Validating the western trauma association algorithm for managing patients with anterior abdominal stab wounds: A western trauma association multicenter trial

Walter L. Biffl, Krista L. Kaups, Tam N. Pham, Susan E. Rowell, Gregory Jurkovich, Clay Cothren Burlew, J. Elterman, Ernest E. Moore

Research output: Contribution to journalArticle

44 Citations (Scopus)

Abstract

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/Ced 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.

Original languageEnglish (US)
Pages (from-to)1494-1502
Number of pages9
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume71
Issue number6
DOIs
StatePublished - Dec 1 2011
Externally publishedYes

Fingerprint

Stab Wounds
Multicenter Studies
Laparotomy
Wounds and Injuries
Operating Rooms
Peritoneal Lavage
Length of Stay
Tomography
Cost-Benefit Analysis
Hospital Emergency Service
Morbidity
Safety
Patient Discharge
Research Ethics Committees
Laparoscopy

Keywords

  • Abdominal trauma
  • Algorithm
  • Computed tomography
  • Diagnostic peritoneal lavage
  • Laparoscopy
  • Local wound exploration
  • Multicenter
  • Penetrating abdominal trauma
  • Penetrating trauma
  • Stab wounds

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Validating the western trauma association algorithm for managing patients with anterior abdominal stab wounds : A western trauma association multicenter trial. / Biffl, Walter L.; Kaups, Krista L.; Pham, Tam N.; Rowell, Susan E.; Jurkovich, Gregory; Burlew, Clay Cothren; Elterman, J.; Moore, Ernest E.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 71, No. 6, 01.12.2011, p. 1494-1502.

Research output: Contribution to journalArticle

Biffl, Walter L. ; Kaups, Krista L. ; Pham, Tam N. ; Rowell, Susan E. ; Jurkovich, Gregory ; Burlew, Clay Cothren ; Elterman, J. ; Moore, Ernest E. / Validating the western trauma association algorithm for managing patients with anterior abdominal stab wounds : A western trauma association multicenter trial. In: Journal of Trauma - Injury, Infection and Critical Care. 2011 ; Vol. 71, No. 6. pp. 1494-1502.
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abstract = "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/Ced 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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author = "Biffl, {Walter L.} and Kaups, {Krista L.} and Pham, {Tam N.} and Rowell, {Susan E.} and Gregory Jurkovich and Burlew, {Clay Cothren} and J. Elterman and Moore, {Ernest E.}",
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T1 - Validating the western trauma association algorithm for managing patients with anterior abdominal stab wounds

T2 - A western trauma association multicenter trial

AU - Biffl, Walter L.

AU - Kaups, Krista L.

AU - Pham, Tam N.

AU - Rowell, Susan E.

AU - Jurkovich, Gregory

AU - Burlew, Clay Cothren

AU - Elterman, J.

AU - Moore, Ernest E.

PY - 2011/12/1

Y1 - 2011/12/1

N2 - 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/Ced 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.

AB - 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/Ced 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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KW - Computed tomography

KW - Diagnostic peritoneal lavage

KW - Laparoscopy

KW - Local wound exploration

KW - Multicenter

KW - Penetrating abdominal trauma

KW - Penetrating trauma

KW - Stab wounds

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