The role of computed tomography in selective management of gunshot wounds to the abdomen and flank

Selective nonoperative management of abdominal gunshot wounds: What you need to know

ABSTRACT

Since the 1990s, there has been a slow but steady adoption of selective nonoperative management (SNOM) for abdominal gunshot wounds (GSW). Multiple studies have shown that SNOM is feasible and can be performed safely, even at trauma centers with low penetrating trauma volumes. The principles of SNOM for abdominal GSW consists of (1) careful patient selection, (2) diagnostic workup with CT, and (3) clinical observation. By implementing SNOM, the number of patients undergoing a nontherapeutic laparotomy can significantly be improved to less than 10%. Overall, approximately one third of patients with abdominal GSW can be managed nonoperatively. This review article provides a practical approach to the management of patients with an abdominal GSW.

Firearm injury to the left buttock with uterus penetrating trauma

A multispecialty trauma team must provide care for pelvic gunshot wounds (PGW) due to the high risk of associated morbidity and mortality, the high density of organs that might be wounded within the pelvis, and the potential consequences of these complicated injuries. We present a case of a 59-year-old woman hemodynamically stable with firearm injury to the left buttock. CT examination showed free air in the peritoneal cavity and in the retroperitoneum and a focal contrast extravasation within the uterine fundus. The patient underwent urgent laparotomy that revealed triple bowel perforation (sigmoid colon, medium rectum, ileum) and a laceration of the posterior and anterior uterine wall at level of the cervix with no signs of active bleeding. The bullet was lodged above the peritoneal reflection, in the right pelvis, and it was removed, and handed over to the judicial authority. The perforated bowel segments were resected with Hartmann's procedure and ileal anastomosis. The uterine laceration was repaired. Although all the viscera and the structures along the trajectory can be harmed, pelvic gunshot wounds have the potential to inflict serious injury. Nongravid uterine traumas are a unique occurrence, and proper care requires an understanding of lesion grading. Finding the gynecological lesion in female patients is essential to receiving the best care and protecting the reproductive system.

Rectal Contrast CT Scans of Limited Utility in Diagnosing Colonic Injuries in Penetrating Trauma: A Meta-Analysis

OBJECTIVES

Using rectal contrast computed tomography (CT) to identify traumatic colorectal injuries has become commonplace; however, these injuries remain relatively infrequent findings on CTs obtained for penetrating back and flank trauma. We conducted a meta-analysis to ascertain the efficacy of rectal contrast CT in identifying such injuries in victims penetrating injuries.

METHODS

PubMed and Embase were queried for relevant articles between 1974 and 2022. Review articles, case studies, and non-English manuscripts were excluded. Studies without descriptive CT and operative findings were excluded. Positive scans refer to rectal contrast extravasation. Sensitivity and specificity of rectal contrast CT scans were calculated with aggregated CT findings that were cross-referenced with laparotomy findings.

RESULTS

Only 8 manuscripts representing 506 patients quantified colorectal injuries and specified patients with rectal contrast extravasation. Seven patients with true colorectal injuries had no contrast extravasation on CT. There was one true positive scan. Another scan identified contrast extravasation, but laparotomy revealed no colorectal injury. Rectal contrast had sensitivity of 12.5%, specificity 99.8%, positive predictive value (PPV) 50%, negative predictive value (NPV) 99%, and a false negative rate of 88% in identifying colonic injuries.

DISCUSSION

The summation of 8 manuscripts suggest that the addition of rectal contrast in identifying colonic and rectal injuries may be of limited utility given its poor sensitivity and may be unnecessary. In its absence, subtle clues such as hematomas, extraluminal air, IV-dye extravasation, and trajectory may be additional indicators of injury. Further investigations are required to demonstrate a true benefit for the addition of rectal contrast.

Expectant management in delayed presentation of war casualties with penetrating abdominal trauma

INTRODUCTION

While the management of acute civilian abdominal injuries is well established, The literature regarding the management of battle-related abdominal injuries presented in a delayed fashion is scarce. The objective of this study was to investigate the safety of non-operative management approach in delayed evacuation of battle-related abdominal injuries.

METHODS

Clinical records of thirty-seven hemodynamically normal patients with battle related injuries and Computed Tomography (CT) findings of penetrating abdominal trauma were retrospectively studied.

RESULTS

All 37 patients suffered penetrating abdominal injuries during the civil war in Syria. In this complex scenario, the casualties presented after a minimum 12-hour delay to our hospital. All patients had abnormal abdominal CT scans with no clinical peritoneal signs. Twenty-one [of the 37] patients exhibited 29 hard signs on CT scan. Of these, 17 patients were treated non-operatively and 4 underwent exploratory laparotomy (of which 2 were non-therapeutic). Sixteen patients exhibited a total of 75 soft signs on CT scan; 15 were treated non-operatively and one underwent non-therapeutic laparotomy. No complications were recorded in either the operative or non-operative groups. In total, 32 patients (86%) were treated non-operatively. Five patients (14%) underwent exploratory laparotomy (3 of which were non-therapeutic). Length of stay was dependent on the unique requirements of each individual patient as determined by the state department for returning across the border.

CONCLUSION

We propose that in battle related casualties, acute survivable penetrating abdominal trauma may be safely treated non-operatively in selected patients who are hemodynamically normal and in whom there is an absence of abdominal pain or tenderness on repeated clinical assessment.

In situ identification of Action 4, SECA and QD-PEP bullets from special police ammunitions by computed tomography

INTRODUCTION

Special deformation bullets were developed for police forces to achieve a defined penetration depth (avoiding over-penetration) and a controlled energy transfer (avoiding collateral damage). This article focuses on Action 4, SECA and QD-PEP bullets. These 9 mm bullets were specially designed for controlled deformation. The characteristic slight mushrooming with a front cross-section of approximately 11.5 mm after entering a ballistic simulant was verified in ballistic tests. To achieve such slight mushrooming, the projectile's core is hollowed. The purpose of this study was to investigate the feasibility of visualising the hollowed cores of Action 4, SECA and QD-PEP bullets using a standard clinical computed tomography (CT) scanner for non-invasive identification of these special bullets from police ammunitions.

METHODS

First, undeformed specimens were scanned to reveal the shape of the hollowed core of each type of special bullet. Second, Action 4, SECA and QD-PEP bullets were fired towards animal cadaver models to visualise their hollow core after deformation inside biological tissue. Third, two reviewers were tasked with identifying special bullets from police ammunition (Action 4 bullets: n = 3) among 10 CT examinations of humans with lodged projectiles who were selected by the supervisor of the study.

RESULTS

The CT scans of the undeformed specimens revealed the special design of the bullets' metal core. All special bullets from police ammunitions that were fired towards an animal cadaver model demonstrated the characteristic slight mushrooming. In accordance with the CT scans of the undeformed bullets, visualisation of the individual internal cavities of the special bullets allowed the Action 4, SECA and QD-PEP bullets to be clearly distinguished. With regard to the real forensic cases, both reviewers clearly identified each of the three Action 4 bullets among all other lodged projectiles.

CONCLUSIONS

This study demonstrates the feasibility of identifying Action 4, SECA and QD-PEP bullets from special police ammunitions by CT. The individual shapes of the cavity inside the bullets were clearly visible on CT. In situ identification of these bullets can aid in the assessment of injuries, and since these bullets are fabricated from non-ferromagnetic metals, their clear identification allows for magnetic resonance imaging (MRI) without the risk of bullet movement inside the body due to the magnetic pull of the MRI unit. Furthermore, this approach could be of great interest to forensic investigators if patients who received gunshot wounds underwent non-operative treatments and the projectile remains in the body. Since the use of CT is also increasing for medico-legal post-mortem examinations, the identification of lodged projectiles is of interest for a virtual autopsy or 'Virtopsy'.

Managing post-traumatic gunshot thoraco-abdominal bleeding by intervention embolisation: A case report

We report an interesting life-threating case of post-traumatic severe bleeding in the thoraco-abdominal region. The patient was initially treated by open surgery, which failed to control bleeding in the intrahepatic and sub-diaphragmatic regions of the liver with associated haematoma collection. As bleeding continued, on the 2nd post-operative day, the patient underwent super-selective embolisation of the bleeding vessels to cease serious bleeding. The pre-embolisation arterial feeders with active bleeding and post-embolisation images by computed tomography subtraction angiography showed complete cessation of haemorrhage. Torrential haemorrhage in the thoraco-abdominal regions can be successfully managed by trained interventional radiologists in highly specialised centres.

Determining Trajectory to Predict Injury: The Use of X-Ray During Resuscitation in Gunshot Wounds

BACKGROUND

The practice of marking gunshot wounds and obtaining X-rays (XRs) has been performed to determine the trajectory of missiles to help identify internal injuries. We hypothesized that surgeons would have poor accuracy in predicting injuries and that X-rays do not alter the clinical decision.

METHODS

We developed a 50-patient (89 injury sites) PowerPoint survey based on cases seen at our level 1 trauma center from 2012 to 2014. Images of a silhouetted BodyMan (BM) with wounds marked, XRs, and vital signs (VSs) were shown in series for 20 s each. Surgeons were asked to record which organs they thought could be injured and to document their clinical decision. Data were analyzed to determine the inter-rater reliability (agreement, intraclass correlation coefficient [ICC]) for each mode of clinical information (BM, XR, VS). Predicted versus actual injuries were compared using absolute agreements.

RESULTS

Ten surgeons completed the survey. We found that no single piece of information was helpful in allowing the surgeon to accurately predict injuries. Pulmonary injury had the highest agreement among all injuries (ICC = 0.727). VSs had the highest ICC in determining the clinical plan for the patient (ICC = 0.342), whereas both BM and XR had low ICCs (0.162 and 0.183, respectively).

CONCLUSIONS

We found that marking wounds and obtaining X-rays, other than a chest X-ray, did not result in accuracy in predicting injury nor alter the clinical decision. VSs were the only piece of information found significant in determining clinical management. We conclude that marking wounds for X-rays is an unnecessary step during the initial resuscitation of patients with gunshot wounds.

The role of computerized tomography in penetrating abdominal trauma

OBJECTIVE

to evaluate the role of abdominal computed tomography in the management of penetrating abdominal trauma.

METHODS

we conducted a historical cohort study of patients treated for penetrating trauma in the anterior abdomen, dorsum or thoracoabdominal transition, that were submitted to a computed tomography carried out on admission. We evaluated the location of the wound and the presence of tomographic findings, and the management of these patients as for nonoperative treatment or laparotomy. We calculated the sensitivity and specificity of computed tomography according to the evolution of the nonoperative treatment or the surgical findings.

RESULTS

we selected 61 patients, 31 with trauma to the anterior abdomen and 30 to the dorsum or thoracoabdominal transition. The mortality rate was 6.5% (n=4), all in the late postoperative period. Eleven patients with trauma to the anterior abdomen were submitted to nonoperative treatment, and 20, to laparotomy. Of the 30 patients with trauma to the dorsum or thoracoabdominal transition, 23 underwent nonoperative treatment and seven, laparotomy. There were three nonoperative treatment failures. In penetrating trauma of the anterior abdomen, the sensitivity of computed tomography was 94.1% and the negative predictive value was 93.3%. In dorsal or thoracoabdominal transition lesions, the sensitivity was 90% and the negative predictive value was 95.5%. In both groups, the specificity and the positive predictive value were 100%.

CONCLUSION

the accuracy of computed tomography was adequate to guide the management of stable patients who could be treated conservatively, avoiding mandatory surgery in 34 patients and reducing the morbidity and mortality of non-therapeutic laparotomies.

Selective nonoperative management of liver gunshot injuries

PURPOSE

Nonoperative management (NOM) of gunshot liver injuries (GLI) is infrequently practiced. The aim of this study was to assess the safety of selective NOM of GLI.

METHODS

A prospective, protocol-driven study, which included patients with GLI admitted to a level 1 trauma center, was conducted over a 52-month period. Stable patients without peritonism or sustained hypotension with right-sided thoracoabdominal (RTA) and right upper quadrant (RUQ), penetrating wounds with or without localized RUQ tenderness, underwent contrasted abdominal CT scan to determine the trajectory and organ injury. Patients with established liver and/or kidney injuries, without the evidence of hollow viscus injury, were observed with serial clinical examinations. Outcome parameters included the need for delayed laparotomy, complications, the length of hospital stay and survival.

RESULTS

During the study period, 54 (28.3%) patients of a cohort of 191 patients with GLI were selected for NOM of hemodynamic stability, the absence of peritonism and CT imaging. The average Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.841 and 25 (range 4-50), respectively. 21 (39%) patients had simple (Grades I and II) and 33 (61%) patients sustained complex (Grades III to V) liver injuries. Accompanying injuries included 12 (22.2%) kidney, 43 (79.6%) diaphragm, 20 (37.0%) pulmonary contusion, 38 (70.4%) hemothoraces, and 24 (44.4%) rib fractures. Three patients required delayed laparotomy resulting in an overall success of NOM of 94.4%. Complications included: liver abscess (1), biliary fistula (5), intrahepatic A-V fistula (1) and hospital-acquired pneumonia (3). The overall median hospital stay was 6 (IQR 4-11) days, with no deaths.

CONCLUSION

The NOM of carefully selected patients with GLI is safe and associated with minimal morbidity.

Trends in nonoperative management of traumatic injuries - A synopsis

Nonoperative management of both blunt and penetrating injuries can be challenging. During the past three decades, there has been a major shift from operative to increasingly nonoperative management of traumatic injuries. Greater reliance on nonoperative, or "conservative" management of abdominal solid organ injuries is facilitated by the various sophisticated and highly accurate noninvasive imaging modalities at the trauma surgeon's disposal. This review discusses selected topics in nonoperative management of both blunt and penetrating trauma. Potential complications and pitfalls of nonoperative management are discussed. Adjunctive interventional therapies used in treatment of nonoperative management-related complications are also discussed.

REPUBLISHED WITH PERMISSION FROM

Stawicki SPA. Trends in nonoperative management of traumatic injuries - A synopsis. OPUS 12 Scientist 2007;1(1):19-35.

Isolated liver gunshot injuries: nonoperative management is feasible?

ABSTRACTObjective:to evaluate the safety and effectiveness of non-operative management (NOM) of liver injury, being the only abdominal injury, from gunshot wounds to the abdomen.Methods:patients who had liver damage diagnosed as single abdominal injury caused by PAF in the right thoracoabdominal region, hemodynamically stable were studied. All underwent examination with computed tomography. Were analyzed: age, gender, levels of trauma, hemodynamic condition and the abdominal examination on admission, the results of the CT scan, the extra-abdominal lesions found, the serum levels of hemoglobin, clinical course, complications, length of hospital stay, outpatient treatment and death.Results:during the study period 169 patients, treated non-operatively, presented liver gunshot wounds. Of these, only 28 patients (16.6%) had liver injury as the only abdominal injury and consequently met the inclusion criteria for this study. The average age was 27.7 years and 25 patients (89.2%) were male. The overall average of verified trauma scores were: RTS 7.45, ISS 10.9, and TRISS 98.7%. The most frequent injuries were grade II and grade III (85.7%). Complications occurred in only one patient who presented a progressive decline in hemoglobin. He underwent a CT scan which showed blush in the liver parenchyma. An arteriography was performed, which showed a successfully embolized arteriovenous fistula. There were no deaths in the patient sample. The average hospital stay was 5.3 days.Conclusion:isolated hepatic injury in gunshot abdominal trauma is uncommon. However, the NOM protocol for this type of injury is safe and has low morbidity. This approach should only be followed in institutions with adequate infrastructure, where an experienced and cohesive team is able to follow a specific protocol, with rigorous periodic evaluation of its results.

Selective non operative management of gunshot wounds to the abdomen: a collective review

BACKGROUND

Over the past four decades there has been a shift from operative to selective conservatism in trauma. Selective nonoperative management (SNOM) of stab wounds to the abdomen is widely accepted in trauma centres. However, selective conservatism with gunshot wounds to the abdomen is controversial. This collective review assesses the evidence of SNOM of gunshot wounds to the abdomen.

METHODS

A Medline search between 1 January 1960 and 31 July 2013 was conducted identifying studies that investigated SNOM of gunshot wounds to the abdomen. Case reports, review articles and editorials were excluded. All other studies that investigated SNOM of gunshot wounds to the abdomen and its outcomes were included.

RESULTS

A total of 37 studies were included of which 22 were prospective, 14 were retrospective and 1 case series. A total of 21330 patients with gunshot wounds to the abdomen were included, of which 6468 (30.3%) were managed nonoperatively. Successful SNOM was possible in 5510 (85.18%) patients and 958 (14.8%) failed SNOM and underwent delayed laparotomies. SNOM reduces rates of non-therapeutic laparotomies and the associated morbidity. Special aspects reviewed include the prehospital and nursing involvement in this modality of care.

CONCLUSIONS

Current evidence supports SNOM of gunshot wounds to the abdomen. It is associated with a decreased rate of non therapeutic laparotomy. Careful patient selection and specially designed protocols should be established and adhered to.

Current management of penetrating torso trauma: nontherapeutic is not good enough anymore

A highly organized approach to the evaluation and treatment of penetrating torso injuries based on regional anatomy provides rapid diagnostic and therapeutic consistency. It also minimizes delays in diagnosis, missed injuries and nontherapeutic laparotomies. This review discusses an optimal sequence of structured rapid assessments that allow the clinician to rapidly proceed to gold standard therapies with a minimal risk of associated morbidity.

The principles of non-operative management of penetrating abdominal injury

The selective non-operative management of penetrating abdominal injury is gaining increasing acceptance. Recognition of the morbidity, mortality, and cost associated with non-therapeutic exploration has provided the impetus for selective management. This review describes the principles of, and evidence for, this strategy. Selective management is widely accepted for the treatment of stab wounds, but the selective management of ballistic injuries, particularly in the military setting, remains contentious. As a result, there are marked variations in the application of this practice. Computed tomography is a prerequisite for the selective management of ballistic injuries, and possibly also stab wounds. Failure of non-operative management, following stab wounds or gunshot wounds, is invariably apparent within 24 hours.

Penetrating wounds to the torso: evaluation with triple-contrast multidetector CT

Penetrating injuries account for a large percentage of visits to emergency departments and trauma centers worldwide. Emergency laparotomy is the accepted standard of care in patients with a penetrating torso injury who are not hemodynamically stable and have a clinical indication for exploratory laparotomy, such as evisceration or gastrointestinal bleeding. Continuous advances in technology have made computed tomography (CT) an indispensable tool in the evaluation of many patients who are hemodynamically stable, have no clinical indication for exploratory laparotomy, and are candidates for conservative treatment. Multidetector CT may depict the trajectory of a penetrating injury and help determine what type of intervention is necessary on the basis of findings such as active arterial extravasation and major vascular, hollow viscus, or diaphragmatic injuries. Because multidetector CT plays an increasing role in the evaluation of patients with penetrating wounds to the torso, the radiologists who interpret these studies should be familiar with the CT findings that mandate intervention.

Penetrating diaphragmatic injury: accuracy of 64-section multidetector CT with trajectography

PURPOSE

To (a) determine the diagnostic performance of 64-section multidetector computed tomography (CT) trajectography for penetrating diaphragmatic injury (PDI), (b) determine the diagnostic performance of classic signs of diaphragmatic injury at 64-section multidetector CT, and (c) compare the performance of these signs with that of trajectography.

MATERIALS AND METHODS

This HIPAA-compliant retrospective study had institutional review board approval, with a waiver of the informed consent requirement. All patients who had experienced penetrating thoracoabdominal trauma, who had undergone preoperative 64-section multidetector CT of the chest and abdomen, and who had surgical confirmation of findings during a 2.5-year period were included in this study (25 male patients, two female patients; mean age, 32.6 years). After a training session, four trauma radiologists unaware of the surgical outcome independently reviewed all CT studies and scored the probability of PDI on a six-point scale. Collar sign, dependent viscera sign, herniation, contiguous injury on both sides of the diaphragm, discontinuous diaphragm sign, and transdiaphragmatic trajectory were evaluated for sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). Accuracies were determined and receiver operating characteristic curves were analyzed.

RESULTS

Sensitivities for detection of PDI by using 64-section multidetector CT with postprocessing software ranged from 73% to 100%, specificities ranged from 50% to 92%, NPVs ranged from 71% to 100%, PPVs ranged from 68% to 92%, and accuracies ranged from 70% to 89%. Discontinuous diaphragm, herniation, collar, and dependent viscera signs were highly specific (92%-100%) but nonsensitive (0%-60%). Contiguous injury was generally more sensitive (80%-93% vs 73%-100%) but less specific (50%-67% vs 83%-92%) than transdiaphragmatic trajectory when patients with multiple entry wounds were included in the analysis. Transdiaphragmatic trajectory was a much more sensitive sign of PDI than previously reported (73%-100% vs 36%), with NPVs ranging from 71% to 100% and PPVs ranging from 85% to 92%.

CONCLUSION

Sixty-four-section multidetector CT trajectography facilitates the identification of transdiaphragmatic trajectory, which accurately rules in PDI when identified. Contiguous injury remains a highly sensitive sign, even when patients with multiple injuries are considered, and is useful for excluding PDI.

Non operative management of gunshot wounds on the right thoracoabdomen

OBJECTIVE

To analyze the results after the implementation of the non-operative management (NOM) of the right upper thoracoabdominal gunshot injuries protocol.

METHODS

Prospective study. From January 2005 to December 2011, 115 patients were included into this study. Criteria for inclusion were gunshot wound to the right thoracoabdominal region, haemodynamic stability, no signs of peritonitis, and realized CT scan. The data collected were analysed by the software EXCEL.

RESULTS

Among the 115 patients included in our study, the mean age was 25.8 years old (range, 14-78 years old), of whom 95.6% were male, 62.6% had thoracoabdominal injuries and 37.4% had exclusively abdominal injuries. The averages of trauma scores were RTS 7.7, ISS 14.8 and TRISS 97%. One hundred and nine patients (94.8%) had liver injury, 72 (62.6%) had diaphragm and lung injury, 28 (24.4%) had renal injury. Complications were present in 12 (10.5%) patients, 7 of these related to the thorax. The NOM failure happened in 4 (3.5%) patients, 2 of them due to bile peritonitis, 1 related to bleeding and 1 the laparotomy was unnecessary. The mean hospital stay was 9.4 days. There were 2 deaths due to associated gunshot brain injury. Sixty seven patients (58.3%) were presented in the follow-up after 2 months of trauma. The CT scan showed injury scar in 58 patients (86.5%).

CONCLUSION

NOM of the penetrating right thoracoabdominal injuries must be seen with caution. The NOM of right thoracoabdominal gunshot injuries is safe only in selected cases, followed by well-defined protocols and when performed in places that have adequate infrastructure.

Practice management guidelines for selective nonoperative management of penetrating abdominal trauma

BACKGROUND

: Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating injury to the abdomen, it is also clear that certain stable patients without peritonitis may be managed without operation. The practice of deciding which patients may not need surgery after penetrating abdominal wounds has been termed selective management. This practice has been readily accepted during the past few decades with regard to abdominal stab wounds; however, controversy persists regarding gunshot wounds. Because of this, the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee set out to develop guidelines to analyze which patients may be managed safely without laparotomy after penetrating abdominal trauma. A secondary goal of this committee was to find which diagnostic adjuncts are useful in the determination of the need for surgical exploration.

METHODS

: A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov).

RESULTS

: The search retrieved English language articles concerning selective management of penetrating abdominal trauma and related topics from the years 1960 to 2007. These articles were then used to construct this set of practice management guidelines.

CONCLUSIONS

: Although the rate of nontherapeutic laparotomies after penetrating wounds to the abdomen should be minimized, this should never be at the expense of a delay in the diagnosis and treatment of injury. With this in mind, a routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness. Likewise, it is also not routinely indicated in stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs. Abdominopelvic computed tomography should be considered in patients selected for initial nonoperative management to facilitate initial management decisions. The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness. Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration in an effort to avoid unnecessary laparotomy.

Single-contrast computed tomography for the triage of patients with penetrating torso trauma

BACKGROUND

We have used single-contrast (intravenous contrast only) computed tomography (SCCT) for triaging hemodynamically stable patients with penetrating torso trauma. We hypothesized that SCCT safely determines the need for operative exploration. Furthermore, trauma surgeons without specialized training in body imaging can accurately apply this modality.

METHODS

We retrospectively reviewed the records of patients with penetrating torso injuries at a university-based urban trauma center to establish the accuracy of SCCT in determining the need for exploratory laparotomy. The scan was considered positive or negative with respect to the need for exploratory laparotomy as documented by the attending surgeon, who may have considered the read of the on call radiologist if available. In a separate study, four trauma surgeons independently reviewed 42 SCCT scans to establish whether the scans alone could be used to determine whether operative exploration was necessary.

RESULTS

Between 1997 and 2008, 306 hemodynamically stable patients with penetrating torso trauma were triaged by SCCT. Overall, SCCT predicted the need for laparotomy with 98% sensitivity and 90% specificity. The positive predictive value was 84% and the negative predictive value (NPV) was 99%. In the 222 patients with gunshot wounds, SCCT had 100% sensitivity and 100% NPV. In the 84 patients with stab wounds, SCCT had 92% sensitivity and 97% NPV. Trauma surgeon agreement in the retrospective review of 42 computed tomography scans was "nearly perfect": positive predictive value was 93% and NPV was 92% for determining the need for exploratory laparotomy surgery.

CONCLUSIONS

SCCT is safe and effective for triaging hemodynamically stable patients with penetrating torso trauma. It successfully determined the need for operative intervention with appropriate clinical accuracy without the additional costs, morbidity, and delay of oral and rectal contrast. Trauma surgeons can reproducibly interpret SCCT with high-predictive accuracy as to whether patients with penetrating torso trauma require operative exploration.

Selective nonoperative management of liver gunshot injuries

OBJECTIVE

Nonoperative management (NOM) of liver gunshot injuries is yet to gain general acceptance. The aim of this study was to assess the feasibility and safety of selective NOM of liver gunshot injuries.

PATIENTS AND METHODS

A prospective, protocol-driven study, which included all liver gunshot injuries admitted to a level I trauma center, was conducted over a 4-year period. Patients with right-sided thoracoabdominal, and right upper quadrant gunshot wounds with or without localized right upper quadrant tenderness underwent contrasted abdominal computed tomography scan evaluation to detect the presence of a liver injury. Patients with confirmed liver injuries were observed with serial clinical examinations. Outcome parameters included need for delayed laparotomy, complications, length of hospital stay, and survival.

RESULTS

During the study period, 63 patients with liver gunshot injuries were selected for NOM. The mean injury severity score was 19.6 (range, 4-34). Simple liver injuries (grades I and II) occurred in 26 (41.3%) patients and complex liver injuries (grades III, IV, and V) occurred in 37 (58.7%) patients. Associated injuries included 14 (22.2%) kidney, 44 (69.8%) diaphragm, 43 (68.3%) lung contusion, 42 (66.7%) hemothorax and/or pneuomothorax, and 21 (33.3%) rib fractures. Five patients required delayed laparotomy resulting in successful NOM rate of 92%. Complications included liver abscess (3), biliary fistula (3), retained hemothorax (4), and nosocomial pneumonia (5). The mean hospital stay was 6.1 (range, 3-23 days). There was no mortality.

CONCLUSION

The NOM of appropriately selected patients with liver gunshot injuries is feasible, safe, and effective, regardless of the liver injury severity.

Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile

INTRODUCTION

While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients' chest tube effluent.

PATIENTS AND METHODS

We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury.

RESULTS

Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3+/-4.1 mg/dL) and was always higher than both serum bilirubin (p<0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p<0.05). One RST injury patient died of line sepsis.

CONCLUSION

Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.

Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds

The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.

Evaluation of selective treatment of penetrating abdominal trauma

OBJECTIVE

In penetrating abdominal trauma, diagnostic imaging and the application of selective clinical management may avoid negative celiotomy and improve outcome.

DESIGN

We prospectively observed patients with penetrating abdominal trauma over 15 months and recorded demographics, presentation, imaging, surgical procedure, and outcome. Patients who underwent immediate laparotomy were compared with patients who were observed and/or had a computed tomography (CT) scan. Outcomes of negative versus positive and immediate versus delayed celiotomy were compared. Chi-square and Student t tests were used. A p value of less than 0.05 was considered significant.

SETTING

A level 1 trauma center.

PARTICIPANTS

Adult patients who presented with penetrating abdominal injury.

RESULTS

In all, 100 consecutive patients (mean age, 32 years) were included (male:female, 91:9; gunshot wound:stab wound, 65:35). Overall, 60 immediate and 10 delayed laparotomies were performed; 30 patients did not undergo surgery. Predictors of immediate celiotomy were hypotension (p = 0.03), anteriorly located entrance wounds (p = 0.0005), and transaxial wounds (p = 0.03). Overall morbidity and mortality was 32% and 2%, respectively. The negative celiotomy rate was 25%. Patients with a positive celiotomy had higher morbidity (p = 0.006) and longer hospital length of stay (p = 0.003) compared with negative celiotomy. A CT scan was employed in 32% of patients, with 100% sensitivity and 94% specificity. Delayed celiotomy (10%) did not adversely impact morbidity (p = 0.70) and was 100% therapeutic, with no deaths.

CONCLUSION

Nonselective immediate celiotomy for penetrating abdominal trauma results in a high rate of unnecessary surgery. Hemodynamically stable patients can safely be observed and/or have contrast CT scans and undergo delayed celiotomy, if indicated. This selective treatment had no adverse effect on patient outcomes and can potentially improve overall outcome.

Selective non-operative management of solid organ injury following abdominal gunshot wounds

BACKGROUND

The objective of this study was to evaluate the outcome of patients sustaining a torso gunshot wound with documented solid organ injury. Our hypothesis was that the non-operative management of isolated solid organ injuries is a safe management option for a select group of patients.

METHODS

A retrospective review of a prospectively collected database was conducted to identify all patients sustaining a torso gunshot resulting in a solid organ injury undergoing non-operative management over a 5-year period (12/1999-01/2005). Patient demographics, injury details, diagnostic imaging, outcome and follow-up were reviewed.

RESULTS

Of 644 gunshot wounds to the torso, 144 (22%) underwent non-operative management. Thirteen of these patients (9%) had 16 solid organ injuries (10 liver, 4 kidney and 2 spleen). CT characterisation of the isolated solid organ injury ranged from AAST Grade I-IV. One of 13 patients failed non-operative management and subsequently underwent laparotomy, which was non-therapeutic. Clinical follow-up was available in all patients for an average of 101 days (median 27, range 6-473). The organ salvage rate was 100%.

SUMMARY

In select haemodynamically stable patients without peritonitis able to undergo serial clinical examination, solid organ injury is not a contra-indication to non-operative management. In the appropriate setting, non-operative management of solid organ injury after gunshot wounding is associated with a high rate of success and organ salvage.

Advances in Abdominal Trauma

Emergency practitioners routinely encounter patients who suffer from abdominal trauma, be it blunt or penetrating. These injuries are often confounded by altered mental status, distracting injuries, or lack of historical information, and may present challenges in management. However, in the last several years new approaches to the diagnosis and management of abdominal trauma, including bedside ultrasound, newer generation computed tomography scans, laparoscopy, and the ability for selected nonoperative management expedite identification of life threatening injury and offer new options in treatment.

Selective nonoperative management of penetrating abdominal solid organ injuries

OBJECTIVE

To assess the feasibility and safety of selective nonoperative management in penetrating abdominal solid organ injuries.

BACKGROUND

Nonoperative management of blunt abdominal solid organ injuries has become the standard of care. However, routine surgical exploration remains the standard practice for all penetrating solid organ injuries. The present study examines the role of nonoperative management in selected patients with penetrating injuries to abdominal solid organs.

PATIENTS AND METHODS

Prospective, protocol-driven study, which included all penetrating abdominal solid organ (liver, spleen, kidney) injuries admitted to a level I trauma center, over a 20-month period. Patients with hemodynamic instability, peritonitis, or an unevaluable abdomen underwent an immediate laparotomy. Patients who were hemodynamically stable and had no signs of peritonitis were selected for further CT scan evaluation. In the absence of CT scan findings suggestive of hollow viscus injury, the patients were observed with serial clinical examinations, hemoglobin levels, and white cell counts. Patients with left thoracoabdominal injuries underwent elective laparoscopy to rule out diaphragmatic injury. Outcome parameters included survival, complications, need for delayed laparotomy in observed patients, and length of hospital stay.

RESULTS

During the study period, there were 152 patients with 185 penetrating solid organ injuries. Gunshot wounds accounted for 70.4% and stab wounds for 29.6% of injuries. Ninety-one patients (59.9%) met the criteria for immediate operation. The remaining 61 (40.1%) patients were selected for CT scan evaluation. Forty-three patients (28.3% of all patients) with 47 solid organ injuries who had no CT scan findings suspicious of hollow viscus injury were selected for clinical observation and additional laparoscopy in 2. Four patients with a "blush" on CT scan underwent angiographic embolization of the liver. Overall, 41 patients (27.0%), including 18 cases with grade III to V injuries, were successfully managed without a laparotomy and without any abdominal complication. Overall, 28.4% of all liver, 14.9% of kidney, and 3.5% of splenic injuries were successfully managed nonoperatively. Patients with isolated solid organ injuries treated nonoperatively had a significantly shorter hospital stay than patients treated operatively, even though the former group had more severe injuries. In 3 patients with failed nonoperative management and delayed laparotomy, there were no complications.

CONCLUSIONS

In the appropriate environment, selective nonoperative management of penetrating abdominal solid organ injuries has a high success rate and a low complication rate.

[Helical computed tomography in penetrating injury to the torso. Diagnostic value in emergent use]

BACKGROUND

Nontherapeutic laparotomy and thoracotomy rates in penetrating torso trauma remain high. The aim of this study was to define the value of helical computed tomography (CT) in this emergency situation.

MATERIAL AND METHODS

Retrospectively, we studied 11 hemodynamically stable patients with penetrating injury to the torso admitted to our trauma center over a 3-year period who underwent intravenous contrasted helical CT immediately after admission. A positive CT scan was defined as showing any evidence of intrathoracal or intra-abdominal injury necessitating immediate operation. Patients with positive CT underwent laparotomy and/or thoracotomy. Patients with negative CT were observed.

RESULTS

Eleven consecutive patients were studied: nine male, two female; mean age 39 years (range 19-62). Nine stab wounds and two shotgun wounds were seen. Seven patients had positive helical CT findings, and four patients were negative. All patients with positive CT findings were operated on; those with negative scans recovered uneventfully. This imaging method accurately predicted whether thoracotomy or laparotomy was needed in 10/11 cases.

CONCLUSION

In penetrating torso trauma, helical CT can clarify the need for thoracotomy or laparotomy vs nonoperative treatment.

Abdominal computed tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative management

BACKGROUND

Computed tomographic (CT) scanning is increasingly used in patients with abdominal gunshot wounds (AGSWs) selected for nonoperative management (NOM). Triple-contrast CT scanning (i.e., intravenous, oral, and rectal) has produced encouraging initial results. The exact role and usefulness of CT scanning with intravenous contrast only is unknown.

METHODS

Hemodynamically stable AGSW patients without generalized abdominal tenderness were offered a trial of NOM, underwent single-contrast (intravenous) CT scanning, and were prospectively followed from July 1, 2002, to May 31, 2004. The sensitivity and specificity of CT scanning to detect organ injuries requiring repair were calculated against the clinical results of NOM. The effect of CT scanning in management was recorded.

RESULTS

One hundred patients with nontangential AGSWs were included. Twenty-six required laparotomy, which was nontherapeutic in five (19%). These five patients underwent operation on the basis of misleading CT findings (n = 3) or development of clinical symptoms (n = 2). Two CT scans were false-negative, and these patients were operated on at 121 and 307 minutes after arrival for hollow visceral injuries and recovered without postoperative complications. Three CT scans were false-positive and resulted in nontherapeutic laparotomies without postoperative complications. The sensitivity and specificity of CT scanning was 90.5% and 96%, respectively. CT findings resulted in a change of management in 40 patients. In nine, the decision to operate was changed to a decision to manage nonoperatively; whereas in eight, the opposite occurred. In addition, in 17, the decision to observe was changed to a decision to discharge; whereas in 1, the opposite occurred. Finally, five patients had additional tests after the findings of CT scanning.

CONCLUSION

Abdominal CT scanning is a safe and useful method of selecting AGSW patients for NOM. Further exploration is needed to define the precise benefits of routine CT scanning over clinical examination with selective CT scanning.

Gunshot Wounds of Abdomen: Evaluation of Stable Patients with Triple-Contrast Helical CT

PURPOSE

To assess helical computed tomography (CT) with contrast material administered intravenously, orally, and rectally (triple contrast helical CT)) in the prospective evaluation of stable patients with abdominal gunshot wounds in whom there is no clinical indication for immediate exploratory laparotomy.

MATERIALS AND METHODS

The study was conducted for 19 months. All patients met the following inclusion criteria: age of 16 years or older, hemodynamic stability, no clinical signs of peritoneal irritation, and signed consent to participate. Patients with obvious indications for laparotomy, such as gastrointestinal bleeding or evisceration, were excluded from the study. Forty-seven patients fulfilled the criteria and underwent abdominal triple-contrast helical CT. CT findings were evaluated by one of four radiologists for evidence of peritoneal penetration and injury to solid organs or hollow viscera. Patients were followed up clinically for 13 weeks. CT findings were compared with those at surgery and/or clinical follow-up.

RESULTS

CT demonstrated abnormalities in 27 (57%) patients. Laparotomy was performed in 11 (23%) patients; 10 procedures were therapeutic and one was nontherapeutic. The remaining 20 patients had a negative CT scan. These patients were treated conservatively. One injury was missed at CT. For prediction of the need for laparotomy, sensitivity of CT was 96%; specificity, 95%; positive predictive value, 96%; negative predictive value, 95%; and accuracy, 96%.

CONCLUSION

In stable patients with gunshot wounds to the abdomen in whom there is no indication for immediate surgery, triple-contrast helical CT can help reduce the number of cases of unnecessary or nontherapeutic laparotomy (negative laparotomy) and can help identify patients with injuries that may be safely treated without surgery.

Penetrating trauma in children

Penetrating injuries account for 10% to 20% of all pediatric trauma admissions at most centers. Gunshot wounds are responsible for the overwhelming majority of penetrating traumatic injuries and have a significantly higher mortality rate than do blunt injury mechanisms. The management of penetrating injuries can be quite challenging and often requires rapid assessment and intervention. Specific management principles are guided by the anatomic location of injury, the determination of trajectory, and the suspected organs injured. Management approaches have been adopted in large part from the more robust adult experience. However, application of these strategies to similar life-threatening injuries in the pediatric population appears appropriate.

Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury--a prospective study in 200 patients

PURPOSE

To assess the accuracy of computed tomography (CT) in demonstrating the presence or absence of peritoneal violation and type of intraperitoneal organ injury, if any, in hemodynamically stable patients with penetrating torso trauma but without definite peritoneal signs or radiographic evidence of free intraperitoneal air.

MATERIALS AND METHODS

During a 29-month period, helical CT with oral, rectal, and intravenous contrast material (triple-contrast) was performed in 200 hemodynamically stable patients, including 169 men (age range, 15-85 years; mean age, 31 years) and 31 women (age range, 17-45 years; mean age, 28 years) with penetrating torso trauma. The study group included 86 patients with gunshot wounds, 111 with stab wounds, and three impaled by sharp objects. CT scans were evaluated prospectively by three trauma radiologists for evidence of peritoneal violation to determine injury to intra- or retroperitoneal solid organs, bowel, mesentery, vascular structures, diaphragm, and urinary tract. Sensitivity, specificity, and accuracy of CT in the diagnosis of peritoneal violation were determined.

RESULTS

CT findings aided diagnosis of peritoneal violation in 34% of patients (68 of 200) and were negative for peritoneal violation in 66% of patients (132 of 200). Two patients with negative CT findings failed to improve with observation and underwent therapeutic laparotomy. CT had 97% sensitivity (66 of 68 findings), 98% specificity (130 of 132 findings), and 98% accuracy (196 of 200 findings) for peritoneal violation. CT aided diagnosis of 28 hepatic, 34 bowel or mesenteric, seven splenic, and six renal injuries. Laparotomy based on CT findings in 38 patients was considered therapeutic in 87% (33 of 38) and nontherapeutic in 8% (three of 38) and had negative results in 5% (two of 38).

CONCLUSION

Triple-contrast helical CT accurately demonstrates peritoneal violation and visceral injury in patients with penetrating torso wounds.

Nonoperative management of abdominal gunshot wounds

Mandatory surgical exploration for gunshot wounds to the abdomen has been a surgical dictum for the greater part of this past century. Although nonoperative management of blunt solid organ injuries and low-energy penetrating injuries such as stab wounds is well established, the same is not true for gunshot wounds. The vast majority of patients who sustain a gunshot injury to the abdomen require immediate laparotomy to control bleeding and contain contamination. Nonoperative treatment of patients with a gunshot injury is gaining acceptance in only a highly selected subset of hemodynamically stable adult patients without peritonitis. Although the physical examination remains the cornerstone in the evaluation of patients with gunshot injury, other techniques such as computed tomography, diagnostic peritoneal lavage, and laparoscopy allow accurate determination of intra-abdominal injury. The ability to exclude internal organ injury nonoperatively avoids the potential complications of unnecessary laparotomy. Clinical data to support selective nonoperative management of certain gunshot injuries to the abdomen are accumulating, but the approach has risks and requires careful collaborative management by emergency physicians and surgeons experienced in the care of penetrating injury.

Emergency department spirometric volume and base deficit delineate risk for torso injury in stable patients

Background

We sought to determine torso injury rates and sensitivities associated with fluid-positive abdominal ultrasound, metabolic acidosis (increased base deficit and lactate), and impaired pulmonary physiology (decreased spirometric volume and PaO₂/FiO₂).

Methods

Level I trauma center prospective pilot and post-pilot study (2000–2001) of stable patients. Increased base deficit was < 0.0 in ethanol-negative and ≤ -3.0 in ethanol-positive patients. Increased lactate was > 2.5 mmol/L in ethanol-negative and ≥ 3.0 mmol/L in ethanol-positive patients. Decreased PaO₂/FiO₂ was < 350 and decreased spirometric volume was < 1.8 L.

Results

Of 215 patients, 66 (30.7%) had a torso injury (abdominal/pelvic injury n = 35 and/or thoracic injury n = 43). Glasgow Coma Scale score was 14.8 ± 0.5 (13–15). Torso injury rates and sensitivities were: abdominal ultrasound negative and normal base deficit, lactate, PaO₂/FiO₂, and spirometric volume – 0.0% & 0.0%; normal base deficit and normal spirometric volume – 4.2% & 4.5%; chest/abdominal soft tissue injury – 37.8% & 47.0%; increased lactate – 39.7% & 47.0%; increased base deficit – 41.3% & 75.8%; increased base deficit and/or decreased spirometric volume – 43.8% & 95.5%; decreased PaO₂/FiO₂ – 48.9% & 33.3%; positive abdominal ultrasound – 62.5% & 7.6%; decreased spirometric volume – 73.4% & 71.2%; increased base deficit and decreased spirometric volume – 82.9% & 51.5%.

Conclusions

Trauma patients with normal base deficit and spirometric volume are unlikely to have a torso injury. Patients with increased base deficit or lactate, decreased spirometric volume, decreased PaO₂/FiO₂, or positive FAST have substantial risk for torso injury. Increased base deficit and/or decreased spirometric volume are highly sensitive for torso injury. Base deficit and spirometric volume values are readily available and increase or decrease the suspicion for torso injury.

Technology-driven triage of abdominal trauma: the emerging era of nonoperative management

Selective nonoperative management of blunt or penetrating abdominal trauma is safe, has eliminated the complications associated with nontherapeutic laparotomies, and is cost-effective. Appropriately selected investigations, such as focused abdominal sonography for trauma, diagnostic peritoneal lavage, spiral computed tomography (CT) scan, diagnostic laparoscopy, or thoracoscopy and angiography, play a critical role in the triage of patients. Future technological advances, such as improvement of the ultrasonic hardware and software that provide automated interpretation and the availability of portable CT scan machines in the emergency room, may improve the speed and accuracy of the initial evaluation. Improvement of the optical system of minilaparoscopes may allow reliable bedside laparoscopy for suspected diaphragmatic injuries.

Selective Management of Penetrating Truncal Injuries: Is Emergency Department Discharge a Reasonable Goal?

We undertook this retrospective review to examine the appropriateness of a protocol for the selective emergency department (ED) workup of asymptomatic penetrating truncal injuries. Records of consecutive patients presenting to our urban Level I trauma center with penetrating truncal injuries between January 1, 1997 and September 2000 were reviewed. Data obtained included: patient demographics, ED workup, ED disposition, complications, and follow-up. Selective ED workup included hospital triple-contrast CT, admission for observation, and local wound exploration for selected anterior abdominal stab wounds. Four hundred fifty-five patients presented with penetrating truncal wounds during the study period. One hundred ninety-four patients were taken directly to the operating room, 136 were discharged based solely on physical examination and plain radiographs, 18 were admitted for observation without ED workup, and 107 had selective ED workup. Sixty-two patients (58% of those selectively worked up) were discharged home after negative ED workup, 18 were managed operatively, and 27 were managed nonoperatively. There were two missed injuries that were later identified and managed with no complications. Follow-up was available on 66 per cent of ED workup patients (range 1–42 months). We conclude that selective management of certain penetrating truncal injuries appears appropriate. Patients having a negative selective ED workup can be safely discharged thereby avoiding the cost and resource utilization associated with hospital admission.

Reevaluation of diagnostic procedures for transmediastinal gunshot wounds

BACKGROUND

Little controversy surrounds the treatment of hemodynamically unstable patients with transmediastinal gunshot wounds (TMGSWs). These patients generally have cardiac or major vascular injuries and require immediate operation. In hemodynamically stable patients, debate surrounds the extent and order of the diagnostic evaluation. These patients can be uninjured, or can have occult vascular, esophageal, or tracheobronchial injuries. Evaluation has traditionally often included angiography, bronchoscopy, esophagoscopy, esophagography, and pericardial evaluation (i.e., pericardial window) for all hemodynamically stable patients with TMGSWs. Expansion of the use of computed tomographic (CT) scanning in penetrating injury led to a modification of our protocol. Currently, our TMGSW evaluation algorithm for stable patients consists of chest radiograph, focused abdominal sonography for trauma, and contrast-enhanced helical CT scan of the chest with directed further evaluation. The purpose of this study is to evaluate the efficiency of contrast-enhanced helical CT scan for evaluating potential mediastinal injuries and to determine whether patients can be simply observed or require further investigational studies.

METHODS

Medical records of hemodynamically stable patients admitted with TMGSWs over a 2-year period were reviewed for demographics, mechanism of injury, method of evaluation, operative interventions, injuries, length of stay, and complications. CT scans were considered positive if they contained a mediastinal hematoma or pneumomediastinum, or demonstrated proximity of the missile track to major mediastinal structures.

RESULTS

Twenty-two stable patients were studied. CT scans were positive in seven patients. Directed further diagnostic evaluation in those seven patients revealed two patients who required operative intervention. Sixty-eight percent of patients had negative CT scans and were observed in a monitored setting without further evaluation. There were no missed injuries. The hospital charges generated with the CT scan-based protocol are significantly less than with the standard evaluation.

CONCLUSION

Contrast-enhanced helical CT scanning is a safe, efficient, and cost-effective diagnostic tool for evaluating hemodynamically stable patients with mediastinal gunshot wounds. Positive CT scan results direct the further evaluation of potentially injured structures. Patients with negative results can safely be observed in a monitored setting without further evaluation.