TY - JOUR
T1 - Management of patients with anterior abdominal stab wounds
T2 - A western trauma association multicenter trial
AU - Biffl, Walter L.
AU - Kaups, Krista L.
AU - Cothren, C. Clay
AU - Brasel, Karen J.
AU - Dicker, Rochelle A.
AU - Bullard, M. Kelley
AU - Haan, James M.
AU - Jurkovich, Gregory J.
AU - Harrison, Paul
AU - Moore, Forrest O.
AU - Schreiber, Martin
AU - Knudson, M. Margaret
AU - Moore, Ernest E.
PY - 2009/5
Y1 - 2009/5
N2 - 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.
AB - 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.
KW - Abdominal stab wounds
KW - Abdominal trauma
KW - Clinical assessments
KW - Clinical trial
KW - Computed tomography scan, serial
KW - Diagnostic peritoneal lavage
KW - Laparotomy
KW - Local wound exploration
KW - Multicenter
KW - Penetrating trauma
KW - Prospective
KW - Protocol
KW - Stab wounds
UR - http://www.scopus.com/inward/record.url?scp=67649660017&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=67649660017&partnerID=8YFLogxK
U2 - 10.1097/TA.0b013e31819dc688
DO - 10.1097/TA.0b013e31819dc688
M3 - Article
C2 - 19430229
AN - SCOPUS:67649660017
SN - 0022-5282
VL - 66
SP - 1294
EP - 1301
JO - Journal of Trauma - Injury, Infection and Critical Care
JF - Journal of Trauma - Injury, Infection and Critical Care
IS - 5
ER -