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Evaluation and Management of Abdominal Stab Wounds: a Western Trauma Association Critical Decisions Algorithm

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Evaluation and Management of Abdominal Stab Wounds: a Western Trauma Association Critical Decisions Algorithm ALGORITHM Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm Matthew J. Martin, MD, Carlos V.R. Brown, MD, David V.Shatz, MD, Hasan B. Alam, MD, Karen J. Brasel, MD, Carl J. Hauser, MD, Marc de Moya, MD, Ernest E. Moore, MD, Susan E. Rowell, MD, Gary A. Vercruysse, MD, Bonny J. Baron, MD, and Kenji Inaba, MD, Portland, Oregon ABSTRACT: This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with ab- dominal stab wounds. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these rec- ommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols. (J Trauma Acute Care Surg. 2018;85: 1007–1015. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.) KEY WORDS: stab wound; penetrating trauma; abdominal; algorithm; Western Trauma Association. his is a recommended evaluation and management algorithm stab wound in any location. It provides several equally accept- T from the Western Trauma Association (WTA) Algorithms able management pathways that can be selected based on the de- Committee addressing the management of adult patients with tails of the patient presentation and injuries, the setting and abdominal stab wounds. Because there is a paucity of published available resources and expertise, and the judgment and prefer- prospective randomized clinical trials that have generated class I ence of the managing surgeon. We believe that this approach data, these recommendations are based primarily on published is ultimately more useful versus a more restrictive “one size fits prospective and retrospective cohort studies identified via struc- all” algorithm, and that it better considers the wide variability in tured literature search, and expert opinion of the WTA members. practice patterns, staffing, resources, experience, and comfort The final algorithm is the result of an iterative process including level with penetrating trauma that exist between centers. We also an initial internal review and revision by the WTA Algorithm recognize that there will be multiple factors that may warrant or Committee members, and then final revisions based on input require deviation from any single recommended algorithm, and during and after presentation of the algorithm to the full WTA that no algorithm can completely replace expert bedside clinical membership. Of note, this work builds on several important pre- judgment. We encourage institutions to use this as a general vious WTA studies regarding a simplified algorithmic approach framework in the approach to these patients, and to customize to abdominal stab wounds, with an expanded and more detailed and adapt the algorithm to better suit the specifics of that pro- algorithm to help guide the managing clinician.1,2 The algorithm gram or location. (Fig. 1) and accompanying comments represent a safe and sen- The overall incidence of penetrating trauma in the civilian sible approach to the evaluation of the patient with an abdominal setting has sharply declined over recent decades. Penetrating mechanisms now account for less than 10% of all trauma evalu- ations at most modern trauma centers in the U.S., with only a select – 3–5 Submitted: January 14, 2018, Revised: March 12, 2018, Accepted: March 24, 2018, few urban centers continuing to see higher rates of 20 30%. Published online: April 13, 2018. Among these penetrating trauma cases, approximately half (50%) From the Legacy Emanuel Medical Center (M.J.M.), Portland, Oregon; Dell Medical are caused by stab wounds, with the majority being from inten- School (C.V.R.B.), University of Texas at Austin, Austin, Texas; University of tional assaults.6 Data from almost 900,000 admissions in the California–Davis (D.V.S.), Sacramento, California; University of Michigan (H.A., G.V.), Ann Arbor, Michigan; Oregon Health and Science University (K.B., S.R.), Portland, 2016 National Trauma Data Bank report found that stab wounds Oregon; Beth Israel Deaconess Medical Center (C.H.), Boston, Massachusetts; represented only 4.1% of all trauma incidents, with an associ- Medical College of Wisconsin (M.D.), Milwaukee, Wisconsin; Denver Health ated case fatality rate of 2.2%.7 This low incidence has resulted (E.E.M.), Denver, Colorado; Kings County Hospital (B.B.), Brooklyn, New York; and University of Southern California (K.I.), Los Angeles, California. in a decreased experience with the evaluation and management Presented at the 47th Annual Western Trauma Association Meeting, Whistler, Utah, of abdominal stab wounds among physicians and other staff at March 5–10, 2017. many trauma centers. Thus, standardized protocols and an algo- Disclaimer: The results and opinions expressed in this article are those of the authors and do not reflect the opinions or official policy of any of the listed affiliated rithmic approach supported by the best available evidence and institutions, the United States Army, or the Department of Defense. expert opinion may contribute to optimize patient management Address for reprints: Matthew J. Martin, MD, Trauma and Emergency Surgery Service, and resource use. Legacy Emanuel Medical Center, 2801 N Gantenbein Portland, OR 97227 503/ The Western Trauma Association has generated several pre- 413-2200; email: [email protected]. vious landmark studies on the management of abdominal stab DOI: 10.1097/TA.0000000000001930 wounds that serve as a starting point for this updated algorithm. J Trauma Acute Care Surg Volume 85, Number 5 1007 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. J Trauma Acute Care Surg Martin et al. Volume 85, Number 5 Figure 1. Western Trauma Association algorithm for the evaluation and management of patients with abdominal stab wounds. Circled letters correspond to sections in the associated manuscript. 1The “gold standard” for abdominal exploration is via laparotomy. However, diagnostic and/or therapeutic laparoscopy may be performed in select stable patients and by a highly skilled surgeon experienced in minimally invasive surgical techniques. 2Signs of operative injury include CT scan visualization of bowel injury or secondary signs (unexplained free fluid, free air, bowel wall thickening, mesenteric injury), diaphragm injury, abdominal vascular injury, or contrast extravasation indicating ongoing bleeding. Note that some of these may also be amenable to observation, angioembolization, or endovascular techniques. 1008 © 2018 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. J Trauma Acute Care Surg Volume 85, Number 5 Martin et al. In 2009, Biffl et al. reported the results of a multicenter prospec- resuscitation or a transient response as characterized by the Ad- tive observational study that enrolled 359 patients.1 The details vanced Trauma Life Support course. Other immediate indications of management or any algorithm/protocol were at the discretion for operation include evisceration (high predictor of operative in- of each institution, but used serial clinical examinations in the juries)12–14 or impalement (removal of object under operative majority of patients. They demonstrated the safety of close ob- control). The initial physical examination then should focus on servation and operation only for hard clinical signs of injury ver- eliciting signs of peritonitis, which should also prompt immediate sus more liberal use of laparotomy, and proposed a simplified exploration if positive. Other less common associated findings algorithm for management of these patients. This simplified al- that usually should prompt immediate surgical exploration in- gorithm was then studied in a second WTA multicenter trial pub- clude hematemesis or gross blood in the gastric aspirate attribut- lished in 2011 that enrolled 222 patients, and again confirmed the able to the stab wound, or gross blood per rectum. In one of the safety and reliability of using serial clinical exams in most patients few studies examining each of these factors independently, the fac- without immediate hard indications for laparotomy.2 Although tors with the highest reported positive predictive values for the these publications provided some of the best available evidence, need for therapeutic laparotomy were development of hypotension it is important to note several factors that may limit their gener- after initial normotension (86%), shock on presentation (83%), alizability. They enrolled only patients with anterior abdominal and generalized peritonitis (81%).15 When considered as a group stab wounds and thus do not provide guidance on flank or back or constellation of indications, these findings are 80–90% pre- locations. The proposed simplified algorithm was largely based dictive of the need for therapeutic laparotomy.1,2,9,12,15,16 on local wound exploration (LWE), which may not be applicable The role of additional bedside radiologic studies in the all types of stab wounds. Finally, the algorithm does not take evaluation of abdominal stab wounds remains
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