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Citation
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Baron BJ, Benabbas R, Kohler C, Biggs C, Roudnitsky V, Paladino L, Sinert R. Acad. Emerg. Med. 2018; 25(7): 744-757. |
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Abstract
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BACKGROUND: Work-up for patients presenting to the Emergency Department (ED) following an anterior abdominal stab wound (AASW) has been debated since the 1960s. Experts agree that patients with peritonitis, evisceration, or hemodynamic instability should undergo immediate laparotomy (LAP), however, workup of stable, asymptomatic or non-peritoneal, patients is not clearly defined.
OBJECTIVES: To evaluate the accuracy of computed tomography of abdomen and pelvis (CTAP) for diagnosis of intra-abdominal injuries requiring Therapeutic Laparotomy (THER-LAP) in ED patients with AASW. Is a negative CT scan without a period of observation sufficient to safely discharge a hemodynamically stable, asymptomatic AASW patient? METHODS: We searched PUBMED, EMBASE, and Scopus from their inception until May 2017 for studies on ED patients with AASW. We defined the reference standard test as LAP for patients who were managed surgically and those with THER-LAP were considered as disease-positive. In those who were managed nonsurgically, inpatient observation was considered the reference standard. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate the risk of bias and applicability of the included studies. We attempted to compute the pooled sensitivity, specificity, Likelihood Ratios (LR+, LR-) using a random-effects model with MetaDiSc software and calculate testing and treatment thresholds for CT scan applying the Pauker and Kassirer model.
RESULTS: Seven studies were included encompassing 575 patients. The weighted prevalence of THER-LAP was 34.3% (95% CI 30.5-38.2%). Studies had variable quality and the inclusion criteria were not uniform. The operating characteristics of CT scan were: sensitivity 50%-100%, specificity 39%-97%, LR+ 1.0-15.7 and LR- 0.07-1.0. The high heterogeneity (I-square>75%) of the operating characteristics of CT scan prevented pooling of the data and therefore the testing and treatment thresholds could not be estimated.
DISCUSSION: The articles revealed a high prevalence (8.7%, 95% CI 6.1-12.2%) of injuries requiring THER-LAP in patients with a negative CT scan and almost half (47%, 95% CI 30-64%) of those injuries involved the small bowel.
CONCLUSIONS: In stable AASW patients, a negative CT scan alone without an observation period is inadequate to exclude significant intra-abdominal injuries. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
Language: en |