Submitted by: Arianne H.

Bugna BSN-4B

Submitted to: Mrs. Marites L. Robleza Clinical Instructor

Gunshot, Stabbing Victims Are Recovering Without Exploratory Surgery

Although more patients with abdominal gunshot and stab wounds can successfully forego emergency "exploratory" surgery and its potential complications, new Johns Hopkins research suggests that choosing the wrong patients for this "watchful waiting" approach substantially increases their risk of death from these injuries. According to says trauma surgeon Adil H. Haider, M.D., M.P.H., an associate professor of surgery, anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine and senior author of the study published in BJS, the British Journal of Surgery managing gunshot and stab wounds without exploratory surgery prevents complications, saves money and keeps 80 percent of patients from getting operations that end up being unnecessary.But not every hospital should pursue this course because if physicians make a mistake, the patient pays. For generations, surgeons have been taught to open the abdomen rapidly following nearly all gunshot and most deep stab wounds with the idea that failing to identify severe intestinal injury or bleeding is far worse than doing an abdominal exploration that turns up nothing. They studied records from the United States' National Trauma Data Bank from 2002 to 2008, identifying 25,737 patients who survived long enough with abdominal gunshot or stab wounds to be admitted to a trauma center. Just over half had been stabbed. For the seven-year period, more than 22 percent of the gunshot wounds were treated without immediate surgery, together with more than one-third of stab wounds. The remaining patients received immediate exploratory abdominal surgery. Over the study period, the rate of so-called selective non-operative management (SNOM) of these trauma patients rose 50 percent for stab wounds and 28 percent for gunshot wounds, which Haider says points to a growing acceptance of this watchful waiting approach. During the same time period, the rate of negative or unnecessary abdominal operations decreased by about 10 percent. Ultimately, some patients chosen for SNOM needed surgery -- 21 percent of gunshot victims and 15 percent of stabbing victims -- even though doctors initially believed that their injuries did not require operations. Such patients, called SNOM "failures," were 4.5 times more likely to die than those who were successfully managed without surgery. It is unclear whether those patients would have died from their wounds if they had undergone surgery immediately, the team reported.SNOM failure was more common in patients with severe injuries requiring blood transfusions and those with damaged spleens. The payoff for successful SNOM is big, Haider notes. The average hospital stay for successful SNOM patients with gunshot wounds was approximately six days, compared with 13 days for those who underwent immediate exploratory surgery and 14 for those who underwent SNOM but ended up needing surgery later. For stabbing victims, the average hospital stay for those who successfully underwent SNOM was four days, compared with seven days for those who had immediate surgery and eight for those who failed SNOM and needed surgery.

Haider says success depends on having a well-staffed intensive care unit, where those undergoing SNOM can be very closely monitored, as well as in-house surgeons and a ready operating room 24 hours a day in case a SNOM patient takes a turn for the worse and requires immediate surgery.

For Gunshot and Stab Victims, On-Scene Spine Immobilization May Do More Harm Than Good
The findings, published in January issue of the Journal of Trauma, suggest that prehospital spine immobilization for these kinds of patients provides little benefit and may lethally delay proven treatments for what are often life-threatening injuries. Wounds from guns and knives are often far from the spine, yet patients are routinely put in a cervical collar and secured to a board, the investigators say. The researchers caution that spine immobilization has been shown to be well worth the time and quite effective in saving lives and reducing disability from injuries sustained in car crashes and similar events. One finding that Haut says startled his team: Some of the least injured gunshot or stab wound victims appear to be at greater risk of death if time is spent on prehospital immobilization. EMTs and others who immobilize gunshot and stab wound patients don't intend to do harm, but a cervical collar may, for example, conceal an injury to the trachea or make inserting a needed breathing tube more difficult.The merits of other prehospital protocols, such as the need for universal intravenous fluid administration, have also been called into question in recent studies. Haut and his colleagues looked at records from more than 45,000 patients with penetrating trauma included in the National Trauma Data Bank from 2001 to 2004. They calculated that the chance of benefiting from spine immobilization in those cases was 1 in 1,000, while 15 additional people potentially died for every 1,000 shooting or stabbing victims immobilized before being taken to the hospital. While standard protocol in Maryland requires spine immobilization for nearly all patients with bullet and knife wounds, there is more flexibility in other jurisdictions, Haut says. In the national data used by his group, only 4.3 percent of shooting and stabbing victims were immobilized before being taken to the emergency department. Gunshot Injuries in Children Are More Severe, Deadly, Costly Than Any Other InjuryGunshot injuries are a leading cause of death and injury in children and adolescents in the United States; they rank second only to motor vehicle crashes as a cause of death for children ages 15 to 19 A research team led by Oregon Health & Science University (OHSU) and the University of California, Davis, reveals that childhood gunshot injuries, while uncommon, are more severe, require more major surgery, have greater mortality and higher per-patient costs than any other mechanism for childhood injury -- particularly among adolescent males. The study is published online in the journal Pediatrics.

Previous studies on gunshot injuries in children have focused almost exclusively on mortality. This study is one of few to include the much broader number of children affected by gunshot injuries and served by 911 emergency services, both in-hospital and out-of-of hospital measures of injury severity, and children with gunshot injuries treated outside major trauma centers. To conduct this research, Newgard and his OHSU colleagues, in addition to investigators from UC Davis and other centers in the western United States, reviewed data from nearly 50,000 injured children aged 19 and younger for whom 9-1-1 emergency medical services (EMS) were activated over a three-year period in five western regions: Portland, Ore.; Vancouver, Wash.; King County, Wash.; Sacramento, Calif.; Santa Clara Calif.; and Denver, Colo. The research team looked at the number of injuries, severity of injury, type of hospital interventions, patient deaths and costs-per-patient in children with gunshot injuries compared with children whose injuries resulted from other mechanisms, including stabbing, being hit by a motor vehicle, struck by blunt object, falls, motor vehicle crashes and others.They found that compared with children who had other mechanisms of injury, children injured by gunshot had the highest proportion of serious injuries (23 percent), major surgery (32 percent), in-hospital deaths (8 percent) and per-patient costs ($28K per patient). The investigators concluded that public health, injury prevention, and health policy solutions are needed to reduce gunshot injuries in children and their major health consequences. The researchers state that curbing these preventable events will require broad-based interdisciplinary efforts, including rigorous research, partnerships with national organizations, and evidence-based legislation.