When to operate on abdominal gunshot wounds

Isolated penetrating gluteal stab injury with uncontrolled bleeding in Türkiye: a case report

Arterial injuries in the gluteal region caused by a knife are rare but serious, with mortality rates of up to 25%. This case report presents the management of a young male patient admitted to the emergency department in hypovolemic shock, with uncontrollable bleeding from an isolated penetrating gluteal injury. Additionally, the details of the surgical approach employed are discussed.

Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds

BACKGROUND

Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW.

METHODS

This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed.

RESULTS

Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99).

CONCLUSION

While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria; Level II.

Obesity and Anterior Abdominal Gunshot Wounds: A Cushion Effect

Background

Although the standard of care for anterior abdominal gunshot wounds (AAGSWs) is immediate laparotomy, these operations are associated with a high rate of negativity and potentially serious complications. Recent data suggest the possibility of selective non-operative management (SNOM) of AAGSWs, but none implicate body mass index (BMI) as a factor in patient selection. Anecdotal experience at our trauma center suggested a protective effect of obesity among patients with AAGSWs, and given the exceptionally high rate of obesity in the Bronx, we sought to analyze the associations of AAGSWs and BMI to inform future trauma research and management. In this study, we aimed to evaluate whether BMI is associated with injury severity, resource utilization, and clinical outcomes of AAGSWs.

Methodology

From our prospectively accrued trauma registry, we retrospectively abstracted all patients greater than 16 years old with Current Procedural Terminology codes associated with gunshot wounds from 2008 to 2016. The electronic medical record was reviewed to define a cohort of patients with at least one AAGSW. Patients were divided into the following cohorts based on BMI: underweight (UW, BMI: <18.5), normal weight (NW, BMI: 18.5-24.9), overweight (OW, BMI: 25-29.9), and obese (OB, BMI: ≥30). Among these cohorts, we analyzed data regarding injury severity, resource utilization, and clinical outcomes.

Results

In this study, none of the patients were UW, 17 (42.5%) patients were NW, 15 (37.5%) patients were OW, and eight (20%) patients were OB. One patient each in the NW and OB cohorts was successfully managed non-operatively, while all others underwent immediate exploratory laparotomy. The mean new injury severity score was significantly lower as BMI increased (NW = 30.9 ± 17.0, OW = 22.9 ± 16.1, and OB = 12.8 ± 13.7; p = 0.039). Patients in the OB cohort were less likely to have abdominal fascial penetration compared to the OW and NW cohorts (p = 0.027 and 0.004, respectively) and sustained fewer mean visceral injuries compared to the OW and NW cohorts (p = 0.027 and 0.045, respectively). OB patients were significantly more likely to have sustained two or more AAGSWs (OB = 27.5%, OW = 6.7%, and NW = 5.9%; p = 0.033), suggesting higher rates of tangential soft tissue injuries. The mean hospital length of stay down-trended as BMI increased but did not achieve statistical significance (NW = 7.4 ± 5.3, OW = 6.6 ± 6.7, and OB = 3.1 ± 2.3; p = 0.19). The OB cohort had the lowest mean hospital charges.

Conclusions

Obesity may yield a protective effect among AAGSW victims, and BMI may provide trauma surgeons another tool to triage patients for SNOM of AAGSWs, potentially diminishing the risks associated with negative laparotomy. Our data serve as the basis for the analysis of a larger patient cohort.

Diagnostic utility of CT for abdominal injury in the military setting: A systematic review and meta-analysis

BACKGROUND

It is critical to accurately identify patients with abdominal injury who truly need to undergo laparotomy during the war in timely fashion. The diagnostic utility of computed tomography (CT) for evaluating abdominal injury in the military setting remains uncertain.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched. Meta-analyses were performed by using a random-effect model. We pooled the area under the summary receiver operating characteristic curves with standard errors, the Q indexes with standard errors, the sensitivities with 95% confidence intervals (CIs), the specificities with 95% CIs, the positive likelihood ratios with 95% CIs, the negative likelihood ratios with 95% CIs, and the diagnostic odds ratios with 95% CIs. The heterogeneity among studies were evaluated by the I2 and P value.

RESULTS

Overall, 5 retrospective studies were included. The area under the summary receiver operating characteristic curve was 0.9761 ± 0.0215 and the Q index was 0.9302 ± 0.0378. The pooled sensitivity was 0.97 (95% CI = 0.92-0.99) without a significant heterogeneity among studies (I2 = 0%, P = .4538). The pooled specificity was 0.95 (95% CI = 0.93-0.97) with a significant heterogeneity among studies (I2 = 90.6%, P < .0001). The pooled positive likelihood ratio was 10.71 (95% CI: 2.91-39.43) with a significant heterogeneity among studies (I2 = 89.2%, P < .0001). The pooled negative likelihood ratio was 0.07 (95% CI = 0.02-0.27) with a significant heterogeneity among studies (I2 = 57.5%, P = .0516). The pooled diagnostic odds ratio was 177.48 (95% CI = 18.09-1741.31) with a significant heterogeneity among studies (I2 = 75.9%, P = .0023).

CONCLUSION

Diagnostic accuracy of CT for abdominal injury is excellent in the military setting. Further work should explore how to shrink CT equipment for a wider use in wartime.

One Bullet Causing Five Holes, Laparoscopic Exploration with Repair: A Case Report and Review of the Literature

Introduction

The proper treatment of penetrating abdominal wounds has been a controversial topic, and the preferred regimen has evolved over time. In recent years, many trauma centers have started using diagnostic laparoscopy in stable trauma patients in an effort to reduce the incidence of nontherapeutic laparotomy. This is more commonly seen in solid organ injuries, and its role is less clearly defined for hollow visceral injuries. Case Presentation. A 19-year-old male presented with a gunshot wound (GSW) to the abdomen with mild peritoneal signs and computed tomography (CT) findings. Diagnostic laparoscopy was performed with the repair of five lacerations to intra-abdominal organs including the sigmoid colon, rectum, bladder, and small bowel. Discussion. To our knowledge, this is the first case report in the literature detailing such a GSW repair. Abdominal GSWs have been repaired laparoscopically in the past, but none have elaborated on the repair of multiple defects of bowel and/or bladder.

Conclusion

Therapeutic laparoscopy can be considered in selected cases of penetrating abdominal trauma. Laparoscopy offers several advantages over laparotomy including decreased mortality, complication rate, and length of stay.

Selective conservative treatment for anterior abdominal gunshot: a literature narrative review

The nonoperative treatment of anterior abdominal gunshot wounds remains controversial. This article presents a narrative review of the literature after the selection of studies in electronic databases (PubMed, Cochrane Library and Lilacs), with the intention of evaluating the clinical and diagnostic tools that should be part of conservative selective approach of these lesions. It was observed that a nonoperative selective treatment can be effectively and safely used, when performed by a trained interdisciplinary team, working in adequate trauma centers. The selective nonoperative treatment is associated with a decrease in negative and nontherapeutic laparotomies, reducing the incidence of complications. It also contributes to the reduction of hospital costs.

Non-operative management of abdominal gunshot injuries: Is it safe in all cases?

Objective

In line with advances in diagnostic methods and expectation of a decrease in the number of negative laparotomies, selective non-operative management of abdominal gunshot wounds has been increasingly used over the last three decades. We aim to detect the possibility of treatment without surgery and present our experience in selected cases referred from Syria to a hospital at the Turkish-Syrian border.

Material and Methods

Between February 2012 and June 2014, patients admitted with abdominal gunshot wounds were analyzed. Computed tomography was performed for all patients on admission. Patients who were hemodynamically stable and did not have symptoms of peritonitis at the time of presentation were included in the study. The primary outcome parameters were mortality and morbidity. Successful selective non-operative management (Group 1) and unsuccessful selective non-operative management (Group 2) groups were compared in terms of complications, blood transfusion, injury site, injury severity score (ISS), and hospital stay.

Results

Of 158 truncal injury patients, 18 were considered feasible for selective non-operative management. Of these, 14 (78%) patients were treated without surgery. Other Four patients were operated upon progressively increasing abdominal pain and tenderness during follow-up. On diagnostic exploration, all of these cases had intestinal perforations. No mortality was observed in selective non-operative management. There was no statistically significant difference between Group 1 and Group 2, in terms of length of hospital stay (96 and 127 h, respectively). Also, there was no difference between groups in terms of blood transfusion necessity, injury site, complication rate, and injury severity score (p>0.05).

Conclusion

Decision making on patient selection for selective non-operative management is critical to ensure favorable outcomes. It is not possible to predict the success of selective non-operative management in advance. Cautious clinical examination and close monitoring of these patients is vital; however, emergency laparotomy should be performed in case of change in vital signs and positive symptoms concerning peritonitis.

Feasibility of selective non-operative management for penetrating abdominal trauma in France

INTRODUCTION

In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France.

METHODOLOGY

Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis.

RESULTS

One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM.

CONCLUSION

Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

Penetrating injury to the buttock: an update

Clinical research on penetrating injury to the buttock is sparse and largely limited to case reports and clinical series. The purpose of this paper is to provide a detailed overview of literature of the topic and to propose a basic algorithm for management of penetrating gluteal injuries (PGI). MEDLINE, EMBASE, Cochran, and CINAHL databases were employed. Thirty-seven papers were selected and retrieved for overview from 1,021 records. PGI accounts for 2-3 % of all penetrating injuries, with a mortality rate up to 4 %. Most haemodynamically stable patients will benefit from traditional wound care and selective non-operative management. When gluteal fascia injury is confirmed or suspected, a contrast-enhanced CT-scan provides the most accurate injury diagnosis. CT-scan-based angiography and endovascular interventions radically supplement assessment and management of patients with penetrating injury to the major buttock and adjacent extra-buttock arteries. Immediate life-saving damage-control surgery is indicated for patients with hypovolemic shock and signs of internal bleeding. A universal basic management algorithm is proposed. This overview shows that penetrating injury to the buttock should be regarded as a potential life-threatening injury, and therefore, patients with such injuries should be managed in trauma centres equipped with hybrid operating theatres for emergency endovascular and open surgery for multidisciplinary teams operating 24/7.

Selective non-operative management of civilian gunshot wounds to the abdomen: a systematic review of the evidence

BACKGROUND

Selective non-operative management (SNOM) of penetrating abdominal wounds has become increasingly common in the past two or three decades and is now accepted as routine management for stab wounds. Gunshot wounds are more frequently managed with mandatory laparotomy but recently SNOM has been successfully applied. This review systematically appraises the evidence behind SNOM for civilian abdominal gunshot wounds.

METHODS

A Medline search from 1990 to present identified civilian studies examining success rates for SNOM of abdominal gunshot wounds. Case reports, editorials and abstracts were excluded. All other studies meeting the inclusion criteria of reporting the success rate of non-operative management of abdominal gunshot wounds were analysed.

RESULTS

Sixteen prospective and six retrospective studies met the inclusion criteria, including 18,602 patients with abdominal gunshot wounds. 32.2% (n=6072) of patients were initially managed non-operatively and 15.5% (n=943) required a delayed laparotomy. The presence of haemodynamic instability, peritonitis, GI bleeding or any co-existing pathology that prevented frequent serial examination of the abdomen from being performed were indications for immediate laparotomy in all studies. Delayed laparotomy results in similar outcomes to those in patients subjected to immediate laparotomy. Implementation of SNOM reduces the rates of negative and non-therapeutic laparotomies and reduces overall length of stay.

CONCLUSIONS

SNOM can be safely applied to some civilian patients with abdominal gunshot wounds and reduces the rates of negative or non-therapeutic laparotomy. Patients who require delayed laparotomy have similar rates of morbidity and mortality and similar length of stay to those patients who undergo immediate laparotomy.

Adrenal gunshot wound: Laparoscopic approach. Report of a case

INTRODUCTION

Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating abdominal injury, it is also clear that certain stable patients may be managed without operation. Controversy persists regarding use of laparoscopy.

PRESENTATION OF CASE

We report a case of gunshot wounds with bullet in left adrenal gland and perirenal subcapsular hematoma. The patients had no signs of peritonitis but in the observation period we noted a significative blood loss, so we performed an exploratory laparoscopy.

DISCUSSION

We found the bullet in adrenal parenchyma. The postoperative period was regular and the patient was discharged without any local or general complication.

CONCLUSION

Although the data are still controversial, the importance of the laparoscopic approach is rapidly increasing also in case of penetrating trauma of the abdomen. This technique assumes both a diagnostic and therapeutic role by reducing the number of negative laparotomies.

The characteristics and outcomes of penetrating thoracic and abdominal trauma among children

PURPOSE

Trauma is the most important etiology of morbidity and mortality among children. Penetrating injuries to the thorax and abdomen are extremely rare in children. In the present study, we compared the characteristics of patients, management, and outcomes of penetrating thoracic and abdominal trauma in children.

MATERIALS AND METHODS

Data from children who were hospitalized for penetrating injuries of the thorax and abdomen from 2006 to 2012 were evaluated retrospectively. These injuries were evaluated with respect to patient details, clinical presentation, circumstances of trauma, management, and outcomes.

RESULTS

Eighty-four patients were hospitalized for penetrating injuries to the thorax and abdomen. The mean age was 10.3 ± 3.79 years. Patient injuries comprised 26 gunshots injuries and 58 stabbing injuries. Thirty-one patients were wounded in the thorax, 43 were wounded in the abdomen, and 10 were wounded in both the thorax and abdomen. Thirty-one patients had undergone surgical interventions, while the other 53 were managed conservatively. The mean hospital stay was 4.41 ± 6.84 days.

CONCLUSIONS

The incidences of penetrating abdominal and thoracic trauma did not differ significantly. Penetrating injuries may be successfully managed by conservative therapy.

Gunshot wounds to the lower urinary tract: a single-institution experience

BACKGROUND

This study aimed to analyze characteristics and outcomes of gunshot wounds to the lower urinary tract at our Level I trauma center. Our hypothesis is that gunshot wounds to the lower urinary tract have characteristic bullet trajectories, injury patterns, and associated injuries.

METHODS

Our prospective trauma database was composed of reviewed gunshot wounds to the lower urinary tract including the pelvic ureter, bladder, or urethra from 1989 through 2011.

RESULTS

We identified 50 patients (median age, 25 years; range, 3-53 years) with lower urinary tract injury. There was a mean of 2.3 bullets per patient (range, 1-8), with 26 patients injured from a single bullet. Urologic injury involving only the bladder occurred in 72% (36 of 50) of the patients. Ureteral injury was diagnosed in 20% (10 of 50) of the patients. Bullet trajectory was known in the majority of multiple bullet injuries and all cases involving a single bullet.All patients but one were managed operatively. During exploration, 90% (34 of 38) with transmural bladder injury had recognized bladder entry and exit wounds. Overall, 80% (40 of 50) had concurrent gastrointestinal injury. In patients with a single gunshot wound to the lower urinary tract, 58% (15 of 26) sustained concomitant intestinal injury, and 23% (6 of 26) sustained rectal injury.Of 20 posteroanterior gunshot wounds, 80% had buttock entry. All 10 single-bullet buttock-entry gunshot wounds injured the bladder. Isolated ureteral injury was associated with lower abdominal entry and anteroposterior trajectory. Urethral injury occurred in 4, with 75% upper-thigh entry.

CONCLUSION

Penetrating injuries to the lower urinary tract most commonly involve the bladder. During exploration for gunshot wounds to the bladder, two injury sites should be expected because failure to close may lead to complications. Gunshot wounds to the lower urinary tract often occur with concomitant bowel injury, with buttock entry. A multidisciplinary approach involving general surgery is imperative.

LEVEL OF EVIDENCE

Epidemiologic study, level IV.

[Management of penetrating abdominal trauma: what we need to know?]

Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.

Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database

BACKGROUND

The aim of this study was to investigate trends in the practice of selective non-operative management (SNOM) for penetrating abdominal injury (PAI) and to determine factors associated with its failure.

METHODS

The National Trauma Data Bank for 2002-2008 was reviewed. Patients with PAI were categorized as those who underwent successful SNOM (operative management not required) and those who failed SNOM (surgery required more than 4 h after admission). Yearly rates of SNOM versus non-therapeutic laparotomy (NTL) were plotted. Multivariable regression analysis was performed to identify factors associated with failed SNOM and mortality.

RESULTS

A total of 12 707 patients with abdominal gunshot and 13 030 with stab wounds were identified. Rates of SNOM were 22.2 per cent for gunshot and 33.9 per cent for stab wounds, and increased with time (P < 0.001). There was a strong correlation between the rise in SNOM and the decline in NTL (r = - 0.70). SNOM failed in 20.8 and 15.2 per cent of patients with gunshot and stab wounds respectively. Factors predicting failure included the need for blood transfusion (odds ratio (OR) 1.96, 95 per cent confidence interval 1.11 to 3.46) and a higher injury score. Failed SNOM was independently associated with mortality in both the gunshot (OR 4.48, 2.07 to 9.70) and stab (OR 9.83, 3.44 to 28.00) wound groups.

CONCLUSION

The practice of SNOM is increasing, with an associated decrease in the rate of NTL for PAI. In most instances SNOM is successful; however, its failure is associated with increased mortality. Careful patient selection and adherence to protocols designed to decrease the failure rate of SNOM are recommended.

Analytical review of 664 cases of penetrating buttock trauma

A comprehensive review of data has not yet been provided as penetrating injury to the buttock is not a common condition accounting for 2-3% of all penetrating injuries. The aim of the study is to provide the as yet lacking analytical review of the literature on penetrating trauma to the buttock, with appraisal of characteristics, features, outcomes, and patterns of major injuries. Based on these results we will provide an algorithm. Using a set of terms we searched the databases Pub Med, EMBASE, Cochran, and CINAHL for articles published in English between 1970 and 2010. We analysed cumulative data from prospective and retrospective studies, and case reports. The literature search revealed 36 relevant articles containing data on 664 patients. There was no grade A evidence found. The injury population mostly consists of young males (95.4%) with a high proportion missile injury (75.9%). Bleeding was found to be the key problem which mostly occurs from internal injury and results in shock in 10%. Overall mortality is 2.9% with significant adverse impact of visceral or vascular injury and shock (P < 0.001). The major injury pattern significantly varies between shot and stab injury with small bowel, colon, or rectum injuries leading in shot wounds, whilst vascular injury leads in stab wounds (P < 0.01). Laparotomy was required in 26.9% of patients. Wound infection, sepsis or multiorgan failure, small bowel fistula, ileus, rebleeding, focal neurologic deficit, and urinary tract infection were the most common complications. Sharp differences in injury pattern endorse an algorithm for differential therapy of penetrating buttock trauma. In conclusion, penetrating buttock trauma should be regarded as a life-threatening injury with impact beyond the pelvis until proven otherwise.

Penetrating abdominal injuries in adults seen at two teaching hospitals in ghana

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.

Has the Pendulum Swung Too Far? The Impact of Missed Abdominal Injuries in the Era of Nonoperative Management

Nonoperative management for traumatic injuries has significantly influenced trauma care during the last decade. We undertook this study to assess the impact of nontherapeutic laparotomies for suspected abdominal injuries compared with delayed laparotomies for questionable abdominal injuries for patients with abdominal trauma. The records of patients admitted to the trauma service between 2002 and 2007 who underwent laparotomies deemed nontherapeutic or delayed were retrospectively reviewed. Demographics, severity of injury, management scheme, and outcome data were analyzed. Sixteen patients underwent delayed laparotomies, whereas 26 patients incurred nontherapeutic laparotomies. Injury severity scores, Glasgow coma scale scores, abdominal abbreviated injury scale score (AIS), and age were similar for both populations. Delayed laparotomies occurred an average of 7 ± 9 days postinjury. Intensive care unit length of stay (26 ± 24 vs 10 ± 6 days), hospital length of stay (40 ± 37 vs 11 ± 10 days), ventilator days (31 ± 29 vs 11 ± 10), and number of abdominal operative procedures (1.9 ± 1.5 vs 1 ± 0) were significantly higher in the delayed laparotomies group versus the nontherapeutic laparotomies group, respectively. Delayed diagnosis of intra-abdominal injuries yielded a significantly increased morbidity and mortality. During the evolving era of technological imaging for traumatic injuries, we must not allow the nonoperative pendulum to swing too far.

Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents

Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting.

Selective non-operative management of solid organ injury following abdominal gunshot wounds

BACKGROUND

The objective of this study was to evaluate the outcome of patients sustaining a torso gunshot wound with documented solid organ injury. Our hypothesis was that the non-operative management of isolated solid organ injuries is a safe management option for a select group of patients.

METHODS

A retrospective review of a prospectively collected database was conducted to identify all patients sustaining a torso gunshot resulting in a solid organ injury undergoing non-operative management over a 5-year period (12/1999-01/2005). Patient demographics, injury details, diagnostic imaging, outcome and follow-up were reviewed.

RESULTS

Of 644 gunshot wounds to the torso, 144 (22%) underwent non-operative management. Thirteen of these patients (9%) had 16 solid organ injuries (10 liver, 4 kidney and 2 spleen). CT characterisation of the isolated solid organ injury ranged from AAST Grade I-IV. One of 13 patients failed non-operative management and subsequently underwent laparotomy, which was non-therapeutic. Clinical follow-up was available in all patients for an average of 101 days (median 27, range 6-473). The organ salvage rate was 100%.

SUMMARY

In select haemodynamically stable patients without peritonitis able to undergo serial clinical examination, solid organ injury is not a contra-indication to non-operative management. In the appropriate setting, non-operative management of solid organ injury after gunshot wounding is associated with a high rate of success and organ salvage.

Colon and rectal injuries

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.

Emergency department spirometric volume and base deficit delineate risk for torso injury in stable patients

Background

We sought to determine torso injury rates and sensitivities associated with fluid-positive abdominal ultrasound, metabolic acidosis (increased base deficit and lactate), and impaired pulmonary physiology (decreased spirometric volume and PaO₂/FiO₂).

Methods

Level I trauma center prospective pilot and post-pilot study (2000–2001) of stable patients. Increased base deficit was < 0.0 in ethanol-negative and ≤ -3.0 in ethanol-positive patients. Increased lactate was > 2.5 mmol/L in ethanol-negative and ≥ 3.0 mmol/L in ethanol-positive patients. Decreased PaO₂/FiO₂ was < 350 and decreased spirometric volume was < 1.8 L.

Results

Of 215 patients, 66 (30.7%) had a torso injury (abdominal/pelvic injury n = 35 and/or thoracic injury n = 43). Glasgow Coma Scale score was 14.8 ± 0.5 (13–15). Torso injury rates and sensitivities were: abdominal ultrasound negative and normal base deficit, lactate, PaO₂/FiO₂, and spirometric volume – 0.0% & 0.0%; normal base deficit and normal spirometric volume – 4.2% & 4.5%; chest/abdominal soft tissue injury – 37.8% & 47.0%; increased lactate – 39.7% & 47.0%; increased base deficit – 41.3% & 75.8%; increased base deficit and/or decreased spirometric volume – 43.8% & 95.5%; decreased PaO₂/FiO₂ – 48.9% & 33.3%; positive abdominal ultrasound – 62.5% & 7.6%; decreased spirometric volume – 73.4% & 71.2%; increased base deficit and decreased spirometric volume – 82.9% & 51.5%.

Conclusions

Trauma patients with normal base deficit and spirometric volume are unlikely to have a torso injury. Patients with increased base deficit or lactate, decreased spirometric volume, decreased PaO₂/FiO₂, or positive FAST have substantial risk for torso injury. Increased base deficit and/or decreased spirometric volume are highly sensitive for torso injury. Base deficit and spirometric volume values are readily available and increase or decrease the suspicion for torso injury.