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Selective Nonoperative Management of Penetrating Torso Injury From Combat Fragmentation Wounds

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Penetrating fragmentation injury to the torso in armed conflict represents a unique wounding pattern rarely seen in civilian trauma. The projectiles range widely in size and velocity. The mechanism of delivery of the projectiles also has the confounding variable of primary blast injury. Historically, the presence of these wounds on the abdomen, flank, back, or buttocks mandated exploratory laparotomy to rule out intraabdominal injury. A policy of routine exploration of all penetrating abdominal injuries was introduced in 1915 as a result of the high mortality associated with nonoperative management of these injuries early in World War I. This policy of mandatory exploration of penetrating abdominal wounds, particularly gunshot wounds GSWs, remained largely unchallenged until the 1990s, when civilian authors reported successful use of selective nonoperative management of abdominal GSWs. However, no series documenting the use of selective nonoperative management of penetrating abdominal wounds caused by explosive or fragmentation munitions has been published, and the mandate to operatively explore all of these patients has remained unchanged since World War I. The Emergency War Surgery manual 2004 clearly outlines the paradigm of care Penetrating injuries below the nipples, above the symphysis pubis, and between the posterior axillary lines must be treated as injuries to the abdomen and mandate exploratory laparotomy. Mandatory surgical exploration has, in part, been driven by the need to evacuate casualties out of a theater of combat and the consequent inability of surgeons to continuously re-evaluate casualties who are nonoperatively managed. This paradigm of care likely results in a very low rate of missed injuries and essentially no delay in diagnosis. It also undoubtedly results in a substantial rate of nontherapeutic operations, which in civilian series of penetrating abdominal trauma ranges from 3.2 to 37.

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  • Ammunition and Explosives
  • Weapons Effects (Biological)

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