Image: PD
1. In evaluating abdominal stab wound patients, physical exam alone was sufficient to determine if patients required therapeutic laparotomy.
2. The sensitivity and specificity of physical exam was higher than that of CT imaging, and were more likely to alter clinical decision making than CT imaging.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Although some patients with abdominal stab wounds obviously require surgical intervention, some patients are stable enough to observe and evaluate before proceeding further. However, management guidelines for abdominal stab wounds are unclear, and the utility of CT is not established, due to the lack of local soft tissue disruption. This study evaluated the diagnostic utility of CT compared to physical examination in abdominal stab wound patients, and demonstrated that physical exam alone was able to determine whether therapeutic laparotomy was required, or observation alone would be sufficient. Moreover, the sensitivity and specificity of physical exam was higher than that of CT. One weakness of this study was that the authors did not specify the methodology of physical exam performed on these patients, or who performed the exams. Also, the minimum observation period was only 24 hours, and it is possible that a patient who was discharged may have had a later complication.
Click to read the study in JAMA Surgery
Click to read an accompanying editorial
Relevant Reading: The Nonoperative Management of Penetrating Abdominal Trauma
In-Depth [prospective study]: This study examined 249 patients older than 16 years of age with abdominal stab wounds. Patients with extra-abdominal injuries requiring intervention were excluded. The cohort was mostly male patients, with average age of 30.8 years. Most patients had a single stab wound (67.5%), with some patients having up to 6 stab wounds. 18.1% of the initial cohort were unstable and required immediate surgical intervention. 10.8% of patients had only superficial wounds and were discharged from the emergency department were excluded. The remaining 177 patients had a CT and underwent a minimum of 24 hours of observation with nonoperative management.
Of the 177 patients with CT and nonoperative management, 154 required no laparotomy intervention, including 30 patients with solid organ damage that was managed nonoperatively, all of whom were discharged within 48 hours without complication. Three patients eventually had thoracic procedures, and 20 patients underwent abdominal exploration, all based on deterioration of their physical exam. Two patients underwent laparotomy due to CT findings only, both leading to negative laparotomies. The sensitivity and specificity of physical exam for determining if laparotomy is necessary was found to be 100% and 98.7% respectively, compared to only 31.3% and 84.2% for CT imaging.
By James Jiang and Allen Ho
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