Abdominal lavage in blunt trauma

[The value of sonography in traumatology and orthopedics : Part 2: emergency diagnostics in blunt abdominal and thoracic trauma]

Ultrasound examinations in trauma patients should be done in the emergency department using curved-array (3.5-7.5 MHz) probes. Blunt trauma of the abdomen and thorax must be regarded as a single organ injury. Sonography is the imaging technique of first choice and has completely replaced peritoneal lavage. Paramount advantages are its ability to provide rapid information and reproducible results at short intervals and in a noninvasive manner. The sensitivity and specificity of sonography in detecting intraabdominal fluid are 97-100% and 80-90%, respectively. To achieve such good results, though, adequate education in ultrasound and state-of-the-art devices is crucial. Clinical experiences prove that standardized sonography must be part of polytrauma management and should be integrated in advanced trauma life support courses. Technical improvements with better image quality and miniaturization of hardware will contribute to increase the use of this technique. However, ultrasound does not replace computed tomography for follow-up in answering more sophisticated questions in multiple injured patients.

Blunt abdominal injuries. Diagnostic peritoneal lavage, ultrasonography and computed tomography scanning

The diagnosis of blunt abdominal injuries is one of the most difficult problems in the management of trauma. There is now better understanding of the diagnostic facilities available. Guidelines regarding the use of diagnostic peritoneal lavage, ultrasonography, or computed tomography scanning should be available in the Accident and Emergency department.

Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid

The minimum volume of intraperitoneal fluid that is detectable in Morison's pouch with ultrasound in the trauma setting is not well defined. To evaluate this question, we used diagnostic peritoneal lavage (DPL) as a model for intraperitoneal hemorrhage and undertook a blinded prospective study of the sensitivity of ultrasound in detecting intraperitoneal fluid. Participants included attending physicians and residents in emergency medicine, radiology, and surgery. During the infusion of the DPL fluid, participants continuously scanned Morison's pouch until they detected fluid. All participants were blinded to the rate of infusion and the volume infused. One hundred patients were entered into the study. The mean volume of fluid detected was 619 mL. Only 10% of participants detected fluid volumes less than 400 mL and the overall sensitivity at one liter was 97%. We conclude that reliable detection of intraperitoneal fluid in Morison's pouch requires a greater volume than has been previously described.

CT scan in blunt abdominal trauma

CT scan has been used in blunt abdominal trauma with increasing popularity during the last decade. The sensitivity, specificity and accuracy of CT scan in blunt abdominal trauma have been reported to be very high. CT scan has been shown to eliminate the disadvantages of diagnostic peritoneal lavage (DPL) in the diagnosis of retroperitoneal organ injuries and when there are associated major pelvic fractures. This study describes the results of CT scan in 50 blunt abdominal trauma patients at the Chulalongkorn Hospital, Bangkok, Thailand. All patients had stable vital signs at the time of CT scanning although 36 per cent were in shock on arrival. In all, 34 per cent had associated pelvic fractures. Retroperitoneal organ injuries were suspected in 80 per cent. Of the patients, 34 per cent underwent exploratory laparotomies because of positive CT scan with three unnecessary operations. The sensitivity of CT scan to predict the necessity of operation is 100 per cent, specificity 92 per cent, accuracy 94 per cent, positive predictive value 82 per cent and negative predictive value 100 per cent. We conclude that CT scan is highly reliable in the management of blunt abdominal trauma, especially when retroperitoneal organ injuries are suspected or when there are associated major pelvic fractures. CT scan is also an invaluable tool in selected cases of non-operative management of hepatic trauma.

Early management of abdominal trauma: the role of diagnostic peritoneal lavage

This report reviews the contemporary value of diagnostic peritoneal lavage (DPL) in the assessment of abdominal trauma, and reports the methods and results of its application within one trauma centre (Washington Hospital Center). DPL was reserved for those patients where doubt existed as to the presence of intra-abdominal injury, and gave a very accurate assessment of intraperitoneal injury. The complication rate was 0.4% and the accuracy of DPL was 97.7%. Except for laparotomy, DPL is the most sensitive indicator of haemoperitoneum available. It was first introduced with the aim of reducing the number of missed diagnoses of abdominal injury and it performs this task excellently when a low threshold for positivity is used. The open technique is safest and gives fewer false positive results, and the colorimetric method of analysis of lavage fluid is recommended, with strict adherence to advised criteria for negativity. A clinical algorithm is described, utilizing DPL, aimed at early diagnosis of all intra-abdominal injuries. This was extremely sensitive and failed in only one case in 384 (0.3%). The attendant, non-therapeutic laparotomy rate was 19%, and is regarded as acceptable within the aims of early diagnosis. In this series, there was no mortality or morbidity attached to the use of DPL or from non-therapeutic laparotomy, and there was only one delayed diagnosis in the entire series. No bowel, bladder, diaphragmatic, duodenal or pancreatic injuries were missed or diagnosed late.

A perspective on the early management of abdominal trauma

Blunt trauma in Australia is most commonly due to road accidents and is often multisystem in its effect on the body. Whereas some cases of intra-abdominal injury result in massive bleeding, and may be readily diagnosed clinically, many abdominal injuries are difficult to diagnose on initial clinical examination. Delays in treatment can result in otherwise avoidable morbidity and mortality, and the practice of diagnosis by repeated clinical examination over long periods of time is to be condemned in principle. All abdominal injuries can (and should) now be diagnosed and treatment commenced within 2-4 h of admission to hospital. Diagnostic peritoneal lavage (DPL) is the most sensitive indicator of intraperitoneal blood after trauma, and if employed early, and interpreted with a low threshold for positivity, early treatment of all intraperitoneal organ disruption can be undertaken. The best organ-imaging technique available for abdominal trauma is computerized tomography (CT) scan, but it is not as sensitive as DPL in the diagnosis of haemoperitoneum, and its accuracy in defining bowel injury is not proved. Several factors dictate the choice of DPL or CT scan in difficult trauma cases, and these include the stability of the patient, the availability of CT scan, the experience of the treating physician with either modality, the organs most at risk of injury in any case, and the decision to attempt conservative or operative management. In a small number of cases, doubt may still exist after CT and/or DPL, and an early laparotomy remains the 'gold standard' of diagnosis in such situations. In penetrating trauma, laparotomy is indicated if wound exploration shows penetration of the peritoneum.

Pneumoperitoneum as a complication of cardiopulmonary resuscitation

A case of pneumoperitoneum following cardiopulmonary resuscitation (CPR) is reported and 11 cases in the literature are reviewed. Four patients had laparotomies failing to demonstrate any visceral perforation or evidence of peritonitis in spite of the massive pneumoperitoneum present. Operative intervention immediately after resuscitation is associated with potentially high morbidity and mortality. Several diagnostic tools are used, including peritoneal lavage and contrast media tests, to accurately diagnose perforated viscus. To avoid an unnecessary celiotomy a clinical treatment protocol has been developed for patients with pneumoperitoneum secondary to CPR. Such diagnostic tools as peritoneal lavage and water-soluble contrast medium test are reviewed and included in this protocol. A nonsurgical approach to patient management may be reasonable if certain criteria are met.

Open versus closed diagnostic peritoneal lavage. A multiphasic prospective randomized comparison

A total of 118 trauma patients were prospectively randomized to receive either open or closed peritoneal lavage. In addition, comparisons were made between using an infraumbilical versus a supraumbilical approach in patients with pelvic fractures. No statistical difference was noted between the open and closed groups, despite the overall accuracy rate of 96.6%. The supraumbilical approach was vastly superior to the infraumbilical approach in patients with pelvic fracture with an accuracy rate of 90.9% versus 57%. In this regard, use of the infraumbilical approach in this setting is to be highly discouraged. Finally, patient body habitus, technique, and physician experience all play a role in the outcome of the lavage.

Experience with diagnostic peritoneal lavage in blunt abdominal trauma

Fifty-one patients who had suffered blunt abdominal trauma were assessed clinically and with diagnostic peritoneal lavage. The latter has been shown to be a safe, accurate means of determining the presence or absence of haemoperitoneum. Furthermore, in patients with disturbed conscious states, the initial clinical assessment has been found to be inaccurate and the performance of diagnostic peritoneal lavage has resulted in a statistically significant increase in diagnostic accuracy (P = 0.006). However, in patients with a normal conscious state, the improvement in diagnostic accuracy achieved by the performance of diagnostic peritoneal lavage was not statistically significant. The technique of diagnostic peritoneal lavage is discussed in detail.

The dominant role of paracentesis technics in the early diagnosis of blunt abdominal trauma

A simplified method of diagnostic abdominal paracentesis and lavage is described. Liberal application of this method as part of the initial physical examination of blunt trauma patients resulted in identification at first examination of 94 per cent (61 of 65) of those who were to have laparotomy. No case in the series was brought to laparotomy as the result of findings at arteriography, radionuclide imaging, or sonarography, and no intraabdominal problem was missed because of failure to use one of these organimaging technics. The very limited role of these imaging procedures in early management of blunt abdominal trauma is discussed.

Diagnosing ascites: the value of abdominal paracentesis

Abdominal paracentesis is a useful and safe technique in the evaluation of ascites. The withdrawn ascitic fluid should be routinely analyzed for appearance, blood cell count, and amylase and total protein concentrations; examined cytologically; and cultured. Results should either substantiate the clinical diagnosis or alert the clinician to the presence of previously unsuspected disease.

[Emergency peritoneoscopy in blunt abdominal trauma and acute abdomen (author's transl)]

Peritoneoscopy, angiography, and peritoneal lavage are highly reliable methods for the detection of intraabdominal bleedings in blunt abdominal traumas. Acute peritonitis in severely ill patients can easily be detected by peritoneoscopy, but not by other methods. The results of emergency peritoneoscopy in 166 patients with blunt abdominal trauma and 115 patients with suspected peritonitis are reported.

Peritoneal lavage and scintigraphic evaluation of blunt abdominal trauma

The emergency management of blunt abdominal trauma requires rapid assembly of accurate information. But history, physical findings and conventional tests may be unreliable. As a result, peritoneal lavage is an integral part of the initial diagnostic protocol in many centers. However, confusion in interpretation, especially of "weak positives," can result in delayed or unnecessary celiotomy. In our regional trauma center, lavage is now reserved for selected cases based on experience with 1,833 cases "scanned" during a five-year period. The indications, contraindications, techniques, interpretation, advantages, disadvantages, and complications of lavage and scanning are presented. A protocol using radionuclide imaging for initial evaluation of blunt abdominal trauma is proposed and representative case studies are included to support this approach.

Reappraisal of the left lateral decubitus X-ray in splenic rupture

The lateral decubitus view of the barium-filled stomach has been reassessed in a series of 42 patients with possible splenic rupture and compared with a group of 17 patients with splenomegaly. Displacement of the gastric fundus of more than 4 cm from the inner rib margin is highly suggestive of splenic rupture. Where doubt exists, the test should be repeated within a short while. Peritoneal lavage and a full blood count investigation both add to the diagnostic accuracy.

Intestinal injury due to non-penetrating abdominal trauma

Five cases of intestinal injury alone due to non-penetrating abdominal trauma are presented. The possible mechanisms of intestinal injury are discussed, together with the presentation, investigation and management of these cases.

Thoracoscopy as an aid to the diagnosis of diaphragmatic injury in penetrating wounds of the left lower chest: a preliminary report

In an attempt to evaluate the place of thoracoscopy, the investigation was performed on 11 patients with penetrating wounds of the left lower chest, who had no definite clinical or radiological indication for operation. In 6 patients the diaphragm was seen clearly, and in 2 of these an unsuspected diaphragmatic injury was found. Both injuries were later confirmed at operation. The other 4 patients had intact diaphragms and were successfully treated conservatively. It is suggested that thoracoscopy is a useful aid in the diagnosis of left-sided, diaphragmatic injury and that the best results are obtained if it is performed within 24 hours of the injury.