[ccm-l] FW: GSW to liver

[Ben Reynolds]

I am not able to pull up this paper, so I'm making assumptions after only reading the abstract.   For example I would be interested to know how you conservatively manage "...26 patients with omental or intestinal evisceration" or when you say that "...27.6% had no significant intra-abdominal injury" what they defined as "insignificant".  I'm sure this is all well explained in the paper itself and I am anxious to read it.  Nonetheless, I think you and I are not talking about the same thing, Ron. 

I'm not arguing whether or not a subset of patients with STAB wounds to the abdomen can be safely observed (in fact I agree wholeheartedly); it's those patients who have been shot in what is PRESUMED to be (radiographically demonstrated) as a SINGLE SOLID ORGAN (in our example the liver) and go on to potentially have a synchronous hollow viscus injury and the multiple factors which can confound an immediate diagnosis.  I further argue that CT is not  a sensitive enough modality to detect adjacent subtle hollow viscus injury.   In that instance, I refer you back to the EAST papers about missed hollow viscus injuries (albeit in the blunt trauma population) and how quickly their mortality goes up over time.

So I stand by my original assertion:  LA County is able to pull this off because of their heavy penetrating trauma volume and I am sure that there is a mature mechanism of support (dedicated units, examination protocols) in effect to make their nonoperative algorithm work.  A place like Memphis or Newark with the same sort of institutional dedication to the nonoperative cause might replicate their success and if such an institution is doing it I would love to see how they do it in print.  

But in a level 1 without the same sort of injury population or in the average level 2 I doubt sincerely the outcomes would be as favorable.    

Ben Reynolds, PA-C
Pittsburgh, PA 
 
----- Original Message ----
From: Ronald Simon <Traumamd at nyc.rr.com>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Monday, December 31, 2007 1:30:07 PM
Subject: Re: [ccm-l] FW: GSW to liver

I must take some issue with the comment below.

Ben Reynolds wrote:
> The best data about missed hollow viscus injuries and their associated mortality is well described in the EAST Hollow Viscus Injury work group*.  These injuries are significant even when found EARLY and their morbidity and mortality goes up significantly with each passing HOUR.   Mind you they were looking at hollow viscus injury from BLUNT mechanism which itself is a rare entity.  Hollow viscus injury from PENETRATING injury is much more common and much less studied radiographically because almost all of the patients in this cohort traditionally get immediate laparotomy. 
There is ample literature that shows that ANTERIOR abdominal SW can be 
safely observed with patients with injuries showing themselves and being 
operated on with NO increase in morbidity or mortality. This is just one 
example of many.

Ann Surg. 1987 Feb;205(2):129-32.    Indications for operation in 
abdominal stab wounds. A prospective study of 651 patients.
Demetriades D, Rabinowitz B.
    This prospective study comprises 651 patients with knife wounds of 
the anterior abdomen. Three hundred and forty-five patients (53%) had 
symptoms of an acute abdomen on admission and were operated on 
immediately. The remaining 306 patients (47%) were managed 
conservatively with serial clinical examinations. This group included 26 
patients with omental or intestinal evisceration, 18 patients with air 
under the diaphragm, 12 patients with blood found on abdominal 
paracentesis, and 18 patients with shock on admission. Only 11 patients 
(3.6%) needed subsequent operation, and there was no mortality. The 
overall incidence of unnecessary laparotomies was 5% (completely 
negative, 3%). Of the 467 patients with proven peritoneal penetration, 
27.6% had no significant intra-abdominal injury. It is concluded that 
many abdominal stab wounds can safely be managed without operation. The 
decision to operate or observe can be made exclusively on clinical 
criteria. Peritoneal penetration, air under the diaphragm, evisceration 
of omentum or bowel, blood found on abdominal paracentesis, and shock on 
admission are not absolute indications for surgery. Alcohol consumption 
by the patient does not interfere with the clinical assessment.

ron simon