Thankfully, very few of us actually deal with these sorts of injuries on a regular basis – and even fewer of us are actually responsible for managing these injuries.
However, this is an important article out of USC pushing back against the trend towards utilizing CT for every traumatic injury possible. There certainly seems, universally in medicine, to be a regression in reliance on the clinical examination along with a corresponding increased use of technology. There are many reasons this occurs – convenience, patient satisfaction, and “zero-miss” mentality – and we’re just now fully accounting for the tremendous costs associated with this flawed evolution in practice.
In this study, all diagnostically equivocal abdominal stab wounds underwent a structured protocol including CT and observation. Over a two-year period, 177 stable patients qualified for this protocol. Overall, 87% were managed non-operatively – but, most importantly, clinical deterioration directed all necessary operative interventions, rather than CT findings. Of the 23 patients who underwent operative intervention, 4 patients underwent operative intervention based solely on CT findings – and all four detected no injury during exploration. The final test characteristics for CT were sensitivity of 31.3% and specificity of 84.2%.
I think these authors are entirely appropriate in describing the use of CT in abdominal stab wounds as inferior to clinical observation. They don’t specifically emphasize the false positives from CT in their discussion, but these findings lead to real patient harms – even just in their small cohort. One of the four CT-directed interventions underwent negative pericardial window for suspected hemopericardium – and suffered a peri-operative cardiac arrest due to complications from anesthesia.
Let’s try to avoid that.
“Prospective Evaluation of the Role of Computed Tomography in the Assessment of Abdominal Stab Wounds”
http://www.ncbi.nlm.nih.gov/pubmed/23824102