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The unstable patient with penetrating chest and abdominal trauma means ACTION! The stable patient, however, is a different story. It’s often a matter of watch and wait, but how much watching and how much waiting should we do?
Jared S. - July 23, 2016 4:31 AM
I think the approach of not getting CT on these patients with stab wounds to the abdomen and chest may be appropriate in an academic setting with a robust team of residents, fellows and all the other resources that come with an institution like this, but I can't imagine a scenario outside the academic setting (even in the level 2 trauma centers where I work) where I wouldn't be forced to get a CT on a patient like this. I simply can't see my trauma surgeon accepting a report on a patient with a "superficial stab wound to the chest and/or abdomen who is stable and not symptomatic, but I think he needs to be observed over the next 12 hours . . . and by the way, I didn't get a CT." I'd probably end up with stab wounds of my own. . .
I'm all for limiting the use of radiation, but surely the low yield of CT after penetrating injury is still higher than the pan-scans we get on every low speed MVC that rolls through the doors? I think I'll keep getting a CT on penetrating injuries not surely going to the OR and rather save my energy to explain to my trauma team why I don't need a CT C/T/L spine for the guy who's foot was run over by his drunk buddy's golf cart!
Thanks for the great work you guys do!
Chris Navarro: EM:RAP Production Team - July 30, 2016 10:40 AM
For Kenji -
"Hi Jared, hope all is good. Was sent your comment on CT and thought I would get in touch.
I didn't have the context of your comment but think it was about not getting a CT scan for someone that comes in with a SW to the abdomen?
Totally agree that we are over using CT in general for blunt trauma, and it is very difficult to keep our residents from automatically ordering one on every patient that rolls in.
For SWs to the abdomen, I think the problem is that (assuming they do not have peritonitis/hypotension/unevaluable/evisceration which would send them immediately to the OR), CT is not perfectly sensitive (nor specific for that matter) for intra-abdominal injury. If a patient comes in with a RUQ or LUQ SW, I will get a CT to evaluate for solid organ injury that might be amenable to IR embolization. For all other SWs to the abdomen though that do not have peritonitis/hypotension/unevaluable/evisceration, the vast majority will be negative or equivocal and since we know the sensitivity is poor and CT can miss hollow viscus injuries, even if it is negative, we end up observing them for 12-24 hours. In our published experience, the CT really did not have a major impact on clinical decision making.
For GSWs however, because the bullet leaves a bubble/soft tissue injury trail, it can be very useful for excluding injuries and all patients who do not go to the OR directly after an abdominal GSW will get a CT.
Hope that helps!
Evan M. - August 4, 2016 10:09 AM
If you determine a penetrating the Thoracic injury probably does go into the thoracic cavity, the chest x-ray is negative, and the cardiac ultrasound is unremarkable; would you still just get a 1 or three hour x-ray? Or would you go ahead and put in a chest tube?