Juan A. Asensio

A selective approach to the management of Gunshot wounds to the back

BACKGROUNDnGunshot wounds to the back with retroperitoneal trajectories have been traditionally managed under the same guidelines as anterior gunshot wounds. Recent work has suggested that selective nonoperative management of anterior abdominal gunshot wounds is safe. The role of this policy in gunshot wounds to the back, where retroperitoneal organ injuries may be more difficult to detect clinically, has not been investigated.nnnOBJECTIVEnTo examine if selective nonoperative management based on clinical assessment is a safe alternative to mandatory exploration for gunshot wounds to the back.nnnDESIGNnProspective study.nnnSETTINGnLarge-volume level-1 university affiliated trauma center.nnnPATIENTS AND METHODSnTwo hundred and three consecutive patients with gunshot wounds to the back were managed according to a protocol during a 12-month period. Patients with hemodynamic instability or peritonitis underwent urgent operation. The rest of the patients were observed with careful serial clinical examinations.nnnRESULTSnEleven patients underwent an emergency room thoracotomy and were excluded. Four more patients were operated upon, despite the absence of abdominal findings, because of associated spinal cord injuries (2 patients), inability to observe due to need for repair of an associated peripheral vascular injury (1 patient), and participation in another protocol of aggressive evaluation of asymptomatic patients with suspected diaphragmatic injuries (1 patient). Of the remaining 188 patients, 58 (31%) underwent laparotomy (56 therapeutic, 2 negative) and 130 (69%) were initially observed owing to negative clinical examination. Following the development of increasing abdominal tenderness, 4 of these 130 (3%) underwent delayed explorations, which were all nontherapeutic. The sensitivity and specificity of initial clinical examination in detecting significant intraabdominal injuries were 100% and 95%, respectively.nnnCONCLUSIONSnMandatory laparotomy is not necessary for gunshot wounds of the back. Clinical examination is a safe method of selecting patients for nonoperative management. An observation period of 24 hours is adequate for patients with no abdominal symptoms.

Helical computed tomographic scan in the evaluation of mediastinal gunshot wounds.

BACKGROUNDnThe standard evaluation of mediastinal gunshot wounds usually requires angiography and either esophagoscopy or esophagography. In the present study, we have evaluated the role of helical computed tomographic (CT) scanning in reducing the need for angiographic and esophageal studies.nnnMETHODSnThis was a prospective study of patients with mediastinal gunshot wounds who were hemodynamically stable and would otherwise require angiography and esophageal evaluation. All patients underwent CT scan of the chest with intravenous contrast to delineate the missile trajectory. If the missile tract was in close proximity to the aorta, great vessels, or esophagus, then traditional evaluation with angiographic or esophageal evaluation was pursued.nnnRESULTSnA total of 24 patients met the inclusion criteria and underwent CT scan evaluation of their mediastinal gunshot wounds. One patient was taken for sternotomy to remove a missile embedded in the myocardium solely on the basis of the result of the CT scan. Because of proximity of the bullet tract, 12 patients required additional evaluation with eight angiograms and nine esophageal studies. One of these patients had a positive angiogram (bullet resting against the ascending aorta) and underwent sternotomy for missile removal; all other studies were negative. The remaining 11 patients were found to have well-defined missile tracts that approached neither the aorta nor the esophagus, and no additional evaluation was pursued. There were no missed mediastinal injuries in this group. Overall, 12 of 24 patients (50%) had a change in management (either received an operation or avoided additional radiographic or endoscopic evaluation) on the basis of the CT scan.nnnCONCLUSIONnThe helical CT scan provides a rapid, readily available, noninvasive means to evaluate missile trajectories. This permits accurate assessment of potential mediastinal injury and reduces the need for routine angiographic and esophageal studies.

Duodenal and Pancreatic Injuries-Complex and Lethal Injuries*

Three Major Trauma Services, two in NSW and one in Victoria recently underwent the process of a trial external verification and consultation visit of their trauma services. This process, a pilot under the auspices of the Royal Australasian College of Surgeons, with multidisciplinary involvement, was an extremely rewarding experience for our Trauma Service at Liverpool. It provided through the incisive critique of the review team, an opportunity for us to identify areas of trauma care that need to be addressed. It is a process I would commend to all Trauma Services. Better Practice is a term that we are increasingly exposed to in medicine. Particularly good examples have been developed in Breast Surgery and Colorectal cancer care. Due to the continuing evolution of care the term Best practice is probably best replaced with Better practice. A key question that we must answer in Australasia is; Do we need minimum standards in trauma care delivery?