Department of Surgery, University of California San Francisco-East Bay, Alameda County Medical Center, Bay 1411 East 31st St, Oakland, CA 94602, USA.
J Am Coll Surg. 2009 Dec;209(6):740-5. doi: 10.1016/j.jamcollsurg.2009.09.010.
Patients with isolated lower extremity gunshot wounds are currently admitted for observation and often undergo angiography. We hypothesized that if such patients have a normal ankle-brachial index (ABI), they can be discharged safely from the emergency department without invasive imaging or admission.
We retrospectively reviewed the records of hemodynamically stable patients with isolated lower extremity gunshot wounds seen at our urban, university-based trauma center and who were discharged from the emergency department. Evaluation consisted of determining which patients were hemodynamically normal, had no fractures, and had an ABI > or =0.9. Patients with an ABI <0.9 underwent CT angiography. We then applied this practice algorithm prospectively, adding evaluation of high probability proximity wounds by ultrasonography or CT angiography to rule out missed injuries.
The retrospective review identified 182 patients who met our criteria. None had bleeding, limb ischemia, or limb loss. The specificity of the evaluation in the retrospective study to predict safe discharge was 100%, with a negative predictive value of 98%. There were 90 patients in the prospective study. Bleeding, limb ischemia, or limb loss did not develop in any patient. The prospective algorithm for predicting safe discharge home had a 100% positive predictive value and 98% negative predictive value. Using this algorithm, costs were 992 dollars per patient. If every patient received ultrasonography or CT angiography, it would have been 1,135 dollars or 4,632 dollars, respectively, per patient.
Hemodynamically normal patients with lower extremity gunshot wounds without fracture and an initial ABI > or =0.9 can be discharged safely from the emergency department without additional diagnostic imaging, potentially saving health care costs.
目前，对于单纯下肢枪伤患者，临床常予观察并进行血管造影。我们假设如果这些患者踝肱指数（ABI）正常，可以安全地从急诊病房出院，无需进行有创影像学检查或住院。
我们回顾性分析了在我们城市的大学附属医院就诊的、血流动力学稳定的单纯下肢枪伤患者的记录，这些患者从急诊病房出院。评估包括确定哪些患者血流动力学正常、无骨折且 ABI＞0.9。ABI＜0.9 的患者行 CT 血管造影。然后，我们前瞻性地应用这种实践算法，通过超声或 CT 血管造影评估高概率临近伤口，以排除遗漏的损伤。
回顾性研究确定了 182 名符合我们标准的患者。所有患者均无出血、肢体缺血或肢体丧失。该评估方法在回顾性研究中预测安全出院的特异性为 100%，阴性预测值为 98%。前瞻性研究中有 90 名患者。没有患者发生出血、肢体缺血或肢体丧失。预测安全出院的前瞻性算法的阳性预测值为 100%，阴性预测值为 98%。使用该算法，每位患者的费用为 992 美元。如果每位患者都接受超声或 CT 血管造影检查，每位患者的费用将分别为 1135 美元或 4632 美元。
血流动力学正常、无骨折且初始 ABI≥0.9 的下肢枪伤患者可以安全地从急诊病房出院，无需进行额外的诊断性影像学检查，从而可能节省医疗保健费用。
