Prospective evaluation of selective nonoperative management of torso gunshot wounds: when is it safe to discharge?

Background: Selective nonoperative management (NOM) has been increasingly used for torso gunshot wounds (GSWs). The optimal observation time required to exclude a hollow viscus injury is not clear. The purpose of this study was to determine the safe period of observation before discharge.

Methods: All patients aged 16 years and older sustaining a torso GSW undergoing a trial of NOM were prospectively enrolled (January 2009 to January 2011). Patient demographics, initial computed tomography (CT) results, time to failure of NOM, operative procedures, and outcomes were collected. Failure of NOM was defined as the need for operation.

Results: A total of 270 patients sustained a GSW to the torso. Of those, 25 patients (9.3%) died in the emergency department and were excluded leaving 245 patients available for the analysis. Mean age was 26.5 years ± 9.9 years (16-62 years), 92.7% (227) were men, and mean Injury Severity Score scale was 13.8 ± 11.3 (1-45). Overall, 115 patients (46.9%) underwent immediate exploratory laparotomy based on clinical criteria (72.2% had peritonitis, 27.8% hypotension, 10.4% unevaluable, and 4.3% evisceration), and 130 patients (53.1%) underwent evaluation with CT for possible NOM. Of those, 39 patients (30.0%) had a positive CT and were subsequently operated on. All had significant intra-abdominal injuries requiring surgical management. A total of 91 patients (70.0%) underwent a trial of NOM (47 had equivocal CT findings and 44 had a negative examination). Of these, 8 patients (8.8%) failed NOM and underwent laparotomy (all had equivocal CT scans). Two patients had a nontherapeutic laparotomy; the remainder had stomach (50.0%), colon (25.5%), and rectal (12.5%) injuries. The mean time from admission to development of clinical or laboratory signs of NOM failure was 2 hours:43 minutes ± 2 hours:23 minutes (0 hour:31 minutes-6 hours:58 minutes). All patients failed within 24 hours of admission.

Conclusion: In the initial evaluation of patients sustaining a GSW to the torso, clinical examination is essential for identifying those who will require emergency operation. For those undergoing a trial of NOM, all failures occurred within 24 hours of hospital admission, setting a minimum required observation period before discharge.