WEST Guidelines - Stab Wounds, Avoid Pitfalls

Written by Clay Smith

Spoon Feed
It is important to see how trauma surgery has evolved regarding abdominal stab wounds. Know their algorithm, especially the caveats and when not send patients home.

Why does this matter?
We need to understand how Trauma manages abdominal stab wounds. Unlike when I started in EM, patients sometimes stay in the ED, and we are left to send them home. Who should not go home?

It’s just a flesh wound
The main goal of this post is to make you aware of this algorithm. It is good and helpful. More importantly, I want to point out the areas where you might get in trouble. First, here is the algorithm.

From cited article and publicly available as a PDF  here .

From cited article and publicly available as a PDF here.

Here are the pitfalls I see.

  • Any unstable patient needs either surgery or surgery admission. Do not let Trauma tell you the patient is fine because they have a normal CT.

  • Patients with altered mental status (AMS) from trauma or intoxication are more risky. Proceed with caution and never discharge a patient with a stab wound who is otherwise “cleared” but still altered.

  • Watch out for upper abdominal stabs that could involve the diaphragm, especially on the left. They need CT imaging with fine cuts at least, and I would advocate for observation on surgery even if negative.

  • Local wound exploration (LWE) is fraught with issues.

    • A second year surgery resident jamming a q-tip into the stab wound until it stops is not LWE. It needs to be anesthetized, opened, and explored with good lighting.

    • LWE is also not good for “small puncture type wounds (i.e., ice pick), long tangential stab wound tracts, significant obesity with very deep subcutaneous fat layer, and multiple stab wounds.”

    • Patients need to be cooperative and have pain control to tolerate LWE. Drunk, wild, combative patients are not good candidates, which excludes many.

  • “Serial clinical exams” explicitly says 24 hours on the algorithm. “Serial exams” is not an ED thing.

  • CT may be helpful for specific injury patterns, such as right upper quadrant stabs. A positive study is easy - admit or operate. But the algorithm states, “ a negative CT scan should not be used as the sole determinant for discharging an abdominal stab wound patient from the emergency department.” EAST found 9% with negative CT ended up needing laparotomy.

It’s easier when trauma just admits these patients. But from their perspective, they had up to a 50% negative exploratory laparotomy rate prior to selective surgery. So, they are more circumspect in assessing abdominal stab wounds. Just be sure you know the caveats of this algorithm.

Another Spoonful
See what the Trauma Pro had to say about this.

Source
Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2018 Nov;85(5):1007-1015. doi: 10.1097/TA.0000000000001930.

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