00963.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The incidence of abdominal stab wounds treated at the Royal Melbourne Hospital, Parkville, Vic., Australia has noticeably increased over the 12 month period to March 2006, mirroring an increase in penetrating abdominal trauma throughout many Australian trauma centres. Management protocols for abdominal stab wounds are still contentious. The current study quantifies the increase in stab wounds at the Royal Melbourne Hospital over a 24 month period and analyses the management modalities used. METHODS A review of the Trauma Unit of the Royal Melbourne Hospital was performed for the period of 20 March 2004 until 20 March 2006. All anterior abdominal stab wounds were collated for the site of injury, investigations performed on admission, results of investigations, operations performed and findings at operation. RESULTS There were 4244 emergency trauma presentations over the 24 month period between 20 March 2004 and 20 March 2006. The second 12 month period showed a 21.5% increase in overall trauma admissions and a 91.3% increase in anterior abdominal stabbings. The percentage of stab wounds treated conservatively fell by 21.8%, with the percentage of laparotomies increasing by 14.2%. Almost 30% of all patients undergoing surgery had no visceral injury at operation. Twenty CT scans were performed preoperatively, with a sensitivity of 79% and specificity of 100%. CONCLUSION Abdominal stab wounds treated at Royal Melbourne Hospital have substantially increased over the past 12 months. Although management is still contentious, a management protocol for anterior abdominal stab wounds is proposed, outlining the role of CT scanning, conservative management, laparoscopy and laparotomy.
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Affiliation(s)
- Warren Matthew Rozen
- Department of Surgery, Trauma Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Mitra B, Gocentas R, O'Reilly G, Cameron PA, Atkin C. Management of haemodynamically stable patients with abdominal stab wounds. Emerg Med Australas 2007; 19:269-75. [PMID: 17564696 DOI: 10.1111/j.1742-6723.2007.00965.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Australasian trauma centres receive relatively low numbers of penetrating injuries from stabbings. There is limited agreement regarding protocols to guide the management of haemodynamically stable patients with penetrating injuries. This has resulted in a wide variation in practice with anecdotally high negative laparotomy rates. The aim of the present study was to review the ED procedures, investigations and disposition of this group of patients. METHODS A retrospective review of all patients presenting with abdominal penetrating injury was undertaken over a 5 year period. Data on demographics, presenting features and management were collected. RESULTS There were 109 patients who were haemodynamically stable (systolic blood pressure > 90) on arrival to the trauma centre. Diagnostic ED procedures and investigations consisted of wound exploration in 47 (43.1%) patients, focused abdominal sonography in trauma in 44 (40.4%) patients and a CT abdomen in 36 (33.0%) of patients. The sensitivity for focused abdominal sonography in trauma and CT when used together was 77.8%. There were 39 laparotomies performed with a negative laparotomy rate of 23.1%. There were 10 laparoscopies performed, none went on to require a laparotomy. Patients undergoing negative laparotomies spent significantly longer times in hospital than patients managed conservatively or those undergoing laparoscopies. CONCLUSIONS The number of penetrating abdominal injuries remains low. Imaging alone cannot reliably exclude intraperitoneal injury. A greater utilization of ED wound exploration and laparoscopy based on agreed guidelines could improve management. An algorithm for the management of these patients is suggested.
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Affiliation(s)
- Biswadev Mitra
- The Alfred Emergency & Trauma Centre, and Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
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Abstract
Emergency practitioners routinely encounter patients who suffer from abdominal trauma, be it blunt or penetrating. These injuries are often confounded by altered mental status, distracting injuries, or lack of historical information, and may present challenges in management. However, in the last several years new approaches to the diagnosis and management of abdominal trauma, including bedside ultrasound, newer generation computed tomography scans, laparoscopy, and the ability for selected nonoperative management expedite identification of life threatening injury and offer new options in treatment.
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Affiliation(s)
- Jennifer L Isenhour
- Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
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Weinberg JA, Magnotti LJ, Edwards NM, Claridge JA, Minard G, Fabian TC, Croce MA. "Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds. Injury 2007; 38:60-4. [PMID: 17129583 DOI: 10.1016/j.injury.2006.08.061] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2006] [Revised: 08/30/2006] [Accepted: 08/30/2006] [Indexed: 02/02/2023]
Abstract
BACKGROUND Diagnostic laparoscopy is useful for the assessment of equivocal penetrating abdominal wounds, and has become the modality of choice for the evaluation of such wounds at our institution. We hypothesised that, in appropriate patients, diagnostic "awake" laparoscopy (AL) could be performed under local anaesthesia in the emergency department (ED), allowing for expedited discharge and potential cost savings. METHODS Selected haemodynamically stable patients with penetrating abdominal injury underwent AL. Suitability for AL was at the discretion of the attending surgeon. Identification of peritoneal penetration by AL led to exploratory laparotomy in the operating room. Patients with no evidence of peritoneal penetration were discharged from the ED (ALneg). These patients were matched to a cohort of 24 patients who underwent diagnostic laparoscopy in the OR which was negative for peritoneal penetration (DLneg). Length of stay and hospital charges were compared. RESULTS Over a 30-month period, 15 patients underwent AL without complication. No peritoneal penetration was found in 11 patients. The remaining four patients underwent exploratory laparotomy, of which two were positive for intra-abdominal injury. Mean time to discharge was 7h in the ALneg group versus 18 h in the DLneg group (p=0.0003). Cost savings on hospital charges averaged 2227 US dollars per patient in the ALneg group compared with the DLneg group. CONCLUSIONS AL may be safely performed in the ED, allowing for expedited patient discharge. Cost savings are achieved by the avoidance of charges inherent to diagnostic laparoscopy performed in the operating room.
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Affiliation(s)
- Jordan A Weinberg
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Abstract
The management of penetrating injuries to the abdomen has evolved back to a selective nonoperative approach. Using clinical examination for screening, evaluable patients without hemodynamic instability or peritonitis can safely undergo a trial of nonoperative management. For stab wounds, this involves serial clinical examination with delayed laparoscopic evaluation of the diaphragm for left thoracoabdominal injuries and CT scanning for suspected solid-organ injuries. The same contraindications to nonoperative management apply to gunshot injuries. Gunshot injuries undergoing nonoperative management require detailed trajectory imaging with CT. The presence of peritoneal violation without definite organ injury requires serial clinical examination. Isolated solid-organ injury is not an absolute contraindication to nonoperative management and may benefit from advanced endovascular and percutaneous interventions to facilitate management. Selective nonoperative management of both stab wounds and gunshot injuries is safe and has been shown to decrease the rate of unnecessary laparotomy, length of hospital stay, and management costs.
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Affiliation(s)
- Kenji Inaba
- Division of Trauma Surgery and Critical Care, Los Angeles County and University of Southern California Medical Center, 1200 North State Street, Rm 10-750, Los Angeles, CA 90033, USA.
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Crandall M, West MA. Evaluation of the abdomen in the critically ill patient: opening the black box. Curr Opin Crit Care 2006; 12:333-9. [PMID: 16810044 DOI: 10.1097/01.ccx.0000235211.79236.83] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE OF REVIEW Evaluation of the abdomen in critically ill patients can be challenging. This article reviews the available data and proposes evidence-based guidelines for evaluation of the abdomen in the critically ill patient. RECENT FINDINGS The critically ill are often clinically unevaluable due to distracting injuries, respiratory failure, obtundation, or other conditions. Even when patients can be examined, the clinical exam can be unreliable and misleading. Critically ill patients who are sufficiently stable to undergo imaging benefit from computerized tomography unless biliary sepsis is suspected, when ultrasound is preferred. There is an important role for endoscopy and angiography in the setting of gastrointestinal hemorrhage, as well as magnetic resonance imaging for mesenteric ischemia. Critically ill patients who are too unstable for imaging may require bedside laparoscopy or diagnostic peritoneal lavage. Abdominal compartment syndrome should be considered in the differential diagnosis of the unstable critically ill patient. Empiric laparotomy may still need to be employed in diagnosis and management of unstable patients. SUMMARY Timely and accurate diagnosis of life-threatening intraabdominal pathology is essential to care for critically ill patients. A multitude of laboratory, radiologic, and interventional modalities are available to evaluate the abdomen in the critically ill.
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Affiliation(s)
- Marie Crandall
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Abstract
PURPOSE This study was designed to develop treatment algorithms for colon, rectal, and anal injuries based on the review of relevant literature. METHODS Information was obtained through a MEDLINE ( www.nobi.nih.gov/entrez/query.fcgi ) search, and additional references were obtained through cross-referencing key articles cited in these papers. RESULTS A total of 203 articles were considered relevant. CONCLUSIONS The management of penetrating and blunt colon, rectal, and anal injuries has evolved during the past 150 years. Since the World War II mandate to divert penetrating colon injuries, primary repair or resection and anastomosis have found an increasing role in patients with nondestructive injuries. A critical review of recent literature better defines the role of primary repair and fecal diversion for these injuries and allows for better algorithms for the management of these injuries.
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Affiliation(s)
- Robert K Cleary
- Department of Surgery, St Joseph Mercy Hospital, Ann Arbor, Michigan 48106, USA.
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