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Original Investigation | Pacific Coast Surgical Association

Prospective Evaluation of the Role of Computed Tomography in the Assessment of Abdominal Stab Wounds

Kenji Inaba, MD1; Obi T. Okoye, MD1; Rachel Rosenheck, MD1; Nicolas Melo, MD1; Bernardino C. Branco, MD1; Peep Talving, MD, PhD1; Lydia Lam, MD1; Sravanthi Reddy, MD2; Ali Salim, MD3; Demetrios Demetriades, MD, PhD1
[+] Author Affiliations
1Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, California
2Department of Radiology, Los Angeles County + University of Southern California Medical Center, Los Angeles, California
3Department of Surgery, Cedars-Sinai Hospital Center, Los Angeles, California
JAMA Surg. 2013;148(9):810-816. doi:10.1001/jamasurg.2013.2521.
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Importance  An important adjunct in the management of abdominal gunshot wounds, the role of computed tomography (CT) in the diagnostic workup of abdominal stab wounds remains controversial.

Objective  To prospectively compare CT against serial physical examination in the evaluation of patients who have sustained a stab wound to the abdomen.

Design, Setting, and Patients  Prospective single-center observational study of all patients sustaining abdominal stab wounds from March 1, 2009, through March 31, 2011. Patients who were hemodynamically unstable, unevaluable, peritonitic, or eviscerated proceeded directly to laparotomy (n = 249). The remainder underwent CT evaluation. The impact of CT findings and physical examination on the decision to operate was analyzed.

Main Outcomes and Measures  Diagnostic accuracy of CT vs physical examination in determining the need for therapeutic laparotomy.

Results  A total of 249 patients were enrolled (94% male; mean [SD]: age, 30.8 [12.9] years [range, 16-87 years]; systolic blood pressure, 128 [28] mm Hg; Glasgow Coma Scale score, 14 [2]; Injury Severity Score, 6.8 [6.5]). Forty-five patients (18.1%) underwent immediate laparotomy, 27 (10.8%) had superficial injuries allowing immediate discharge, and the remaining 177 (71.1%) underwent CT. Of these, 154 (87.0%) were successfully observed, with 20 (11.3%) requiring laparotomy, 2 (1.1%) thoracotomy, and 1 (0.6%) sternotomy. Of the 20 laparotomies, 16 (80.0%) were therapeutic. All patients who underwent therapeutic laparotomy did so based on their physical examination. The most common finding leading to laparotomy was the development of peritonitis in 70%. The CT scan findings did not alter clinical decision making. The sensitivity and specificity of physical examination were 100.0% and 98.7%, respectively, while those of CT were 31.3% and 84.2%, respectively.

Conclusions and Relevance  In this prospective evaluation of abdominal stab wound management, serial physical examination was able to discriminate between patients requiring a therapeutic laparotomy and those who could be safely observed. A physical examination–based diagnostic algorithm was effective and decreased radiation burden in the management of abdominal stab wounds.

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Figure.
Management of Patients With Abdominal Stab Wounds

CT indicates computed tomography.

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