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Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating injury to the abdomen, it is also clear that certain stable patients without peritonitis may be managed without operation. The practice of deciding which patients may not need surgery after penetrating abdominal wounds has been termed selective management. This practice has been readily accepted during the past few decades with regard to abdominal stab wounds; however, controversy persists regarding gunshot wounds. Because of this, the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee set out to develop guidelines to analyze which patients may be managed safely without laparotomy after penetrating abdominal trauma. A secondary goal of this committee was to find which diagnostic adjuncts are useful in the determination of the need for surgical exploration.: A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov).: The search retrieved English language articles concerning selective management of penetrating abdominal trauma and related topics from the years 1960 to 2007. These articles were then used to construct this set of practice management guidelines.: Although the rate of nontherapeutic laparotomies after penetrating wounds to the abdomen should be minimized, this should never be at the expense of a delay in the diagnosis and treatment of injury. With this in mind, a routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness. Likewise, it is also not routinely indicated in stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs. Abdominopelvic computed tomography should be considered in patients selected for initial nonoperative management to facilitate initial management decisions. The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness. Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration in an effort to avoid unnecessary laparotomy.

Background: Continuing improvements in computerized tomography scan technology and widespread acceptance of focused abdominal sonography for trauma (FAST) have prompted the suggestion that diagnostic peritoneal lavage (DPL) is obsolete. This sentiment, coupled with decreasing resident familiarity with DPL, has led to a poor understanding of the modem indications for DPL and no clear guidelines. We hypothesized that, while its indications may have changed, DPL remains essential in the rapid, effective triage of the trauma patient. Methods: We queried our Level I trauma center's trauma registry from January 1996 through August 2006 for patients who underwent a DPL as part of their initial evaluation. Specific variables investigated were indications for or results of DPL, performance of a laparotomy in the first 24 hours, and operative findings. Results: Six hundred twenty-seven patients underwent DPL (145 positive, 482 negative). Although the accuracy of DPL for predicting therapeutic laparotomy for all patients was only 77%, in the subset of hemodynamically unstable patients (of which only 46% had a positive FAST), it was 100%. Conversely, only 7% of all patients with negative DPL subsequently had a therapeutic laparotomy, with only 5% in the subset of stab wounds. Conclusion: DPL continues to be a vital tool in the evaluation of the trauma patient. A positive test in the hemodynamically unstable patient with potential multisystem trauma allows for expeditious intervention. A negative test in abdominal stab wounds supports observation and early subsequent discharge. Our current guidelines continue to emphasize the complimentary roles of DPL. FAST. and computerized tomography scan in the trauma bay.

Background: For hemodynamically stable patients with suspected abdominal injuries, the diagnostic accuracy of computed tomographic scans remains unmatched. Focused assessment with sonography for trauma (FAST) is useful in trauma evaluation to identify intraabdominal fluid early in the unstable patient. In skilled hands, sensitivity is shown to be close to 100%. However, some recent studies have questioned its sensitivity in subgroups at risk of bleeding. In most studies, hemodynamic markers of instability have been limited to hypotension. The purpose of this study was to determine the sensitivity and specificity of initial FAST for detection of hemoperitoneum in the potentially unstable patient as judged by objective hemodynamic parameters available early during resuscitation. Methods: Prospective observational study at a major European trauma center. FAST was performed in trauma patients by the trauma team radiologist. The study population consisted of the subgroup deemed potentially unstable on arrival as defined by systolic blood pressure ≤90 mm Hg, pulse rate ≥120, or base deficit ≥8. Results were compared with one of the following reference standards: computed tomographic scan, diagnostic peritoneal lavage, exploratory laparotomy, or observation. Results: One hundred and four patients constituted the study group. There were 75 true-negative, 10 false-negative, 16 true-positive, and 3 false-positive FAST results. Sensitivity and specificity were 62% and 96%, positive and negative predictive values 84% and 89%, respectively, and overall accuracy was 88%. Conclusion: A negative initial FAST in hemodynamically unstable patients, even in the hands of radiologists, cannot reliably exclude intraabdominal bleeding. These patients should undergo additional diagnostic tests to exclude intraperitoneal hemorrhage.

Background: Controversy exists regarding the interpretation of diagnostic peritoneal lavage results. This is especially true in the evaluation of patients sustaining penetrating trauma, specifically stab wounds to the lower chest and abdomen. Ideally one wants to avoid missed injuries and minimize unnecessary operations. Methods: This is a retrospective review of 195 patients sustaining stab wounds to the anterior lower chest and abdomen at Parkland Memorial Hospital between 1993 and 2005, looking at missed injuries and false positive rates using red cell counts of 100,000, 10,000, and the standard criteria for blunt trauma including >500 white blood cells (WBCs), amylase, and/or bile. Results: The first analysis used > 100,000 red blood cells (RBC S )/mm 3 as a positive value. The false positive rate was 12.2%. The second analysis used >10,000 RBCs/mm 3 as a positive value with a false positive rate of 44%. When considering the entire study population (195 patients), the false positive rate increased when using the lower number (>10,000) from 2.5% to 15.8% (p 100,000 red cells and/or >500 white cells, the presence of bile or amylase. Conclusion: Decreasing the red blood cell count from > 100,000 to > 10,000 as the criteria for operating on patients with stab wounds to the anterior lower chest and/or abdomen will significantly increase the number of nontherapeutic procedures. Based on this study, >100,000 ABCs/mm 3 appears to be a valid and safe number to use when evaluating these patients, particularly when used with other positive criteria such as increased white cells, bile, and amylase.

Background: Current management of penetrating extraperitoneal rectal injury includes diversion of the fecal stream. The purpose of this study is to assess whether nondestructive penetrating extraperitoneal rectal injuries can be managed successfully without diversion of the fecal stream. Methods: This study was performed at an urban Level I trauma center during a 28-month period from February 2003 through June 2005. All patients who suffered nondestructive penetrating extraperitoneal rectal injuries were managed with a diagnosis and treatment protocol that excluded fecal stream diversion. Patients were placed in one of two management arms based upon clinical suspicion for intraperitoneal injury. In the first arm, patients with suspicion for rectal injury and a positive clinical examination for intraperitoneal injuries were delivered to the operating room for exploratory laparotomy. Proctoscopy was performed before exploratory laparotomy. Extraperitoneal rectal injuries were left to heal by secondary intention. Intraperitoneal rectal injuries were repaired primarily. Patients did not receive fecal diversion or perineal drainage. In the second management arm, patients with a negative clinical examination for intraperitoneal injury and wounding agent trajectory suspicious for rectal injury underwent diagnostic peritoneal lavage (DPL), cystography, and proctoscopy in the emergency room. Positive DPL or cystography warranted laparotomy as above. Patients with positive proctoscopy alone were admitted and placed on a clear liquid diet. Barium enema was performed 5 to 7 days postinjury for all rectal injuries with diets advanced accordingly. A matched historic control group of rectal injury patients who underwent fecal diversion was compared with the nondiversion protocol group. Patients from both groups were matched for penetrating abdominal trauma index (PATI), age and mechanism of injury. Results: There were 14 consecutive patients diagnosed with penetrating rectal injury placed in the nondiversion management protocol. Of these, 9 (64%) patients in the nondiversion group required laparotomy. The average age in the diversion historical control group was 30.5 years and 29.3 years in the nondiversion group. The average PATI in the diversion group was 15.3 and 16.1 in the nondiversion protocol group. The average length of stay for the diversion and nondiversion groups was 9.8 days (range, 7-15) and 7.2 days (range, 4-10), respectively. There were no complications associated with rectal injuries in either group. Conclusions: Nondestructive penetrating rectal injuries can be managed successfully without fecal diversion. Randomized prospective study will be necessary to assess this management method.

Background Abdominal computed tomographic (CT) scan is accepted as the primary diagnostic modality in stable patients with blunt abdominal trauma. A recent survey of 328 trauma surgeons demonstrated marked variation in the management of patients with head injuries and the finding of free intra-abdominal fluid without solid organ injury on CT scan. This study was undertaken to attempt to determine what to do when free fluid without solid organ injury is seen on abdominal CT scan in patients with blunt trauma. Methods Articles concerning the incidence and significance of free intra-abdominal fluid on CT scan of blunt trauma patients without solid organ injury were systematically reviewed. A MEDLINE search was performed using terms such as tomography-x-ray computed, wounds-nonpenetrating, small intestine/injuries, time factors, and abdominal trauma and diagnostic tests. Bibliographies of pertinent articles were reviewed. Appropriate articles were evaluated for quality and data were combined to reach a conclusion. Results Meta-analysis could not be performed because no randomized, prospective, controlled trials could be found. Forty-one articles were excluded from the analysis because they looked at only patients with known injuries to intestine, diaphragm, or pancreas and the investigation of the CT scan findings did not include negative scans. Ten articles, which described CT scan results for all patients presenting with blunt abdominal trauma for a defined period of time, formed the basis of this study. Isolated free fluid was seen in 463 (2.8%) of over 16,000 blunt trauma patients scanned. A therapeutic laparotomy was performed in only 122 (27%) of these patients. Conclusion The isolated finding of free intra-abdominal fluid on CT scan in patients with blunt trauma and no solid organ injury does not warrant laparotomy. Alert patients may be followed with physical examination. Patients with altered mental status should undergo diagnostic peritoneal lavage.

Objective: Accurate data are needed to evaluate clinical outcomes, therapeutic modalities, and quality of care in trauma. Administrative data, usually used for billing, and trauma registries, have been used to perform these functions. This study compares data for trauma patients from administrative and trauma registry databases at a Level I trauma center. Methods: Data from patients injured in 1998 were obtained from both the trauma registry and administrative database. These International Classification of Diseases, Ninth Revision, Clinical Modification codes signify an admitting diagnosis of trauma. Patients from each database were matched by admission date, medical record number, age, and name. The two matched data sets were compared for accuracy in recording data. X 2 analysis was used to compare groups. Results: There were 2,702 patients found in both databases. One hundred eighteen patients with significant trauma were recorded in the trauma registry, but not in the administrative database. Comparison of recorded data for matched patients is as follows. The underreporting of mechanism of injury, diagnoses, diagnostic interventions, surgical procedures, and complications was rampant throughout the administrative database. Statistical significance was seen in the comparison between the trauma registry and the administrative database with motor vehicle collisions (458 vs. 391), abdominal injuries (346 vs. 293), orthopedic injuries (1,243 vs. 1,101), and thoracic injuries (486 vs. 397). Diagnostic interventions such as diagnostic peritoneal lavage, head computed tomographic scans, and abdominal computed tomographic scans were all grossly underrecorded, with only 40%, 12%, and 9% captured by the administrative database, respectively. Analysis of surgical procedures revealed these same trends, with statistical significance seen in abdominal and orthopedic procedures. Complications such as acute respiratory distress syndrome and deep venous thrombosis showed statistically significant differences. Mortality was underreported in the administrative database, with 14 deaths omitted. Conclusion: This study shows that administrative data have copious omissions of specific injuries, diagnostic and therapeutic interventions, as well as complications. The trauma registry recorded more of the diagnoses, diagnostics, procedures, and outcomes in the care of trauma patients. Trauma registries may be more useful than administrative databases in assessing quality of care and diagnostic and therapeutic interventions.

Background: Focused Assessment with Sonography for Trauma (FAST) is rapidly establishing its place in the evaluation of blunt abdominal trauma. However, no prospective study specifically evaluates its role in penetrating abdominal trauma. Methods: Data were collected prospectively in 75 consecutive stable patients with penetrating trauma to the abdomen, flank, or back, from December 1998 to June 1999. Those with an obvious need for emergent laparotomy were excluded. FAST was performed as the initial diagnostic study on all patients. Wound location, type of weapon, and findings of diagnostic peritoneal lavage, triple-contrast computed tomographic scan, or laparotomy were recorded. The presence of peritoneal blood was noted. Data were analyzed using the X 2 test. Results: Of the 75 patients, there were 32 stab and 43 gunshot wounds. There were 66 male patients and 9 female patients; the mean age was 30 years; 41 had proven abdominal injury and 34 had no injury; and 21 patients had a positive FAST. Nineteen had peritoneal blood and injuries requiring repair at the time of laparotomy. There were two false-positive studies. Fifty-four patients had a negative FAST. In 32 patients, this was a true-negative study. Thirteen patients had a false-negative FAST and had peritoneal blood and significant injury on further evaluation. Nine patients had a negative FAST and no peritoneal blood but still had abdominal injuries requiring operative repair, including liver (four), small bowel (four), diaphragm (three), colon (three), and stomach (one). The overall sensitivity of FAST was 46% and the specificity was 94%. The positive predictive value was 90%, and the negative predictive value was 60%. Conclusion: FAST can be a useful initial diagnostic study after penetrating abdominal trauma. A positive FAST is a strong predictor of injury, and patients should proceed directly to laparotomy. If negative, additional diagnostic studies should be performed to rule out occult injury.

Background: Determination of intra-abdominal injury following blunt abdominal trauma (BAT) continues to be a diagnostic challenge. Ultrasound (US) has been described as a potentially useful diagnostic tool in this setting and is being used with increasing frequency in trauma centers. We determined the diagnostic capability of US in the evaluation of BAT. Methods: A retrospective analysis of our trauma US database was performed over a 30-month period. Computed tomographic scan, diagnostic peritoneal lavage, or exploratory laparotomy confirmed the presence of intra-abdominal injury. Results: During the study period, 8,197 patients were evaluated at the Ryder Trauma Center. Of this group, 2,576 (31%) had US in the evaluation of BAT. Three hundred eleven (12%) US exams were considered positive. Forty-three patients (1.7%) had a false-negative US; of this group, 10 (33%) required exploratory laparotomy. US had a sensitivity of 86%, a specificity of 98%, and an accuracy of 97% for detection of intra-abdominal injuries. Positive predictive value was 87% and negative predictive value was 98%. Conclusion: Emergency US is highly reliable and may replace computed tomographic scan and diagnostic peritoneal lavage as the initial diagnostic modality in the evaluation of most patients with BAT.

Background: Accurate data are needed to evaluate clinical outcomes, therapeutic modalities, and quality of care in trauma. Administrative data, usually used for billing, have been used to evaluate performance and assess therapy in other medical specialties. This study was performed to determine whether administrative databases are accurate in the recording of information about trauma patients with splenic injuries. Methods: Patients who had blunt splenic injuries were identified using a state trauma registry. The medical records of those patients were reviewed. The data collected by chart review were compared with data in the statewide administrative database of patients who had splenic injuries at the same four Level I and II trauma centers in the same 5-year period. Age, sex, admission date, and hospital were matched to assure comparison of the identical cohort. X 2 analysis was used to compare dichotomous data and Student's t test continuous data. Results: The administrative database identified 641 and the trauma registry identified 529 patients with a diagnosis of splenic injury. A total of 401 patients were found in both databases. Of these, 120 (22.7%) patients were not recorded in the administrative database. Injury Severity Score was underreported by the administrative database (25.74 ± 14.7 vs. 19.52 ± 11, p < 0.0001). The administrative database underreported orthopedic, chest, and head injuries (317 vs. 215, 325 vs. 228, and 234 vs. 155, respectively; all p < 0.0001). Use of abdominal computed tomographic scan and diagnostic peritoneal lavage were also underreported (260 vs. 56 and 104 vs. 17, both p < 0.0001). The number of operations on the spleen and number of orthopedic procedures were underreported (259 vs. 225, p < 0.014 and 147 vs. 94, p < 0.0001). Complications were markedly underreported by the administrative database (200 vs. 47, p < 0.0001) Conclusion: This study shows that administrative data lack accuracy in the recording of associated injuries, injury severity, diagnostics, procedures, and outcomes data in patients with splenic injuries. Whether these data should be used to evaluate treatment modalities or quality of care in trauma is questionable.

Background: The use of ultrasound (U/S) for the evaluation of patients with blunt abdominal trauma is gaining increasing acceptance. Patients who would have undergone computed tomographic (CT) scan may now be evaluated solely with U/S. Solid organ injuries with minimal or no free fluid may be missed by surgeon sonographers. Objective: The purpose of this study was to describe the incidence and clinical importance of liver and splenic injuries with minimal or no free intraperitoneal fluid visible on CT scan. We hypothesized that these solid organ injuries occur infrequently and are of minor clinical significance. Methods: Patient records and CT scans were reviewed for the presence of and outcome associated with blunt liver and splenic injuries with minimal (

Objective To evaluate the necessity of abdominal screening beyond physical examination in awake and alert blunt trauma patients who require emergent extra-abdominal trauma surgery. Methods Data from an urban Level I trauma center was reviewed for all blunt trauma patients who underwent extra-abdominal emergency procedures during the period from January 1995 through August 1998. Awake and alert patients (Glasgow Coma Scale [GCS] score > or = 14) with negative abdominal physical examination results who underwent extra-abdominal emergent surgery were entered in the study. All patients entered were older than 14 years of age, hemodynamically stable, and underwent further abdominal evaluation with computed tomographic scan or diagnostic peritoneal lavage after the decision for extra-abdominal surgical intervention. Emergent surgery occurred within 8 hours of admission. Data was collected for results of diagnostic studies, hemodynamic status, mechanism of injury, indications for operative intervention, and admission blood ethanol (EtOH) levels. Results A total of 210 patients with an average age of 33 years (range, 14-92 years) were entered in the study. The most common mechanism of injury was motor vehicle crash (67%). Sixty-six (32%) patients presented with EtOH levels > 100 mg/dL; 181 (86%) patients presented with a GCS score of 15, and 29 (14%) presented with a GCS score of 14. The majority of surgical procedures were orthopedic (86%). Diagnostic peritoneal lavage was performed in 55 (26%) patients, and computed tomographic scans were obtained in 155 (74%) patients. Three (1.4%) intraperitoneal injuries were diagnosed in the study population. Two of the injuries were stable grade 1 liver injuries, and missed diaphragmatic injury was diagnosed on postadmission day 1. Conclusion Before emergent extra-abdominal trauma surgery, abdominal evaluation with physical examination is sufficient to identify surgically significant abdominal injury in the awake and alert blunt trauma patient. Screening with additional studies does not impact patient outcome.

Objective: Many trauma centers have separated emergency and general surgery from trauma care. However, decreased trauma volume and more frequent nonoperative management may limit operative experience and the economic viability of the trauma service. Trauma surgeons at our Level I trauma center have long provided all emergency surgical care and elective surgery. We sought to determine the impact of this policy. Methods: We reviewed all admissions to the trauma service from June of 1992 to July of 1998 and cross-referenced this with our trauma registry. The number of major and minor procedures performed was also determined, and we reviewed all operative procedures by the trauma service for June of 1996 to October of 1998. Results: Total admissions by the trauma service averaged 3,003 patients/year (range, 2,798-3,198 patients). Nontrauma patients accounted for 34% of all trauma service admissions (range, 26-40% ). During this time period, there was no change in volume of operative or intensive care unit procedures, whereas minor procedures recently decreased from a peak of 141/month to 50/month. This was largely due to decreased use of diagnostic peritoneal lavage (surgeon reimbursable) and an increased use of computed tomographic scan and ultrasound (not presently reimbursed) to evaluate blunt abdominal trauma. During the past 2 years, nontrauma cases accounted for 33% of all operative procedures by the trauma service. Conclusions: Maintenance of emergency and general surgical care by the trauma service has allowed us to buffer impact of variations in trauma volume and to maintain operative skills in an era of increased nonoperative management of many injuries.

Blunt small bowel injury (SBI) may be difficult to diagnose accurately. Diagnostic delays are associated with increased morbidity and mortality.A cross-sectional survey of members of the American Association for the Surgery of Trauma was conducted. A Likert-type multiple-choice scale was used to evaluate use and usefulness of diagnostic and laboratory tests. Data were analyzed by using univariate and multivariate techniques.A total of 461 of the 702 members (68%) surveyed responded, of which 133 members (29%) were excluded because they did not currently manage adult SBI. Of the remaining 328 respondents, 244 members (74%) reported prior experience as the most important influence on their current practice of diagnosing blunt SBI. None of the standard laboratory tests were reported as useful. Seventy-seven percent of respondents use computed tomographic (CT) scan most or all of the time for diagnosis (p0.05 compared with other modalities). Most respondents estimated their annual incidence of SBI at 5% with a15% frequency of delay in diagnosis. Forty-four percent of the respondents estimated the mortality associated with a delay in diagnosis ator =5%. Respondents varied significantly in their management of the patient with an unreliable abdominal exam and a CT scan finding of isolated free fluid. In patients with head injuries, 28% observe, 12% repeat the CT scan, 42% perform diagnostic peritoneal lavage, and 16% operate. For intoxicated patients, 51% observe, 11% repeat the CT scan, 26% perform diagnostic peritoneal lavage, and 10% operate. A more aggressive approach with diagnostic and operative intervention was significantly (p0.05) advocated by respondents practicing without residents, more than 15 years out from residency, or by those with a perception of higher morbidity and mortality from delays in diagnosis.There is significant variation in the diagnostic approach to the patient with suspected SBI. The perceived mortality of delayed diagnosis is much less than reported. Those surgeons with more experience or perception of greater morbidity and mortality from a delayed diagnosis are more aggressive. Further investigation into the diagnosis and treatment of this injury is needed.

Background: Controversies regarding how urgent bowel perforation should be diagnosed and treated exist in recent reports. The approach for early diagnosis is also debatable. The purposes of this study were to evaluate the relationship between treatment delay and outcome of small bowel perforation after blunt abdominal trauma and to determine the best assessment plan for the diagnosis of this injury. Methods: One hundred eleven consecutive patients with small bowel perforations caused by blunt abdominal trauma were retrospectively reviewed. The patients were divided into four groups according to the time interval between injury and surgery. Hospital stay, time to resume oral intake, and mortality and morbidity rates were compared between groups. Physical signs, laboratory and computed tomographic findings, and the results of diagnostic peritoneal lavage were analyzed to find the most sensitive and specific test for early diagnosis of small bowel perforation. Results: Delay in surgery for more than 24 hours did not significantly increase the mortality with modern method of treatment; however, complications increased dramatically. Hospital stay and time to resume oral intake increased significantly when surgery was delayed for more than 24 hours. Abdominal tenderness was a common finding, but it was not specific for bowel perforation. Only 40% of the computed tomographic scans were diagnostic for bowel perforations: 50% of them showed suggestive signs, and 10% were considered as negative. Persistence of abdominal signs indicated peritoneal lavage. By using cell count ratio in diagnostic peritoneal lavage and/or increased lavage amylase activity, presence of particulate matter and/or bacteria in the lavage fluid, all patients with intraperitoneal bowel perforation were diagnosed accurately before operation. Conclusion: Small bowel perforation has low mortality and complication rates if it is treated earlier than 24 hours after injury. The principle of "rushing to the operation suite" for a stable blunt abdominal trauma patients without detailed systemic examination is not justified. The priority of treatment for the small bowel perforation should be lower than the limb-threatening injuries. Diagnostic peritoneal lavage provides high sensitivity and specificity rates for the diagnosis of small bowel perforation if a specially designed positive criterion is applied.

Background: The focused abdominal sonogram for trauma (FAST) has been used by surgeons and emergency physicians (CLIN) to screen reliably for hemoperitoneum after trauma. Despite recommendations for appropriate training, ranging from 50 to 400 proctored examinations, there are no supporting data. Methods: We prospectively examined the initial FAST experience of CLIN in detecting hemoperitoneum by using diagnostic peritoneal lavage, computed tomography, and clinical findings as the diagnostic gold standard. Results: 241 patients had FAST performed by 12 CLIN (average, 20/CLIN ; range, 2-43); 51 patients (21.2%) had hemoperitoneum and 17 patients (7.1%) required laparotomy. Initial experience with FAST by CLIN produced 35 true positives, 180 true negatives, 16 false negatives, and 3 false positives; sensitivity, 68%; specificity, 98%. Initial error rate was 17%, which fell to 5% after 10 examinations (x 2 ; p < 0.05). Conclusion: Previous recommendations for the number of proctored examinations for individual nonradiologist clinician sonographers to develop competence are excessive.

Background: Injuries of the hollow viscera are far less common in blunt abdominal trauma than in penetrating abdominal trauma. This article is a 25-year retrospective study of 70 patients with injuries of the small intestine caused by blunt trauma. All patients were treated surgically at the trauma hospital (Unfallkrankenhaus) in Graz. In our series, blunt abdominal trauma causing hollow viscus injuries occurred in conjunction with multiple trauma in 68.8% of cases. The overall mortality rate was 25.7%. Methods: The following methods were used for evaluating the intestinal injury: detailed history of the accident and examination of the patients (e.g., transverse abdominal bruise) diagnostic peritoneal lavage before 1984, abdominal sonography since 1984, computed tomography, and laboratory tests. Results: Prognosis and results depended partly on the general condition of the patient, as well as the timeliness of diagnosis and surgical management of the small bowel injury. Delays in diagnosis were common because of the overall condition of the patient, as well as the difficulty in establishing a definitive diagnosis by using current radiologic and serologic modalities. Conclusion: It should be stated that the high mortality of small bowel injuries after blunt abdominal trauma justifies an aggressive approach to diagnosis and surgical treatment of these injuries. This article focuses on injury mechanisms and current concepts in diagnosis and the therapy of small intestine lacerations in blunt abdominal trauma.

Background: North American trauma centers are beginning to note the limitations of emergent torso sonography. The purpose of this prospective study was to evaluate the frequency, causes, associations, and sequelae of indeterminate (IND) sonograms in blunt trauma. Methods: Among adult blunt trauma patients assessed with screening torso sonography, clinician sonographers recorded the abdominal sonogram as positive, negative, or IND for free fluid. Patients with IND sonograms were further investigated with repeat sonography, computed tomography, or diagnostic peritoneal lavage. Results: Among 417 patients with blunt trauma (mean Injury Severity Score = 21) managed with sonography, there were 28 (6.7%) IND and 389 (93.3%) non-IND sonograms. Sonograms were IND because of patient factors in 71% (20 of 28) and because of operator factors in 29% (8 of 28). None of the 28 patients were managed with repeat sonography alone. All 4 diagnostic peritoneal lavage examinations gave negative results, whereas 8 of 23 computed tomographic scans were abnormal (6 of 8 patients underwent laparotomy). The mean time required for diagnostic workup was 117 minutes in the IND group and 48 minutes in the non-IND group (p < 0.001 in both cases). Conclusion: This prospective study has demonstrated that IND sonograms are not common at our center (6.7%), are usually attributable to patient factors, and are associated with greater diagnostic time. Patients with IND sonograms require further investigation because they often have injuries requiring laparotomy.

Background: Scepticism has been expressed regarding the accuracy of computed tomography for evaluating patients with blunt abdominal trauma in low-volume institutions. Diagnostic peritoneal lavage has been suggested as a more reliable method, and recently ultrasound has been proposed as a quick alternative. We sought to determine the accuracy of computed tomography at our low-volume center, which lacks 24-hour, in-house computed tomography dedicated radiologists. Methods: A prospective case series of patients who had computed tomographic evaluation requested for suspected blunt abdominal trauma were enrolled over a 1-year study period. Results: Fifty-five patients were enrolled. Injuries were identified in 12 patients, six of whom required intervention. The diagnostic accuracies for the detection of injury were 86% and 90.5% for radiology residents and attending radiologists, respectively. The likelihood ratios for the detection of an injury requiring intervention were identical for both groups of interpreters and were 0.17 for negative result and 35.6 for positive result. Conclusion: The accuracy of computed tomography for evaluating blunt abdominal trauma at a low-volume institution is comparable to that reported from higher-volume centers and may be the procedure of choice, averting the expected higher incidence of nontherapeutic laparotomy attendant with more widespread application of diagnostic peritoneal lavage and the missed injuries that may be expected from the occasional ultrasonographer.

Background: Although diagnostic peritoneal lavage (DPL) is a well-established, reliably objective method of diagnosis of intraperitoneal injury, it is too sensitive to be used as an indicator for emergency celiotomy. Therefore, since the development of ultrasonography and advanced computed tomographic scanners, the role of DPL has been markedly reduced. Despite such remarkable advances, however, radiologic diagnosis of intestinal injury cannot always provide definitive results, and DPL may still be valuable in such instances. We have developed a new DPL criteria specifically designed to aid in the diagnosis of intestinal injury and have evaluated its effectiveness. Methods: From August 1988 to December 1995, we performed DPL in 250 patients with blunt abdominal trauma and analyzed the diagnostic accuracy of our new criteria. We used the standard quantitative white blood cell (WBC) criterion for detection of intestinal injury supplemented by a positive-negative borderline adjusted to WBC≥ red blood cell (RBC)/150, where RBC≥ ≥ 10 x 10 4 /mm 3 . Results: Our criteria had a diagnostic sensitivity of 96.6 % and a specificity of 99.4% for intestinal injury after exclusion of 57 patients in whom DPL was performed within 3 hours or after 18 hours from the time of injury. In 133 patients with hemoperitoneum, emergency celiotomy was performed in only 48; the remaining 85 patients with negative DPL based on the WBC criterion avoided surgery, and conservative management resulted in no complications. Conclusion: With the proposed criteria, DPL can be used to diagnose or exclude intestinal injury even in the presence of hemoperitoneum.

Objective: To determine whether surgeons and residents with minimal training can evaluate accurately emergency ultrasound (US) examinations compared with radiologists for blunt abdominal trauma. Methods: Over 7 months, we conducted a prospective study comparing the evaluation of emergency US for blunt abdominal trauma by surgeons and attending radiologists. US readings from the surgical team and the radiologists were correlated with outcome. Results: One hundred-twelve patients were included in the study. Ninety-two patients had an US read as negative by the surgical and radiology services with no subsequent injuries identified. Eighteen patients had an US deemed positive by the surgical service and radiologists. Injuries were confirmed in this group by operation or computed tomography. One patient had an US deemed positive by the surgical team and subsequently negative by the radiologist. A diagnostic peritoneal lavage was performed which was negative. Another patient had an US interpreted as negative by the surgical evaluator and positive by the radiologist. Exploratory laparotomy was negative for intraabdominal hemorrhage or organ injury. Overall results reveal an accuracy on US reading of 99% for the surgical team and 99% for the attending radiologists. Conclusion: Surgeons and surgical residents at different levels of training can accurately interpret emergency ultrasound examinations for blunt trauma from the real-time images, at a level comparable to attending radiologists.

Background: The difference in speed, efficiency, and safety between diagnostic peritoneal lavage (DPL) and abdominal computerized tomography in the evaluation of adult blunt trauma patients with multiple injuries was investigated. Methods: A prospective protocol was analyzed. Adult blunt trauma patients admitted to a Level I trauma center in 1994 were examined. Registry and chart data were used. Patients admitted before the institution of the protocol (January 1-June 30, 1994) were compared with those admitted afterward (July 1-December 31, 1994). Time spent in the emergency department before definitive placement or surgical intervention was studied. Results: Patients in the second period, when DPL was used more frequently, spent significantly less time in the emergency department and radiology. No missed injuries were identified in either group. The percentages of nontherapeutic laparotomies were similar between the two groups. Cost was significantly lower in the group that underwent DPL. Conclusion: Patients with severe head injury, open fractures, or any evidence of hemodynamic instability are better served by DPL as the primary diagnostic modality. Its sensitivity and specificity are equivalent to those of computerized tomography; this facilitates evaluation and allows for simultaneous procedures and quicker initiation of definitive treatment.

The purpose of this study is to evaluate the effect of having attending trauma surgeons with added qualifications in surgical critical care present for the initial resuscitation at a regional trauma center.This study is a retrospective review of patients admitted between August of 1994 and December of 1995 from our trauma registry. The patients were categorized by the call preference of the admitting physician as in-house (IH) or call-back from home (CB), day of admission (weekend vs. weekday), time of admission (AM VS. PM), and a value of the injury severity scaleor = 15 or15. Demographics, admission vital signs, Injury Severity Scale, Glasgow Coma Score, and elapsed time to diagnostic, therapeutic, and/or operative interventions were studied. The effect on intensive care unit length of stay, mortality, and hospital cost for resuscitation were also studied.The study population consisted of 1,043 patients. The IH and CB groups each included two attending surgeons. IH significantly reduced the average time to completion of diagnostic peritoneal lavage (22 vs. 34 minutes; p0.05), therapeutic intervention (21 vs 38 minutes; p0.05), and transport to the operating room (206 vs. 312 minutes; p0.05) during the AM compared with CB. There was no difference in these times for the PM admissions. There was no significant difference in intensive care unit length of stay. Among patients with severe head and thoracoabdominal injury (Abbreviated Injury Score4 and 3, respectively) there was no difference in mortality. Analysis of cost for emergency room resuscitation in severely injured patients (Injury Severity Scoreor = 15), seen during weekdays, was significantly less when evaluated by IH (IH = $5,097 vs. CB = $6,779; p0.05).During the initial resuscitation of patients with severely injured during the weekdays, IH significantly reduced the cost, and elapsed time to diagnostic testing, therapeutic intervention, and to the operating room, respectively. IH reduced fatalities compared with CB.

Background: Historically, patients with deep posterior wounds underwent a formal celiotomy to rule out injury. Currently, we use a policy of selective management. The purpose of this review is to evaluate our experience with selective management to identify potential areas of further improvement. Methods and Results: This study includes 203 patients over a 10-year period. By changing from a policy of mandatory exploration to selective management the total celiotomy rate decreased from 100 to 24% and the therapeutic celiotomy rate increased from 15 to 80%. Conclusions: In stable patients, a diagnostic peritoneal lavage should be performed as the initial diagnostic study. When diagnostic peritoneal lavage is negative, triple contrast computed tomography should be performed to evaluate the remaining retroperitoneal structures. Any suggestion of pericolonic extrav-asation of contrast or air, edema, or hemorrhage must be interpreted as a positive study and prompt consideration for operative exploration.

Although there is an interest in emergent abdominal sonography (EAS), the clinical utilization of EAS in North America is minimal. The purpose of this study was to develop a new diagnostic algorithm for blunt abdominal injury based on a prospective blinded comparison of EAS, diagnostic peritoneal lavage (DPL), and computed tomography (CT). EAS (+ = fluid, - = no fluid) was performed before the DPL or CT, in 400 patients with a mean Injury Severity Score of 26; 293 had a CT and 107 had a DPL. The EASs required 2.6 +/- 1.2 minutes with 82% < or = 3 minutes. The accuracy of EAS for free fluid was 94% with a positive and negative predictive value of 82 and 96%, respectively. Only 1 of 338 patients with EAS- had an acute therapeutic laparotomy. Three patients with EAS- had a delayed laparotomy based on evolving clinical findings. The radiologists interpretation of the EAS video disagreed with the clinician sonographer in only 3% of cases. Based on these results, a diagnostic algorithm was developed using EAS as a screening test with selective use of DPL and CT. Emergent abdominal sonography performed by clinician sonographers is a rapid and accurate test for peritoneal fluid in blunt trauma victims, and the need for laparotomy in patients with a negative EAS is rare. Our study supports the routine use of EAS as a screening test in a diagnostic algorithm for the evaluation of blunt abdominal trauma.

Objectives : The aims of this study were to determine if angiographic findings can be used to predict successful nonoperative therapy of splenic injury and to determine if coil embolization of the proximal splenic artery provides effective hemostasis. Methods : Splenic injuries detected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, computed tomography (CT), angiography, transcatheter embolization, and laparotomy. Computed tomography was performed initially or after positive diagnostic peritoneal lavage. Angiography was performed urgently in stabilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone ; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest. Results : Patients (172) with blunt splenic injury are the subject of this study. Twenty-two patients were initially managed operatively because of associated injuries or disease (11 patients) or because the surgeon was unwilling to attempt nonoperative therapy (11 patients) and underwent splenectomy (17 patients) or splenorrhaphy (5 patients). One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management. Eighty-seven of the 90 patients managed by bed rest alone, and 56 of 60 patients treated by splenic artery occlusion and bed rest had a successful outcome. Overall splenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries. Sixty percent of patients received no blood transfusions. Three of 150 patients treated nonoperatively underwent delayed splenectomy for infarction (one patient) or splenic infection (two patients). Conclusions : (1) Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography. (2) The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management. We suggest its use to triage CT-diagnosed splenic injuries to bed rest or intervention. (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic injury. It expands the number of patients who can be managed nonoperatively.

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.

The objective of this prospective study was to determine the sensitivity, specificity, and accuracy of the rapid trauma ultrasound examination, performed by emergency physicians, for detecting free peritoneal and thoracic fluid in patients presenting to a level I trauma center with major blunt or penetrating torso trauma. Emergency medicine residents and faculty were trained to perform an ultrasound examination of the torso evaluating for free intraperitoneal, retroperitoneal, pleural, and pericardial fluid. In the 245 study patients, emergency physicians examined 975 intracavitary spaces and demonstrated 64 positive findings for free fluid as documented by computed tomography scan, diagnostic peritoneal lavage, exploratory laparotomy, chest radiography, tube thoracostomy, or formal two-dimensional echocardiography. The rapid trauma ultrasound examination was 90% sensitive, 99% specific, and 99% accurate. Ultrasonography can serve as an accurate diagnostic adjunct in detecting free peritoneal and thoracic fluid in trauma patients. Appropriately trained emergency physicians can accurately perform and interpret these trauma ultrasound examinations.

The need for simultaneous diagnosis and treatment of life-threatening intracranial mass lesions and intra-abdominal injury results in controversy over the appropriate triage of unconscious blunt trauma patients with stable vital signs. To aid in early decisions for these patients, a retrospective analysis of 290 patients with Glasgow Coma Scale (GCS) scoresor = 8 and systolic blood pressures (SBP)90 mm Hg was undertaken. The hypothesis of this study was that life-threatening abdominal injury frequently occurs in these patients and injuries cannot be consistently identified from vital signs alone. Data were analyzed for injury mechanism, SBP, heart rate (HR), Injury Severity Score (ISS), Revised Trauma Score (RTS), Abbreviated Injury Scale score for the abdomen and brain (A-AIS, CNS-AIS), and the need for emergent laparotomy. Patients with concurrent injuries were more likely to come from motor vehicle crashes than falls (p0.001). Although severe abdominal injuries (A-AISor = 3) were frequently identified based on SBP and HR, the use of clinical signs alone resulted in more missed injuries than did using the results diagnostic peritoneal lavage (DPL). This study suggests that all unconscious normotensive blunt trauma patients undergo immediate DPL to prevent missing life-threatening injuries.

Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities in the evaluation of patients with suspected blunt abdominal trauma (BAT). Diagnostic peritoneal lavage is fast and accurate but associated with complications. Computed tomography is also accurate, yet requires that patients be stable and transportable. A prospective study was designed to determine the utility of emergency ultrasound (US) studies in the initial assessment of BAT. Two hundred acutely injured patients with suspected BAT were evaluated with US. Patients were eligible for the study if they met trauma criteria and had suspected BAT. Subsequently, without knowledge of the US results, DPL or CT was performed. Ultrasound showed a sensitivity of 83%, a specificity of 100%, and an accuracy of 97% in detecting intra-abdominal injuries. Six injuries were missed but only one was felt to be significant. If US had been used in all 200 patients, 199 would have had appropriate care. We conclude US is reliable in the detection of free intraperitoneal fluid and may be used in place of DPL or CT.

Diagnosis of diaphragmatic injury (DI) can be difficult in patients with penetrating trauma because physical examination, computed tomographic scan, chest x-ray films, and diagnostic peritoneal lavage may miss these injuries. Mandatory exploration has been recommended because of the increased mortality associated with missed DI. Thoracoscopy was prospectively evaluated as a less invasive method for diagnosing DI in patients with penetrating trauma. Over a 14-month period, 14 patients were evaluated by thoracoscopy; video thoracoscopy was used in the last 9. Findings of thoracoscopy were confirmed by laparotomy or laparoscopy. Thoracoscopy correctly identified the presence or absence of DI in nine and five patients, respectively (all patients). Video thoracoscopy was easier and faster to perform than non-video thoracoscopy. This is the first reported series in which video thoracoscopy has been used for trauma. We found this procedure to be safe, accurate, and less invasive than laparotomy for diagnosing DI.

This study evaluated the role and advantages of diagnostic laparoscopy (DL) compared with diagnostic peritoneal lavage (DPL) in 75 trauma patients who were prospectively studied with DL followed by DPL. Of these, 59 patients had blunt injuries and 16 stab wounds. Seventy patients (93%) had the procedures performed in the emergency department (ED); 41 (59%) of these were awake and under local anesthesia. Forty-two patients had negative DPL and DL results with no subsequent sequelae. Twenty-three patients had negative DPL results and abnormal DL results. Of these, 20 were managed nonsurgically, and three (DPL < 10,000 RBC) underwent surgery based solely on DL findings of diaphragmatic lacerations from stab wounds. These were repaired. All 23 had an uneventful course. Three patients had positive DPL and insignificant DL findings. Laparotomy and DL findings correlated. A splenectomy for iatrogenic injury unrelated to DL and two nontherapeutic laparotomies were performed. Seven patients demonstrated both positive DPL and significant DL findings, and all had therapeutic laparotomies. Management based on DL rather than DPL would potentially have improved care in 8% of cases (6 of 75). Reliance on DL improved care in 19% (3 of 16) of patients with stab wounds and possibly could have in 3% (2 of 59) of those with blunt injuries. Management using DL would have potentially improved care in 30% (3 of 10) of patients with positive DPL findings and 5% (3 of 65) with negative DPL findings. Diagnostic laparoscopy can be performed safely in stable patients under local anesthesia in the ED. It offers no advantage over DPL as a primary assessment tool in blunt trauma. It does have advantages in the management of stab wounds. Diagnostic laparoscopy has a role in redefining DPL criteria for laparotomy and, in selected patients, as an adjunct to DPL, allowing further diagnosis and potentially the treatment of injuries without laparotomy.

Evaluation of blunt abdominal trauma is clinically challenging. Diagnostic peritoneal lavage (DPL) and computed tomographic (CT) scanning have become primary diagnostic modalities. We examined the efficacy and role of ultrasonographic (US) studies in the initial abdominal evaluation of blunt trauma patients. Over an 8-month period, patients whose abdominal work-up indicated the need for DPL or CT were evaluated sonographically within the first hour after admission by trauma fellows (PGY-6) with at least 1 hour of theoretical training and 1 hour of practical training. Sonograms considered positive were those showing free peritoneal fluid or organ disruption. Hard copies of the sonograms were evaluated by a staff radiologist without knowledge of the fellows' interpretations or of DPL or CT results. Based on the fellows' interpretation of the real-time sonograms, among the first 163 patients studied were 11 true-positive, 146 true-negative, one false-positive, and five false-negative results. Sixteen patients had intra-abdominal injury documented by DPL, CT, or laparotomy. Ultrasonography was 91% sensitive in detecting the presence of hemoperitoneum. Overall, ultrasonography was 69% sensitive, 99% specific, and 96% accurate in diagnosing abdominal injury. We conclude that emergency sonography on admission can serve as a valuable adjunct to the physical diagnosis of clinically significant hemoperitoneum. It is noninvasive, portable, and accurate in determining the need for further diagnostic/surgical intervention.

The management of blunt trauma victims with indeterminate diagnostic peritoneal lavage (DPL) findings remains controversial. We reviewed 1,196 patients undergoing DPL to identify patients with indeterminate DPL (red cell counts of 20,000 to 99,999 rbc/mm3). Only 4% (48%) had indeterminate DPL results. Repeat DPL (R-DPL) was performed in 31 patients. Six repeat DPLs produced positive results (greater than 100,000 rbc/mm3), 15 produced indeterminate results, and 10 produced negative results (less than 20,000 rbc/mm3). A review of the nine laparotomies performed in this group revealed only two operations that were therapeutic. Twelve patients had abdominal CT scans following indeterminate DPL. Six patients had negative CT scans and were successfully managed without operation. The findings were positive on six other CT scans. Four patients with positive CT scans, including two splenic injuries, one liver injury, and one renal laceration, were managed successfully without surgery. The remaining two patients with positive CT scans underwent laparotomy. The first had a renovascular injury diagnosed from the CT scan after negative findings on repeat DPL. The second had a minor splenic injury diagnosed from the CT scan. A subsequent repeat DPL produced a positive result prompting a nontherapeutic operation. Eleven patients were observed without repeat DPL or CT scanning. Of these, four eventually underwent laparotomy on the basis of clinical suspicion alone. Only one of these patients required therapeutic intervention at the time of laparotomy. Intra-abdominal injury was common in patients with indeterminate DPL results, however, only four (8%) of the patients required a therapeutic operation. Both negative repeat DPL results or negative findings on CT scans predicted successful nonoperative management.(ABSTRACT TRUNCATED AT 250 WORDS)

The reliability of ultrasonographic detection (US) of hemoperitoneum in blunt abdominal trauma was evaluated in a prospective study of 72 patients. Independent of the examiner, sensitivity, specificity, and accuracy were, respectively, 86.7%, 100%, and 97.2%. Laparotomy was indicated in 76.9% of US hemoperitoneum-positive cases. No negative laparotomies were performed in this study group. If hemoperitoneum is revealed in US and vital signs are unstable, we think laparotomy is indicated. We believe that US in an emergency center is a quick, safe screening method in the evaluation of blunt abdominal trauma. US might take over a great part of the role of diagnostic peritoneal lavage.

Trauma remains the major cause of death in children and young adults. Adult and pediatric patients differ significantly in both mechanism of and physiologic response to injury. We reviewed the records of all consecutive adult and pediatric blunt trauma patients admitted to a major metropolitan trauma center for a 10-year period. An extensive computerized database has been maintained for all patients since 1977. A comparative statistical analysis of mechanism of injury, specific organ injury, and clinical outcome was performed. Altogether, 1,722 adults and 289 children were treated during the study period. Blunt trauma accounted for 82.8% of adult and 94.3% of pediatric injury (p = 0.00005), and only these patients were considered for analysis. Diagnostic peritoneal lavage was performed in 249 children and 1,464 adults, with a respective accuracy of 99.6% and 97.2%. Mechanism of injury was comparable for both groups, although children were far more likely to be injured by falls, bicycle accidents, or struck by an automobile. Comparative analysis of specific injuries demonstrated significantly fewer pediatric chest (p = 0.001), spine (p = 0.03), and pelvic (p = 0.003) injuries. Central nervous system (CNS) injury in children was a strong determinant of outcome: serious pediatric CNS trauma was associated with a tenfold increase in mortality. Mortality for children in the absence of CNS injury was less than 3%. Spinal injury also appeared to be a predictor of poor outcome in the pediatric population, with an associated mortality of greater than 50%. Overall, survival was age independent (82.5% of adults and 85.8% of children were survivors.(ABSTRACT TRUNCATED AT 250 WORDS)

Nine hundred and three patients undergoing diagnostic peritoneal lavage (DPL) over a 6-year period were retrospectively reviewed to evaluate the utility of the white blood cell (WBC) count in the lavage fluid. Eleven patients (1.2%) had dialysate WBC counts greater than 500/mm3, with erythrocyte counts less than 10(5)/mm3. Nine of these patients who were lavaged within 4 hours of injury had no intra-abdominal pathology. Two patients, lavaged after 4 hours, demonstrated intra-abdominal injury. Two hundred twenty-three patients (24.7%) had grossly clear dialysate which was not sent for laboratory analysis. None of these patients required laparotomy. We conclude that the WBC count in DPL fluid is of no diagnostic value in victims of blunt abdominal trauma who are lavaged within 4 hours of injury. In addition, laboratory analysis of clear dialysate is not required in these patients.

We randomized 327 blunt trauma patients to compare the open peritoneal lavage technique with the percutaneous (Seldinger wire) technique. The open and closed lavage groups were similar with respect to accuracy and safety. There were one complication in the percutaneous group and two in patients treated by the open method. The incidence of positive lavage was similar in each group. There was one false positive in the percutaneous group and none in the open method group. False negative results did not occur by either method. The percutaneous lavage method required less time for performance, had better patient tolerance, and only required one surgeon to perform the procedure. Percutaneous diagnostic peritoneal lavage (DPL), in the hands of trauma surgeons, is a safe and acceptable alternative to the open DPL method and actually had several advantages as mentioned above.

Forty-five consecutive patients with penetrating thoraco-abdominal trauma underwent surgical exploration to evaluate the ability of peritoneal lavage to detect peritoneal penetration. Eight patients fulfilled standard criteria for operation and did not undergo lavage. The remaining 37 patients underwent diagnostic peritoneal lavage using a closed technique before exploratory laparotomy. Using 10,000 RBC/mm3 as our previously established criterion for peritoneal penetration, there were seven true positive, one false positive, 28 true negative, and one false negative lavage for an overall accuracy of 94.6% with 87.5% sensitivity and 96.6% specificity as determined by subsequent laparotomy. While 33% of this patient cohort were found to have significant injuries (four had isolated diaphragmatic injuries, all detected by peritoneal lavage), 67% were subjected to negative surgical exploration, as accurately predicted by peritoneal lavage. Negative laparotomy carried a 10.7% operative morbidity. Based on these data we advocate diagnostic peritoneal lavage in patients with thoraco-abdominal penetrating trauma who otherwise lack operative indications.

There has been recent enthusiasm for computed tomography (CT) to supplant diagnostic peritoneal lavage (DPL) in the detection of abdominal injuries. We prospectively compared CT to DPL following acute blunt trauma or stab wound to the abdomen. Patients with hemodynamic instability or overt signs of intraperitoneal pathology underwent urgent laparotomy and were excluded from study. Those with indications for DPL had lavage catheter insertion via open technique and attempted aspiration for gross blood. This was followed by contrast CT of the abdomen with a Technicare 2010 scanner. Lavage fluid, when required, was then instilled, recovered, and analyzed. CT interpretations were made in a blind fashion by a single staff radiologist. Decision for laparotomy was based on clinical, DPL, and CT data. In blunt trauma (N = 65), DPL detected 5/5 (100%) injuries discovered at laparotomy and CT 2/5 (40%). Following stab wounds (N = 35), DPL was true positive in 7/7 (100%) and CT in 1/7 (14.3%), with one false positive CT leading to negative laparotomy and one false positive DPL which prompted unnecessary celiotomy. Overall, the sensitivity of DPL was 100% versus 25% for CT and specificity 98.9% for both DPL and CT. In particular, CT missed seven solid visceral (five liver, two spleen), five hollow visceral, one major vascular, and three diaphragmatic lesions requiring operative intervention. In our experience, CT demonstrated an alarming incidence of false-negative studies. Given the widespread variability of CT equipment and personnel we would argue strongly against the use of CT alone in the evaluation of acute abdominal trauma and continue to support DPL as the most accurate and reliable instrument of detection.

Evaluation of abdominal trauma in pregnant patients presents a number of dilemmas. Few series compare the various modalities available in this situation. The present review characterizes various techniques and their results. The charts of all patients with a secondary diagnosis of pregnancy admitted to a Level I trauma center over a 7 1/2-year period were reviewed. Forty were considered to have sustained possible blunt abdominal trauma: 30 were occupants in motor vehicle collisions, five were pedestrians, four sustained falls, and one was riding a motorcycle. Immediate laparotomy for emergency caesarean section or other indications was performed in three cases (7%). In 13 cases (32%) evaluation was accomplished by diagnostic peritoneal lavage (DPL). Three patients (7%) underwent computerized tomography of the abdomen. The remaining 22 patients (55%) were observed with serial physical exams, and hematocrits. The group that was observed had a mean ISS of 5.9. The mean Glasgow Coma Score (GCS) was 14.9. No patients had to undergo exploratory laparotomy for abdominal injury during hospitalization. In the 13 patients undergoing DPL, the mean ISS was 34.6, and the mean GCS was 10.6. Overall accuracy was 92% with no major complications. Pregnant patients sustaining minor injuries and blunt abdominal trauma may be safely observed. Those with major injuries, shock, altered mental status, or neurologic deficit require further studies to rule out intra-abdominal injury. Diagnostic peritoneal lavage proved to be safe and accurate in these patients. Diagnostic peritoneal lavage proved to be safe and accurate in these patients. CT scan and ultrasonography are other modalities which merit further assessment as a primary diagnostic technique in abdominal trauma occurring during pregnancy.

Three hundred one hemodynamically stable patients with equivocal abdominal examinations following blunt abdominal trauma had a CT scan followed by DPL. Both studies were negative in 194 patients (71.6%) and positive in 51 patients (27.1%). Seven of the 51 patients (13.7%) had an additional significant injury at operation that was not seen on the CT scan. Nineteen patients had a negative CT scan, a positive DPL, and a significant injury confirmed at celiotomy. In this group of 19 patients, the CT failed to identify seven splenic, three hepatic, and three small bowel injuries. There were two complications attributed to DPL. Three patients had a false negative DPL. Diagnostic peritoneal lavage continues to be a reliable study (sensitivity--95.9%, specificity--99%, accuracy--98.2%). The CT scan is not as sensitive (sensitivity--74.3%, p less than 0.001; specificity--99.5%, accuracy--92.6%). It is concluded that selective use of both procedures is appropriate as long as one recognizes the inherent limitations of each.

Forty-four patients sustaining blunt trauma with resultant diaphragmatic rupture during a 5 1/2-year period are presented. In 41 (93%), the diagnosis was established within 6 hours of admission. The correct diagnosis was made preoperatively in 19 patients operated on acutely (42%), in 22 (53%), ruptured diaphragm was an incidental finding at celiotomy or thoracotomy. The admission chest roentgenography, diagnostic peritoneal lavage, UGI contrast studies, and computed tomography were the most useful diagnostic aids. The transabdominal operative approach was utilized in 39 patients (89%). All patients had associated extra-abdominal injuries and 26 patients (59%) had associated intra-abdominal injuries. The mortality rate was 20.4%; early deaths were attributable to hemorrhage and severe head injury, late deaths to sepsis and progressive multiorgan failure. Language: en

A case of pneumoperitoneum due to cocaine abuse is presented. Although most commonly associated with surgical disease, pneumoperitoneum may actually be a manifestation of non-surgical intrathoracic pathology. In this patient percutaneous diagnostic peritoneal lavage resulted in return of a large quantity of air and was negative for bleeding or contamination.

Vertical deceleration injuries represent a distinct form of urban blunt trauma. We reviewed 161 adult patients, admitted over 36 months, who jumped or fell from a height of one to seven stories and survived emergency department resuscitation. Charts and radiographs were analyzed to identify common injuries, complications, and causes of death. Those who fell five or more stories had a mean ISS of 41, for a predicted survival of 50% but actual survival of 83%. Virtually all these patients had multiple fractures. Sixty per cent of them presented in shock, yet more than two thirds had angiographically demonstrated retroperitoneal hemorrhage as their major source of bleeding. Thirteen patients had significant intra-abdominal injuries, with only one associated with major hemorrhage. Utilizing early diagnostic peritoneal lavage, ten of 13 patients explored had a therapeutic laparotomy. Hollow viscus perforations accounted for about one half of the abdominal injuries, including three duodenal injuries. Conclusions. 1) Patients who present in shock after falls from height are much more likely to be bleeding from retroperitoneal than intraperitoneal sources. 2) Early tap and lavage followed by emergency angiography and transcatheter embolization is the treatment of choice in this group of patients. 3) Although these patients often have multiple complex injuries, the prognosis for long-term survival is good. Therefore, we advocate early aggressive operation stabilization of fractures to permit patient mobilization, facilitate pulmonary toilet and nursing care, and to decrease long-term disability.

In order to reassess the value of diagnostic peritoneal lavage (DPL) in patients with blunt abdominal trauma, we conducted a prospective study over a 15-month period involving 138 patients. There were 29 (28.3%) patients with positive DPL and 103 (71.7%) with negative DPL in this series. Of the 29 patients with positive DPL, 28 (96.5%) were found to have significant intra-abdominal injuries; 27 by exploratory laparotomy and in one case at autopsy. One patient with a grossly positive DPL had a negative exploratory laparotomy (3.4% false positive rate). All 109 patients with negative DPL were admitted. In only one case a significant intra-abdominal injury was demonstrated (0.9% false negative rate). The overall mortality in this series was 11.6% and there were no complications related to the DPL. Our results suggest that DPL is indeed an accurate indicator of significant intra-abdominal injuries in patients with blunt abdominal trauma.

Comatose blunt trauma patients undergo diagnostic peritoneal lavage to aid in the management of severe injuries. In deference to routine performance of lavage, patients felt to be a risk for abdominal injury were prospectively studied by using selective criteria for lavage. One hundred consecutive comatose blunt trauma patients were studied; five underwent urgent celiotomy for refractory hypotension. Five criteria for lavage were: history of postinjury hypotension, abdominal physical findings suggestive of underlying abdominal injuries, evidence of fracture of the bones of the trunk and/or femur, blunt trauma of unknown etiology, and operative general anesthesia required for nonabdominal injuries. Fifty-five patients satisfied at least one of the above criteria and underwent peritoneal lavage. Forty patients not satisfying the criteria were observed without peritoneal lavage, as it was felt they had a decreased probability of serious abdominal injury. One of these patients had a minor liver laceration found at the time of autopsy following his death from severe head injury. None of the other patients had evidence of intra-abdominal injury by autopsy or subsequent clinical course. Utilizing the selective criteria, none of the 100 consecutive blunt trauma patients had major delay in abdominal diagnosis or missed significant abdominal pathology defined by operation, clinical course, or autopsy. Routine peritoneal lavage in all comatose blunt trauma patients may subject the patient to unnecessary risk, waste valuable time, increase the cost of care, and alter subsequent diagnostic procedures. Based on this small study, it appears that comatose blunt trauma victims not fulfilling the criteria may be effectively evaluated without the use of peritoneal lavage.(ABSTRACT TRUNCATED AT 250 WORDS)

One hundred twenty-three patients with lower chest and abdominal stab wounds were evaluated. If chest wounds were located between the two anterior axillary lines and abdominal examination was negative, peritoneal lavage was performed. If abdominal wounds were located between the two anterior axillary lines and physical examination was negative, local exploration was performed followed by lavage if local exploration was positive. Patients with negative lavage were observed and those with positive lavage were operated upon. Of the patients in this selected series 69.9% were spared an operative procedure. The incidence of negative laparotomy was 4.1%. It is concluded that the combination of local exploration and peritoneal lavage will increase diagnostic accuracy, eliminate unnecessary hospitalization, and reduce the number of negative laparotomies.

Thirteen cases of jejunal perforation from blunt trauma are presented. There are no reliable signs or symptoms, and a normal physical examination may be seen. Free intraperitoneal air on plain radiograms is characteristically absent. Simple debridement and closure is adequate. Mortality is usually associated with other serious concomitant injuries, and complications are associated with diagnostic delays. Diagnostic peritoneal lavage is a safe and reliable procedure for establishing an early diagnosis of serious intraperitoneal injury. Its routine use in all cases of serious blunt abdominal trauma is advocated.