R P Gonzalez1, B Turk, M E Falimirski, M R Holevar. 1. Department of Surgery, University of South Alabama Medical Center, Mobile 36617-2293, USA. rgonzalez@usamail.ussouthal.edu
Abstract
OBJECTIVE: To prospectively evaluate a method for management of abdominal stab wounds that allows for immediate emergency room discharge. METHODS: Anterior abdominal stab wound patients were prospectively placed in a study trial during a 48-month period. Consent was obtained for all patients before study entry. Anatomic boundaries for abdominal stab wounds were costal margins, inguinal ligaments, and anterior axillary lines. Hemodynamically stable patients with negative physical examinations were entered in the study and evaluated with closed diagnostic peritoneal lavage (DPL). Patients with DPL results less than 1000 RBCs/mm3 were sent home. Patients with DPL results greater than 1000 RBCs/mm3 (including gross blood) were admitted for observation. Hemodynamically stable patients with evisceration and no abdominal tenderness had the viscera replaced in the emergency room. Eviscerated patients did not undergo DPL and were admitted for observation. Patients that presented with hemodynamic instability or peritonitis were not entered in the study and underwent immediate surgical intervention. RESULTS: Ninety hemodynamically stable patients were entered in the study. Forty-four (49%) patients had DPL < 1000 RBCs/mm3, 34 of which were discharged home. Of the 10 admissions that qualified for discharge, 4 were admitted due to elevated ethanol levels and no family assistance, 3 were admitted to psychiatry, and 3 required other surgical procedures. No patient with DPL < 1000 RBCs/mm3 required laparotomy or had complications associated with their stab wounds. Thirty-eight (42%) patients were observed because DPL counts were greater than 1000 RBCs/mm3. Eight (21%) of these patients developed positive physical examinations that prompted exploratory laparotomy, of which five (63%) were therapeutic. There were no complications associated with delayed laparotomy. Four (4%) patients had DPL results greater than 500 WBCs/mm3, all of which underwent immediate exploratory laparotomy. Four (4%) patients presented with evisceration, one of which underwent therapeutic laparotomy. CONCLUSION: Abdominal stab wound patients that are hemodynamically stable can be safely sent home from the emergency room when DPL counts are less than 1000 RBCs/mm3. Observation of hemodynamically stable patients allows for low laparotomy rates with minimal morbidity.
OBJECTIVE: To prospectively evaluate a method for management of abdominal stab wounds that allows for immediate emergency room discharge. METHODS: Anterior abdominal stab wound patients were prospectively placed in a study trial during a 48-month period. Consent was obtained for all patients before study entry. Anatomic boundaries for abdominal stab wounds were costal margins, inguinal ligaments, and anterior axillary lines. Hemodynamically stable patients with negative physical examinations were entered in the study and evaluated with closed diagnostic peritoneal lavage (DPL). Patients with DPL results less than 1000 RBCs/mm3 were sent home. Patients with DPL results greater than 1000 RBCs/mm3 (including gross blood) were admitted for observation. Hemodynamically stable patients with evisceration and no abdominal tenderness had the viscera replaced in the emergency room. Eviscerated patients did not undergo DPL and were admitted for observation. Patients that presented with hemodynamic instability or peritonitis were not entered in the study and underwent immediate surgical intervention. RESULTS: Ninety hemodynamically stable patients were entered in the study. Forty-four (49%) patients had DPL < 1000 RBCs/mm3, 34 of which were discharged home. Of the 10 admissions that qualified for discharge, 4 were admitted due to elevated ethanol levels and no family assistance, 3 were admitted to psychiatry, and 3 required other surgical procedures. No patient with DPL < 1000 RBCs/mm3 required laparotomy or had complications associated with their stab wounds. Thirty-eight (42%) patients were observed because DPL counts were greater than 1000 RBCs/mm3. Eight (21%) of these patients developed positive physical examinations that prompted exploratory laparotomy, of which five (63%) were therapeutic. There were no complications associated with delayed laparotomy. Four (4%) patients had DPL results greater than 500 WBCs/mm3, all of which underwent immediate exploratory laparotomy. Four (4%) patients presented with evisceration, one of which underwent therapeutic laparotomy. CONCLUSION: Abdominal stab wound patients that are hemodynamically stable can be safely sent home from the emergency room when DPL counts are less than 1000 RBCs/mm3. Observation of hemodynamically stable patients allows for low laparotomy rates with minimal morbidity.