List Archives

Sun Oct 25 18:17:15 GMT 2009

How you management the patient with a stabbed abdomen who is
haemodynamically normal and has no peritonitis is one of the simplest
but hardest questions in modern trauma care.   Fundamentally there are
a number of ways of managing these patients.  The reason why it
generates such debate is because it's fundamentally a question not of
the patient but of the resources and expertise available.

If you're in a hospital with lots of doctors & nurses, enough beds and
low quality imaging or imaging expertise, then admission with regular
haemodynamic observation and serial clinical examination has been
shown to be safe and effective.  This is the case in South Africa
where this management plan originated and also in many parts of the
world.  It should be considered the safe fall-back option.

In our situation, beds are at a premium (especially monitored beds),
few doctors on call and a high possibility that patients will not be
reviewed by a surgeon until the next morning.  We also have 2
high-spec scanners on site and good on-call radiology coverage.  So we
use CT as a screening tool.  NOT to diagnosis bowel injury (although
the new scanners are pretty good) but because if the wound track
clearly goes nowhere near anything important then we can discharge the
patient.

The literature does not support laparoscopy for these patients.
HOWEVER if you are in a hospital and there is an experienced
laparoscopic surgeon on call perhaps they can identify bowel
perforation (early) reliably.  (I don't believe you should be looking
at laparoscopy for just diagnosing peritoneal penetration).  But this
does require beds and operating room space etc etc.

I also don't believe local wound exploration is a good test.  Nor do I
think FAST is useful in these patients.  MRI??  Never seen any
literature to support it but it seems, for the moment at least, like
expensive overkill (compared to a high-quality CT).

So - how you manage these patient depends less on the patient and more
on clinical expertise and hospital resources at your disposal.  Hence
the arguments - we're all looking at this from different starting
points.

Karim

2009/10/25 McSwain, Norman E Jr. <nmcswai at tulane.edu>:
> How much does an MRI cost vs serial physical examinations?
> Has accuracy of MRI for holes in Small Bowel been reviewed?
>
> Norman
>
> Typed by the thumbs of
> Norman on his BlackBerry
>
> Norman McSwain, MD
> Tulane Univ Surgery
> 504 988-5111
>
> ----- Original Message -----
> From: trauma-list-bounces at trauma.org <trauma-list-bounces at trauma.org>
> To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
> Sent: Sun Oct 25 01:39:25 2009
> Subject: RE: selectice conservative management of stab injury abdomen-
>
> I think I'm gonna be sick....
> ________________________________________
> From: trauma-list-bounces at trauma.org [trauma-list-bounces at trauma.org] On Behalf Of caesar ursic [cmursic at gmail.com]
> Sent: Sunday, October 25, 2009 1:23 AM
> To: Trauma-List [TRAUMA.ORG]
> Subject: Re: selectice conservative management of stab injury abdomen-
>
> Excellent question!
> MRI certainly has a very high resolving power, and unlike laparoscopy, is
> non-invasive.
> so...MRI for stab wounds:  who's for it?
>
> CM Ursic, MD
> general surgeon
>
>
>
> On Sat, Oct 24, 2009 at 5:56 PM, <galucas at att.net> wrote:
>
>> Do you have MRI capabilities?
>> --
>> Gayle A. Lucas
>>
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selectice conservative management of stab injury abdomen-