Management of patients with anterior abdominal stab wounds: A western trauma association multicenter trial

Walter L. Biffl, Krista L. Kaups, C. Clay Cothren, Karen J. Brasel, Rochelle A. Dicker, M. Kelley Bullard, James M. Haan, Gregory Jurkovich, Paul Harrison, Forrest O. Moore, Martin Schreiber, M. Margaret Knudson, Ernest E. Moore

Research output: Contribution to journalArticle

66 Scopus citations

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.

Original languageEnglish (US)
Pages (from-to)1294-1301
Number of pages8
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume66
Issue number5
DOIs
StatePublished - May 1 2009
Externally publishedYes

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Keywords

  • Abdominal stab wounds
  • Abdominal trauma
  • Clinical assessments
  • Clinical trial
  • Computed tomography scan, serial
  • Diagnostic peritoneal lavage
  • Laparotomy
  • Local wound exploration
  • Multicenter
  • Penetrating trauma
  • Prospective
  • Protocol
  • Stab wounds

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Biffl, W. L., Kaups, K. L., Cothren, C. C., Brasel, K. J., Dicker, R. A., Bullard, M. K., Haan, J. M., Jurkovich, G., Harrison, P., Moore, F. O., Schreiber, M., Knudson, M. M., & Moore, E. E. (2009). Management of patients with anterior abdominal stab wounds: A western trauma association multicenter trial. Journal of Trauma - Injury, Infection and Critical Care, 66(5), 1294-1301. https://doi.org/10.1097/TA.0b013e31819dc688