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Dissections INTERVENTIONAL

31 July 2009
Evidence-based Medicine for Surgeons

Local wound exploration remains a valuable triage tool for the evaluation of anterior
abdominal stab wounds
Authors: Cothren CC, Moore EE, Warren FA, et al
Journal: The American Journal of Surgery 2009; 198: 223-226
Centre: University of Colorado School of Medicine, Denver, Colorado, USA
Current standards of care do not support local wound exploration (LWE) and diagnostic peritoneal
lavage (DPL) in the evaluation of hemodynamically stable patients with anterior abdominal stab
wounds (AASW); computed tomography (CT) scanning or serial examinations are the
BACKGROUND recommended techniques. In theory, patients without fascial penetration on LWE can be
discharged from the emergency department (ED), rather than undergo a mandatory in-hospital
observation period. Those patients with a negative DPL can be observed for 12 to 24 hours in the
ED before discharge, thus avoiding inpatient admission.

RESEARCH QUESTION IN SUMMARY


Population Local wound exploration in anterior abdominal stab wounds

A series of patients seen at a


trauma centre in the USA. with
anterior abdominal stab wounds
(AASW).

Indicator variable
Local wound exploration (LWE)
followed by diagnostic peritoneal
lavage (DPL) in those with a
breached posterior fascia.

Outcome variable
Primary: need for laparotomy,
observation in the ED or discharge
from the ED.

Comparison
None.

LWE - local wound exploration, DPL = diagnostic peritoneal lavage


Authors' claim(s): “...Only 11% of patients with AASWs without overt indication for laparotomy require
surgical care. LWE remains a valid method to exclude intra-abdominal injury and to eliminate hospitalization in
more than one third of AASW patients.”

THE TISSUE REPORT


Evidence-based Medicine, whatever its shortcomings, has driven home the necessity of randomized clinical trials as the
basis for establishing the validity of interventions in practice, more so when making a claim that the study strategy is equal to
or better than existing recommendations. A small trial, with no controls, is not evidence. Unfortunately, the anecdotal style
of this paper, makes it easy to remember and quote as proof for support of this particular strategy.

EBM-O-METER
Evidence level Overall rating Bias levels
Double blind RCT Sampling
Randomized controlled trial (RCT) Comparison
Trash Swiss Safe News-
Prospective cohort study - not randomized cheese worthy Measurement
Life's too Holds water
short for this Full of holes “Just do it”
Case controlled study
Interestingl | Novel l | Feasible l
Case series - retrospective  Ethical l | Resource saving l

The devil is in the details (more on the paper) ... 

© Dr Arjun Rajagopalan
SAMPLING
Sample type Inclusion criteria Exclusion criteria Final score card
Simple random Stab wounds between Thoracoabdominal, AASW
the costal margins, back, or flank wounds 
Stratified random Target ?
inguinal ligaments, and
Cluster bilateral anterior axillary Accessible 2008
lines 
Consecutive Intended 139
Convenience Drop outs -
Judgmental Study 139

 = Reasonable | ? = Arguable |  = Questionable


Duration of the study: 3 years (actual dates not stated)

Sampling bias: A small series, from a single centre, analysed retrospectively.

COMPARISON
Randomized Case-control Non-random Historical None

Controls - details
Allocation details After sterile preparation the wound was infiltrated with 1% lidocaine with epinephrine. If
necessary, the stab wound was extended to facilitate adequate visualization of the fascia. A
local wound exploration was considered positive if the posterior fascia was violated. DPL was
performed in the standard fashion via an infraumbilical approach and considered positive or
negative based on established criteria.
Comparability No comparison made.
Disparity -

Comparison bias: No attempt was made to compare this strategy with existing standards of care.

MEASUREMENT
Measurement error
Device used Device error Observer error
Gold std.

Device suited to task


Training

Scoring

Blinding
Repetition

Protocols

Y ? N

1.Outcome - laparotomy, observation in the ED, - - - - - - -


discharge from the ED

Measurement bias: All outcomes measured were simple, discrete items with little scope for measurement bias.

© Dr Arjun Rajagopalan