The Diagnostic Yield of Commonly Used Investigations in Pelvic Gunshot Wounds.

Background: Patients who sustain pelvic gunshot wounds (GSWs) are at significant risk for injury due to the density of pelvic structures. Currently, the optimal work-up for pelvic GSWs is unclear. The aim of this study was to determine the diagnostic yield of tests commonly used in the investigation of pelvic GSWs and to develop a diagnostic algorithm. Methods: All patients >=15 years old presenting to LAC+USC Medical Center (01/2008-02/2015) who sustained >=1 pelvic GSW were retrospectively identified. Patient demographics, clinical assessment, investigations, procedures, and outcomes were abstracted. The diagnostic yield of CT scan, cystogram, gross inspection of the urine, urinalysis, endoscopy, and digital rectal exam (DRE) in the detection of clinically significant injuries to the pelvis were calculated. Results: Three hundred and seventy patients were included. Patients with peritonitis, hemodynamic instability, an unevaluable abdomen, or evisceration were taken to the operating room for immediate laparotomy (n=138, 37.3%). All others (n=232, 62.7%) underwent CT scan and further investigations as indicated. The sensitivity, specificity, positive predictive value, and negative predictive value of the investigations were: CT scan - 1.00, 0.98, 0.74, 1.00; cystogram - 1.00 for all parameters; gross inspection of the urine - 1.00 for all parameters; urinalysis - 1.00, 0.71, 0.17, 1.00; endoscopy - 1.00, 0.82, 0.75, 1.00; and DRE - 0.77, 0.99, 0.77, and 0.99. Conclusions: In the work-up of pelvic GSWs, patients with hemodynamic instability, peritonitis, evisceration, or an unevaluable abdomen should undergo immediate laparotomy while all others should undergo CT scan. CT-positive patients should be managed for their injuries. If the CT is negative, the likelihood of a clinically significant injury is very low. If the CT is equivocal for rectal or bladder injury, endoscopy or cystogram should be used to guide definitive management. There is no role for routine urinalysis or DRE. Further prospective validation of these findings is warranted. Level of Evidence: III Study Type: Diagnostic Test (C) 2016 Lippincott Williams & Wilkins, Inc.

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