Disposition of CT-Negative Patients with Blunt Abdominal Trauma
May 1, 1998 3 minutes read
Disposition of CT-Negative Patients with Blunt Abdominal Trauma
ABSTRACT & COMMENTARY
Source: Livingston DH, et al. Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: Results of a prospective, multi-institutional trial. J Trauma Inj Infect Crit Care 1998;44:273-280.
Livingston and colleagues performed a prospective, multi-institutional study investigating several issues in the blunt abdominal trauma (BAT) patient undergoing abdominal CT scan (CT) in the ED, including 1) the need for subsequent hospitalization after a negative evaluation (CT and other investigations), 2) the negative predictive value (NPV) of CT, and 3) the identification of patients who may be safely discharged from the ED after a negative CT. All trauma patients admitted to four trauma centers over a 22-month period with suspected BAT were eligible for study entry. Patients were excluded for the following reasons: age younger than 16 years, urgent operation necessary, GCS less than 14, head injury with focal neurologic examination, skull fracture, presentation more than 12 hours since injury, warfarin therapy, laboratory abnormalities (platelets < 50,000 and PT > 3 seconds above control), and a number of medical conditions (end-stage renal disease on hemodialysis, cirrhosis, severe CHF, and any bleeding disorder). All patients underwent helical CT interpreted by surgeons and/or radiologists, in addition to other studies as deemed clinically necessary, and these patients were admitted to the hospital for a minimum of 20 hours. Various demographic variables, clinical findings, and outcome issues were analyzed. Toxicologic studies including ethanol determinations were performed at the discretion of the treating physicians.
During the study period, 6409 trauma patients, with 3822 cases of suspected BAT, were encountered; after the exclusions, 2744 patients were enrolled, with 2299 patients ultimately used for data analysis after additional exclusions for protocol violation. CT was negative for injury (and/or free intraperitoneal fluid) in 1809 patients, positive for injury in 389 patients, and nondiagnostic for injury in 78 patients. Nine patients with initially negative CT underwent exploratory laparotomy, with six cases demonstrating injuries requiring operative repair (intestinal, 3; renal, 1; bladder, 1; and diaphragm, 1) and three cases demonstrating either nontherapeutic (2) or negative findings (1). Extra-abdominal injuries were present in 97% of patients. Only 18% of patients were discharged from the hospital within 24 hours of presentation. Bowel injuries were seen via CT in 22 patients and missed in three patients. Only 66% of patients had a documented repeat physical examination during the hospital course. Toxicologic screening results were not quantified. The NPV of CT in the BAT population was 99.63%. Livingston et al conclude that BAT patients with a negative CT do not benefit from hospital admission and prolonged observation.
COMMENT BY WILLIAM J. BRADY, MD
The current standard of care in the BAT patient recommends an inpatient disposition for observation despite a negative ED evaluation. The work by Livingston et al attempts to address the issue, suggesting that an outpatient disposition is possible. Unfortunately, the results do not necessarily support this conclusion. First, as noted in the study, only 498 patients (18%) were discharged rapidly-within 24 hours-from the hospital, indicating that most patients had additional injuries or other ongoing issues requiring hospital-based care. Second, the intoxicated patient in the ED with a negative CT represents a problem case that is best admitted to the hospital. Livingston et al do not quantify the toxicologic issues in this patient population and only state that ". . . obviously drunk patients do not go home . . ." in the discussion section. The injury-masking effects of ethanol and other intoxicating substances are not adequately addressed in this paper. Third, the issue of the patient who is incapable of self-care after ED discharge due to age, comorbidities, or compliance issues is not addressed. For example, the physician is often faced with the elderly trauma patient with a negative evaluation who is incapacitated by the injury event and will likely benefit from an inpatient disposition. Also, the patient who lives alone, lacking adult supervision after discharge, may also benefit from inpatient observation. Finally, Livingston et al report that only 66% of patients admitted for prolonged observation underwent documented repeat abdominal examinations; this figure should prompt a re-evaluation of the inpatient practices at these institutions and not be used as yet another reason supporting discharge from the ED in the BAT patient. In short, a number of issues make the results from this work difficult to apply to many BAT patients in the ED. Undoubtedly, a minority of cases do not benefit from hospitalization and may be safely discharged from the ED. Unfortunately, this article does not clearly identify this subpopulation.
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