• Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA. Practice management guidelines for nonoperative management of penetrating abdominal trauma. Chicago (IL): Eastern Association for the Surgery of Trauma (EAST); 2007. 49 p.

This is the current release of the guideline.

Penetrating abdominal trauma

Management
Treatment

Critical Care
Emergency Medicine
Family Practice
Gastroenterology
Internal Medicine
Surgery

Advanced Practice Nurses
Nurses
Physician Assistants
Physicians

To provide practice management guidelines for nonoperative management of penetrating abdominal trauma

Patients with penetrating abdominal trauma

Diagnosis/Assessment

1. Physical examination
2. Assessment of indications for laparotomy
3. Triple-contrast (oral, intravenous, and rectal contrast) abdominopelvic computed tomography (CT)
4. Angiography

Treatment

1. Observation
2. Laparotomy

• Mortality and morbidity
• Length of hospital stay
• Sensitivity and specificity of clinical examination and imaging methods

Searches of Electronic Databases

51

The 51 references included 1 Class I, 26 Class II, and 24 Class III (see "Rating Scheme for the Strength of the Evidence").

Weighting According to a Rating Scheme (Scheme Given)

Class I: Prospective, randomized clinical trials

Class II: Clinical studies in which data was collected prospectively or retrospective analyses based on clearly reliable data

Class III: Studies based on retrospectively collected data

Systematic Review with Evidence Tables

Not stated

Expert Consensus

Not stated

Level 1: The recommendation is convincingly justifiable based on the available scientific information alone. This recommendation is usually based on Class I data; however, strong Class II evidence may form the basis for a level 1 recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, low quality or contradictory Class I data may not be able to support a level 1 recommendation.

Level 2: The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence.

Level 3: The recommendation is supported by available data but adequate scientific evidence is lacking. This recommendation is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Not stated

Not applicable

The levels of recommendation (1-3) and classes of evidence (I-III) are defined at the end of the "Major Recommendations" field.

Level 1

There is insufficient data to support a Level 1 recommendation on this topic.

Level 2

1. Patients who are hemodynamically unstable or who have diffuse abdominal tenderness after penetrating abdominal trauma should be taken emergently for laparotomy.
2. Patients with an unreliable clinical examination (i.e., severe head injury, spinal cord injury, severe intoxication, or need for sedation or intubation) should be explored or further investigation done to determine if there is intraperitoneal injury.
3. Others may be selected for initial observation. In these patients:
   1. Triple-contrast (oral, intravenous, and rectal contrast) abdominopelvic computed tomography (CT) should be strongly considered as a diagnostic tool to facilitate initial management decisions as this test can accurately predict the need for laparotomy.
   2. Serial examinations should be performed, as physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen. Patients requiring delayed laparotomy will develop abdominal signs.
   3. If signs of peritonitis develop, laparotomy should be performed.
   4. If there is an unexplained drop in blood pressure or hematocrit, further investigation is warranted.

Level 3

1. The vast majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after twenty-four hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness.
2. Patients with penetrating injury to the right upper quadrant of the abdomen with injury to the right lung, right diaphragm, and liver may be safely observed in the presence of stable vital signs, reliable examination and minimal to no abdominal tenderness.
3. Angiography and investigation for and treatment of diaphragm injury may be necessary as adjuncts to initial nonoperative management of penetrating abdominal trauma.
4. Mandatory exploration for all penetrating renal trauma is not necessary.

Definitions:

Classes of Evidence

Class I: Prospective, randomized clinical trials

Class II: Clinical studies in which data was collected prospectively or retrospective analyses based on clearly reliable data

Class III: Studies based on retrospectively collected data

Levels of Recommendation

Level 1: The recommendation is convincingly justifiable based on the available scientific information alone. This recommendation is usually based on Class I data; however, strong Class II evidence may form the basis for a level 1 recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, low quality or contradictory Class I data may not be able to support a level 1 recommendation.

Level 2: The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence.

Level 3: The recommendation is supported by available data but adequate scientific evidence is lacking. This recommendation is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Appropriate management and treatment of patients with penetrating abdominal trauma

Complications related to management/treatment

• The Eastern Association for the Surgery of Trauma (EAST) is a multi-disciplinary professional society committed to improving the care of injured patients. The Ad hoc Committee for Practice Management Guideline Development of EAST develops and disseminates evidence-based information to increase the scientific knowledge needed to enhance patient and clinical decision-making, improve health care quality, and promote efficiency in the organization of public and private systems of health care delivery. Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors' personal observations and do not imply endorsement by nor official policy of the Eastern Association for the Surgery of Trauma.
• "Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."* These guidelines are not fixed protocols that must be followed, but are intended for health care professionals and providers to consider. While they identify and describe generally recommended courses of intervention, they are not presented as a substitute for the advice of a physician or other knowledgeable health care professional or provider. Individual patients may require different treatments from those specified in a given guideline. Guidelines are not entirely inclusive or exclusive of all methods of reasonable care that can obtain/produce the same results. While guidelines can be written that take into account variations in clinical settings, resources, or common patient characteristics, they cannot address the unique needs of each patient nor the combination of resources available to a particular community or health care professional or provider. Deviations from clinical practice guidelines may be justified by individual circumstances. Thus, guidelines must be applied based on individual patient needs using professional judgment.

* Institute of Medicine. Clinical practice guidelines: directions for a new program. MJ Field and KN Lohr (eds) Washington, DC: National Academy Press. 1990: pg 39.

An implementation strategy was not provided.

Getting Better

Effectiveness

• Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA. Practice management guidelines for nonoperative management of penetrating abdominal trauma. Chicago (IL): Eastern Association for the Surgery of Trauma (EAST); 2007. 49 p.

Not applicable: The guideline was not adapted from another source.

2007

Eastern Association for the Surgery of Trauma - Professional Association

Eastern Association for the Surgery of Trauma (EAST)

EAST Practice Management Guidelines Committee

Committee Members: John J. Como, MD (Chairman) MetroHealth Medical Center, Case School of Medicine; Faran Bokhari, MD (Vice-Chairman) Stroger Hospital of Cook County, Rush Medical College; William C. Chiu, MD, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine; Therese M. Duane, MD, Virginia Commonwealth University Medical Center, Medical College of Virginia; Michele R. Holevar, MD, Mount Sinai Hospital, Chicago Medical School; Margaret A. Tandoh, MD, Upstate Medical Center, SUNY Upstate Medical University

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on September 12, 2008.

This NGC summary is based on the original guideline, which is copyrighted by the Eastern Association for the Surgery of Trauma (EAST).