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Sun Dec 30 20:55:27 GMT 2007

And I am not suggesting that a nontherapeutic laparotomy is a benign procedure, but missing an injury IS.   I'll illustrate my point with a single system injury which has a well studied natural history.

The best data about missed hollow viscus injuries and their associated mortality is well described in the EAST Hollow Viscus Injury work group*.  These injuries are significant even when found EARLY and their morbidity and mortality goes up significantly with each passing HOUR.  Mind you they were looking at hollow viscus injury from BLUNT mechanism which itself is a rare entity.  Hollow viscus injury from PENETRATING injury is much more common and much less studied radiographically because almost all of the patients in this cohort traditionally get immediate laparotomy.  

If you then say that we will decide to selectively not operate on penetrating (civilian firearm) trauma to the abdomen you must be cognizant that these injuries if missed will be of significant morbidity for four reasons:
1.  No radiographic modality (even CT) is good at identifying them**.
2.  CT for penetrating trauma to the abdomen is a relatively new concept and is uncharted territory in many institutions and unless you see a LOT of this sort of injury you may not recognize the SUBTLE CT findings which indicate a second system injury.
3.  When the liver is shot it may hurt to such a degree as to MASK other peritonitic findings.
4.  By the time a physical exam or vital signs indicate that your patient needs an operation their window for favorable outcome may have already CLOSED. 

Just as an aside, many (myself included) believe that laparoscopy is misapplied much more often than it is of benefit in trauma.  I believe it has very utility in a GSW to the abdomen.  

Ben Reynolds, PA-C
Pittsburgh, PA

*Fakhry SM, Brownstein M, Watts DD, Baker CC, Oller D.  Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma. 2000 Mar;48(3):408-14; discussion 414-5.

Watts DD, Fakhry SM; EAST Multi-Institutional Hollow Viscus Injury Research Group. Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the East multi-institutional trial. J Trauma. 2003 Feb;54(2):289-94. Erratum in: J Trauma. 2003 Apr;54(4):749.

Williams MD, Watts D, Fakhry S. Colon injury after blunt abdominal trauma: results of the EAST Multi-Institutional Hollow Viscus Injury Study. J Trauma. 2003 Nov;55(5):906-12

**Fakhry SM, Watts DD, Luchette FA; EAST Multi-Institutional Hollow Viscus Injury Research Group. Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial. J Trauma. 2003 Feb;54(2):295-306.

----- Original Message ----
From: "Louis Brusco Jr., M.D." <lb86 at columbia.edu>
To: Ben Reynolds <aneurysm_42 at yahoo.com>
Cc: errington at erringtonthompson.com; "Trauma & Critical Care mailing list" <trauma-list at trauma.org>; Critical Care List <ccm-l at ccm-l.org>
Sent: Sunday, December 30, 2007 3:16:24 PM
Subject: Re: [ccm-l] FW: GSW to liver

I guess my question is to that last statement:

the morbidity of a diagnostic (nontherapeutic) laparotomy can PALE in comparison to the mortality associated with missed injury (hollow viscus, biliary, vascular).

In the era of CT Guided drainage - laparoscopy - is that statement 
REALLY true?  If you monitor the patient to make sure that they do not 
bleed to death - monitor heart rate, BP, Hct. etc fastidiously and 
jumping on any drop - then deal with the complications swiftly - 
infection, bile leak, etc - is that statement really true? Please note - 
I am not saying these should be handled non-operatively - just asking 
the question:

We are saying that it is acceptable to have X exploratory laparotomies 
which, in retrospect, nothing was done and were not needed, in order to 
prevent Y problems that would have been better dealt with with a 
laparotomy early on and then are less well dealt with CT guided 
drainage, antibiotics etc.  What # or percentage is X?  What # or 
percentage is Y?

We have all seen patients with negative exploratory laparotomies develop 
post-operative complications - so it is not a benign procedure.

Lou

-- 
Louis Brusco Jr., M.D., F.C.C.M.
Associate Medical Director
St. Luke's-Roosevelt Hospital Center
NYC

Co-Director, Surgical Intensive Care Unit
Director, Critical Care Anesthesiology
Medical Director, Post-Anesthesia Care Unit

Ben Reynolds wrote:
> On the whole, I think Errington's approach was the safest. 
>
> The impetus for nonoperative management of penetrating (specifically civilian FIREARM) abdominal trauma comes primarily out of LA and Baltimore (overwhelmingly the former).  Their results, I think are mixed and do NOT provide a strong enough foundation to defend a reproducible and sustainable "standard of care" in all institutions.  Way too many questions are left unanswered and no papers from other centers have come out duplicating their results (THAT I KNOW OF).  Probably because few other places see as much penetrating trauma as they do in order to accomplish nonoperative management successfully.
>
> A laparotomy is a DIAGNOSTIC test with as near to a 100% sensitivity and specificity as one can get and is THERAPEUTIC if you make a diagnosis that requires intervention.  In general one shouldn't fall into believing that a penetrating wound to the right upper quadrant would ONLY involve liver.  CT cannot accurately diagnose a penetrating injury to the bile ducts, the gallbladder or the colon (among other structures).  
>
> I think that it's important to keep in mind that the morbidity of a diagnostic (nontherapeutic) laparotomy can PALE in comparison to the mortality associated with missed injury (hollow viscus, biliary, vascular).    
>
> Ben Reynolds, PA-C
> Pittsburgh, PA
>
> ----- Original Message ----
> From: Errington Thompson <errington at erringtonthompson.com>
> To: "Louis Brusco Jr., M.D." <lb86 at columbia.edu>
> Cc: Critical Care List <ccm-l at ccm-l.org>
> Sent: Sunday, December 30, 2007 11:26:27 AM
> Subject: RE: [ccm-l] FW: GSW to liver
>
> There is a growing body of literature that says that CT'ing these patients
> are safe.  I believe that a good CT scan is only as good as the radiologists
> reading the scan.  I fear missing bowel injuries in patients I know will
> have fluid on their CT scans. 
>
> Of course, I could laparoscope the patient.  That is something that I
> considered at the time.  The patient probably could have benefitted from
> being scoped.  I'm still on the fence on this one. 
>
> Serial exams - Eddie Cornwell and the guys at LA County looked at this.  You
> need a specialized unit to this protocol.  Breaking the protocol has
> significant consequences to the patient - prolonged ICU/hospital
> stay/infectious complications.  Great study. 
>
> Errington C. Thompson, MD, FACS, FCCM
> Trauma/Surgical Critical Care
> Author - Letter to America
> Asheville, NC
>
> -----Original Message-----
> From: Louis Brusco Jr., M.D. [mailto:lb86 at columbia.edu] 
> Sent: Sunday, December 30, 2007 10:54 AM
> To: errington at erringtonthompson.com
> Cc: 'Critical Care List'
> Subject: Re: [ccm-l] FW: GSW to liver
>
> E
>
> Isn't this one where the literature is little help?  If you look at the 
> literature - the patient should go to OR or get a DPL - but sometimes 
> they look SO SO good - and you go in and find nothing that you had to do 
> anything about - with modern, good SICU care - why not admit them and 
> wait it out?  The down side - he bleeds out and you get him to the OR 
> too late - if that happens one out of 1000 - is that too much of a risk 
> for you?  I am sure Ken M will have an opinion here that I am 
> interesting in hearing.  When I get these patients in the ICU - and I 
> hear the absolutes (take GSW to Abd to OR - take Zone X neck stab wound 
> to OR) I wonder if modern imaging and ICU care has yet changed that...
>
> Lou
>
>

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[ccm-l] FW: GSW to liver