Selective nonoperative management of torso gunshot wounds: when is it safe to discharge?

Abstract

Background: For patients sustaining torso gunshot wounds (GSWs) who undergo a trial of nonoperative management (NOM), the optimal observation time required to exclude a hollow viscus injury before discharge is unknown. The purpose of this study was to analyze a continuous series of patients undergoing NOM after sustaining a GSW to the torso to determine the safe period of observation before discharge.

Methods: This is a retrospective analysis of a continuous series of patients assessed at a Level I Trauma Center undergoing NOM of their torso GSWs from 2005 to 2007. After Institutional Review Board approval, injury demographics, operative procedures, time to operation, computed tomographic imaging results, and outcomes were abstracted.

Results: During the 3-year study period, a total of 863 patients sustained a GSW to the torso. Of these, 61 patients (7.1%) died in the emergency department and 15 (1.7%) did not have admission data. After excluding these patients, a total of 787 patients were available for analysis. Mean age was 26.2 +/- 9.7 years (range, 16 - 87 years), 93.6% were male, and mean Injury Severity Score was 10.7 +/- 10.6. Overall, 151 patients (19.2%) underwent immediate exploratory laparotomy, based on clinical criteria, and 636 patients (80.8%) underwent a trial of NOM. Of these, patients, 29 (4.6%) failed and were subsequently taken to the operating room. Two patients had a negative laparotomy; the remaining had colon or rectal (58.6%), small bowel (24.1%), stomach (17.2%), and bladder (6.9%) injuries requiring repair. All patients developed clinical or laboratory evidence of a missed injury by 24 hours of observation.

Conclusion: For patients undergoing NOM of their torso GSWs, all patients who failed and required a laparotomy did so within 24 hours of admission. Patients undergoing selective NOM required a minimum of 24 hours of close observation before discharge.