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Validating the Western Trauma Association Algorithm for Managing Patients With Anterior Abdominal Stab Wounds: A Western Trauma Association Multicenter Trial

Biffl, Walter L. MD; Kaups, Krista L. MD; Pham, Tam N. MD; Rowell, Susan E. MD; Jurkovich, Gregory J. MD; Burlew, Clay Cothren MD; Elterman, J. MD; Moore, Ernest E. MD

Journal of Trauma and Acute Care Surgery: December 2011 - Volume 71 - Issue 6 - p 1494-1502
doi: 10.1097/TA.0b013e31823ba1de
Original Article

The optimal management of stable patients with anterior abdominal stab wounds (AASWs) remains a matter of debate. A recent Western Trauma Association (WTA) multicenter trial found that exclusion of peritoneal penetration by local wound exploration (LWE) allowed immediate discharge (D/C) of 41% of patients with AASWs. Performance of computed tomography (CT) scanning or diagnostic peritoneal lavage (DPL) did not improve the D/C rate; however, these tests led to nontherapeutic (NONTHER) laparotomy (LAP) in 24% and 31% of cases, respectively. An algorithm was proposed that included LWE, followed by either D/C or admission for serial clinical assessments, without further imaging or invasive testing. The purpose of this study was to evaluate the safety and efficacy of the algorithm in providing timely interventions for significant injuries.

Methods: A multicenter, institutional review board-approved study enrolled patients with AASWs. Management was guided by the WTA AASW algorithm. Data on the presentation, evaluation, and clinical course were recorded prospectively.

Results: Two hundred twenty-two patients (94% men, age, 34.7 years ± 0.3 years) were enrolled. Sixty-two (28%) had immediate LAP, of which 87% were therapeutic (THER). Three (1%) died and the mean length of stay (LOS) was 6.9 days. One hundred sixty patients were stable and asymptomatic, and 81 of them (51%) were managed entirely per protocol. Twenty (25%) were D/C'ed from the emergency department after (−) LWE, and 11 (14%) were taken to the operating room (OR) for LAP when their clinical condition changed. Two (2%) of the protocol group underwent NONTHER LAP, and no patient experienced morbidity or mortality related to delay in treatment. Seventy-nine (49%) patients had deviations from protocol. There were 47 CT scans, 11 DPLs, and 9 laparoscopic explorations performed. In addition to the laparoscopic procedures, 38 (48%) patients were taken to the OR based on test results rather than a change in the patient's clinical condition; 17 (45%) of these patients had a NONTHER LAP. Eighteen (23%) patients were D/C'ed from the emergency department. The LOS was no different among patients who had immediate or delayed LAP. Mean LOS after NONTHER LAP was 3.6 days ± 0.8 days.

Conclusions: The WTA proposed algorithm is designed for cost- effectiveness. Serial clinical assessments can be performed without the added expense of CT, DPL, or laparoscopy. Patients requiring LAP generally manifest early in their course, and there does not appear to be any morbidity related to a delay to OR. These data validate this approach and should be confirmed in a larger number of patients to more convincingly evaluate the algorithm's safety and cost-effectiveness compared with other approaches.

From the Departments of Surgery, Denver Health Medical Center/University of Colorado, Denver, Colorado (W.L.B., C.C.B., E.E.M.); Department of Surgery, Community Regional Medical Center/University of California-San Francisco (K.L.K., G.J.J.), Fresno, California; Harborview Medical Center/University of Washington (T.N.P.), Seattle, Washington; and Department of Surgery, Oregon Health Sciences University (S.E.R., J.E.), Portland, Oregon.

Submitted for publication June 24, 2011.

Accepted for publication October 5, 2011.

Presented at the 41st Annual Meeting of the Western Trauma Association February 27–March 5, 2011, Big Sky, Montana.

Address for reprints: Walter L. Biffl, MD, Department of Surgery, Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204-4507; email:

Copyright © 2011 Wolters Kluwer Health, Inc. All rights reserved.