A SELECTIVE APPROACH TO THE MANAGEMENT OF GUNSHOT WOUNDS TO THE BACK

BACKGROUND: Gunshot wounds to the back with retroperitoneal trajectori es have been traditionally managed under the same guidelines as anteri or gunshot wounds, Recent work has suggested that selective nonoperati ve management of anterior abdominal gunshot wounds is safe. The role o f this policy in gunshot wounds to the back, where retroperitoneal org an injuries may be more difficult to detect clinically, has not been i nvestigated, OBJECTIVE: TO examine if selective nonoperative managemen t based on clinical assessment is a safe alternative to mandatory expl oration for gunshot wounds to the back, DESIGN: Prospective study, SET TING: Large-volume level-1 university affiliated trauma center, PATIEN TS AND METHODS: TWO hundred and three consecutive patients with gunsho t wounds to the back were managed according to a protocol during a 12- month period, Patients with hemodynamic instability or peritonitis und erwent urgent operation, The rest of the patients were observed with c areful serial clinical examinations, RESULTS: Eleven patients underwen t an emergency room thoracotomy and were excluded, Four more patients were operated upon, despite the absence of abdominal findings, because of associated spinal cord injuries (2 patients), inability to observe due to need for repair of an associated peripheral vascular injury (1 patient), and participation in another protocol of aggressive evaluat ion of asymptomatic patients with suspected diaphragmatic injuries (1 patient), Of the remaining 188 patients, 58 (31%) underwent laparotomy (56 therapeutic, 2 negative) and 130 (69%) were initially observed ow ing to negative clinical examination, Following the development of inc reasing abdominal tenderness, 4 of these 130 (3%) underwent delayed ex plorations, which were all nontherapeutic. The sensitivity and specifi city of initial clinical examination in detecting significant intraabd ominal injuries were 100% and 95%, respectively, CONCLUSIONS: Mandator y laparotomy is not necessary for gunshot wounds of the back. Clinical examination is a safe method of selecting patients for nonoperative m anagement. An observation period of 24 hours is adequate for patients with no abdominal symptoms. (C) 1997 by Excerpta Medica, Inc.