penetrating injury

2014/9/20 Huang Guan-Lin M.D.

Abdominal

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

How to manage this patient?

Indications for laparotomy

• Hemodynamic unstable• Peritoneal irritation/diffuse abdominal pain >> S/S• Fascia penetration• Gunshot wound with transperitoneal path

Symptoms?

Yes No

Hemodynamicstable

Yes OP OP

no OP ????

• Hemodynamic stable Knife/gunshot Distance Blood loss

• Gun shot injury: 98% peritoneal penetration• Stabbing injury: 30% intraperitoneal injury

What do I do in ER?

• Seems no emergent OP problem/active bleeding now

• On IV, check the CBC, prepare blood• FAST / abdominal CT >internal bleeding/emergent OP indication

• 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…

• My question is …

Other examination?How long in obs room?Is there any evidence support the Tx?Possibility of laparotomy in obs pts?

Symptoms?

Yes No

Hemodynamicstable

Yes OP OP

no OP NOM

NOM= SELECTIVE NON OPERATIVE MANEGEMENT

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

Nancy(1969), New Orleans charity hospitalUnnecessary laparotomy Complication in

Unnecessary laparotomyEarly 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%

Morbidity of nontherapeutic laparotomy

• Complications of laparotomy(41.3%) Atelectasis:41.3% Pleural effusion:9.8% Pneumothorax:5.2% Pneumonia:3.9%

Mortality:0.8%

• Hospital stay:Uncomplicated : 5.1daysComplicated: 11.9 days

J Trauma. 1995;38:350-356Am surg 1994;60:744-747

Q2:Gun-shot injury on selective NOM?

• 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 cavity97.6% 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

Q3:Local wound exploration feasible?

• Negative fascia penetration: conservative TX

• Positive fascia penetration: mandatory op? Fabian(1993): negative laparotomy rate 50%

• Still further investigation if fascia penetration

Q4:Better adjuncts examination for selective NOM?

• ECHO: not enough data• Angiography: not enough data

• DPL: high sen, spe, accuracy in old times

• CT: Shanmuganathan(2004) Sen:97%, spe:98%, accuracy:98% in penetrating stab wds Velmahos(2005) GSW: Sen 90.5, Spe: 96%

Radiology 2004:231:775-784J trauma 2005:59:1155-1161

Q5How long would be the observation time?

• 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)

TAKE HOME MESSAGE

NOM indicationStab wound: rationale for NOM

Gun shot wound: still in debatesExamination: CTOBS time:24hrs

Huang Guan-Lin M.D.Kaohsiung CGMH urology department

• Stab wound: liver > small bowel > diaphragm >colon• Gunshot wound: small bowel > colon > liver >abdominal

vascular

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