Penetrating injury

IN ABDOMINAL PENETRATING WOUND
CONSERVATIVE TX IS ACCEPTABLE

1. penetrating injury 2014/9/20 Huang Guan-Lin M.D. Abdominal

2. 20 歲男性 周末狂歡 跟旁人對傳播妹爭風吃醋 步入急診室，據傳被用 長達 10 公分的扁鑽 刺入 生命徵象 BP:130/85 HR:98 BT:37.6 急診 醫師嘗試床 邊診視傷口 但因為傷口較深而無法得知是否深入腹膜 且傷口附近持續在滲血 , no peritoneal sign

3. How to manage this patient?

4. Indications for laparotomy Hemodynamic unstable Peritoneal irritation/diffuse abdominal pain >> S/S Fascia penetration Gunshot wound with transperitoneal path Symptoms? Yes No Hemodynamic stable Yes OP OP no OP ????

5. Hemodynamic stable Knife/gunshot Distance Blood loss Gun shot injury: 98% peritoneal penetration Stabbing injury: 30% intraperitoneal injury

6. What do I do in ER?

7. Seems no emergent OP problem/active bleeding now On IV, check the CBC, prepare blood FAST / abdominal CT >internal bleeding/emergent OP indication

8. Seems no emergent OP problem/active bleeding now On IV, check the CBC, prepare blood FAST / abdominal CT >internal bleeding/emergent OP indication Patient easy, CT report. Intend to let him MBD in AM8:00 Duty VS consult GS CR…

9. My question is … Other examination? How long in obs room? Is there any evidence support the Tx ? Possibility of laparotomy in obs pts ?

10. Symptoms? Yes No Hemodynamic stable Yes OP OP no OP NOM NOM= SELECTIVE NON OPERATIVE MANEGEMENT

11. Q1: In stable stab wd pts , rationale for early laparotomy?

12. Nancy(1969), New Orleans charity hospital Unnecessary laparotomy Complication in Unnecessary laparotomy Early laparotomy 66% 24% Clinical judgement 25% 0% Friedmann (1968): 70% negative laparotomy rate in mandatory laparotomy Lee(1984): 7.8% negative laparotomy rate in selective management initial presentation and examination accuracy: 88%

13. Morbidity of nontherapeutic laparotomy

14. Complications of laparotomy(41.3%) Atelectasis:41.3% Pleural effusion:9.8% Pneumothorax:5.2% Pneumonia:3.9% Mortality:0.8% Hospital stay: Uncomplicated : 5.1days Complicated: 11.9 days J Trauma. 1995;38:350-356 Am surg 1994;60:744-747

15. Q2: Gun-shot injury on selective NOM?

16. Still in controversy If NOM was chosen, need other examination Lowe, 1977, retrospective review of 362 pts with GSW 108 pts Tangential injury, NOM 254 pts Suspect penetrating visceral cavity 97.6% need surgical repair Velmahos , 2001, retrospective 792 pts with NOM GSW 80 pts Delayed laparotomy, therapeutic rate:72% 712 pts NOM Routine laparotomy 47% false negative

17. Q3: Local wound exploration feasible?

18. Negative fascia penetration: conservative TX Positive fascia penetration: mandatory op? Fabian(1993): negative laparotomy rate 50% Still further investigation if fascia penetration

19. Q4: Better adjuncts examination for selective NOM?

20. ECHO: not enough data Angiography: not enough data DPL: high sen , spe , accuracy in old times CT: Shanmuganathan (2004) S en:97%, spe:98%, accuracy:98% in penetrating stab wds Velmahos (2005) GSW: Sen 90.5, S pe : 96% Radiology 2004:231:775-784 J trauma 2005:59:1155-1161

21. Q5 How long would be the observation time?

22. MBD after 24hrs obs with minimal or no abdominal tenderness Alzamel (2005) Retrospective 650pts with NOM and delayed laparotomy in 12hrs Velmehos (1997) stable, tolerate food after 24hrs(1856pts)

23. TAKE HOME MESSAGE NOM indication Stab wound: rationale for NOM Gun shot wound: still in debates Examination: CT OBS time:24hrs Huang Guan-Lin M.D. Kaohsiung CGMH urology department

24. Stab wound: liver > small bowel > diaphragm >colon Gunshot wound: small bowel > colon > liver >abdominal vascular

25. ATLS textbook Easy miss diagnosis Hollow viscus rupture Solid organ bleeding Bony pelvis bleeding Significant blood loss may present in No dramatic change in appearance No obvious change in peritoneal sign