Penetrating Abdominal Stab Wound Research Articles

Bacillus cereus bacteremia in a patient with an abdominal stab wound

Bacillus cereus is a gram positive microorganism commonly involved in gastrointestinal infection but capable of causing severe infections and bacteremia. We describe here a case of bacteremia caused by B. cereus in a previously healthy young woman admitted to the intensive care unit following emergency surgery due to a penetrating abdominal stab wound and subsequent hepatic lesion. She developed fever during admission and cultures were taken. B. cereus was isolated in blood and hepatic fluid collection cultures. Treatment was adjusted according to the isolate, with good clinical results. It is important to highlight the pathogenic potential of this microorganism and not underestimate it as a contaminant when it is isolated from blood samples.

Selective non-operative management of abdominal stab wounds is a safe and cost effective strategy: A South African experience.

INTRODUCTION Selective non-operative management (SNOM) of abdominal stab wounds is well established in South Africa. SNOM reduces the morbidity associated with negative laparotomies while being safe. Despite steady advances in technology (including laparoscopy, computed tomography [CT] and point-of-care sonography), our approach has remained clinically driven. Assessments of financial implications are limited in the literature. The aim of this study was to review isolated penetrating abdominal trauma and analyse associated incurred expenses. METHODS Patients data across the Pietermaritzburg Metropolitan Trauma Service (PMTS) are captured prospectively into the regional electronic trauma registry. A bottom-up microcosting technique produced estimated average costs for our defined clinical protocols. RESULTS Between January 2012 and April 2015, 501 patients were treated for an isolated abdominal stab wound. Over one third (38%) were managed successfully with SNOM, 5% underwent a negative laparotomy and over half (57%) required a therapeutic laparotomy. Over five years, the PMTS can expect to spend a minimum of ZAR 20,479,800 (GBP 1,246,840) for isolated penetrating abdominal stab wounds alone. CONCLUSIONS Provided a stringent policy is followed, in carefully selected patients, SNOM is effective in detecting those who require further intervention. It minimises the risks associated with unnecessary surgical interventions. SNOM will continue to be clinically driven and promulgated in our environment.

Feasibility of selective non-operative management for penetrating abdominal trauma in France

In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France. Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis. One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM. Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

Patients with Penetrating Abdominal Stab Wounds Which Require Laparotomy?

BackgroundThe optimal management of hemodynamically stable asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe cost-effective manner. Common evaluation strategies are local wound exploration (LWE), diagnostic peritoneal lavage (DPL), serial clinical assessment (SCAs) and computed tomography (CT) imaging. Making a decision about the right time to operate on a patient with a penetrating abdominal stab wound, especially those who have visceral evisceration, is a continuing challenge.ObjectivesUntil the year 2010, our strategy was emergency laparotomy in patients with penetrating anterior fascia and those with visceral evisceration. This survey was conducted towards evaluating the results of emergency laparotomy. So, better management can be done in patients with penetrating abdominal stab wounds.Patients and MethodsThis retrospective cross-sectional study was performed on patients with abdominal penetrating trauma who referred to Al- Zahra hospital in Isfahan, Iran from October 2000 to October 2010. It should be noted that patients with abdominal blunt trauma, patients under 14 years old, those with lateral abdomen penetrating trauma and patients who had unstable hemodynamic status were excluded from the study. Medical records of patients were reviewed and demographic and clinical data were collected for all patients including: age, sex, mechanism of trauma and the results of LWE and laparotomy. Data were analyzed with PASW v.20 software. All data were expressed as mean ± SD. The distribution of nominal variables was compared using the Chi-squared test. Also, diagnostic index for LWE were calculated. A two-sided P value less than 0.05 was considered to be statistically significant.ResultsDuring the 10 year period of the study, 1100 consecutive patients with stab wounds were admitted to Al-Zahra hospital Isfahan, Iran. In total, about 150 cases had penetrating traumas in the anterior abdomen area. Sixty-three (42%) patients were operated immediately due to shock, visceral evisceration or aspiration of blood via a nasogastric tube on admission. Organ injury was seen in 78% of patients with visceral evisceration. Among these 87 cases, 29 patients’ (33.3%) anterior fascia was not penetrated in LWE. So, they were observed for several hours and discharged from the hospital without surgery. While for the remaining 58 patients (66.6%), whose LWE detected penetration of anterior abdominal fascia, laparotomy was performed which showed visceral injuries in 11 (18%) cases.ConclusionsAll in all, 82 percent of laparotomies in patients with penetrated anterior abdominal fascia without visceral evisceration, who had no signs of peritoneal irritation, were negative. So, we recommended further evaluation in these patients. However, visceral evisceration is an indication for exploratory laparotomy, since in our study; the majority of patients had organ damages.

Comparison of conservative management and laparotomy in the management of stable patients with abdominal stab wound

IntroductionThe management of the hemodynamically stable patients with penetrating abdominal stab wounds is a problematic issue among trauma surgeons. MethodsIn a retrospective study, we analyzed stable patients with anterior abdominal stab wound from August 2009 to 2010. The patients who were hemodynamically unstable or had developed peritonitis were excluded. In our center, the patients are treated through conservative or operative management depending on the protocol of management of the stable penetrating abdominal stab wound in our center. We compared the effectiveness, mean duration of hospital admission, and the time of starting diet in 2 groups. ResultsThere were 99 cases including 47 patients in the conservative group and 52 in the laparotomy group. The laparotomy was negative in 73% and positive in 27% of the patients. In the conservative group, all the patients remained asymptomatic and stable except for 6 patients who needed subsequent laparotomy. The maximum period between admission and delayed laparotomy in these 6 patients was 17 hours. The mean length of hospital stay and the time of starting diet were 70.4 vs 43 hours and 42.3 vs 30.6 hours in the operative group and conservative group, respectively. P < .05 was considered significant. ConclusionOur study showed that conservative management of asymptomatic and stable patients with anterior abdominal stab wound with physical examination can decrease the rate of normal laparotomy and the length of hospitalization and help to start diet earlier. This study made this hypothesis that after 17 hours of observation, diet can be started for the stable asymptomatic patients.

Management of penetrating abdominal stab wounds.

The authors present the results of a therapeutic trial of the conservative or surgical management of penetrating abdominal stab wounds (PASW) based on clinical criteria. In a prospective series of 100 patients, 70 were treated non-operatively. Thirty patients were operated upon, twenty-one immediately and nine during the 48 h observation period. In five laparotomies no significant injuries were found. Morbidity was similar in both immediate and delayed laparotomy groups (3/21 versus 1/9). Acute alcoholic intoxication identifies a subgroup of patients that are difficult to evaluate and hence are more likely to be managed by laparotomy (chi 2 = 4.056, P less than 0.05). The authors conclude that selective surgical management of PASW based on clinical criteria is an accurate and safe procedure.

Evaluation of diagnostic peritoneal lavage in suspected penetrating abdominal stab wounds using a dipstick technique

The total protein content (g/l) and white blood cell count (cells/mm3) diagnostic peritoneal lavage was assessed using a urine dipstick in 46 patients with suspected penetrating abdominal stab wounds and equivocal physical examination. Those patients with a protein content greater than or equal to 1 g/l and white blood cell count of greater than 500 cells/mm3 were submitted to laparotomy while those with lower values underwent observation and repeat physical examination. In all, 26 patients had a positive lavage and significant injuries were found in 23 of these. Of 18 patients with a negative lavage, 17 were managed successfully without operation while one patient died from complications related to central venous catheterization. In two patients the lavage results were equivocal. One underwent a negative laparotomy and the remaining patient recovered uneventfully. The test has a 100 per cent sensitivity and 86 per cent specificity and provides an accurate, cheap, and rapid means of diagnosis of intra-abdominal injury in penetrating trauma.

Vagaries of the lavage white blood cell count in evaluating abdominal stab wounds

The clinical value of an elevated white blood cell (WBC) count on a diagnostic peritoneal lavage (DPL) performed in an asymptomatic patient with a penetrating abdominal stab wound is controversial. We performed a comprehensive analysis of asymptomatic patients (no signs of peritonitis) with stab wounds who underwent an exploratory laparotomy based solely on a WBC count > 500/mm3 in the effluent of an open DPL. Twenty-eight patients, 25 with injury to the gastrointestinal (GI) tract and 3 with injury to the liver, obtained true-positive results from DPL. Their mean WBC count in lavage effluent obtained at a mean of 7.6 hours after the stab wound was 3,380/mm3 and their mean serum WBC count, obtained at the same time, was 12,324/mm3. Fifteen patients had false-positive results from DPL. They were lavaged at a mean of 7.2 hours after the stab wound, and had a mean lavage WBC count of 1,228/mm3 and a mean serum WBC count of 9,084/mm3. Patients lavaged at a mean 6 to 7 hours after an abdominal stab wound will have a significant incidence of false-positive studies based on an elevated WBC count alone. Lavage WBC counts > 3,000/mm3, particularly when associated with a serum WBC count > 11,000, are likely to be true positives and to indicate injury to the GI tract.

Unreliability of standard quantitative criteria in diagnostic peritoneal lavage performed for suspected penetrating abdominal stab wounds

Thirty-five patients with abdominal stab wounds in whom clinical examination was equivocal on 2 separate occasions underwent diagnostic peritoneal lavage (DPL) prior to laparotomy. The red and white blood cell counts (cells/mm 3) of the lavage effluent were compared with the operative findings. There were 26 positive and 9 unnecessary laparotomies, the latter consisting of 4 negative and 5 non-therapeutic operations. Use of the standard quantitative criteria for red cells in DPL failed to identify significant injury in eight patients (31%), while the standard white cell count missed six injuries (23%). Their combined use resulted in three missed injuries (12%). Two false-positive results occurred using the red cell count alone and four using the white cell count alone, producing a combined false-positive result in four patients (11%). Reducing the cell threshold level to exclude missed injuries would increase dramatically the rate of unnecessary laparotomies. Although the standard quantitative criteria for DPL are superior to clinical assessment in patients with equivocal findings, their use in penetrating trauma does not achieve the same diagnostic accuracy as in blunt abdominal trauma.

Selective management of stab wounds of the abdomen.

THE management of the patient with a stab wound of the abdomen has, in most institutions, been rather standardized in the past two decades. Based on the experiences of World War II and Korea, patients with a suspected intraperitoneal injury due to perforating trauma were subjected to immediate laparotomy. 1,2 There is little disagreement that laparotomy is mandatory in the treatment of perforating high velocity bullet or missile injuries, either in military or in civilian life. However, the application of the principle of immediate surgery to the penetrating abdominal stab wound seen so often in civilian life has not met with unqualified success. At the heart of the matter is the fact that a disturbingly high proportion of patients subjected to laparotomy require no specific surgical repair, 3 presumably because the viscera tend to slide away from the advancing point of the stabbing instrument. Furthermore, these patients often constitute considerable