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We undertook this retrospective review to examine the appropriateness of a protocol for the selective emergency department (ED) workup of asymptomatic penetrating truncal injuries. Records of consecutive patients presenting to our urban Level I trauma center with penetrating truncal injuries between January 1, 1997 and September 2000 were reviewed. Data obtained included: patient demographics, ED workup, ED disposition, complications, and follow-up. Selective ED workup included hospital triple-contrast CT, admission for observation, and local wound exploration for selected anterior abdominal stab wounds. Four hundred fifty-five patients presented with penetrating truncal wounds during the study period. One hundred ninety-four patients were taken directly to the operating room, 136 were discharged based solely on physical examination and plain radiographs, 18 were admitted for observation without ED workup, and 107 had selective ED workup. Sixty-two patients (58% of those selectively worked up) were discharged home after negative ED workup, 18 were managed operatively, and 27 were managed nonoperatively. There were two missed injuries that were later identified and managed with no complications. Follow-up was available on 66 per cent of ED workup patients (range 1-42 months). We conclude that selective management of certain penetrating truncal injuries appears appropriate. Patients having a negative selective ED workup can be safely discharged thereby avoiding the cost and resource utilization associated with hospital admission.

With decreasing violent crime and an increase in the use of nonoperative management techniques the viability of urban trauma centers has come into question. In addition the workload and productivity for surgeons at such centers may be threatened. The current study examines the changing characteristics of patients admitted to an urban Level I trauma center over a 5-year period and examines factors that may affect trauma surgeon utilization. We reviewed all trauma registry admissions from January 1995 through December 1999. Data were collected regarding patient demographics, mechanism of injury, diagnostic workup, injury character and severity, operative procedures, intensive care unit (ICU) length of stay (LOS), hospital LOS, and patient disposition. Admissions declined 23 per cent over the 5-year period. Fewer patients were admitted to general practice units whereas more patients required ICU admission. Over the study period both mean patient age and mean Injury Severity Score increased significantly. Gunshot wound admissions declined by 45 per cent, but the percentage of those admitted who required operation rose 17 per cent. Number of operations for trauma performed by general surgeons was unchanged over time. Hospital LOS declined over time, and ICU LOS was unchanged. Although trauma center admissions--particularly those due to violent crime--are on the decline the operative productivity of trauma surgeons has remained unchanged. Patients admitted to the hospital are older and more severely injured; they undeniably require a higher level of care and service coordination. Urban trauma centers remain viable and are in fact more efficient in caring for sicker patients.