Role of laparoscopy in management of patients with anterior abdominal stab wounds.

BACKGROUND: In this retrospective cohort study, we assessed the utility of laparoscopic surgery for diagnostic and therapeutic purposes in patients with anterior abdominal stab wounds (AASWs). We also investigated patient characteristics that might suggest a greater suitability of laparoscopic interventions. METHODS: Over a 25-year span, we analyzed AASW patients who had operations, categorizing them based on the presence of significant intra-abdominal injuries and whether they received laparoscopic surgery or laparotomy. We compared variables such as preoperative conditions, surgical details, and postoperative outcomes. We further evaluated the criteria indicating the necessity of direct laparotomies and traits linked to overlooked injuries in laparoscopic surgeries. RESULTS: Of 142 AASWs surgical patients, laparoscopic surgery was conducted on 89 (62.7%) patients. Only 2 (2.2%) had overlooked injuries after the procedure. Among patients without significant injuries, those receiving laparoscopic surgery had less blood loss than those receiving laparotomy (30.0 vs. 150.0 ml, p = 0.004). Patients who underwent laparoscopic surgery also had shorter hospital stays (significant injuries: 6.0 vs. 11.0 days, p < 0.001; no significant injuries: 5.0 vs. 6.5 days, p = 0.014). Surgical complications and overlooked injury rates were comparable between both surgical methods. Bowel evisceration correlated with higher laparotomy odds (odds ratio = 16.224, p < 0.001), while omental evisceration did not (p = 0.107). CONCLUSIONS: Laparoscopy is a safe and effective method for patients with AASWs, fulfilling both diagnostic and therapeutic needs. For stable AASW patients, laparoscopy could be the preferred method, reducing superfluous nontherapeutic laparotomies.

Epidemiology, repair technique, and predictors of stroke and mortality in penetrating carotid artery injuries.

OBJECTIVE: Penetrating carotid artery injuries (PCAI) are significantly morbid and deadly, often presenting in extremis with associated injuries and central nervous system deficit. Repair may be challenging with arterial reconstruction vs ligation role poorly defined. This study evaluated contemporary outcomes and management of PCAI. METHODS: PCAI patients in the National Trauma Data Bank from 2007 to 2018 were analyzed. Outcomes were compared between repair and ligation groups after additionally excluding external carotid injuries, concomitant jugular vein injuries, and head/spine Abbreviated Injury Severity score of ≥3. Primary end points were in-hospital mortality and stroke. Secondary end points were associated injury frequency and operative management. RESULTS: There were 4723 PCAI (55.7% gunshot wounds, 44.1% stab wounds). Gunshot wounds more frequently had associated brain (73.8% vs 19.7%; P < .001) and spinal cord (7.6% vs 1.2%; P < .001) injuries; stab wounds more frequently had jugular vein injuries (19.7% vs 29.3%; P < .001). The overall in-hospital mortality was 21.9% and the stroke rate was 6.2%. After exclusion criteria, 239 patients underwent ligation and 483 surgical repair. Ligation patients had lower presenting Glasgow Coma Scale (GCS) than repair patients (13 vs 15; P = .010). Stroke rates were equivalent (10.9% vs 9.3%; P = .507); however, in-hospital mortality was higher after ligation (19.7% vs 8.7%; P < .001). In-hospital mortality was higher in ligated common carotid artery injuries (21.3% vs 11.6%; P = .028) and internal carotid artery injuries (24.5% vs 7.3%; P = .005) compared with repair. On multivariable analysis, ligation was associated with in-hospital mortality, but not with stroke. A history of neurological deficit before injury lower GCS, and higher Injury Severity Score (ISS) were associated with stroke; ligation, hypotension, higher ISS, lower GCS, and cardiac arrest were associated with in-hospital mortality. CONCLUSIONS: PCAI are associated with a 22% rate of in-hospital mortality and a 6% rate of stroke. In this study, carotid repair was not associated with a decreased stroke rate, but did have improved mortality outcomes compared with ligation. The only factors associated with postoperative stroke were low GCS, high ISS, and a history of neurological deficit before injury. Beside ligation, low GCS, high ISS, and postoperative cardiac arrest were associated with in-hospital mortality.

[Gunshot Wounds and Penetrating Injuries]. / Schusswaffenverletzungen und penetrierende Traumata.

The acute medical care in Germany after gunshot and stab wounds in the pre-hospital and in-hospital setting is a rarity in an international comparison. The resulting lack of routine in the acute care of critically injured people after penetrating trauma should therefore be countered with regular theoretical and practical training. In addition to standardized care algorithms for the care of severely injured people, knowledge of kinetics and wound ballistics is required for focused treatment. The article focuses mainly on the early treatment phase.

Thoracic Penetrating Wounds with Cardiac Injury: A Single-Center Experience.

Background: Management protocols for patients with penetrating cardiac injury have undergone a dramatic transition during the last decades. However, even today cardiac trauma remains a major medical problem. Methods: Retrospective single-center case series study, 41 patients with precordial wounds hospitalized at the Institute of Emergency Medicine, Chisinau, period 2005-2020. Mean age - 45.8 Ã+- 8.9 years, M:F/19.5:1. Traumatic event: stabbing (82.9%,n=34) or gunshot wound (17.1%,n=7). Preoperative paraclinical examinations: electrocardiography, chest X-ray, FAST, pleurotomy, pericardial puncture, and thoracoscopy. Results: 36 (87.8%) patients were hemodynamically unstable on hospitalization, and 19 (52.8%) were immediately transferred to the operating room. Preferred surgical access: left anterolateral thoracotomy - 26 (63.4%), right anterolateral thoracotomy - 13 (31.7%), and left posterolateral thoracotomy - 2 (4.9%). Non-penetrating lesions were discovered in 5 (12.2%) while penetrating trauma in other 36 (87.8%) cases, most frequently the right ventricle being injured. Additional intrathoracic lesions discovered in 29 (70.7%) patients: pulmonary parenchyma rupture - 25 (86.2%), internal mammary artery injury - 3 (10.3%), and intercostal artery injury - 1 (3.5%). The average length of stay was 13.2 Ã+- 4 days, including stay in the Intensive Care Unit - 2.9 Ã+- 1.2. Mortality rate -17.1% (n=7). Conclusions: Successful cardiac suture determined the survival rate of 82.9%. Lethality increases proportionally to the severity of the cardiac injury, the volume of blood loss, and damage to the right vs left heart chambers.

[Current view on stab/cut injuries]. / Sovremennoe sostoyanie voprosa koloto-rezanykh povrezhdenii.

Currently, mechanical trauma is the most significant cause of violent death. The injuries caused by sharp objects rank high in the structure of mechanical trauma. The study objective is to review domestic and foreign literature on the study of stab/cut injuries, identify the main issues and consider new promising diagnostic methods. The stab/cut wound morphology is widely described in the available literature, but little attention has been paid to their study of late postmortem changes. This issue requires consideration since putrefactive corpses (hidden by placing the corpse in water, burying it in the ground, etc.) are often the object of forensic medical examination. New methods for assessing stab/cut injuries are also considered: computed tomography, multilayer computed tomography, scanning electron microscopy, and energy dispersive x-ray spectroscopy. Each of the diagnostic methods has its undeniable advantages and prospects for widespread use in expert practice, but they cannot completely replace the main methods and are intended only to supplement them.

[Diagnosis and treatment of kidney damage following stab and blunt abdominal injuries]. / Diagnostika i lechenie povrezhdenii pochek pri zakrytykh travmakh i koloto-rezanykh raneniyakh zhivota.

OBJECTIVE: To improve treatment outcomes in victims with kidney damage following blunt and stab abdominal trauma by using of minimally invasive methods of diagnosis and treatment. MATERIAL AND METHODS: About 1.2-3.5% of all victims arrived to the Dzhanelidze St. Petersburg Research Institute for Emergency Care have kidney injuries. We analyzed the results of treatment of 117 patients with isolated and combined blunt and stab abdominal injuries. The retrospective (2014-2017) group included 62 victims, and the prospective (2018-2021) group enrolled 55 patients who were treated according to the new algorithm. This algorithm included non-surgical and minimally invasive management for patients with systolic blood pressure >90 mm Hg after contrast-enhanced CT. Angiography with selective embolization was required for ongoing bleeding. We analyzed incidence of open interventions, organ-sparing procedures, complications, duration of treatment and mortality. Between-group differences were assessed using the χ2 test and Student's test. RESULTS: In both groups, kidney damage in most victims with abdominal trauma was due to road accident and catatrauma. Most patients had combined abdominal injuries, mainly in combination with head and chest lesions. Severity of injuries and clinical condition were similar in both groups. In the retrospective group, there were 9 laparotomies with nephrectomy. Nephrorraphy was performed in 8 cases, kidney vessel suture - in 4 patietns. In the prospective group, nephrectomy was performed in 3 patients with unstable hemodynamics and injuries AAST grade V. Nephrorraphy was performed in 4 victims. In one case, vascular suture was applied for tangential vein damage. All laparoscopies in both groups were diagnostic without nephrectomy. We used non-surgical treatment in 34 patients of the prospective group. One patient underwent angiography and selective embolization of renal artery branches. There were no significant between-group differences in the incidence of infectious and non-infectious complications. Mortality rate was 30.6% (n=19) and 27.3% (n=15) in the retrospective and prospective groups, respectively. CONCLUSION: The proposed algorithm for kidney injury made it possible to reduce the incidence of laparoscopies and laparotomies by 2 times, preserve the damaged kidney in 94.5% of cases and avoid invasive treatment in 62% of victims.

Prospective evaluation of the selective nonoperative management of abdominal stab wounds: When is it safe to discharge?

BACKGROUND: The optimal observation time required to exclude hollow viscus injury in patients undergoing selective nonoperative management (SNOM) for abdominal stab wounds (SWs) remains unclear. The aim of this study was to determine the safe period of observation required before discharge. METHODS: In this prospective observational study, all patients who sustained an abdominal SW were screened for study inclusion (July 2018 to May 2021). The primary study outcome was time to SNOM failure, defined as the need for surgical intervention after an initial period of observation. RESULTS: During the study period, 256 consecutive patients with an abdominal SW met the study criteria. The mean age was 33 (26-46) years, and 89% were male. Of all patients, 77% had single SW, and 154 (60%) had an anterior abdominal SW (most common site right upper quadrant, 31%). Forty-six (18%) underwent immediate laparotomy because of evisceration (59%), hemodynamic instability (33%), or peritonitis (24%). The remaining 210 patients (82%) were taken for computed tomography scan (n = 208 [99%]) or underwent clinical observation only (n = 2 [<1%]). Of the patients undergoing computed tomography scan, 27 (13%) triggered operative intervention, and 9 (4%) triggered angioembolization. The remaining 174 patients (83%) underwent SNOM. Of these, three patients (2%) failed SNOM and underwent laparotomy: two developed peritonitis at 10 and 20 hours after arrival, respectively, and at laparotomy had small bowel and gastric injuries. The third patient developed increasing leukocytosis but had nontherapeutic laparotomy. CONCLUSION: Selective nonoperative management of stab wounds to the abdomen commonly avoids nontherapeutic operative intervention and its resultant complications. A small percentage of patients will fail SNOM, and therefore, close clinical observation of these patients in hospital is critical. All patients in this series who failed SNOM did so within 24 hours of presentation. Therefore, we recommend a period of 24 hours of close clinical monitoring to exclude a hollow viscus injury before discharge of patients with abdominal stab wounds who do not meet the criteria for immediate operative intervention. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.

[Is thoracoscopic heart suturing possible for stab wounds?] / Vozmozhno li torakoskopicheskoe ushivanie rany serdtsa pri koloto-rezanom ranenii?

The authors report two clinical cases with similar stab wounds of the heart. The first patient underwent open wound closure, the second one - thoracoscopic suturing of the wound. The authors concluded that conversion may be unnecessary after diagnosis of heart injury if severe bleeding is absent.

Routine laboratory parameters predict intensive care unit admission and hospitalization in patients suffering stab injuries.

Background: Knife crime has increased considerably in recent years in Northern Europe. Affected patients often require immediate surgical care due to traumatic organ injury. Yet, little is known about clinically relevant routine laboratory parameters in stab injury patients and how these are associated with intensive care unit (ICU) admission, hospitalization and number of surgeries. Methods: We retrospectively analyzed 258 stab injury cases between July 2015 and December 2021 at an urban Level I Trauma Center. Annual and seasonal incidences, injury site, injury mechanism, Injury Severity Score (ISS), and surgical management were evaluated. First, correlations between routine laboratory parameters for hematology, coagulation, and serum biochemistry (peak, and Δ (change from admission to peak within 3 days following admission)) and length of hospital stay, ICU stay, and number of surgeries were assessed using Spearman's rank correlation coefficients. Second, multivariable Least Absolute Shrinkage and Selection Operator (LASSO) regression analyses were conducted to identify parameters predictive of clinical outcomes. Third, longitudinal developments of routine laboratory parameters were assessed during hospital admission. Results: In 2021, significantly more stab injuries were recorded compared with previous years and occurred less during winter compared with other seasons. Mean ISS was 8.3 ± 7.3, and ISS was positively correlated with length of hospital and ICU stay (r = 0.5-0.8, p < 0.001). Aspartate transaminase (AST) (Δ) (r = 0.690), peak C-reactive protein (CrP) (r = 0.573), and erythrocyte count (Δ) (r = 0.526) showed the strongest positive correlations for length of ICU stay for penetrating, thoracoabdominal, and organ injuries, respectively. No correlations were observed between routine laboratory parameters and number of surgeries. For patients with penetrating injuries, LASSO-selected predictors of ICU admission included ISS, pH and lactate at admission, and Δ values for activated partial thromboplastin time (aPTT), K+, and erythrocyte count. CrP levels on day 3 were significantly higher in patients with penetrating (p = 0.005), thoracoabdominal (p = 0.041), and organ injuries (p < 0.001) compared with those without. Conclusion: Our data demonstrate an increase in stab injury cases in 2021 and an important link between changes in routine laboratory parameters and ICU admission and hospitalization. Monitoring ISS and changes in AST, CrP, erythrocyte count, pH, lactate, aPTT, and K+ may be useful to identify patients at risk and adjust surgical and ICU algorithms early on.

The role of leukocytes in predicting whether laparotomy is required in patients with penetrating abdominal stab wound.

BACKGROUND: This study aimed to determine the importance of leukocytes, leukocyte subgroups, platelets, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio in deciding whether laparotomy is required during observation in patients with penetrating abdominal stab wounds who were followed up because there was no indication for an emergency laparotomy. METHODS: Patients who did not indicate an emergency laparotomy were monitored. After 48 hours from initial hospitalization, patients who did not require laparotomy were discharged nonoperatively. The total leukocytes, leukocyte subsets, platelets, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio of patients who underwent laparotomy during the follow-up compared with those who were discharged nonoperatively. The sensitivity and specificity of these laboratory values in predicting the necessity of laparotomy were calculated. RESULTS: In the operated group (n = 71), leukocytes, neutrophils, monocytes, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio examined during observation were significantly higher (P < .001). Eosinophils and lymphocytes were significantly lower (P < .001) than in nonoperated (n = 476). Based on the deviation in the reference ranges of leukocyte and its subgroups, we report the sensitivity and specificity for predicting the necessity of laparotomy as 86% and 72% for leukocyte, 88% and 75% for neutrophil, 92% and 83% for neutrophil-to-lymphocyte ratio, and 72% and 77% for platelet-to-lymphocyte ratio, respectively. In receiver operating characteristic curve analysis, the cut-off value was found to be 4 for neutrophil-to-lymphocyte ratio and 125 for platelet-to-lymphocyte ratio (area under the curve/receiver operating characteristic curve of 0.929 and 0.808, respectively). CONCLUSION: Leukocyte, leukocyte subgroups, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio may be useful to determine if a laparotomy is necessary in patients in whom the necessity of laparotomy is undetermined owing to unclear examination findings.

A Prospective Audit of 805 Consecutive Patients With Penetrating Abdominal Trauma: Evolving Beyond Injury Mechanism Dictating Management.

BACKGROUND: Global trends of penetrating abdominal trauma (PAT) have seen a shift toward a selectively conservative management strategy. However, its widespread adoption for gunshot injuries has been sluggish. The purpose of this study is to compare the injury mechanisms of gunshot (GSW) and stab wounds (SW) to the abdomen in presentation, management, and outcomes. METHODS: Prospective cohort study, set in Cape Town, South Africa, over 2 years. All patients presenting to the center with PAT during this time were included. Presentation, management, and outcomes were compared by injury mechanism, with a focus on the operative strategy (operative vs nonoperative). RESULTS: During the study period, 805 patients (SW 37.6%; GSW 62.4%) with PAT were managed. Immediate laparotomies were performed in 119 (39.3%) SW and 355 (70.7%) GSW, with a therapeutic laparotomy rate of 85.7% and 91.8% for SW and GSW, respectively. Nonoperative management (NOM) was implemented in 184 SW (60.7%) and 147 GSW (29.3%) (P < 0.001), with a 92.9% and 92.5% success rate for SW and GSW, respectively. The therapeutic laparotomy rate for the delayed laparotomies (DOM) was 69.2% for SW, and 90.9% for GSW. The accuracy of clinical assessment (with adjuncts) in determining the need for laparotomy was: GSW-92% and SW-91%. Univariate analysis revealed the mechanism not to be associated with DOM. The overall mortality rate was 7.2%, and nonfatal morbidities 22.2%. CONCLUSION: Although GSW is a more morbid and often fatal injury, the general principles of selective conservatism hold true for both GSW and SW, equally.

Evaluation of diagnostic laparoscopy for penetrating abdominal injuries: About 131 anterior abdominal stab wound.

BACKGROUND: The management of hemodynamically stable patients with anterior abdominal stab wounds (AASW) is debated. Mini-invasive techniques using laparoscopy and non-operative management (NOM) have reduced the rate of nontherapeutic laparotomies after AASW leading to unnecessary morbidity. The aim of this study was to determine with a systematic diagnostic laparoscopy of peritoneal penetration (PP), patients who do not require abdominal exploration in the management of stable patient with an AASW. METHODS: All patients with AASW were retrospectively recorded from 2006 to 2018. Criteria of inclusion were AASW patients who underwent a systematic diagnostic laparoscopy. Criteria of exclusion were patients with an evisceration, impaling, clinical peritonitis, and hemodynamic instability. If no PP was detected, laparoscopy was terminated. If defects of peritoneum were found, a laparotomy was performed looking for diagnosis and treatment of intra-abdominal injuries. RESULTS: On 131 AASW patients, 35 underwent immediate emergency laparotomy, 96 underwent diagnostic laparoscopy, 47 were positive (PP) and had an intra-abdominal exploration by laparotomy, 32 (68.1%) had intra-abdominal injuries which required treatment. All patients with an intra-abdominal injury had a positive diagnostic laparoscopy. For the 49 patients with a negative laparoscopy, the mean hospital stay was 1.6 days with ambulatory care for some patients. No patient presented a delayed injury. Non-therapeutic laparotomy rate was 15.6%. For patients who did not have an intra-abdominal injury the morbidity rate was low (3%). CONCLUSION: Our study shows that diagnostic laparoscopy was safe, with a low duration of hospitalization, a possible ambulatory care and had an excellent ability to screen the patients who did not need a abdominal exploration. This management can avoid many unnecessary laparotomies with an acceptable rate of negative laparotomy, without any delayed diagnosis of intra-abdominal injuries and with a low morbidity rate.

Leukocytes are not Reliable in Predicting Possible Diaphragmatic Injury in Patients with Penetrating Left Thoracoabdominal Stab Wounds.

BACKGROUND: The diaphragm is injured in approximately one-third of penetrating left thoracoabdominal stab wounds. Diagnostic laparoscopy or thoracoscopy is performed to reveal the diaphragmatic injury. This study investigated whether leukocytes, leukocyte subgroups, platelets, the neutrophil-to-lymphocyte ratio (NLR), and the thrombocyte-to-lymphocyte ratio (PLR) can be used to detect diaphragm injury without the need for diagnostic laparoscopy. METHODS: Patients hospitalized between January 2010 and January 2020 due to penetrating left thoracoabdominal stab wounds were examined. Laparotomy was performed in patients who had indications for laparotomy, such as hemodynamic instability and peritonitis. Diagnostic laparoscopy was performed to reveal possible diaphragmatic injury in patients who did not require laparotomy after 48h of follow-up. Leukocytes, leukocyte subgroups, platelets, NLR, and PLR were measured both at admission and during follow-up, and the results were compared between patients with and without diaphragm injury during diagnostic laparoscopy. RESULTS: The study included 108 patients with penetrating left thoracoabdominal stab wounds that did not require laparotomy after 48h of follow-up. Of these, 102 patients were male (94.44%), and the average age was 27.68 years (range 15-66 years). Diaphragm injury was detected in 31 patients (28.70%) in diagnostic laparoscopy, and the diaphragm was intact in 77 patients (71.30%). In the comparison of patients with and without diaphragmatic injury, no statistically significant difference was found in terms of age, gender, platelets, leukocyte values, NLR, and PLR both at admission and during follow-up. CONCLUSIONS: Leukocytes, leukocyte subsets, platelets, NLR, and PLR were insufficient in the detection of asymptomatic diaphragmatic injuries caused by penetrating left thoracoabdominal stab wounds.

Injuries Sustained During Incarceration Among Prisoners.

BACKGROUND: The U.S. prison population has increased substantially in recent years, and violent injury is common among prisoners. We sought to describe injury patterns and other characteristics of prisoners who presented to a trauma center after injury. Because penetrating trauma from an improvised weapon (e.g., shank) is frequent, we also sought to compare characteristics and outcomes of prisoners and non-prisoners who sustained an anterior abdominal stab or shank wound (AASW). METHODS: We analyzed injured adult prisoners who presented to a Level 1 trauma center between February, 2011, and April, 2017. We described characteristics of the injured prisoners and their hospitalizations. We compared prisoners who sustained an AASW to a random sample of non-prisoners with the same mechanism of injury using the chi-square test, Student's t-test, and logistic and Poisson regression. RESULTS: Of 14,461 hospitalized injured adults, 299 (2.0%) were injured while incarcerated. 185 (62%) encounters involved interpersonal violence and 36 prisoners (12%) presented with self-inflicted injuries. 98 (33%) had a psychiatric disorder. Among 33 prisoners and 66 non-prisoners who sustained an AASW, prisoners were less likely to have undergone a laparotomy [14/33 (42%) vs 44/66 (67%); RR 0.64 (95% CI 0.41-0.98)] or sustained an injury requiring operative intervention [2/33 (6%) vs 23/66 (35%); RR 0.17 (95% CI 0.04-0.69)]. CONCLUSIONS: Many injured prisoners have psychiatric illness, are involved in interpersonal violence, or harm themselves. Among hospitalized patients, abdominal stab/shank wounds sustained in prison are less likely to result in significant injuries or operative intervention than similar wounds in non-prisoners.

Fatal hemorrhage from a periumbilical wound: Stabbing or hemorrhage from a caput medusae?

Varices are the main clinical manifestation of portal hypertension, and their bleeding is the predominant cause of mortality from this condition. Periumbilical varices are known as "caput medusae." Reports of their bleeding are rare, with only three fatal cases described in the literature. The antemortem diagnosis is relatively simple, while the postmortem diagnosis is more complex. This paper is the first report of fatal hemorrhage from a caput medusae for which the diagnosis was made postmortem, thanks to a complete diagnostic process including scene and circumstances, medical history, and autopsy with detailed histology. The circumstantial analysis showed the presence of a large amount of blood at the scene, blood which originated from a small abdominal wound; an analysis of the subject's clinical data reported that he was affected by portal hypertension. The autopsy revealed some dilated and convoluted veins in the subcutaneous tissue of the umbilical region; a fistula between these veins and the abdominal wound was detected. The histological study confirmed the presence of periumbilical varices, one of them ruptured and connected with the overlying skin. The cause of death was attributed to a massive hemorrhage generated by a periumbilical varix in a patient affected by portal hypertension.

The scourge of knife crime: trends in knife-related assault managed at a major centre in South Africa.

BACKGROUND: Knife wounds are common and represent a major burden to the South African healthcare system. This study reviews trends in spectrum, management and outcome of these injuries at a single trauma centre in KwaZulu-Natal(KZN). METHOD: The regional hybrid electronic registry (HEMR) was reviewed for the period January 2013 - December 2018, and all patients who suffered a knife-related assault were identified and reviewed. RESULTS: During the period under review, a total of 2117 patients suffered a knife-related assault. Regions injured were as follows: head 445, neck 572, face 258, chest 939, abdomen 649, pelvic/urogenital 49, upper limb 418, and lower limb 105. The median ISS was 9 (4-10). Imaging comprised 1242 chest X-rays, 315 abdominal X-rays, 162 abdominal ultrasounds/ FAST, and 929 CT scans of which 634 were CT angiograms. A total of 783 (37%) patients required an operation. The rate of laparotomy was 447/649 (69%) and of thoracotomy/sternotomy/thoracoscopy 95/939 (10%). The rate of vascular exploration for upper and lower limb vascular injury was 101/523 (19%). Mortality was 49/2117 (2.3%).. CONCLUSION: Although our clinical outcomes over this period appear to be consistent, suggesting a familiarity with managing knife-related trauma, the persistently high rate of knife-related injury suggests that we have failed to develop a preventative strategy to try and reduce this scourge.

Penetrating cardiac trauma in stab wounds: A study of diagnostic accuracy of the cardiac area.

BACKGROUND: Stab wounds (SW) to the thorax raises suspicion for cardiac injuries; however, the topographic description is variable. The present study aims to evaluate different topographical descriptions within the thorax and establish their diagnostic value in penetrating cardiac trauma by SW. METHODS: Medical records of all patients admitted to our center with thoracic SW from January 2013 to June 2016 were included in this study. Diagnostic value potential was measured using different areas of the thorax described in the literature. RESULTS: In this study, we analyzed 306 cases. Thirty-eight (12.4%) patients had a cardiac injury managed surgically. Death by cardiac injury occurred in seven (18.4%) patients. The cardiac area defined between the right mid-clavicle line until the left anterior axillary line, and between 2nd and 6th intercostal spaces was the more accurate. It has sensitivity of 97.3%, specificity 72%, positive predictive value 33%, negative predictive value 99.4% and accuracy 75.1% for penetrating cardiac trauma. ROC was 0.894 IC 95% (0.760-0.901). CONCLUSION: Among the thoracic areas, topographical limits between the right mid-clavicle line and the left anterior axillary line, and between 2nd and 6th intercostal spaces are the more accurate and are highly indicative of cardiac injury in patients with SW to the thorax.

Performance of pre-hospital evaluations in ruling out invasive chest stab wounds.

BACKGROUND: Some guidelines advocate for managing patients with penetrating thoracic wounds in trauma centres with cardiothoracic surgery. This systematic approach is questionable. Only 15% of these patients require surgery. It is known that clinical examination fails to detect hemopneumothorax in penetrating trauma. However, no studies have evaluated the combined diagnostic performance of vital signs and the clinical evaluation of wounds. The clinical characteristics of wounds have not been investigated. We aimed to evaluate the ability of combinations of pre-hospital signs to rule out invasive chest stab trauma. METHODS: This was a prospective observational study. All consecutive adult patients hospitalized in the perioperative acute care unit of a tertiary university hospital were included. Injury diagnoses were provided by exploratory surgery and imaging tests. Patients with a final diagnosis of invasive wounds (IWs) and patients with only superficial wounds were compared. Data regarding management and outcome were analysed. RESULTS: A total of 153 patients were included. After imaging or surgery, 58 (38%) patients were diagnosed with only superficial wounds, and 95 (62%) were diagnosed with thoracic or abdominal IWs. The false-negative rate of pre-hospital evaluations in the diagnosis of IWs was 42% [31-51]IQR25-75. In stable patients, pre-hospital data could not rule out IWs, with a negative predictive value of 58% and a positive predictive value of 70%. Twenty-nine (19%) patients required early emergent cardiothoracic surgery. Among these patients, 8 (28%) had no evidence of IWs in the pre-hospital period. Among the 59 patients without pre-hospital signs of IWs, 19 (33%) underwent at least one emergent procedure. CONCLUSIONS: The combination of pre-hospital vital signs, visual evaluation of wounds, and physical examination failed to rule out IWs in patients with chest stab wounds. This implies that caution is needed in triage decision-making.

Selective non-operative management for penetrating abdominal injury in a Dutch trauma centre.

INTRODUCTION: Selective non-operative management (SNOM) for penetrating abdominal injury (PAI) is accepted in trauma centres in South Africa and the US. Owing to the low incidence of gunshot wounds (GSWs) in Western Europe, few are inclined to practise SNOM for such injuries although it is considered for stab wounds (SWs). This study evaluated the outcome of patients admitted to a Dutch level 1 trauma centre with PAI. METHODS: A retrospective study was undertaken of all PAI patients treated over 15 years. In order to prevent bias, patients admitted six months prior to and six months following implementation of a treatment algorithm were excluded. Data concerning type of injury, injury severity score and treatment were compared. RESULTS: A total of 393 patients were included in the study: 278 (71%) with SWs and 115 (29%) with GSWs. Of the 178 SW patients in the SNOM group, 111 were treated before and 59 after introduction of the protocol. The SNOM success rates were 90% and 88% respectively (p=0.794). There were 43 patients with GSWs in the SNOM cohort. Of these, 32 were treated before and 11 after implementation of the algorithm, with respective success rates of 94% and 100% (p=0.304).The protocol did not bring about any significant change in the rate of non-therapeutic laparotomies for SWs or GSWs. However, the rate of admission for observation for SWs increased from 83% to 100% (p<0.001). There was a decrease in ultrasonography for SWs (from 84% to 32%, p<0.001) as well as for GSWs (from 87% to 43%, p<0.001). X-ray was also used less for GSWs after the protocol was introduced (44% vs 11%, p=0.001). CONCLUSIONS: SNOM for PAI resulting from either SWs or GSWs can be safely practised in Western European trauma centres. Results are comparable with those in trauma centres that treat high volumes of PAI cases.

Does computed tomography scan add any diagnostic value to the evaluation of stab wounds of the anterior abdominal wall? A systematic review and meta-analysis.

BACKGROUND: The aim of this systematic review and meta-analysis was to evaluate whether computed tomography (CT) scan adds any diagnostic value in the evaluation of stab wounds of the anterior abdominal wall as compared with serial clinical examination (SCE). METHODS: PubMed, EMBASE, Cochrane Library, and MEDLINE via Ovid were systematically searched for records published from 1980 to 2018 by two independent researchers (M.G., R.L.). Quality assessment, data extraction, and analysis were performed according to the Cochrane Handbook for Systematic Reviews of Interventions. Mantel-Haenszel method with odds ratio (OR) and 95% confidence interval (95% CI) as the measure of effect size was used for meta-analysis. RESULTS: Three studies (1 randomized controlled trial and 2 observational studies) totaling 319 patients were included in the meta-analysis. Overall laparotomy rate was 12.8% (22 of 172 patients) in SCE versus 19% (28 of 147 patients) in CT. This difference was not significant (OR [95% CI], 0.63 [0.34-1.16]; p = 0.14). Negative laparotomy rate was 3.5% (6 of 172 patients) in SCE versus 5.4% (8 of 147 patients) in CT. The difference was not significant (OR [95% CI], 0.61 [0.20-1.83]; p = 0.37). CONCLUSION: This meta-analysis compared SCE with CT scan in patients presenting with stab wounds of the anterior abdominal wall and provided level II evidence showing no additional benefit in CT scan. Further observational and experimental clinical studies are needed to confirm the findings of this meta-analysis. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level II.