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A selective approach to the management of gunshot wounds to the back
G C Velmahos1, D Demetriades, E Foianini
1Department of Surgery, University of Southern California and the Los Angeles County + USC Medical Center, 90033, USA.
Background:
Gunshot wounds to the back with retroperitoneal trajectories have been traditionally managed under the same guidelines as anterior gunshot wounds. Recent work has suggested that selective nonoperative management of anterior abdominal gunshot wounds is safe. The role of this policy in gunshot wounds to the back, where retroperitoneal organ injuries may be more difficult to detect clinically, has not been investigated.
Objective:
To examine if selective nonoperative management based on clinical assessment is a safe alternative to mandatory exploration for gunshot wounds to the back.
Design:
Prospective study.
Setting:
Large-volume level-1 university affiliated trauma center.
Patients And Methods:
Two hundred and three consecutive patients with gunshot wounds to the back were managed according to a protocol during a 12-month period. Patients with hemodynamic instability or peritonitis underwent urgent operation. The rest of the patients were observed with careful serial clinical examinations.
Results:
Eleven patients underwent an emergency room thoracotomy and were excluded. Four more patients were operated upon, despite the absence of abdominal findings, because of associated spinal cord injuries (2 patients), inability to observe due to need for repair of an associated peripheral vascular injury (1 patient), and participation in another protocol of aggressive evaluation of asymptomatic patients with suspected diaphragmatic injuries (1 patient). Of the remaining 188 patients, 58 (31%) underwent laparotomy (56 therapeutic, 2 negative) and 130 (69%) were initially observed owing to negative clinical examination. Following the development of increasing abdominal tenderness, 4 of these 130 (3%) underwent delayed explorations, which were all nontherapeutic. The sensitivity and specificity of initial clinical examination in detecting significant intraabdominal injuries were 100% and 95%, respectively.
Conclusions:
Mandatory laparotomy is not necessary for gunshot wounds of the back. Clinical examination is a safe method of selecting patients for nonoperative management. An observation period of 24 hours is adequate for patients with no abdominal symptoms.