List Archives

Tue Oct 27 09:07:59 GMT 2009

Dr. Teperman, unless your patient has consented to this discussion (see BTW,
below), it is probably in violation of federal HIPAA restrictions.   The
penalties can be severe.

We would all do well to take a lesson: the details of these cases belong to
the patients, not us.

Pret Bjorn, RN
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Teperman, Sheldon
Sent: Monday, October 26, 2009 3:39 PM
To: 'trauma-list at trauma.org'
Subject: RE: trauma-list Digest, Vol 76, Issue 35-Selective
Conservativestabs of the Abdomen

Its funny-We have been trying to answer this very question up here in the
Bronx. The question came about when we hired a bright young Surgeon who  did
his Trauma Fellowship at UC -Davis. Sal Ahmad came to us with a very
aggressive bent on how to manage anterior stab wounds-that is to say- he
wanted to operate on most of them -and that perhaps the air up here  was too
thin and we were not getting it right. So we made a bet.
        Sal spent the last three years looking at close to two hundred of
these pts( isolated anterior stab wounds)- and we are in the process of
submission.  He did some fancy Artificial Neural Network Modeling-which I
don't presume to understand.  But bottom line- It would appear that Carter
Nance and those that followed got it right.  With conservative and selective
management and  with Liberal CT scanning ( which he says had a high positive
predictive value-atleast for us). We managed not to loose a single Pt and
had nary a missed injury.  I agree with Dr. Brohi- that it has a lot to do
with resources and how comfortable your people are with penetrating trauma.
But clearly if your paying attention, you can watch lots of people without
hurting them- and the CT helps with the watching

....Sheldon Teperman

        BTW - although we are presently writing about Stab wounds- We do
specialize in another form of penetrating trauma in the Bronx... If you have
been following the news coming out of NYC. A 92 year old Lady took a stray
bullet through her living room window last week ( a gang thing maybe)-
landing her in my OR. How that bullet found her retro hepatic cava is a
mystery to me- but an even bigger mystery is how we think its fine that an
18 year old boy becomes a murderer with a  gun, which if they ever find it,
will have an over 90% chance of having gotten to him from a state with lax
gun safety laws. Likely from a disreputable dealer or just as likely from an
unregulated sale at a gun show.
        My older  brother Lew is a Transplant surgeon- and he likes to say
that when a trauma surgeon is looking at the Retrohepatic Cava- he is
looking at the Pt's soul- which is Ascending to heaven.  I think we all lost
a bit of our collective souls that day...

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of trauma-list-request at trauma.org
Sent: Monday, October 26, 2009 12:45 PM
To: trauma-list at trauma.org
Subject: trauma-list Digest, Vol 76, Issue 35

Send trauma-list mailing list submissions to
        trauma-list at trauma.org

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When replying, please edit your Subject line so it is more specific
than "Re: Contents of trauma-list digest..."

Today's Topics:

   1. RE: selectice conservative management of stab injury abdomen-
      (Gross, Ronald)
   2. RE: selectice conservative management of stab injury abdomen-
      (McSwain, Norman E Jr.)
   3. RE: selectice conservative management of stab injury abdomen-
      (Gross, Ronald)
   4. RE: selectice conservative management of stab injury abdomen-
      (McSwain, Norman E Jr.)
   5. Re: selectice conservative management of stab injury abdomen-
      (Krin135 at aol.com)
   6. RE: selectice conservative management of stab injury abdomen-
      (Gross, Ronald)
   7. Re: selectice conservative management of stab injury abdomen-
      (Krin135 at aol.com)
   8. RE: selectice conservative management of stab injury abdomen-
      (McSwain, Norman E Jr.)
   9. RE: selectice conservative management of stab injury abdomen-
      (Gross, Ronald)
  10. RE: selectice conservative management of stab injury abdomen-
      (Gross, Ronald)
  11. Selective Conservative Management of ant/flank abdominal stab
      wounds:   summary (Krin135 at aol.com)
  12. Re: Selective Conservative Management of ant/flank abdominal
      stab      wounds: sum... (Krin135 at aol.com)
  13. RE: Selective Conservative Management of ant/flank abdominal
      stab      wounds:summary (McSwain, Norman E Jr.)
  14. RE: Selective Conservative Management of ant/flank abdominal
      stabwounds: sum... (McSwain, Norman E Jr.)

----------------------------------------------------------------------

Message: 1
Date: Mon, 26 Oct 2009 08:44:47 -0400
From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
Subject: RE: selectice conservative management of stab injury abdomen-
To: "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
Message-ID:
        <FD2BE6867A90F543AAD02E429F878633014D37A0DB7B at bhsexc11.bhs.org>
Content-Type: text/plain; charset="us-ascii"

I will get a CT if I am suspicious for peritoneal involvement, but I do
personally examine these patients on admission and every 4-6 hrs thereafter
for 18-24 hours, after which they are sent home.  My residents follow a
similar exam schedule, but on alternate times, so that in reality the
patients are seen almost every 2-3 hours.
Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Sanjay Gupta
Sent: Sunday, October 25, 2009 9:37 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: selectice conservative management of stab injury abdomen-

Well,now that someone has brought this point up:

How many of the trauma surgeons who are Professors in a University, actually
admit the stable patients with penetrating trauma and with no peritoneal
signs, and do not do a CT scan, and examine them at admission and every 4
hours PERSONALLY thereafter, until the patient has either been cleared or a
laparotomy has been decided upon.  (or is the job delegated to the Trauma
Chief resident who in turn delegates the job to the trauma intern).

I ask the above question because in a typical level II trauma center in a
community hospital in the US, there is a single trauma surgeon who covers
trauma, the surgical ICU and the surgical emergencies.  He or she also
cannot delegate the above responsibility to anyone else.

Also, in those rare instances, when laparotomy is decided to be done in a
delayed fashion, what is your opinion about the medico-legal risk.

Sanjay Gupta

(No blackberry or I-phone.Do not care for one either)

----- Original Message ----
From: caesar ursic <cmursic at gmail.com>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Sun, October 25, 2009 3:47:14 PM
Subject: Re: selectice conservative management of stab injury abdomen-

"*There are many paths that lead to the summit of one and the same mountain*
"

-Buddha

On Sun, Oct 25, 2009 at 8:17 AM, Karim Brohi <karimbrohi at gmail.com> wrote:

> 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
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

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----------------------------------------------------------------------
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you are hereby notified that you have received this communication in error
and that any review, disclosure, dissemination, distribution or copying of
it or its contents is prohibited. If you have received this communication in
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794-0000 and destroy all copies of this communication and any attachments.
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visit our Internet web site at http://www.baystatehealth.com.

------------------------------

Message: 2
Date: Mon, 26 Oct 2009 08:29:39 -0500
From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
Subject: RE: selectice conservative management of stab injury abdomen-
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:
        <B79C02DCC4FA074DB02381DF1C5D60BA02C74916 at EX07.ad.tulane.edu>
Content-Type: text/plain;       charset="us-ascii"

Ron
Why do you get a CT if you are " suspicious for peritoneal involvement"?
What does it all? Does it change your treatment?

Norman

Norman McSwain MD
Professor, Tulane School of Medicine
Trauma Director, Charity Hospital Trauma Center
norman.mcswain at tulane.edu
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
Sent: Monday, October 26, 2009 7:45 AM
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: selectice conservative management of stab injury abdomen-

I will get a CT if I am suspicious for peritoneal involvement, but I do
personally examine these patients on admission and every 4-6 hrs
thereafter for 18-24 hours, after which they are sent home.  My
residents follow a similar exam schedule, but on alternate times, so
that in reality the patients are seen almost every 2-3 hours.
Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Sanjay Gupta
Sent: Sunday, October 25, 2009 9:37 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: selectice conservative management of stab injury abdomen-

Well,now that someone has brought this point up:

How many of the trauma surgeons who are Professors in a University,
actually admit the stable patients with penetrating trauma and with no
peritoneal signs, and do not do a CT scan, and examine them at admission
and every 4 hours PERSONALLY thereafter, until the patient has either
been cleared or a laparotomy has been decided upon.  (or is the job
delegated to the Trauma Chief resident who in turn delegates the job to
the trauma intern).

I ask the above question because in a typical level II trauma center in
a community hospital in the US, there is a single trauma surgeon who
covers trauma, the surgical ICU and the surgical emergencies.  He or she
also cannot delegate the above responsibility to anyone else.

Also, in those rare instances, when laparotomy is decided to be done in
a delayed fashion, what is your opinion about the medico-legal risk.

Sanjay Gupta

(No blackberry or I-phone.Do not care for one either)

----- Original Message ----
From: caesar ursic <cmursic at gmail.com>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Sun, October 25, 2009 3:47:14 PM
Subject: Re: selectice conservative management of stab injury abdomen-

"*There are many paths that lead to the summit of one and the same
mountain*
"

-Buddha

On Sun, Oct 25, 2009 at 8:17 AM, Karim Brohi <karimbrohi at gmail.com>
wrote:

> 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
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

----------------------------------------------------------------------
CONFIDENTIALITY NOTICE: This email communication and any attachments may
contain confidential and privileged information for the use of the
designated recipients named above. If you are not the intended
recipient, you are hereby notified that you have received this
communication in error and that any review, disclosure, dissemination,
distribution or copying of it or its contents is prohibited. If you have
received this communication in error, please reply to the sender
immediately or by telephone at (413) 794-0000 and destroy all copies of
this communication and any attachments. For further information
regarding Baystate Health's privacy policy, please visit our Internet
web site at http://www.baystatehealth.com.
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------------------------------

Message: 3
Date: Mon, 26 Oct 2009 10:14:50 -0400
From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
Subject: RE: selectice conservative management of stab injury abdomen-
To: "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
Message-ID:
        <FD2BE6867A90F543AAD02E429F878633014D37A0DB80 at bhsexc11.bhs.org>
Content-Type: text/plain; charset="us-ascii"

I am embarrassed to say this, but when it is done it is more a knee-jerk
reaction to my insecurity on a particular case than rational.  Most often I
will scan those patients who's mental status is clouded on admission by
drugs or alcohol, and so my initial  exam on admission has been, in my
opinion, clouded and therefore less than reliable.

Does it change my treatment?  Frankly no, but (and don't hurt me for this) I
feel a bit better..........

Ron
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of McSwain, Norman E Jr.
Sent: Monday, October 26, 2009 9:30 AM
To: Trauma-List [TRAUMA.ORG]
Subject: RE: selectice conservative management of stab injury abdomen-

Ron
Why do you get a CT if you are " suspicious for peritoneal involvement"?
What does it all? Does it change your treatment?

Norman

Norman McSwain MD
Professor, Tulane School of Medicine
Trauma Director, Charity Hospital Trauma Center
norman.mcswain at tulane.edu
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
Sent: Monday, October 26, 2009 7:45 AM
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: selectice conservative management of stab injury abdomen-

I will get a CT if I am suspicious for peritoneal involvement, but I do
personally examine these patients on admission and every 4-6 hrs
thereafter for 18-24 hours, after which they are sent home.  My
residents follow a similar exam schedule, but on alternate times, so
that in reality the patients are seen almost every 2-3 hours.
Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Sanjay Gupta
Sent: Sunday, October 25, 2009 9:37 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: selectice conservative management of stab injury abdomen-

Well,now that someone has brought this point up:

How many of the trauma surgeons who are Professors in a University,
actually admit the stable patients with penetrating trauma and with no
peritoneal signs, and do not do a CT scan, and examine them at admission
and every 4 hours PERSONALLY thereafter, until the patient has either
been cleared or a laparotomy has been decided upon.  (or is the job
delegated to the Trauma Chief resident who in turn delegates the job to
the trauma intern).

I ask the above question because in a typical level II trauma center in
a community hospital in the US, there is a single trauma surgeon who
covers trauma, the surgical ICU and the surgical emergencies.  He or she
also cannot delegate the above responsibility to anyone else.

Also, in those rare instances, when laparotomy is decided to be done in
a delayed fashion, what is your opinion about the medico-legal risk.

Sanjay Gupta

(No blackberry or I-phone.Do not care for one either)

----- Original Message ----
From: caesar ursic <cmursic at gmail.com>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Sun, October 25, 2009 3:47:14 PM
Subject: Re: selectice conservative management of stab injury abdomen-

"*There are many paths that lead to the summit of one and the same
mountain*
"

-Buddha

On Sun, Oct 25, 2009 at 8:17 AM, Karim Brohi <karimbrohi at gmail.com>
wrote:

> 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
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

--
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To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

----------------------------------------------------------------------
CONFIDENTIALITY NOTICE: This email communication and any attachments may
contain confidential and privileged information for the use of the
designated recipients named above. If you are not the intended
recipient, you are hereby notified that you have received this
communication in error and that any review, disclosure, dissemination,
distribution or copying of it or its contents is prohibited. If you have
received this communication in error, please reply to the sender
immediately or by telephone at (413) 794-0000 and destroy all copies of
this communication and any attachments. For further information
regarding Baystate Health's privacy policy, please visit our Internet
web site at http://www.baystatehealth.com.
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/

----------------------------------------------------------------------
CONFIDENTIALITY NOTICE: This email communication and any attachments may
contain confidential and privileged information for the use of the
designated recipients named above. If you are not the intended recipient,
you are hereby notified that you have received this communication in error
and that any review, disclosure, dissemination, distribution or copying of
it or its contents is prohibited. If you have received this communication in
error, please reply to the sender immediately or by telephone at (413)
794-0000 and destroy all copies of this communication and any attachments.
For further information regarding Baystate Health's privacy policy, please
visit our Internet web site at http://www.baystatehealth.com.

------------------------------

Message: 4
Date: Mon, 26 Oct 2009 09:16:43 -0500
From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
Subject: RE: selectice conservative management of stab injury abdomen-
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:
        <B79C02DCC4FA074DB02381DF1C5D60BA02C74957 at EX07.ad.tulane.edu>
Content-Type: text/plain;       charset="us-ascii"

Radiation is a good thing. It made me feel better too but it only hit my
neck :)

Norman

Norman McSwain MD
Professor, Tulane School of Medicine
Trauma Director, Charity Hospital Trauma Center
norman.mcswain at tulane.edu
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
Sent: Monday, October 26, 2009 9:15 AM
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: selectice conservative management of stab injury abdomen-

I am embarrassed to say this, but when it is done it is more a knee-jerk
reaction to my insecurity on a particular case than rational.  Most
often I will scan those patients who's mental status is clouded on
admission by drugs or alcohol, and so my initial  exam on admission has
been, in my opinion, clouded and therefore less than reliable.

Does it change my treatment?  Frankly no, but (and don't hurt me for
this) I feel a bit better..........

Ron
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of McSwain, Norman E
Jr.
Sent: Monday, October 26, 2009 9:30 AM
To: Trauma-List [TRAUMA.ORG]
Subject: RE: selectice conservative management of stab injury abdomen-

Ron
Why do you get a CT if you are " suspicious for peritoneal involvement"?
What does it all? Does it change your treatment?

Norman

Norman McSwain MD
Professor, Tulane School of Medicine
Trauma Director, Charity Hospital Trauma Center
norman.mcswain at tulane.edu
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
Sent: Monday, October 26, 2009 7:45 AM
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: selectice conservative management of stab injury abdomen-

I will get a CT if I am suspicious for peritoneal involvement, but I do
personally examine these patients on admission and every 4-6 hrs
thereafter for 18-24 hours, after which they are sent home.  My
residents follow a similar exam schedule, but on alternate times, so
that in reality the patients are seen almost every 2-3 hours.
Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Sanjay Gupta
Sent: Sunday, October 25, 2009 9:37 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: selectice conservative management of stab injury abdomen-

Well,now that someone has brought this point up:

How many of the trauma surgeons who are Professors in a University,
actually admit the stable patients with penetrating trauma and with no
peritoneal signs, and do not do a CT scan, and examine them at admission
and every 4 hours PERSONALLY thereafter, until the patient has either
been cleared or a laparotomy has been decided upon.  (or is the job
delegated to the Trauma Chief resident who in turn delegates the job to
the trauma intern).

I ask the above question because in a typical level II trauma center in
a community hospital in the US, there is a single trauma surgeon who
covers trauma, the surgical ICU and the surgical emergencies.  He or she
also cannot delegate the above responsibility to anyone else.

Also, in those rare instances, when laparotomy is decided to be done in
a delayed fashion, what is your opinion about the medico-legal risk.

Sanjay Gupta

(No blackberry or I-phone.Do not care for one either)

----- Original Message ----
From: caesar ursic <cmursic at gmail.com>
To: Trauma-List [TRAUMA.ORG] <trauma-list at trauma.org>
Sent: Sun, October 25, 2009 3:47:14 PM
Subject: Re: selectice conservative management of stab injury abdomen-

"*There are many paths that lead to the summit of one and the same
mountain*
"

-Buddha

On Sun, Oct 25, 2009 at 8:17 AM, Karim Brohi <karimbrohi at gmail.com>
wrote:

> 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
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Message: 5
Date: Mon, 26 Oct 2009 10:40:31 EDT
From: Krin135 at aol.com
Subject: Re: selectice conservative management of stab injury abdomen-
To: trauma-list at trauma.org
Message-ID: <bdb.4e4aea67.38170edf at aol.com>
Content-Type: text/plain; charset="US-ASCII"

Are you looking to pick up free air/blood or do you inject some  contrast
into the wound tract for these exams?
ck

In a message dated 10/26/2009 08:15:32 Central Standard Time,
Ronald.Gross at baystatehealth.org writes:

I am  embarrassed to say this, but when it is done it is more a knee-jerk
reaction  to my insecurity on a particular case than rational.  Most often I
will  scan those patients who's mental status is clouded on admission by
drugs or  alcohol, and so my initial  exam on admission has been, in my opi
nion,  clouded and therefore less than reliable.

Does it change my  treatment?  Frankly no, but (and don't hurt me for this)
I feel a bit  better..........

Ron
snip

------------------------------

Message: 6
Date: Mon, 26 Oct 2009 10:43:44 -0400
From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
Subject: RE: selectice conservative management of stab injury abdomen-
To: "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
Message-ID:
        <FD2BE6867A90F543AAD02E429F878633014D37A0DB84 at bhsexc11.bhs.org>
Content-Type: text/plain; charset="us-ascii"

I'm looking for fluid and/or air.  Now, what I would do with the fluid is a
whole other story......in other words, if I did see fluid, should I/would I
do a DPL?  Frankly, no, if the abdomen is completely benign, with no
rigidity and normal bowel sounds, a normal set of labs and a very low level
of suspicion.  Free air on the other hand would force me to the OR
regardless of the exam or my (poorly conceived) level of suspicion!

Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Krin135 at aol.com
Sent: Monday, October 26, 2009 10:41 AM
To: trauma-list at trauma.org
Subject: Re: selectice conservative management of stab injury abdomen-

Are you looking to pick up free air/blood or do you inject some  contrast
into the wound tract for these exams?
ck

In a message dated 10/26/2009 08:15:32 Central Standard Time,
Ronald.Gross at baystatehealth.org writes:

I am  embarrassed to say this, but when it is done it is more a knee-jerk
reaction  to my insecurity on a particular case than rational.  Most often I
will  scan those patients who's mental status is clouded on admission by
drugs or  alcohol, and so my initial  exam on admission has been, in my opi
nion,  clouded and therefore less than reliable.

Does it change my  treatment?  Frankly no, but (and don't hurt me for this)
I feel a bit  better..........

Ron
snip

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Message: 7
Date: Mon, 26 Oct 2009 10:53:32 EDT
From: Krin135 at aol.com
Subject: Re: selectice conservative management of stab injury abdomen-
To: trauma-list at trauma.org
Message-ID: <c05.6e8d4b6a.381711ec at aol.com>
Content-Type: text/plain; charset="US-ASCII"

Would there be any utility to do a 'fistula gram' of the wound track to see
 if there is peritoneal penetration as long as you felt you needed to scan
due to  mental incapacity of the patient?

(I was 'raised' in the 'serial exam' school, btw....and have seen more than
 a couple of cases where anterior/flank abdominal stab wounds failed to
penetrate  due to the overlying tissue.)

ck

In a message dated 10/26/2009 08:44:25 Central Standard Time,
Ronald.Gross at baystatehealth.org writes:

I'm  looking for fluid and/or air.  Now, what I would do with the fluid is
a  whole other story......in other words, if I did see fluid, should I/would
I do  a DPL?  Frankly, no, if the abdomen is completely benign, with no
rigidity and normal bowel sounds, a normal set of labs and a very low level
of
 suspicion.  Free air on the other hand would force me to the OR
regardless of the exam or my (poorly conceived) level of  suspicion!

Ron

-----Original Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On  Behalf Of Krin135 at aol.com
Sent: Monday, October 26, 2009 10:41 AM
To:  trauma-list at trauma.org
Subject: Re: selectice conservative management of  stab injury abdomen-

Are you looking to pick up free air/blood or do  you inject some  contrast
into the wound tract for these  exams?
ck

In a message dated 10/26/2009 08:15:32 Central  Standard Time,
Ronald.Gross at baystatehealth.org writes:

I  am  embarrassed to say this, but when it is done it is more a knee-jerk
reaction  to my insecurity on a particular case than rational.   Most often
I
will  scan those patients who's mental status is clouded  on admission by
drugs or  alcohol, and so my initial  exam on  admission has been, in my opi
nion,  clouded and therefore less than  reliable.

Does it change my  treatment?  Frankly no, but (and  don't hurt me for
this)
I feel a bit   better..........

Ron
snip

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------------------------------

Message: 8
Date: Mon, 26 Oct 2009 09:49:21 -0500
From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
Subject: RE: selectice conservative management of stab injury abdomen-
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:
        <B79C02DCC4FA074DB02381DF1C5D60BA02C74999 at EX07.ad.tulane.edu>
Content-Type: text/plain;       charset="us-ascii"

Free air frequently comes in with the knife. You should use the same
indications of acute abdomen with air as the indication for operative
managements.

Norman

Norman McSwain MD
Professor, Tulane School of Medicine
Trauma Director, Charity Hospital Trauma Center
norman.mcswain at tulane.edu
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
Sent: Monday, October 26, 2009 9:44 AM
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: selectice conservative management of stab injury abdomen-

I'm looking for fluid and/or air.  Now, what I would do with the fluid
is a whole other story......in other words, if I did see fluid, should
I/would I do a DPL?  Frankly, no, if the abdomen is completely benign,
with no rigidity and normal bowel sounds, a normal set of labs and a
very low level of suspicion.  Free air on the other hand would force me
to the OR regardless of the exam or my (poorly conceived) level of
suspicion!

Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Krin135 at aol.com
Sent: Monday, October 26, 2009 10:41 AM
To: trauma-list at trauma.org
Subject: Re: selectice conservative management of stab injury abdomen-

Are you looking to pick up free air/blood or do you inject some
contrast
into the wound tract for these exams?
ck

In a message dated 10/26/2009 08:15:32 Central Standard Time,
Ronald.Gross at baystatehealth.org writes:

I am  embarrassed to say this, but when it is done it is more a
knee-jerk
reaction  to my insecurity on a particular case than rational.  Most
often I
will  scan those patients who's mental status is clouded on admission by

drugs or  alcohol, and so my initial  exam on admission has been, in my
opi
nion,  clouded and therefore less than reliable.

Does it change my  treatment?  Frankly no, but (and don't hurt me for
this)
I feel a bit  better..........

Ron
snip

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------------------------------

Message: 9
Date: Mon, 26 Oct 2009 11:19:04 -0400
From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
Subject: RE: selectice conservative management of stab injury abdomen-
To: "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
Message-ID:
        <FD2BE6867A90F543AAD02E429F878633014D37A0DB88 at bhsexc11.bhs.org>
Content-Type: text/plain; charset="us-ascii"

I have never used a "fistulogram/tractogram" nor have I ever found LWE
satisfactory.  Most of the folks I deal with (and I am sure I am NOT unique
in this aspect) are, shall I say, less than cooperative for either!
Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Krin135 at aol.com
Sent: Monday, October 26, 2009 10:54 AM
To: trauma-list at trauma.org
Subject: Re: selectice conservative management of stab injury abdomen-

Would there be any utility to do a 'fistula gram' of the wound track to see
 if there is peritoneal penetration as long as you felt you needed to scan
due to  mental incapacity of the patient?

(I was 'raised' in the 'serial exam' school, btw....and have seen more than
 a couple of cases where anterior/flank abdominal stab wounds failed to
penetrate  due to the overlying tissue.)

ck

In a message dated 10/26/2009 08:44:25 Central Standard Time,
Ronald.Gross at baystatehealth.org writes:

I'm  looking for fluid and/or air.  Now, what I would do with the fluid is
a  whole other story......in other words, if I did see fluid, should I/would
I do  a DPL?  Frankly, no, if the abdomen is completely benign, with no
rigidity and normal bowel sounds, a normal set of labs and a very low level
of
 suspicion.  Free air on the other hand would force me to the OR
regardless of the exam or my (poorly conceived) level of  suspicion!

Ron

-----Original Message-----
From:  trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On  Behalf Of Krin135 at aol.com
Sent: Monday, October 26, 2009 10:41 AM
To:  trauma-list at trauma.org
Subject: Re: selectice conservative management of  stab injury abdomen-

Are you looking to pick up free air/blood or do  you inject some  contrast
into the wound tract for these  exams?
ck

In a message dated 10/26/2009 08:15:32 Central  Standard Time,
Ronald.Gross at baystatehealth.org writes:

I  am  embarrassed to say this, but when it is done it is more a knee-jerk
reaction  to my insecurity on a particular case than rational.   Most often
I
will  scan those patients who's mental status is clouded  on admission by
drugs or  alcohol, and so my initial  exam on  admission has been, in my opi
nion,  clouded and therefore less than  reliable.

Does it change my  treatment?  Frankly no, but (and  don't hurt me for
this)
I feel a bit   better..........

Ron
snip

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------------------------------

Message: 10
Date: Mon, 26 Oct 2009 11:20:31 -0400
From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
Subject: RE: selectice conservative management of stab injury abdomen-
To: "'Trauma-List [TRAUMA.ORG]'" <trauma-list at trauma.org>
Message-ID:
        <FD2BE6867A90F543AAD02E429F878633014D37A0DB89 at bhsexc11.bhs.org>
Content-Type: text/plain; charset="us-ascii"

You have a point there, Norm.  Having been burned twice using that
assumption, however, has made me quite nervous about the free air issue.....

Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of McSwain, Norman E Jr.
Sent: Monday, October 26, 2009 10:49 AM
To: Trauma-List [TRAUMA.ORG]
Subject: RE: selectice conservative management of stab injury abdomen-

Free air frequently comes in with the knife. You should use the same
indications of acute abdomen with air as the indication for operative
managements.

Norman

Norman McSwain MD
Professor, Tulane School of Medicine
Trauma Director, Charity Hospital Trauma Center
norman.mcswain at tulane.edu
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
Sent: Monday, October 26, 2009 9:44 AM
To: 'Trauma-List [TRAUMA.ORG]'
Subject: RE: selectice conservative management of stab injury abdomen-

I'm looking for fluid and/or air.  Now, what I would do with the fluid
is a whole other story......in other words, if I did see fluid, should
I/would I do a DPL?  Frankly, no, if the abdomen is completely benign,
with no rigidity and normal bowel sounds, a normal set of labs and a
very low level of suspicion.  Free air on the other hand would force me
to the OR regardless of the exam or my (poorly conceived) level of
suspicion!

Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Krin135 at aol.com
Sent: Monday, October 26, 2009 10:41 AM
To: trauma-list at trauma.org
Subject: Re: selectice conservative management of stab injury abdomen-

Are you looking to pick up free air/blood or do you inject some
contrast
into the wound tract for these exams?
ck

In a message dated 10/26/2009 08:15:32 Central Standard Time,
Ronald.Gross at baystatehealth.org writes:

I am  embarrassed to say this, but when it is done it is more a
knee-jerk
reaction  to my insecurity on a particular case than rational.  Most
often I
will  scan those patients who's mental status is clouded on admission by

drugs or  alcohol, and so my initial  exam on admission has been, in my
opi
nion,  clouded and therefore less than reliable.

Does it change my  treatment?  Frankly no, but (and don't hurt me for
this)
I feel a bit  better..........

Ron
snip

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------------------------------

Message: 11
Date: Mon, 26 Oct 2009 12:21:46 EDT
From: Krin135 at aol.com
Subject: Selective Conservative Management of ant/flank abdominal stab
        wounds: summary
To: trauma-list at trauma.org
Message-ID: <bfb.68e75112.3817269a at aol.com>
Content-Type: text/plain; charset="US-ASCII"

For group perusal, and possibly for inclusion in the Trauma Wiki if  not
there already.

1: IF the patient is stable, cooperative, not suffering from mental
confusion due to trauma or intoxication, AND has a benign abdomen on
examination,
THEN conservative management with multiple serial exams for at  least 24
hours is safe, effective, and recommended. The development of any of  the
following: peritoneal signs, hemodynamic instability (falling  hematocrit,
liable pulse rate, decreasing urine output), elevating fever,  elevating WBC
or
other signs of deterioration, is a POSITIVE indication for open  laparotomy.

2: Imaging studies MAY be helpful in cases where the patient is obtunded,
intoxicated or otherwise less than cooperative. The presence of free
abdominal air is a POSITIVE indication for open laparotomy.

Question: are CT scans enough more sensitive/specific for free air than a
true upright or right side up lateral decubitus abdominal radiograph to
recommend the higher cost/radiation/time needed for the CT?

3: Since free fluid, in and of itself, is not an indication for open
laparotomy in the stable, benign patient, FAST exams are not helpful in
evaluating these injuries.

4: Laparoscopic procedures are not efficient enough at finding potentially
serious bowel injuries to advocate using these methods over a small
incision  open exploratory laparotomy.

5: both laparoscopic and open laparotomy procedures carry significant short
 and long term morbidity and mortality in excess of that found with serial
exams  in the stable, benign patients.

6: Once 24 hours of observation are complete without deterioration, then
consideration for feeding the patient and then releasing them home if the
feedings are tolerated and the patient is voiding, is safe, and effective.

7: "Prophylactic antibiotics" are not needed in the stable, benign  patient.

Sound reasonable?

ck

------------------------------

Message: 12
Date: Mon, 26 Oct 2009 12:24:25 EDT
From: Krin135 at aol.com
Subject: Re: Selective Conservative Management of ant/flank abdominal
        stab    wounds: sum...
To: trauma-list at trauma.org
Message-ID: <d0c.60d21756.38172739 at aol.com>
Content-Type: text/plain; charset="US-ASCII"

forgot to include 8: Local wound exploration (either direct visualization
or via contrast study) is of little utility in the stable, benign patient.

In a message dated 10/26/2009 10:22:27 Central Standard Time,
Krin135 at aol.com writes:

For  group perusal, and possibly for inclusion in the Trauma Wiki if  not
there already.

1: IF the patient is stable, cooperative, not  suffering from mental
confusion due to trauma or intoxication, AND  has a benign abdomen on
examination,
THEN conservative management  with multiple serial exams for at  least 24
hours is safe, effective,  and recommended. The development of any of  the
following: peritoneal  signs, hemodynamic instability (falling  hematocrit,
liable pulse  rate, decreasing urine output), elevating fever,  elevating
WBC or
other signs of deterioration, is a POSITIVE indication for open
laparotomy.

2: Imaging studies MAY be helpful in cases where the  patient is obtunded,
intoxicated or otherwise less than cooperative.  The presence of free
abdominal air is a POSITIVE indication for open  laparotomy.

Question: are CT scans enough more sensitive/specific for  free air than a
true upright or right side up lateral decubitus  abdominal radiograph to
recommend the higher cost/radiation/time  needed for the CT?

3: Since free fluid, in and of itself, is not an  indication for open
laparotomy in the stable, benign patient, FAST  exams are not helpful in
evaluating these injuries.

4:  Laparoscopic procedures are not efficient enough at finding potentially

serious bowel injuries to advocate using these methods over a small
incision  open exploratory laparotomy.

5: both laparoscopic  and open laparotomy procedures carry significant
short
and long term  morbidity and mortality in excess of that found with serial
exams  in  the stable, benign patients.

6: Once 24 hours of observation are  complete without deterioration, then
consideration for feeding the  patient and then releasing them home if the
feedings are tolerated  and the patient is voiding, is safe, and effective.

7: "Prophylactic  antibiotics" are not needed in the stable, benign
patient.

Sound  reasonable?

ck

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Message: 13
Date: Mon, 26 Oct 2009 11:39:13 -0500
From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
Subject: RE: Selective Conservative Management of ant/flank abdominal
        stab    wounds:summary
To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
Message-ID:
        <B79C02DCC4FA074DB02381DF1C5D60BA01D28A04 at EX07.ad.tulane.edu>
Content-Type: text/plain; charset="iso-8859-1"

There are inconsistencies here
Norman

Norman McSwain MD
Trauma Director, Spirit of Charity Trauma Center
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu>

________________________________

From: trauma-list-bounces at trauma.org on behalf of Krin135 at aol.com
Sent: Mon 10/26/2009 11:21 AM
To: trauma-list at trauma.org
Subject: Selective Conservative Management of ant/flank abdominal stab
wounds:summary