Our society is unusually violent with increasing numbers of gunshot wounds. The Legal Community Against Violence has reported the United States experiences epidemic levels of gun violence, which claims over 30,000 lives annually, according to the U.S. Centers for Disease Control and Prevention. Two people are wounded for every person who dies from a gunshot wound. There are greater than 100,000 Americans victimized by gun violence every year. Therefore proper surgical guidelines to deal with gunshot wounds are vital.
Christina Frangou has reported for General Surgery News “Torso Gunshot Victims Require at Least 24 Hours of Observation.” Researchers reported at the American Association for the Surgery of Trauma annual meeting that patients with gunshot wounds to the torso who do not require operative management should be kept under close observation in the hospital for a minimum of 24 hours. Lead investigator Kenji Inaba, MD, has said “Until now, we did not have good data to support how long we should be observing these patients undergoing nonoperative management before they could be safely discharged home. Now, we watch them carefully for 24 hours and if there is no evidence of a missed injury, we discharge them home.”
It was found in an earlier retrospective study that all patients undergoing selective nonoperative management required a minimum of 24 hours of close observation before discharge. Dr. Inaba and colleagues then performed a prospective study of all patients who presented to the USC hospital with torso gunshot wounds between January 2009 and January 2011 in order to confirm the initial findings. In this study, 270 patients presented to the hospital with torso gunshot wounds; 130 met the criteria for observation. These patients were stable, had no peritonitis, were examinable without evisceration and had computed tomography (CT) scans.
Based on those iniital results, 39 (30%) of the patients underwent a therapeutic laparotomy after positive findings, whereas 44 of the patients were placed under close observation after negative CT results (33.8%) and 47 after equivocal results (36.2%). Out of the patients observed after CT scan, eight (8.8%) who initially had equivocal CT results ultimately were foound to require laparotomies. There were several clear patterns identified in the patients who eventually needed laparotomy.
Significantly, the symptoms which prompted the laparotomy “were apparent within hours of admission, starting with tachycardia.” Tachycardia, which was the most common early indicator of trouble, occurred in 75% of patients in the group that required operative treatment. Peritonitis was found to be the “most common final trigger” for surgical intervention (63%). Other significant symptoms included a white blood cell count increase of more than 11,000 (63%), fever higher than 38 C (38%) and a drop in hemoglobin of at least 2 g/dL.
Timothy Fabian, MD, has commented that these study results corroborated results from the 2010 retrospective review, which revealed that nonoperative management could be a way to “more appropriately use physician and hospital resources” for patients with penetrating trauma as long as patients are selected very carefully. It is hoped if patients are well selected, nonoperative management can spare them the morbidity of an exploratory laparotomy.
However, patients who end up having a delayed operation after a period of observation are found to be at greater risk for infectious complications. Dr. Fabian has gone on to say “It’s going to increase morbidity in that group of patients you were wrong about. We need a little more work in terms of multicenter, prospective studies to make sure we are selecting the right group of patients.”
Photographer: Simon Howden
Mandel News Service