Medical support and treatment During this observation period, patients receive IV hydration with isotonic crystalloid solutions (Ringer's lactate is preferred in our institution) and kept on NPO status. We give no antibiotics, other than the standard single dose of cefazolin, given in the ED, to avoid masking developing symptoms.
Stab wounds are routinely irrigated and closed during this time. Gunshot wounds are irrigated but left open to heal by secondary intention. Serial examinations and laboratory tests are continued for 12 to 24 hours. Patients whose wounds are located in the anterior or posterior left upper quadrant or in the posterior right upper quadrantare recommended for diagnostic laparoscopy to evaluate
for occult diaphragmatic injury.
14,15 All other patients who remain afebrile, hemodynamically stable, and asymptomatic are given a regular diet. If they tolerate the diet, they are discharged home, unless they require admission for other injuries. Patients who require admission for other reasons and have remained stable for the 12 to 24 hours they were observed will go to a lower-acuity area, such as the ward, unless their other injuries require closer monitoring. If CT demonstrates a solid-organ injury, such as a liver laceration, management will continue to be nonoperative as long as hemodynamic stability is maintained, but the patient will be admitted to the ward or the ICU for continued hemoglobin monitoring depending on the severity of the injury as classified by CT.16-19 Failure of nonoperative management usually occurs within 24 hours, so more lengthy observation is unwarranted in the absence of significant solid-organ injury.17
Discussion
A policy of selective nonoperative management has been accepted for blunt trauma in most trauma centers. Acceptance of selective nonoperative management of stab wounds to the abdomen has increased over the past two decades. However, gunshot wounds and stab wounds with proven peritoneal violation have been managed much more aggressively, with routine surgical exploration. Several studies now have examined the safety and utility of selective nonoperative management of gunshot and stab wounds to the abdomen.
1,17,20-22 Our center has found that approximately 25% to 30% of anterior abdominal gunshot wounds and approximately 50% of anterior abdominal stab wounds can be managed successfully without surgery.
Observation is important Clinical observation is accurate for selecting patients requiring exploration. Site of entry or exit of the penetrating trauma should not be the sole deciding factor in whether the patient needs operative intervention (see Figure 2). Some authors have expressed concern about missing hollow viscus perforation or that a delay in diagnosis will increase morbidity and mortality, but many studies have shown that a few hours' delay does not worsen outcomes.
8,23,24 The initial examination was 97.1% sensitive in identifying patients needing operation. Subsequent examinations will identify the remaining patients without increasing morbidity or mortality.
10,17 Advantages Selective nonoperative management has the advantages of avoiding unnecessary surgery in a great number of patients, lowering overall hospital costs, and shortening hospital stays. One study found that the mean hospital stay for patients with nontherapeutic operations was 6.4 days, with a complication rate of 27.6% and a mean hospital charge of $18,123.17 In five of the eight patients who developed complications, these were likely a direct result of the anesthesia or laparotomy. In the observed group, 13% required an operation, with four of these patients having a delay of 6 to 13.5 hours, during which one of them developed a psoas abscess. For the patients successfully managed nonoperatively, the mean hospital stay was 3.3 days and mean hospital charges were $8,595.17 Successful observation can avoid the potential complications of nontherapeutic operation, including wound infection, possible future small bowel obstruction, and the risks associated with anesthesia.
Conclusion
If a center follows strict protocols for close monitoring of hemodynamics, laboratory values, and clinical status, a large number of patients with penetrating abdominal trauma can be successfully managed nonoperatively. Proper patient selection, resources that permit close observation, and frequent abdominal examinations are paramount in obtaining the best results. Selective nonoperative management of penetrating abdominal trauma is safe, efficient, and cost-effective in the appropriate clinical setting and can lead to fewer unnecessary operations in patients with penetrating wounds to the abdomen. JAAPA
The author works in the Department of Surgery, Division of Trauma, Los Angeles County and University of Southern California (LAC+USC) Medical Center. She has indicated no relationships to disclose relating to the content of this article. Steve Wilson works in cardiac, thoracic, and vascular surgery at the Heart Center, Peninsula Regional Medical Center, Salisbury, Md, and is a member of the editorial board of JAAPA.
The author acknowledges Dr. Ali Salim, Dr. Demetrios Demetriades, and the trauma registry for help in the preparation of this article.
Steve Wilson, PA-C, DEPARTMENT EDITOR
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