Transcript Controversies in Abdominal Trauma

Controversies in
Abdominal Trauma
Controversies in
Emergency Ultrasound
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Should EM physicians perform
ultrasound?
How should this work be funded?
What new areas of use should be
explored?
It isn’t rocket science ...
Rationale
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24x7 access
Shorten the time to intervention in life
threats
Decrease the length of stay in the ED
Decrease the cost of care and improve
resource utilization
Improve diagnostic accuracy
Abdominal Trauma Ultrasound
Accuracy
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Sensitivity: 80% - 100%
Specificity: 85% - 98%
Intraperitoneal fluid:
– 82-98% sensitivity
– 88-100% specificity
– Prospective trials: sensitivity 87-98%,
specificity 99-100% (Pearl, 1996)
Intraperitoneal injury:
– 69-96% sensitivity
– 95-100% specificity
Sensitivity/Volume of Fluid
Branney, 1995
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Abdominal Trauma Ultrasound
Learning Curves
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12 non-radiologist scanners
8 hours of didactics, 10 supervised exams
50 practice exams on patients
Free Fluid: Sensitivity 68%; Specificity 98%
Error rate from 17% to 5% after only 10
exams
9.8% indeterminate scan rate
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(Shackford, et al)
Abdominal Trauma Ultrasound
Training Required
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No definite standard
Didactic: 4-8 hours of training
Supervised exams: 15
Experiential: 20-50 exams
Is there still a place for
DPL?
Diagnostic Peritoneal Lavage
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Component 1: Aspiration of 10cc of blood
– Indication for emergent laparotomy IF
hemodynamically unstable
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Component 2: Lavage
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>100,000 RBCs
>20 IU Amylase (Alk Phos)
>500 WBC
Bile, Gram Stain
Diagnostic Peritoneal Lavage
Problems
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Non invasive management of
abdominal trauma
Complications: 0.3%
More time consuming than ultrasound
Less information than CT scan
Diagnostic Peritoneal Lavage
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Sharp decrease in use
– Increased availability of ultrasound
– Helical CT scans: faster and better
– Non invasive always wins
Diagnostic Peritoneal Lavage
Indications
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Hypotensive patient with a negative
FAST exam
Stab wound to the abdomen
Gunshot wound to the abdomen
– DPL vs. Laparotomy
Prioritization in trauma
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Head Injury
Hypovolemia
– Chest trauma
– Intraperitoneal (Spleen,
liver)
– Retroperitoneal (Pelvis,
renal)
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Occult lethal injuries
– Traumatic aortic injury
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Head CT
Chest x-ray
Ultrasound/DPL
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Abd CT
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Chest CT
Transesophageal echo
Arteriography
Prioritization in trauma
Two Contenders
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Head Injury
– Most CNS deaths from head injury are
due to a delay in decompression
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Intraperitoneal Injury
– Injuries are amenable to therapy
– Preventing prolonged hypovolemic shock
is critical to outcome
Prioritization in trauma
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Unstable with positive ultrasound
 Emergent Laparotmy + ICP bolt
Unstable with negative ultrasound
 DPL  if DPL +Laparotomy
Stable with positive ultrasound or
DPL Head CT & Abdominal CT