CT ‘adds nothing’ to stab wound decisions
medwireNews: Serial physical examination has more impact than computed tomography (CT) findings on therapy decisions in patients with abdominal stab wounds, shows a prospective analysis.
In a commentary accompanying the study in JAMA Surgery, Martin Schreiber (Oregon Health & Science University, Portland, USA) says that although “not the first to report the success of observing patients with anterior abdominal stab wounds, this contribution remains important because it represents an example of how critically analyzing an established center’s data can change practices.”
In 177 patients without indications for immediate surgery who underwent both procedures, all decisions to undertake laparotomy were based on physical examination findings rather than the CT results, report Kenji Inaba (University of Southern California, Los Angeles, USA) and co-workers.
After having a CT scan the patients underwent at least 24 hours of observation. Eighteen patients underwent laparotomy during this time, all because of deteriorating physical examination findings. The most common reason was peritonitis, in 70%, followed by hemodynamic instability, in 40%.
Sixteen of these laparotomies revealed clinically significant findings that required intervention, including injuries to the colon, diaphragm, liver, spleen, and hepatic and splenic arteries, while the other two were negative. A further two patients underwent laparotomy as a precaution because of their CT findings, despite no cause for concern from physical examinations, and both of these were negative.
Physical examination was thus much more accurate than CT for detecting clinically significant injuries, with a sensitivity and specificity of 100.0% and 98.7%, respectively, compared with just 31.3% and 84.2%.
The researchers explain that, in contrast to gunshot wounds, “blade entry is associated with far less kinetic energy and tissue disruption, resulting in a path that is often difficult to visualize” on CT. Hence, CT is of less use in patients with stab wounds; it is not as accurate as physical examination, does not save time or facilitate earlier discharge, and exposes patients to radiation.
However, Schreiber raises concerns about the amount of work required for serial physical examinations, noting, “it is not clear who is examining these patients, how frequently, and in what setting.”
He says: “It is important to realize that observation of stable stab wound patients may not be feasible in all settings because it is resource intensive.”
medwireNews (www.medwirenews.com) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013
By Eleanor McDermid, Senior medwireNews Reporter