title: Double jeopardy revisited: clinical decision making in unstable patients with, thoraco-abdominal stab wounds and, potential injuries in multiple body cavities.
abstract: BACKGROUND
  In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult.Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy.
  
  
  METHODS
  All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death.
  
  
  RESULTS
  Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18–40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80–90 mm Hg). Median base excess was 6.5 (quartile range 12 to 2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group.
  
  
  CONCLUSIONS
  Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.
authors.affiliation: Metropolitan Trauma Service Pietermaritzburg, Department of General Surgery, Nelson R Mandela School of Medicine, University of Kwa-Zulu Natal, South Africa. nirusha.maharaj@kznhealth.gov.za
authors.forename: Damian L
authors.initials: DL
authors.lastname: Clarke
authors.forename: Tamara M H
authors.initials: TM
authors.lastname: Gall
authors.forename: Sandie R
authors.initials: SR
authors.lastname: Thomson
mesh_terms: D000007:Abdominal Injuries / Q000150:complications / Q000401:mortality / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D019091:Critical Pathways; D003657:Decision Making; D006801:Humans; D007022:Hypotension / Q000150:complications / Q000401:mortality / Q000601:surgery; D007813:Laparotomy / Q000379:methods* / Q000401:mortality; D008297:Male; D009104:Multiple Trauma / Q000150:complications / Q000401:mortality / Q000601:surgery; D013898:Thoracic Injuries / Q000150:complications / Q000401:mortality / Q000601:surgery*; D013908:Thoracotomy / Q000379:methods* / Q000401:mortality; D016896:Treatment Outcome; D014951:Wounds, Stab / Q000150:complications / Q000401:mortality / Q000601:surgery*; D055815:Young Adult