From the University of Tennessee Health Science Center, Memphis, Tennessee.
J Trauma Acute Care Surg. 2013 Dec;75(6):1013-7; discussion 1017-8. doi: 10.1097/TA.0b013e3182a1fde8.
The National Institute of Medicine's report Hospital-Based Emergency Care: At the Breaking Point highlighted the critical issue of emergency department overcrowding. At our institution, patients with anterior abdominal stab wounds (AASW) have been managed with a protocol that uses diagnostic laparoscopy (DL) after positive result on local wound exploration. Patients with negative DL result are eligible for discharge directly from the recovery room. The purpose of this study was to evaluate the use of DL for AASWs in light of the recommendations that suggested serial abdominal examination (SAE) is preferred to determine the need for laparotomy.
Patients admitted to a Level 1 trauma center from January 2010 through August 2012 with AASWs were included (contemporary period to Western Trauma Association study). Information regarding baseline characteristics, diagnostic workup, injury management, and outcomes were retrospectively reviewed and compared with the SAE AASW algorithm.
A total of 158 patients with AASWs were evaluated using our institutional algorithm. Thirty-eight patients (24%) went directly to the operating room for peritonitis, shock, or evisceration; 120 underwent local wound exploration; 99 had positive result (82%). Twenty-eight patients had immediate laparotomy owing to worsening clinical examination findings. Seventy had DL, and 19 of these patients were discharged home from the recovery room, with a mean length of stay of 6.4 hours. When comparing patients managed using the DL algorithm to those managed using the SAE-based algorithm, the nontherapeutic laparotomy rate was lower, although not statistically significant. However, the DL algorithm produced a significantly higher percentage of patients discharged directly home following local wound exploration.
With some trauma centers suffering from emergency department overcrowding and constrained resources, DL may offer an alternative to SAE to efficiently use available resources. Both SAE and DL are safe and offer similar therapeutic laparotomy rates. The method used to evaluate patients after AASW should be tailored to institutional needs and resources.
Therapeutic/care management, level IV.
美国国家医学研究院的报告《以医院为基础的急救护理：处于崩溃边缘》强调了急诊部门过度拥挤这一关键问题。在我们的机构中，对于有前腹部刺伤（AASW）的患者，我们采用了一种方案，即在局部伤口探查阳性结果后进行诊断性腹腔镜检查（DL）。DL 结果阴性的患者有资格直接从恢复室出院。本研究的目的是根据建议评估 DL 在 AASW 中的使用，这些建议表明，与确定剖腹手术的需要相比，连续腹部检查（SAE）是首选。
纳入了 2010 年 1 月至 2012 年 8 月期间因 AASW 入住一级创伤中心的患者（与 Western Trauma Association 研究同期）。回顾性审查了有关基线特征、诊断性检查、损伤管理和结局的信息，并与 SAE AASW 算法进行了比较。
共 158 例 AASW 患者使用我们的机构算法进行评估。38 例（24%）因腹膜炎、休克或内脏脱出而直接进入手术室；120 例行局部伤口探查术；99 例阳性（82%）。28 例因临床检查结果恶化而行即刻剖腹术。70 例行 DL，其中 19 例从恢复室直接出院，平均住院时间为 6.4 小时。与使用 SAE 算法管理的患者相比，使用 DL 算法管理的患者非治疗性剖腹术率较低，但无统计学意义。然而，DL 算法使更多的患者在局部伤口探查后直接出院回家。
在一些急诊部门过度拥挤和资源有限的情况下，DL 可以替代 SAE，从而有效地利用现有资源。SAE 和 DL 都是安全的，且提供相似的治疗性剖腹术率。用于评估 AASW 患者的方法应根据机构的需求和资源进行调整。
治疗/护理管理，IV 级。
