Observation Period for Gunshot Wounds Clarified

CHICAGO – Nonoperative management of gunshot wounds has become an accepted practice at many trauma centers despite a slightly heightened risk of complications, but the time frame for safe discharge of these patients is still uncertain.

The minimum seems to be 24 hours, according to Dr. Kenji Inaba, the lead investigator of a prospective trial from the University of Southern California in Los Angeles. Defining an appropriate observation period for nonoperative management is important, he said, "because we can expect that up to 6.2% of these patients will require delayed laparotomy." He described nonoperative management as a "resource-intensive process requiring serial examinations and serial laboratory evaluations."

At the annual meeting of the American Association for Surgery in Trauma, Dr. Inaba presented results for 270 patients who sustained torso gunshot wounds (GSW) over a 2-year period. Of those, 25 (9.3%) died in the emergency department, leaving 245 for analysis. All subjects were aged 15 years or older.

The prospective results he presented are the second phase of his group’s research. Last year, the researchers published a retrospective study of 787 patients. Of the 636 patients who underwent a trial of nonoperative management in that study, 4.6% of patients failed and had to undergo laparotomy (J. Trauma 2010;68:1301-4). Of the 4.6% patients who had laparotomy, 97% had failed nonoperative management within 12 hours, and the rest failed within 24 hours.

Avoiding nontherapeutic laparotomy is noteworthy, he said, because it has been associated with complication rates ranging from 9% to 26%. The goal of the prospective study was to validate this observation period, he said.

The protocol for the prospective study indicated surgery for GSW victims who were unstable or eviscerated, could not be evaluated, or had peritonitis – 115 in all. The remaining 130 patients got a CT scan. Of those, 39 (30%) had positive findings: mostly hollow-viscus injuries, followed by solid-organ injury, vascular injury, and bladder injuries, according to Dr. Inaba of the department of surgery at USC. These patients had surgery. Among the remaining patients who got a CT scan, 44 (34%) had a negative scan and 47 (36%) had an equivocal finding. All patients in the latter two groups were put under observation.

The CT scans were read by the resident on call and checked for concordance with a radiologist, Dr Inaba said; discordant findings did not impact clinical management.

Among those who had a negative or equivocal CT scan, about 9% (all of whom had equivocal findings on CT) went for laparotomy later on, Dr. Inaba said. The most common earliest sign of failure was tachycardia; the most common latest sign was peritonitis, Dr. Inaba said.

In all, 75% of the surgical procedures were therapeutic. Among the patients who had therapeutic laparotomy, the operation revealed injuries of the stomach, colon, and rectum. The mean time for proceeding to laparotomy was 2 hours 43 minutes, according to Dr. Inaba, with 50% having failed nonoperative management by 6 hours, 75% by 12 hours, and 100% by 24 hours.

"According to this study, the clinical examination was seen yet again to very effectively identify those with gunshot wounds that required an immediate trip to the OR," Dr. Inaba said. "For all other remaining patients who didn’t go immediately to the OR, the CT was of value. If CT was positive, there was very high yield for taking that trip to the OR. If it was negative, it was very unlikely there would’ve been a missed injury."

For those with an equivocal CT scan, observation was "very important," Dr. Inaba said, because it was key for eventually distinguishing who needed laparotomy. "We feel it’s important that [at a minimum] these patients be watched for at least 24 hours before they are safely discharged home," he said.

Dr. Timothy C. Fabian of the University of Tennessee, Memphis, questioned the rigor of follow-up after discharge. "Follow-up is extremely important in order to completely put nonoperative management into perspective," he said.

Dr. Peter Rhee of the University of Arizona, Tucson, echoed that concern: "When I worked in Los Angeles for 5 years, follow-up was nonexistent," he said. "Of the people you didn’t operate on, were you able to state [definitively that] they had no injuries?"

Dr. Inaba acknowledged that the follow-up was problematic, as the investigators had no data on what happened to these patients after discharge.

Dr. Inaba had no disclosures to report.

CHICAGO – Nonoperative management of gunshot wounds has become an accepted practice at many trauma centers despite a slightly heightened risk of complications, but the time frame for safe discharge of these patients is still uncertain.

The minimum seems to be 24 hours, according to Dr. Kenji Inaba, the lead investigator of a prospective trial from the University of Southern California in Los Angeles. Defining an appropriate observation period for nonoperative management is important, he said, "because we can expect that up to 6.2% of these patients will require delayed laparotomy." He described nonoperative management as a "resource-intensive process requiring serial examinations and serial laboratory evaluations."

At the annual meeting of the American Association for Surgery in Trauma, Dr. Inaba presented results for 270 patients who sustained torso gunshot wounds (GSW) over a 2-year period. Of those, 25 (9.3%) died in the emergency department, leaving 245 for analysis. All subjects were aged 15 years or older.

The prospective results he presented are the second phase of his group’s research. Last year, the researchers published a retrospective study of 787 patients. Of the 636 patients who underwent a trial of nonoperative management in that study, 4.6% of patients failed and had to undergo laparotomy (J. Trauma 2010;68:1301-4). Of the 4.6% patients who had laparotomy, 97% had failed nonoperative management within 12 hours, and the rest failed within 24 hours.

Avoiding nontherapeutic laparotomy is noteworthy, he said, because it has been associated with complication rates ranging from 9% to 26%. The goal of the prospective study was to validate this observation period, he said.

The protocol for the prospective study indicated surgery for GSW victims who were unstable or eviscerated, could not be evaluated, or had peritonitis – 115 in all. The remaining 130 patients got a CT scan. Of those, 39 (30%) had positive findings: mostly hollow-viscus injuries, followed by solid-organ injury, vascular injury, and bladder injuries, according to Dr. Inaba of the department of surgery at USC. These patients had surgery. Among the remaining patients who got a CT scan, 44 (34%) had a negative scan and 47 (36%) had an equivocal finding. All patients in the latter two groups were put under observation.

The CT scans were read by the resident on call and checked for concordance with a radiologist, Dr Inaba said; discordant findings did not impact clinical management.

Among those who had a negative or equivocal CT scan, about 9% (all of whom had equivocal findings on CT) went for laparotomy later on, Dr. Inaba said. The most common earliest sign of failure was tachycardia; the most common latest sign was peritonitis, Dr. Inaba said.

In all, 75% of the surgical procedures were therapeutic. Among the patients who had therapeutic laparotomy, the operation revealed injuries of the stomach, colon, and rectum. The mean time for proceeding to laparotomy was 2 hours 43 minutes, according to Dr. Inaba, with 50% having failed nonoperative management by 6 hours, 75% by 12 hours, and 100% by 24 hours.

"According to this study, the clinical examination was seen yet again to very effectively identify those with gunshot wounds that required an immediate trip to the OR," Dr. Inaba said. "For all other remaining patients who didn’t go immediately to the OR, the CT was of value. If CT was positive, there was very high yield for taking that trip to the OR. If it was negative, it was very unlikely there would’ve been a missed injury."

For those with an equivocal CT scan, observation was "very important," Dr. Inaba said, because it was key for eventually distinguishing who needed laparotomy. "We feel it’s important that [at a minimum] these patients be watched for at least 24 hours before they are safely discharged home," he said.

Dr. Timothy C. Fabian of the University of Tennessee, Memphis, questioned the rigor of follow-up after discharge. "Follow-up is extremely important in order to completely put nonoperative management into perspective," he said.

Dr. Peter Rhee of the University of Arizona, Tucson, echoed that concern: "When I worked in Los Angeles for 5 years, follow-up was nonexistent," he said. "Of the people you didn’t operate on, were you able to state [definitively that] they had no injuries?"

Dr. Inaba acknowledged that the follow-up was problematic, as the investigators had no data on what happened to these patients after discharge.

Dr. Inaba had no disclosures to report.

CHICAGO – Nonoperative management of gunshot wounds has become an accepted practice at many trauma centers despite a slightly heightened risk of complications, but the time frame for safe discharge of these patients is still uncertain.

The minimum seems to be 24 hours, according to Dr. Kenji Inaba, the lead investigator of a prospective trial from the University of Southern California in Los Angeles. Defining an appropriate observation period for nonoperative management is important, he said, "because we can expect that up to 6.2% of these patients will require delayed laparotomy." He described nonoperative management as a "resource-intensive process requiring serial examinations and serial laboratory evaluations."

At the annual meeting of the American Association for Surgery in Trauma, Dr. Inaba presented results for 270 patients who sustained torso gunshot wounds (GSW) over a 2-year period. Of those, 25 (9.3%) died in the emergency department, leaving 245 for analysis. All subjects were aged 15 years or older.

The prospective results he presented are the second phase of his group’s research. Last year, the researchers published a retrospective study of 787 patients. Of the 636 patients who underwent a trial of nonoperative management in that study, 4.6% of patients failed and had to undergo laparotomy (J. Trauma 2010;68:1301-4). Of the 4.6% patients who had laparotomy, 97% had failed nonoperative management within 12 hours, and the rest failed within 24 hours.

Avoiding nontherapeutic laparotomy is noteworthy, he said, because it has been associated with complication rates ranging from 9% to 26%. The goal of the prospective study was to validate this observation period, he said.

The protocol for the prospective study indicated surgery for GSW victims who were unstable or eviscerated, could not be evaluated, or had peritonitis – 115 in all. The remaining 130 patients got a CT scan. Of those, 39 (30%) had positive findings: mostly hollow-viscus injuries, followed by solid-organ injury, vascular injury, and bladder injuries, according to Dr. Inaba of the department of surgery at USC. These patients had surgery. Among the remaining patients who got a CT scan, 44 (34%) had a negative scan and 47 (36%) had an equivocal finding. All patients in the latter two groups were put under observation.

The CT scans were read by the resident on call and checked for concordance with a radiologist, Dr Inaba said; discordant findings did not impact clinical management.

Among those who had a negative or equivocal CT scan, about 9% (all of whom had equivocal findings on CT) went for laparotomy later on, Dr. Inaba said. The most common earliest sign of failure was tachycardia; the most common latest sign was peritonitis, Dr. Inaba said.

In all, 75% of the surgical procedures were therapeutic. Among the patients who had therapeutic laparotomy, the operation revealed injuries of the stomach, colon, and rectum. The mean time for proceeding to laparotomy was 2 hours 43 minutes, according to Dr. Inaba, with 50% having failed nonoperative management by 6 hours, 75% by 12 hours, and 100% by 24 hours.

"According to this study, the clinical examination was seen yet again to very effectively identify those with gunshot wounds that required an immediate trip to the OR," Dr. Inaba said. "For all other remaining patients who didn’t go immediately to the OR, the CT was of value. If CT was positive, there was very high yield for taking that trip to the OR. If it was negative, it was very unlikely there would’ve been a missed injury."

For those with an equivocal CT scan, observation was "very important," Dr. Inaba said, because it was key for eventually distinguishing who needed laparotomy. "We feel it’s important that [at a minimum] these patients be watched for at least 24 hours before they are safely discharged home," he said.

Dr. Timothy C. Fabian of the University of Tennessee, Memphis, questioned the rigor of follow-up after discharge. "Follow-up is extremely important in order to completely put nonoperative management into perspective," he said.

Dr. Peter Rhee of the University of Arizona, Tucson, echoed that concern: "When I worked in Los Angeles for 5 years, follow-up was nonexistent," he said. "Of the people you didn’t operate on, were you able to state [definitively that] they had no injuries?"

Dr. Inaba acknowledged that the follow-up was problematic, as the investigators had no data on what happened to these patients after discharge.

Dr. Inaba had no disclosures to report.