A. G. Goldenberg1, J. Badach1, C. Arya1, J. San Roman1, J. Gaughan1, J. P. Hazelton1 1Cooper University Hospital,Division Of Trauma,Camden, NJ, USA
Introduction: Cavitary triage is important in treating patients with gunshot wounds of the torso, as it allows the surgeon to define the sequence of clinical management. The practice of marking wounds with radio-opaque markers and obtaining X-rays of various body regions has been done in an attempt to determine the trajectory of missiles and help identify which organs may be injured. We hypothesized that such X-rays do not alter the clinical decision of the surgeon in regards to emergent operation vs. further diagnostics, and that hemodynamic parameters would be the most crucial piece of information for the surgeon.
Methods: We developed a 50-patient (89 injury sites) PowerPoint survey based on cases seen at our Level-1, urban trauma center from 2012 through 2014. X-ray images were de-identified and cases were selected so that none of the survey participants would have had contact with the study patients during their initial resuscitation. Images of a silhouetted BodyMan (BM) with wounds marked, X-rays of the neck and torso (XR), and vital signs (VS) were shown in series for 20 seconds each. Surgeons were asked after each image to record which organs they thought could be injured and to document their next step in management (emergent operation vs. further diagnostics).
Results: Ten surgeons with varying clinical experience completed the survey (>6y in practice, n=3; 1 to 6y in practice, n=4; in-training Fellow, n=3). Data was analyzed to determine the inter-rater reliability (agreement, ICC) for each mode of clinical information (BM, XR, VS). Predicted vs. actual injuries were compared using absolute agreement and kappa statistics. We found that no one piece of information (BM, XR, or VS) was helpful in allowing the surgeon to accurately determine the predicted vs. actual organ injuries. Overall, the most experienced surgeons (>6y in clinical practice) were better than in-training Fellows (PGY-6) in accurately predicting actual injury (93% vs 78%, p=0.021). Pulmonary injury, as evidenced by the chest X-ray, had the highest agreement amongst all potential injuries (ICC=0.727). VS had the highest ICC across all groups in determining the clinical plan for the patient (ICC=0.342), while both BM and XR had low ICCs across all groups in determining clinical plan (ICC=0.162, 0.183).
Conclusion: In this pilot study we found that marking wounds and obtaining X-rays, other than a chest X-ray, did not result in accuracy in predicting injury, nor agreement among participants. Further, these X-rays did not alter the decision making of the surgeon relative to need for operative intervention. Patient vital signs were the only piece of information found significant in determining clinical management. We conclude that marking wounds for radiographic localization is an unnecessary step during the initial resuscitation of patients with gunshot wounds to the neck and torso.