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espanolLa evaluacion enfocada con ecografia en trauma (FAST) se ha utilizado y estudiado ampliamente en trauma contundente y penetrante durante las ultimas 3 decadas. Antes de FAST, los procedimientos invasivos como el lavado peritoneal de diagnostico y la laparotomia exploratoria se utilizaban comunmente para diagnosticar lesiones intraabdominales. En la actualidad, el examen FAST se ha convertido en un estudio mas completo del abdomen, el corazon, el torax, la vena cava inferior, entre otras, existiendo muchas variaciones en la tecnica, los protocolos y la interpretacion. Las estrategias de manejo de traumatismos como laparotomia, endoscopia, angiografia por tomografia computarizada, intervencion angiografica, imagenes seriadas y observacion clinica tambien han cambiado a lo largo de los anos. Esta tecnica, en ocasiones, ha logrado reemplazar la tomografia computarizada y el diagnostico de lavado peritoneal, sin producir retrasos en el procedimiento quirurgico. En tal sentido, la relacion entre la informacion clinica del paciente y los resultados del examen deben estar guiados a la orientacion de los enfoques terapeuticos en escenarios de dificil acceso como unidades de cuidados intensivos en zonas de guerra, lugares rurales o distantes, donde otros metodos de imagenologia no estan disponibles. Esta revision discutira la evolucion del examen FAST a su estado actual y evaluara su papel en evolucion en el manejo agudo del paciente traumatizado EnglishFocused trauma ultrasound assessment (FAST) has been used and studied extensively in blunt and penetrating trauma over the past 3 decades. Before FAST, invasive procedures such as diagnostic peritoneal lavage and exploratory laparot-omy were commonly used to diagnose intra-abdominal injuries. Today, the FAST examination has become a more compre-hensive study of the abdomen, heart, thorax, inferior vena cava, among others, with many variations in technique, protocols, and interpretation. Trauma management strategies such as laparotomy, endoscopy, computed tomography angiography, angiographic intervention, serial imaging, and clinical observation have also changed over the years. This technique, on occasion, has succeeded in replacing computed tomography and peritoneal lavage diagnosis, without causing delays in the surgical procedure. In this sense, the relationship between the clinical information of the patient and the results of the examination should be guided to the orientation of therapeutic approaches in settings of difficult access such as intensive care units in war zones, rural or distant places, where other methods imaging are not available. This review will discuss the evolution of the FAST exam to its current state and assess its evolving role in the acute management of the trauma patient

Background Focused Assessment with Sonography for Trauma (FAST) has supplanted diagnostic peritoneal lavage (DPL) as the preferred bedside evaluation for traumatic hemoperitoneum. Diagnostic peritoneal aspiration (DPA) is a simpler, faster modification of DPL with an unclear role in contemporary practice. This study delineated modern roles for DPA and defined its diagnostic yield. Methods All trauma patients presenting to our Level I center who underwent DPA were included (May 2015 to May 2020). Demographics, comorbidities, clinical/injury data, and outcomes were collected. The diagnostic yield and accuracy of DPA were calculated against the criterion standard of hemoperitoneum at exploratory laparotomy or computed tomography scan. Results In total, 41 patients underwent DPA, typically after blunt trauma (n = 37, 90%). Patients were almost exclusively hypotensive (n = 20, 49%) or in arrest (n = 18, 44%). Most patients had an equivocal or negative FAST and hypotension or return of spontaneous circulation after resuscitative thoracotomy (n = 32, 78%); or had a positive FAST and known cirrhosis (n = 4, 10%). In two (5%) patients, one obese, the catheter failed to access the peritoneal cavity. Diagnostic peritoneal aspiration sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 100%, 100%, and 90%, with an accuracy of 93%. One (2%) complication, a small bowel injury, occurred. Conclusion Despite near ubiquitous FAST availability, DPA remains important in diagnosing or excluding hemoperitoneum with exceedingly low rates of failure and complications. Diagnostic peritoneal aspiration is most conclusive when positive, without false positives in this study. Diagnostic peritoneal aspiration was most used among blunt hypotensive or postarrest patients who had an equivocal or negative FAST, in whom the preliminary diagnosis of hemoperitoneum is a critically important decision making branch point. Level of evidence Diagnostic, level III.

Diagnostic peritoneal lavage (DPL) is an invasive procedure, mostly of historical significance, used to diagnose hemoperitoneum or bowel injury in patients who have experienced blunt or penetrating abdominal trauma. This procedure is now primarily used in hemodynamically unstable patients cared for in resource-constrained environments to determine the need for exploratory laparotomy. Due to the rapidly progressing use of focused assessment with sonography for trauma (FAST) and computed tomography (CT), DPL is no longer considered the primary modality for diagnosing blood in the abdominal cavity and has been removed from ATLS guidelines. The only absolute contraindication is an obvious need for laparotomy. Relative contraindications include coagulopathy, prior abdominal surgeries, abdominal wall infections, pregnancy, and morbid obesity. DPL can be done via two different approaches: open or closed. The most common technique is closed with modified Seldinger technique. The procedure can be performed via either infraumbilical or supraumbilical approach. The most common location is infraumbilical. Positive findings during a DPL indicate a need for emergent exploratory laparotomy for the hemodynamically unstable patient. Positive findings include >10 cc of frank blood or enteric contents aspirated during phase 1 of the procedure or > 100,000 RBC/mm3 and/or > 500 WBC/mm3 during phase 2 of the procedure. When resources are limited, DPL can be a useful procedure when determining the need for exploratory laparotomy after trauma.

The diagnosis of traumatic injuries has undergone sweeping changes in the last century. Various diagnostic modalities have been introduced and tested, including diagnostic peritoneal lavage, local wound exploration, abdominal ultrasound (FAST), and computed tomography. Despite the variety of options

Background: In the last decade, the risk of terrorist attacks has increased largely almost worldwide. In this setting, disaster response personnel must understand the unique physiopathology of injuries as-sociated with explosions and must be prepared to assess and treat the people injured in such tragedies. The ammunition explosion in Gërdec, Vora, just 13 miles from the capital of Albania, Tirana, confronted our country with a real human tragedy with severe casualties. The striking force of the two consecutive explosions resulted in two consecutive earthquakes with respectively an amplitude of 9.2 and 2.5 on the Richter scale. Objective: To explain the classification of explosives and in connection with it to identify the major types of explosive and blast injuries, and the management options in the cases of explosions and blast injuries. Material & Methods: Efforts to dismantle Albania’s stockpiles of obsolete munitions took a catastroph-ic turn on March 15th, when a series of explosions occurred as crews were clearing out a storage depot in Gërdec, on 15th of March 2008, at 12:15 AM hours. Gërdec is located 10 km northwest of the capital of Albania, Tirana; near the national highway Tirana-Durres and at a distance of 3-4 km in air line from National Airport. Data presented here were collected from the patients’ files in our Trauma UHC and from the official reports from the different governmental offices. Conclusion: The explosive and blast injuries now present a true modern epidemic disease that threat-en the very survival of the free world. A thorough understanding of detonation and blast dynamics by the treating teams is required to better correlate the injury patterns presented. This is also critical for revision of current multiple casualty protocols. It is up to the medical establishment to prepare suitable protocols, coordinate manpower and secure medical resources to successfully handle such events.

Ultrasound-guided gastrointestinal and genitourinary procedures are routinely performed in the acute care settings. These include paracentesis, diagnostic peritoneal lavage, gastric tube placement, nasogastric tube placement, ultrasound-guided hernia reduction, bladder catheterization, suprapubic catheter placement and aspiration, and penile blocks. Ultrasound guidance allows these procedures to be performed in a safer fashion than traditional blind or landmark-based approaches, minimizing complications and unsuccessful attempts. With proper training, ultrasound guidance can be incorporated into these procedures with minimal difficulty because its use requires only minor modifications to traditional techniques. This chapter will discuss a variety of ultrasound-guided gastrointestinal and genitourinary procedures relevant to the clinical practice in acute care settings.

Background: Abdominal trauma can be mysterious to some practitioners. If patients are evaluated for being stable or unstable, then abdominal trauma can be easily managed. Using a combination of physical examination, eFAST Scan, DPL and CT scans, patients can be quickly and efficiently evaluated. Objectives: To determine the positive predictive value (PPV) of computed tomography and diagnostic peritoneal lavage for diagnosis of solid organ damage in patients with blunt abdominal trauma (BAT) taking surgical findings as gold standard. Study Design: Cross sectional study. Setting: Department of Surgery at Lahore General Hospital, Lahore. Period: Six months i.e. from 21.5.2016 to 20.11.2016. Materials and Methods: Data Collection: CT scan was performed with oral and intravenous contrast. DPL was done with sample assessment. Only those cases were included with positive findings in CT Scan or DPL. These patients underwent laparotomy under general anesthesia by a one standard surgical team. Results of surgical findings were compared between groups with CT scan and DPL. All the information was collected on predesigned proforma. Results: The mean age of the patients was 44.48±14.83 years. There were 66 (55%) males and 54 (45%) females in our study. In this study PPV for CT-scan group was 90.1% while PPV for group with DPL was 51.3%. Conclusion: PPV for CT Scan group was higher than that of DPL group for diagnosing solid organ damage in patients with BAT. Hence, evidence shows that CT Scan should be used as an initial investigation of choice in haemo-dynamically stable patients with BAT.

Background The diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high. Patients and methods Blunt abdominal trauma patients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR ≥ 1. CT findings, DPL and surgery results, and global outcome were analyzed. Results Thirty-seven were included in the study (27 males, median age of 30 years (range, 17–69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion ( p = 0.02) and small bowel wall abnormalities ( p = 0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59–100]) and 43% (CI 95% [25–63]). The sensitivity remained 100% (CI 95% [59–100]) when the ratio was ≥4 ( n = 10 patients), and the specificity reached 90% (CI 95% [73–98]). Conclusion DPL is sensitive for the diagnosis of BBMI in stable trauma patients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR ≥ 1. Indications for exploratory laparotomy could be restricted to patients with a CCR ≥ 4 to improve the specificity of diagnosis management.

Background: Ultrasonography is a cheap, Readily avaialable, safe and non invasive investigation used in the evalution of patients with abdominal injuries No radiation effects are seen in ultrasonography Along with ultrasonography, CT scan and MRI is also used in diagnosing different abdorminal lesions. Aim of the study: Aim of our study was to evaluate diagnostic value of ultrasonography in the patients with abdominal injuries. Subjects and Methods: 120 patients were included in this study. Out of these 120 patients 95 patients were admitted with blunt abdominal trauma and 25 patients were admitted with penetrating abdominal injuries.Ultrasonography results in each patients is classified as true positive, false positive and false negative by comparing with findings at either diagnostic peritoneal lavage or surgery (1). Results: Out of 120 abdominal injury patients 95 were with blunt trauma and 25 patients were admitted with penentrating abdominal injuries. By scanning to detect free fluid, true positive were 102(85%) and false positive were 8(6.6%) false negative 6(5.2%) true negative are 9(7.5%). Conclusion: ultrasonography has a high diagnostic value in the screening of patients with blunt abdominal trauma and penetrating type injuries. In devoloping countries and in rural part of india emergency diagnosic facilities especially radiological investigations like ultrasonography and CT scan are lacking. So governement has to take initiations in arranging these type of diagnostic facilities to prevent the morbidity and mortality due to abdominal injuries.

Hypotension associated with intra-abdominal injury is most commonly the result of a solid organ injury (liver, spleen, kidney) but may be due to vascular injury or injuries to the visceral mesentery. Hypotension in the face of blunt abdominal trauma requires rapid, systematic evaluation and intervention to optimize survival.

Dialysis treatment may be carried out with peritoneal dialysis (PD), haemodialysis (HD) and filtering and dialysis (HDF). This chapter is a practical description of use, care and control of peritoneal dialysis. Peritoneal dialysis system is established under sterile conditions in an operating room and is treated aseptically as a surgical site. Peritoneum is a deep tissue structure with excellent conditions for growth of bacteria. PD must therefore be treated very carefully, as an open surgical site.

Background: Diagnostic Peritoneal Lavage (DPL) is a routine method for evaluating internal organ damage in patients with blunt or penetrating torso trauma. Internal organ damage can lead to elevated alkaline phosphatase (ALP) levels in the DPL fluid. In this study, the researchers aimed to assess the prognostic value of elevated alkaline phosphatase levels and the need for laparotomy. Methods: In this study, the researchers evaluated 42 patients with torso trauma (18 penetrating and 24 blunt traumas). The ALP was positive for all the patients in DPL (2 IU/mL

Intra-abdominal sepsis has a high mortality and significant incidence in severely ill intensive care patients. Early recognition with prompt diagnosis and treatment are imperative to improve survival. Current common diagnostic modalities such as laboratory data, conventional X-rays, ultrasound (US), computerized tomography (CT), and diagnostic peritoneal lavage (DPL) are limited by the amount of information each provides and the lack of any therapeutic benefit. Bedside diagnostic laparoscopy (BDL), a relatively novel approach for diagnosing intra-abdominal pathology, has several advantages over conventional methods. BDL can provide a definitive diagnosis on intra-abdominal bowel viability and confirm the presence of purulent or fecal peritonitis. In addition, BDL has a similar risk profile to DPL and may provide a therapeutic benefit. Therefore, in the hemodynamically unstable patient, BDL is a low-risk, potentially therapeutic procedure capable of accurately diagnosing intra-abdominal pathology and avoiding nontherapeutic laparotomy.

Diagnostic peritoneal aspiration (DPA) refers to the insertion of a catheter in the peritoneal cavity and aspiration of any fluid. Diagnostic peritoneal lavage (DPL) involves infusion of normal saline, lavage of the cavity, and macroscopic and microscopic evaluation of the returned fluid. DPA and DPL have largely been replaced by CT scan and abdominal ultrasound. However, in select cases it can provide quick information about intraperitoneal bleeding or infection. The most common trauma indication for DPA/DPL is suspicion of intraperitoneal bleeding in a hemodynamically unstable patient with a negative or equivocal ultrasound, who cannot undergo CT scan evaluation. DPA/DPL might be useful in selected unstable ICU patients with suspected peritonitis or who otherwise cannot be safely transferred for CT scan evaluation. There is evidence that the DPA is as sensitive as DPL in identifying clinically significant intraperitoneal bleeding. DPA/DPL does not identify retroperitoneal bleeding.

Hollow viscus injuries (HVI) are the source of significant morbidity and mortality in trauma patients, especially in patients with poor physiologic reserve which is common in the extremes of age. Though HVI is more common in penetrating trauma, over 50% of hollow viscus injuries from blunt trauma are caused by motor vehicle crashes (MVCs). Because of seatbelt syndrome and improper belt placement, small bowel injuries are threefold more likely to occur than large bowel injuries in MVCs. Blunt traumatic injuries of the stomach and rectal injuries are even less common. Because of synergy between increased metabolic demands, age-related decline in end-organ function, comorbidities, and associated sequelae in frail patients, HVI leads to lower chances for survival compared to younger patients. Abdominal ultrasound and diagnostic peritoneal lavage (DPL) are important adjuncts in the initial diagnosis and management of posttraumatic hemorrhage and HVI in hemodynamically unstable patients. Computed tomography (CT) scans are useful in the detection of HVI in stable trauma patients. Serial assessments of organ perfusion must be performed because occult hypoperfusion is common in advanced aged patients, especially those with frailty syndrome. Delay in operative management of HVI in the geriatric patient leads to more morbidity and mortality compared to younger patients. Massive transfusion protocols, damage control resuscitation, and staged surgical procedures are mission critical not only for survival of the hypothermic, acidotic, and coagulopathic patient, but also for successful management of HVI. Complex duodenal and rectal injuries are the most difficult to surgically repair and have higher rates of complications than other HVI. As is done in pediatric patients, to decrease preventable MVC-related HVI in the elderly, campaigns focused on the education of adult and older patients need to be created and implemented in the correct use and placement of lap and harness belts.

Focused assessment with sonography in trauma (FAST) has been extensively utilized and studied in blunt and penetrating trauma for the past 3 decades. Prior to FAST, invasive procedures such as diagnostic peritoneal lavage and exploratory laparotomy were commonly utilized to diagnose intraabdominal injury. Today the FAST examination has evolved into a more comprehensive study of the abdomen, heart, chest, and inferior vena cava, and many variations in technique, protocols, and interpretation exist. Trauma management strategies such as laparotomy, laparoscopy, endoscopy, computed tomographic angiography, angiographic intervention, serial imaging, and clinical observation have also changed over the years. This state of the art review will discuss the evolution of the FAST examination to its current state in 2017 and evaluate its evolving role in the acute management of the trauma patient. The authors also report on the utility of FAST in special patient populations, such as pediatric and pregnant trauma patients, and the potential for future research, applications, and portions of this examination that may be applicable to radiology-based practice. © RSNA, 2017 Online supplemental material is available for this article.

Introduction: Use of cadavers as replacement of mannequins has been practiced since many years now and they are more suitable in resource scarce societies where cadavers are available. Cadavers that are used for the purpose of anatomy teaching at undergraduate level can be used for hands on training of various clinical and procedural skills. We describe the finding of a hands on workshop on procedural skills conducted at our institute. Methodology: During hands on session of combat advanced trauma life support course (C-ATLS), procedural skills Tracheostomy, Colostomy, Diagnostic Peritoneal Lavage, Suprapubic Catheter Insertion, Tube Thoracostomy, Pericardiocentesis, Venesection and Application of External Fixator were taught using traditionally embalmed human cadavers. Structured and non-structured feedbacks from both facilitators of the course and participants were obtained to assess the suitability of cadavers for skills training. Results: Most facilitators and participants responded that use of cadavers in the skills training was suitable as per the learning objectives and needs. Some drawbacks of using these cadavers were also noted. Conclusion: Traditionally fixed human cadavers can be effectively used for hands on training program of procedural skills of C-ATLS.

Introduction Reliability of serum pancreatic enzyme levels in predicting pancreatic injuries has been a parameter of interest and the present recommendations on its utility are based primarily on anecdotal observations. The aim of this study was to evaluate the utility of serum pancreatic enzyme assessment in predicting blunt pancreatic injury with imaging and surgical correlation and compare our results with a systematic review of literature till date. Methods A prospective cohort study conducted over 4 years in a tertiary care referral centre with 164 consecutive patients who presented to the emergency department with a history of blunt abdominal trauma and had serum pancreatic enzyme assessment, USG and subsequent diagnostic CECT were analyzed. The CT findings and AAST grade of pancreatic injury, various intra-abdominal injuries and time elapsed since injury and other associated factors were correlated with serum pancreatic enzyme levels. For systematic review of literature MEDLINE database was searched between 1940 and 2012, also the related citations and bibliographies of relevant articles were analyzed and 40 articles were included for review. We compared our results with the systematic critique of literature till date to formulate recommendations. Results 33(21%) patients had pancreatic injury documented on CT and were graded according to AAST. Statistically significant elevated serum amylase levels were observed in patients with pancreatic and bowel injuries. However, elevated serum lipase was observed specifically in patients with pancreatic injury with or without bowel injury. Combined serum amylase and lipase showed 100% specificity, 85% sensitivity in predicting pancreatic injury. Elevated (n = 28, 85%) vs. normal (n = 5, 15%) serum amylase and lipase levels showed sole statistically significant association with time elapse since injury to admission, with a cutoff of 3 h. Conclusions Based on our results and the systematic review of the literature till date we conclude, persistently elevated or rising combined estimation of serum amylase and lipase levels are reliable indicators of pancreatic injury and is time dependent, nondiagnostic within 6 h or less after trauma. In resource constrained countries where CT is not available everywhere it may support a clinical suspicion of pancreatic injury and can be reliable and cost-effective as a screening tool.

We compared the diagnostic accuracy of emergency medicine residents (EMRs) and radiology residents (RRs) in performing focused abdominal sonography for trauma (FAST). The cohort in this prospective study comprised 200 unstable patients (163 males and 37 females; mean ± standard deviation of age, 34.3 ± 16.4 y) who presented with trauma. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. Patients with positive FAST results underwent further diagnostic procedures such as computed tomography, diagnostic peritoneal lavage and laparotomy. Those with negative FAST results underwent clinical follow-up for 72 h until their condition deteriorated or they were discharged. Sensitivity, specificity, positive and negative predictive values and accuracy in evaluating free intraperitoneal fluid were 80%, 95%, 57%, 98% and 94% when FAST was performed by EMRs and 86%, 95%, 59%, 98% and 94% when FAST was performed by RRs. The level of agreement between EMRs and RRs was moderate (κ = 0.525). FAST is a useful screening tool for initial assessment of free abdominal fluid in patients with trauma. Our results indicate that EMRs can perform sonography on trauma patients as successfully as RRs.

The objective of this study is to compare post-training self-efficacy between artificial simulators and live animal training for the performance of emergency medical procedures. Volunteer airmen of the 81st Medical Group, without prior medical procedure training, were randomly assigned to two experimental arms consisting of identical lectures and training of diagnostic peritoneal lavage, thoracostomy (chest tube), and cricothyroidotomy on either the TraumaMan (Simulab Corp., Seattle, Washington) artificial simulator or a live pig (Sus scrofa domestica) model. Volunteers were given a postlecture and postskills training assessment of self-efficacy. Twenty-seven volunteers that initially performed artificial simulator training subsequently underwent live animal training and provided assessments comparing both modalities. The results were first, postskills training self-efficacy scores were significantly higher than postlecture scores for either training mode and for all procedures (p0.0001). Second, post-training self-efficacy scores were not statistically different between live animal and artificial simulator training for diagnostic peritoneal lavage (p = 0.555), chest tube (p = 0.486), and cricothyroidotomy (p = 0.329). Finally, volunteers undergoing both training modalities indicated preference for live animal training (p0.0001). We conclude that artificial simulator and live animal training produce equivalent levels of self-efficacy after initial training, but there is a preference in using a live animal model to achieve those skills.

BACKGROUND: Lately, Focused Assessment with Sonography in Trauma (FAST) is preferred over diagnostic peritoneal lavage (DPL) as adjunct to primary survey. However, this is not evidence-based as there has been no randomized trial. METHODS: In this study, 200 consecutive torso trauma patients meeting inclusion criteria were randomized to undergo either DPL or FAST. The results were then compared with either contrast enhanced computerized tomography (CECT) (in patients managed non-operatively) or laparotomy findings (in patients undergoing operative treatment). Outcome parameters were: result of the test, therapeutic usefulness, role in diagnosing bowel injury and time taken to perform the procedure. RESULTS: Two hundred patients with a mean age of 28.3 years were studied, 98 in FAST and 102 in DPL group. 104 sustained blunt trauma and 76 sustained penetrating trauma due to stabbing. In addition, 38 (38.7%) were FAST positive and 48 (47%) were DPL positive (p=0.237, not significant). As a guide to therapeutically beneficial laparotomy, negative DPL was better than negative FAST. For non-operative decisions, positive FAST was significantly better than positive DPL. DPL was significantly better than FAST in detecting as well as not missing the bowel injuries. DPL took significantly more time than FAST to perform. CONCLUSION: This study shows that DPL is better than FAST.

Background The optimal management of hemodynamically stable asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe cost-effective manner. Common evaluation strategies are local wound exploration (LWE), diagnostic peritoneal lavage (DPL), serial clinical assessment (SCAs) and computed tomography (CT) imaging. Making a decision about the right time to operate on a patient with a penetrating abdominal stab wound, especially those who have visceral evisceration, is a continuing challenge. Objectives Until the year 2010, our strategy was emergency laparotomy in patients with penetrating anterior fascia and those with visceral evisceration. This survey was conducted towards evaluating the results of emergency laparotomy. So, better management can be done in patients with penetrating abdominal stab wounds. Patients and Methods This retrospective cross-sectional study was performed on patients with abdominal penetrating trauma who referred to Al- Zahra hospital in Isfahan, Iran from October 2000 to October 2010. It should be noted that patients with abdominal blunt trauma, patients under 14 years old, those with lateral abdomen penetrating trauma and patients who had unstable hemodynamic status were excluded from the study. Medical records of patients were reviewed and demographic and clinical data were collected for all patients including: age, sex, mechanism of trauma and the results of LWE and laparotomy. Data were analyzed with PASW v.20 software. All data were expressed as mean ± SD. The distribution of nominal variables was compared using the Chi-squared test. Also diagnostic index for LWE were calculated. A two-sided P value less than 0.05 was considered to be statistically significant. Results During the 10 year period of the study, 1100 consecutive patients with stab wounds were admitted to Al-Zahra hospital Isfahan, Iran. In total, about 150 cases had penetrating traumas in the anterior abdomen area. Sixty-three (42%) patients were operated immediately due to shock, visceral evisceration or aspiration of blood via a nasogastric tube on admission. Organ injury was seen in 78% of patients with visceral evisceration. Among these 87 cases, 29 patients’ (33.3%) anterior fascia was not penetrated in LWE. So, they were observed for several hours and discharged from the hospital without surgery. While for the remaining 58 patients (66.6%), whose LWE detected penetration of anterior abdominal fascia, laparotomy was performed which showed visceral injuries in 11 (18%) cases. Conclusions All in all, 82 percent of laparotomies in patients with penetrated anterior abdominal fascia without visceral evisceration, who had no signs of peritoneal irritation, were negative. So, we recommended further evaluation in these patients. However, visceral evisceration is an indication for exploratory laparotomy, since in our study; the majority of patients had organ damages.

Bowel and mesentery are injured in an estimated 1%-5% of cases after blunt trauma [1e3] and is the third most common type of injury from blunt trauma to abdominal organs [4e7]. There are 3 basic mechanisms that govern injury to bowel and mesentery, and include direct crushing force, shearing force, and a sudden increase in intraluminal pressure that results in burst injuries [8]. Missed or delayed diagnosis is multifactorial. Symptoms may be absent on initial presentation and, when present, may be nonspecific. Furthermore, clinical assessment of some patients may not be reliable in the presence of concomitant injuries. The result of these undiagnosed injuries is increased morbidity and mortality [2,9e13]. Diagnostic tests in patients with suspected abdominal injury include peritoneal lavage, ultrasonography, and computed tomography (CT). Although sensitivity of peritoneal lavage for detection of hemoperitoneum is higher than 90% [14e16], it is neither specific nor sensitive, with undetected bowel perforation seen in up to 10% of cases [17]. Focused ultrasound assessment in trauma has a sensitivity of 86% for detection of free intra-abdominal fluid but is nonspecific with regard to organ injury [18]. In comparison, multidetector CT is more sensitive and specific than diagnostic peritoneal lavage, abdominal ultrasound, and clinical examination for the diagnosis of bowel and mesenteric injuries [19], with improved diagnostic accuracy making it the imaging modality of choice for evaluation of abdominal and pelvic trauma [20e29].

The diagnosis of intraperitoneal hemorrhage must bequickly with a high accuracy, before an acute exploratory laparotomy. This study was conducted to find out if intravesical pressure measurement should be as an alternative indicator of diagnostic peritoneal lavage in predicting intraperitoneal hemorrhage that indicating an acute exploratory laparotomy. Using an Explorative, Cross Sectional Design. Results of the exploratory laparotomy were used as  a standard of determining the accuracy of Diagnostic Peritoneal Lavage and intravesical pressure measurement in predicting theindication for the exploratory laparotomy. 18 of 24 patients has positive results of diagnostic peritoneal lavage, but an active intraperitoneal hemorrhage only found in 15 patients, witha positive predictive value 83,33 %, negative predictive value 100%. The results of intravesical pressure measurement in the same patients predicted 17 patients has positive results, with slight a higher positive predictive value (88,24 %), negative predictive value  100%. The conclusion is the measurement of intravesical pressure is an alternative procedure of Diagnostic Peritonel lavage for predicting intraperitoneal hemorrhage. Key words:Blunt Trauma Abdomen; Intravesical Pressure Measurement; Diagnostic Peritoneal Lavage; Exploratory Laparotomy; Intraperitoneal Hemorrhage.

Background and Objectives Positive peritoneal cytology equates M1 disease in patients with gastric cancer. Diagnostic peritoneal lavage (DPL) is a proven test to detect occult visceral injury in trauma patients. The objective of this study is to determine whether DPL can be used to assess peritoneal cytology in patients with gastric cancer. Methods Patients with gastric adenocarcinoma were prospectively enrolled to undergo DPL prior to diagnostic laparoscopy (DL). Saline was instilled through a percutaneous catheter and fluid was collected for cytology (DPL-cyt). Washings obtained during DL were used as controls (DL-cyt). Results DPL was successful in 22/27 patients (81.5%). Among the 22 successful DPLs, 12 had positive cytology (54.5%). Positive DPL-cyt specimens matched DL-cyt specimens in 12/12 cases (specificity = 100%). One of 10 cases with negative DPL-cyt was positive on the final DL-cyt (sensitivity = 92%). There were six patients with negative DPL-cyt who had visible M1 disease diagnosed with DL (DPL evaluation of M1 disease, sensitivity 54.5%, specificity = 100%). Conclusions DPL is a safe method of detecting positive cytology in patients with gastric cancer, however gross M1 disease may be missed without visual inspection. The specific role of DPL in the staging workup of patients with gastric cancer remains to be determined. J. Surg. Oncol. 2013;107:794–798. © 2013 Wiley Periodicals, Inc.

Background: Diaphragmatic injuries due to penetrating trauma remain a diagnostic challenge. Inspection is the best approach in diagnosis as palpation may miss some injuries. The following approaches have been used, either alone or together, to recognize penterating trauma injuries: physical examination, chest x-ray, computed tomography scan, focused assessment with sonography for trauma, and diagnostic peritoneal lavage (DPL). These modalities have been reported to miss 10 to 30 percent of injuries. These diagnostic tools have a low sensitivity and specificity to detect morbidities associated with these injuries. Finding a suitable diagnostic modality is essential for patient care. In this study, we assessed the diagnostic value of video-assisted thoracoscopy as an approach to diagnose diaphragmatic injuries in patients with negative DPL. Materials and Methods: This case series was conducted on 33 patients with penetrating thoracoabdominal trauma referred to the Loghman Hospital in Theran, Iran, from 2013 to 2014 (during an 18-month period). All negative DPL and hemodynamically stable hemopneumothorax patients with no indications for emergent surgical interventions were included in the study. All these patients underwent diagnostic thoracoscopy. Data were collected and analyzed by SPSS software version 20. Results: Thirty-three patients were eligible to participate in this study with a mean age of 23.79±6.42 years. The youngest participant was 17 years old and the oldest was 51. A penetrating wound was located in the right side in 11 patients (33.3%) and on the left side in 19 subjects (57.6%). Three patients (9.1%) had trauma on both sides of their thorax. During thoracoscopy, 6 subjects (18.2%) were found to have asymptomatic diaphragmatic injuries. Conclusions: Diaphragmatic injuries can be missed based on negative DPL. Application of video- assisted thoracoscopy is a minimally invasive procedure that is a practical approach for the evaluation, and management of trauma patients with diaphragmatic injuries

Unlike penetrating abdominal injuries where the decision to operate is relatively straight forward, those combat casualties that sustain blunt abdominal trauma offer more of a diagnostic and clinical challenge. For unstable patients with a positive focused abdominal sonography in trauma or diagnostic peritoneal lavage, exploratory laparotomy should be undertaken immediately. All grade IV-V splenic injuries should undergo splenectomy, patients undergoing attempted splenic salvage should be monitored in the Role 3 facility and embolization of such splenic injuries may be considered if available. Patients who fail non-operative management of the spleen require splenectomy at the Role 3 prior to aeromedical evacuation. Overwhelming post-splenectomy infection is a serious disease that can progress from a mild flu-like illness to fulminant sepsis in a short period of time. Although relatively rare, it has a high mortality rate with delayed or inadequate treatment. All splenectomized patients and those deemed to be functionally asplenic should be vaccinated within 14 days from splenectomy and prior to aeromedical evacuation.

The morbidity, mortality, and economic costs resulting from trauma in general, and blunt abdominal trauma in particular, are substantial. The "panscan" (computed tomographic [CT] examination of the head, neck, chest, abdomen, and pelvis) has become an essential element in the early evaluation and decision-making algorithm for hemodynamically stable patients who sustained abdominal trauma. CT has virtually replaced diagnostic peritoneal lavage for the detection of important injuries. Over the past decade, substantial hardware and software developments in CT technology, especially the introduction and refinement of multidetector scanners, have expanded the versatility of CT for examination of the polytrauma patient in multiple facets: higher spatial resolution, faster image acquisition and reconstruction, and improved patient safety (optimization of radiation delivery methods). In this article, the authors review the elements of multidetector CT technique that are currently relevant for evaluating blunt abdominal trauma and describe the most important CT signs of trauma in the various organs. Because conservative nonsurgical therapy is preferred for all but the most severe injuries affecting the solid viscera, the authors emphasize the CT findings that are indications for direct therapeutic intervention.

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 the need for an operation. The practice of deciding which patients may not need surgery after penetrating abdominal wounds has been termed “non-operative management.” This practice has been readily accepted during the past few decades with regard to abdominal stab wounds; however, controversy persists regarding when a conservative management approach is appropriate for penetrating gunshot wounds. Abdominal gunshot injuries are still commonly treated with mandatory exploration because of the multiple reports emphasizing a high incidence of significant injuries and the complications that result from a missed injury or a delayed diagnosis. The enthusiasm for nonoperative management in patients with penetrating abdominal trauma is based on a relatively high incidence of nontherapeutic or negative laparotomy from civilian low-velocity injuries. Reports on the incidence of unnecessary laparotomies range from 23% to 53% for patients with stab wounds and 5.3%-27% for patients with gunshot wounds.1 Complications develop in 2.5%-41% of all trauma patients undergoing unnecessary laparotomy, and small bowel obstruction, pneumothorax, ileus, wound infection, myocardial infarction, visceral injury, and even death have been reported secondary to unnecessary laparotomy. 2,3 The process of selecting patients for nonoperative management requires considering several factors: the specific mechanism (stab vs gunshot), the velocity of the inflicting agent (low vs high), and the different areas of the torso that may be affected (intraperitoneal, retroperitoneal, and thoracoabdominal). In developing management strategies for penetrating abdominal trauma, it is helpful to divide the abdomen into regions: the anterior abdomen (from xiphoid to pubis, between the anterior axillary lines); the flank and back (posterior to the anterior axillary lines); and the thoracoabdomen (from the nipple line to the costal margin). The approach for each of these regions varies. If the patient is selected for initial nonoperative management, additional diagnostic methods often become necessary. An abdominopelvic multidetector computed tomography is now strongly regarded as the main diagnostic tool to facilitate initial management decisions. However, other methods that can be considered include diagnostic peritoneal lavage, ultrasonography (US), and laparoscopy.

Background With recent advances in radiologic diagnostic procedures, the use of diagnostic peritoneal lavage (DPL) has markedly declined. In this study, we reviewed data to reevaluate the role of DPL in the diagnosis of hollow organ perforation in patients with blunt abdominal trauma. Methods Adult patients who had sustained blunt abdominal trauma and who were hemodynamically stable after initial resuscitation underwent an abdominal computed tomographic (CT) scan. Diagnostic peritoneal lavage was performed for patients who were indicated to receive nonoperative management and where hollow organ perforation could not be ruled out. Results During a 60-month period, 64 patients who had received abdominal CT scanning underwent DPL. Nineteen patients were diagnosed as having a positive DPL based on cell count ratio of 1 or higher. There were 4 patients who sustained small bowel perforation. The sensitivity and specificity of the cell count ratio for a hollow organ perforation in this study were 100% and 75%, respectively. No missed hollow organ perforations were detected. Conclusion For patients with blunt abdominal trauma and hemoperitoneum who plan to receive nonoperative management, DPL is still a useful tool to exclude hollow organ perforation that is undetected by CT.

OBJECTIVES Nowadays, use of selective nonoperative management has decreased the incidence of nontherapeutic laparotomies in patients with anterior thoracoabdominal stab wounds. The safety of selective nonoperative management was investigated in these patients, not requiring emergency laparotomy. PATIENTS AND METHODS Patients referred to the Tabriz Imam Reza Hospital with anterior thoracoabdominal stab wounds were studied from August 2008 to 2010. The hemodynamically unstable patients, those with evidence of peritoneal irritation or with organ evisceration, underwent an emergency laparotomy. For other patients, diagnostic peritoneal lavage (DPL) was used and patients with positive results were operated. Patients with negative DPL results underwent serial physical and laboratory examinations. RESULTS A total of 204 patients were studied. Sixty-two cases (30.4%) had emergency operations, with 12 (19.4%) cases of nontherapeutic laparotomies. On the basis of DPL results in 142 (69.6%) patients, laparotomy was carried out in another 18 (12.7%) cases with a nontherapeutic result in eight (5.6%) cases. Finally, 124 (60.8%) patients were left for further observation and serial physical and laboratory examinations. Accordingly, five (4%) patients needed delayed laparotomy without any serious complications due to the delayed operation. The length of hospital stay and nontherapeutic laparotomies in our study were lower than mandatory laparotomy management and also, there were no significant complications or mortalities within the 90 days follow-up period. CONCLUSION This study showed that the proposed approach of selective nonoperative management in patients with anterior thoracoabdominal stab wounds is safe, feasible, and probably cost-effective.

Introduction The vast majority of the published data on the appropriate use of the diagnostic peritoneal lavage (DPL) is dated. Currently in Canada, there is a significant grey-zone surrounding the teaching and use of the DPL. The objectives of this article are to briefly review the recent literature, to analyze the patterns in the use of the DPL in Canada, and to determine whether general surgery residents are being taught the skill. Methods Literature review was conducted using PubMed and Ovid. The Canadian Institute for Health Information (CIHI) supplied the available data on DPL usage in Canada. General surgery program directors in Canada were contacted by e-mail to determine if the DPL was still being taught. Results Between the years of 2001 and 2006 in Canada, 38 DPLs were coded into the CIHI's database. Males accounted for 84.2% of the DPLs, and 23.7% of all DPLs resulted in a laparotomy. Motor vehicle crashes were the reason that 42% of the DPLs were performed. The majority of general surgery residency programs in Canada are not teaching the DPL outside of what is taught in the advanced trauma life support (ATLS) course. Discussion The literature reviewed shows that the DPL continues to play a role in the current management of patients suffering from both blunt and penetrating trauma, although a much more limited role than in the past. How to cite this article Boone D, Clarkson CA. The Diagnostic Peritoneal Lavage: A Brief Review of the Current Literature and an Analysis of Its use and Teaching in Canada. Panam J Trauma Critical Care Emerg Surg 2012;1(3):150-153.

The optimal management of stable patients with anterior abdominal stab wounds (AASWs) remains a matter of debate. A recent Western Trauma Association (WTA) multicenter trial found that exclusion of peritoneal penetration by local wound exploration (LWE) allowed immediate discharge (D/C) of 41% of patients with AASWs. Performance of computed tomography (CT) scanning or diagnostic peritoneal lavage (DPL) did not improve the D/C rate; however, these tests led to nontherapeutic (NONTHER) laparotomy (LAP) in 24% and 31% of cases, respectively. An algorithm was proposed that included LWE, followed by either D/C or admission for serial clinical assessments, without further imaging or invasive testing. The purpose of this study was to evaluate the safety and efficacy of the algorithm in providing timely interventions for significant injuries.A multicenter, institutional review board-approved study enrolled patients with AASWs. Management was guided by the WTA AASW algorithm. Data on the presentation, evaluation, and clinical course were recorded prospectively.Two hundred twenty-two patients (94% men, age, 34.7 years ± 0.3 years) were enrolled. Sixty-two (28%) had immediate LAP, of which 87% were therapeutic (THER). Three (1%) died and the mean length of stay (LOS) was 6.9 days. One hundred sixty patients were stable and asymptomatic, and 81 of them (51%) were managed entirely per protocol. Twenty (25%) were D/C'ed from the emergency department after (-) LWE, and 11 (14%) were taken to the operating room (OR) for LAP when their clinical condition changed. Two (2%) of the protocol group underwent NONTHER LAP, and no patient experienced morbidity or mortality related to delay in treatment. Seventy-nine (49%) patients had deviations from protocol. There were 47 CT scans, 11 DPLs, and 9 laparoscopic explorations performed. In addition to the laparoscopic procedures, 38 (48%) patients were taken to the OR based on test results rather than a change in the patient's clinical condition; 17 (45%) of these patients had a NONTHER LAP. Eighteen (23%) patients were D/C'ed from the emergency department. The LOS was no different among patients who had immediate or delayed LAP. Mean LOS after NONTHER LAP was 3.6 days ± 0.8 days.The WTA proposed algorithm is designed for cost-effectiveness. Serial clinical assessments can be performed without the added expense of CT, DPL, or laparoscopy. Patients requiring LAP generally manifest early in their course, and there does not appear to be any morbidity related to a delay to OR. These data validate this approach and should be confirmed in a larger number of patients to more convincingly evaluate the algorithm's safety and cost-effectiveness compared with other approaches.

Study objective A recent Cochrane Review has demonstrated that emergency ultrasonography decreases the amount of computerised tomographic scans in blunt abdominal trauma. 13 However, there is no systematic review that has evaluated the utility of the Focused Assessment with Sonography for Trauma (FAST) exam in penetrating torso trauma. We systematically reviewed the medical literature for the utility of the FAST exam to detect free intraperitoneal blood after penetrating torso trauma. Methods We searched PUBMED and EMBASE databases for randomised controlled trials from 1965 through December 2009 using a search strategy derived from the following PICO formulation of our clinical question: Patients: patients (12+ years) sustaining penetrating trauma to the torso. Intervention: FAST exam during their initial trauma workup. Comparator: either local wound exploration (LWE), computerised tomography (CT), diagnostic peritoneal lavage (DPL), or laparotomy. Outcome: intraperitoneal and pericardial free fluid. The methodological quality of the studies was assessed. Qualitative methods were used to summarise the study results. Analysis Sensitivities and specificities were compared using a Forest Plot (95% CI) calculated by Revman 5 (Review Manager Version 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008) between the FAST exam and definitive diagnostic modalities such as LWE, CT, DPL, or laporotomy. Results We identified eight observational studies (n = 565 patients) that met our selection criteria. The prevalence of a positive FAST exam after penetrating trauma was fairly low ranging from 24.2% to 56.3%. The FAST exam for penetrating trauma is a highly specific (94.1–100.0%), but not very sensitive (28.1–100%) diagnostic modality. Conclusion From the review of the literature, a positive FAST exam has a high incidence of intraabdominal injury and should prompt an exploratory laparotomy. However, a negative initial FAST exam after penetrating trauma should prompt further diagnostic studies such as LWE, CT, DPL, or laparotomy.

Background Adhesions are common after conventional surgery; natural orifice transluminal endoscopic surgery (NOTES) avoids peritoneal disruption and may reduce adhesions. Objectives To determine whether adhesions (and peritoneal contamination) are less common with NOTES transgastric colon injury and repair (TGCR) than with laparoscopic colon repair (LCR). Design/Setting Porcine survival study. Interventions After colon preparation and administration of antibiotics, forty 25-kg male pigs were randomly assigned to either TGCR or LCR. TGCR involved an endoscopic gastrotomy (needle-knife plus balloon dilation), CO 2 pneumoperitoneum, and a 2-cm needle-knife transmural incision of spiral colon. Colotomies were repaired with clips; gastrotomies were closed with clips and a detachable snare. Main Outcome Measurements Adhesions were assessed at necropsy at 21 days; biopsy specimens were blindly reviewed. A 9-point adhesion score (density/vascularity, width, and extent) was averaged from 3 reviewers. Peritoneal lavage was sent for cell count and culture. Results Two of 20 TGCR pigs died immediately (unrecognized preoperative autopsy-proven pneumonia). The median procedure times were 70.5 and 19.0 minutes for TGCR and LCR, respectively; weight gains were 7.1 and 8.2 kg, respectively. The median adhesion scores were 4.3 and 3.7, respectively ( P = .26); subscores were similar (1.9, 1.5, 1.3 vs 1.7, 1.1, 1.0, respectively ( P = .3-.6)). Peritoneal lavage bacterial growth was nonsignificantly lower after TGCR than after LCR (38.9% vs 60.0%, respectively; P = .30); administration of intragastric antibiotics did not decrease contamination. Three TGCR (vs no LCR) pigs had histologic peritonitis. Limitations Animal model, colon prepped, injury immediately recognized. Conclusion NOTES colon repair is feasible after transmural injury. Adhesions, histologic peritonitis, and contamination were similar to those with laparoscopy and were not helped by intragastric antibiotics.

BACKGROUND: Diagnostic peritoneal lavage (DPL) is a preferred diagnostic approach for patients with abdominal trauma. The aim of this article is to determine the effect of catheter diameter on procedure time and on the incidence of liquid transfer complications in patients with abdominal trauma. METHODS (Study Design): Sixty-eight patients (49 males, 19 females; age range, 16–82 years; mean age, 32.4 years) with abdominal trauma were prospectively randomized to undergo standard catheter (3 mm) open, wide catheter (5 mm) open, standard semi-open, or wide catheter semi-open DPL. Mean DPL, surgical procedure and liquid transfer time and complication ratio were compared. RESULTS: Total DPL duration was significantly shorter for the wide catheter open technique than for the standard open technique (19 vs. 28.5 min, p < 0.01). Total surgical procedure duration for the wide catheter semi-open technique was also significantly shorter than for the standard semi-open technique (10.25 vs. 18 min, p < 0.01). There were two liquid transfer complications with the wide catheter open method, compared with five for the standard open technique, and one and six, respectively, for the wide catheter semi-open and standard semi-open techniques (p < 0.01). CONCLUSIONS: Increasing the catheter diameter from 3 mm to 5 mm for open and semi-open DPL procedures decreased the total surgical procedure duration and reduced the incidence of liquid transfer-induced complications.

Background Recent guidelines do not support local wound exploration (LWE) or diagnostic peritoneal lavage (DPL) in the evaluation of patients with anterior abdominal stab wounds (AASWs), favoring computed tomography scanning or serial examinations. In patients without immediate indications for laparotomy, we hypothesized that LWE/DPL would identify patients requiring surgery while limiting unnecessary hospital admissions. Methods Patients sustaining penetrating trauma at our level I trauma center over a 3-year period were reviewed. Results During the study period, 139 patients with AASW followed our LWE/DPL algorithm. Fifty-six patients had LWE without fascial penetration: 46 were discharged immediately, 10 required admission. Fifty-eight patients had fascial penetration on LWE but negative DPL: 37 were observed for less than 24 hours, 19 were observed for more than 24 hours, and 2 patients developed peritonitis requiring exploration. Twenty-five patients had positive LWE/DPL: 13 had therapeutic laparotomy, 12 had nontherapeutic laparotomy. Conclusions Only 11% of patients with AASWs without overt indication for laparotomy require surgical care. LWE remains a valid method to exclude intra-abdominal injury and to eliminate hospitalization in more than one third of AASW patients.

The optimal management of hemodynamically stable, asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe, cost-effective manner. Common evaluation strategies include local wound exploration (LWE)/diagnostic peritoneal lavage (DPL), serial clinical assessments (SCAs), and computed tomography (CT) imaging. The purpose of this multicenter study was to evaluate the clinical course of patients managed by the various strategies, to determine whether there are differences in associated nontherapeutic laparotomy (NONTHER LAP), emergency department (ED) discharge, or complication rates.A multicenter, Institutional Review Board-approved study enrolled patients with AASWs. Management was individualized according to surgeon/institutional protocols. Data on the presentation, evaluation, and clinical course were recorded prospectively.Three hundred fifty-nine patients were studied. Eighty-one had indications for immediate LAP, of which 84% were therapeutic. ED D/C was facilitated by LWE, CT, and DPL in 23%, 21%, and 16% of patients, respectively. On the other hand, LAP based on abnormalities on LWE, CT, and DPL were NONTHER in 57%, 24%, and 31% of patients, respectively. Twelve percent of patients selected for SCA ultimately had LAP (33% were NONTHER); there was no apparent morbidity due to delay in intervention.Shock, evisceration, and peritonitis warrant immediate LAP after AASW. Patients without these findings can be safely observed for signs or symptoms of bleeding or hollow viscus injury. To limit the number of hospital admissions, we propose a uniform strategy using LWE to ascertain the depth of penetration; the patient may be safely discharged in the absence of peritoneal violation. Peritoneal penetration, absent evidence of ongoing hemorrhage or hollow viscus injury, should not be considered an indication for LAP, but rather an indication for admission for SCAs. We suggest that a prospective multicenter trial be performed to document the safety and cost-effectiveness of such an approach.

Background To assess if diagnostic laparoscopy (DL) is superior to nonoperative modes (serial abdominal examination with/without computed axial tomography [CAT] and diagnostic peritoneal lavage) in determining the need for therapeutic laparotomy (TL) after anterior abdominal stab wound (ASW). Methods Retrospective review of ASW patients. Patients were divided into group A (DL/exploratory laparotomy) to identify peritoneal violation (PV) and group B (initial nonoperative modes). Results Seventy-three patients met inclusion criteria. In group A (n = 38), 29 patients (76%) had PV by DL and underwent exploratory laparotomy. Only 10 (35%) underwent TL (sensitivity for PV = 100%; specificity and positive predictive value of PV in determining need for TL = 29% and 33%, respectively). In group B (n = 35), 7 patients (20%) underwent TL, yielding an improved specificity (96%) and positive predictive value (88%). Conclusions We find no role for DL in the evaluation of ASW patients solely to determine PV.

Background: Blunt Bowel and Mesenteric injuries (BBMI) can present diagnostic difficulties and are occasionally recognized in a delayed fashion. Most studies evaluating these injuries predate multidetector Computerized Tomography (CT) scan technology. We set out to analyze whether the current era of multislice CT scanning has led to changes in the incidence of missed injuries in BBMI or altered the patterns of diagnosis. Methods: All patients with blunt small and large intestinal injury as well as mesenteric lacerations, recognized in the operating room (OR) between November 2000 and December 2006 were identified from the trauma registry. A 4 slice helical multidetector CT scanner was in use for abdominal CT scans during the first portion of the study (November 2000—July 2005) whereas a 16 slice scanner was in use in the second portion (July 2005-December 2006). Rectal injuries and serosal tears were excluded. Results: Eighty-two patients were identified with BBMI. Twenty-five patients went directly to the OR for laparotomy after a positive Diagnostic Peritoneal Lavage, a positive Focused Abdominal Sonogram or other injury. Of the 57 patients who underwent CT, findings indicating possible BBMI were present in 46 patients (80.7%). These included free fluid without solid organ injury (50.9%), free air (10.5%), active mesenteric bleeding (10.5%), and bowel swelling (5.3%). Eleven patients (19.3%) had delayed bowel or mesenteric injury recognition with the diagnosis ultimately made by repeat CT or in the OR (range, 1-10 days). Conclusion: Missed injuries remain common in BBMI even in the current era of multislice CT scanners. Free fluid w/o solid organ injury, though not specific, continues to be an important finding. Adjuncts to CT continue to be necessary for the optimal diagnosis of bowel injuries.

The reliability of sonography and peritoneal lavage in assessing the need for immediate surgical intervention in blunt abdominal trauma was examined in a controlled prospective and retrospective study. Whereas no false results occurred using peritoneal lavage, false negative findings in sonography were 9.8% and false positive findings 3.9%. A significant difference was also found on retrospective evaluation of all cases with diagnostic peritoneal lavage (2.2% false results) and ultrasound investigations (14.9% false results). This demonstrates that sonography cannot fully replace peritoneal lavage as a diagnostic method in blunt abdominal trauma.

Objective: Review the clinical presentation, assessment, resuscitation, and medical and surgical management of dogs with hemoperitoneum. Etiology: Hemoperitoneum is defined as free intra-abdominal hemorrhage. Hemoperitoneum occurs from traumatic and nontraumatic causes. Common etiologies include atraumatic rupture of intra-abdominal masses, coagulopathies, as well as blunt, and penetrating trauma to the abdomen. Diagnosis: Definitive diagnosis of hemoperitoneum entails demonstration of free intra-abdominal blood via paracentesis or diagnostic peritoneal lavage. Imaging and other diagnostic tests including coagulation studies may help to determine underlying causes of hemoperitoneum or concurrent organ dysfunction. Therapy: Goals of therapy for patients with hemoperitoneum include maintenance and restoration of effective circulating volume, maintenance and restoration of oxygen-carrying capacity, and arrest of hemorrhage. These goals can be achieved via fluid resuscitation, administration of blood products or hemoglobin-based oxygen carriers, as well as application of abdominal counterpressure, and surgical intervention. Surgery usually is required for bleeding intra-abdominal neoplasms. Emergency surgery is recommended for hemorrhaging patients with penetrating trauma, gastric dilatation and volvulus, bleeding cysts, liver lobe torsion, splenic torsion, and any other condition resulting in organ ischemia. Prognosis: Prognosis in patients with hemoperitoneum may depend on the underlying cause and concurrent injuries.

Background: Point-of-care ultrasound (POCUS) is a vital tool for diagnosis and management of emergency room patients. Focused assessment with sonography for trauma (FAST) is a bedside ultrasound performed by clinicians in the evaluation of trauma patients. In 2012, Haroborview Medical Center, the only level-one trauma center in five northwestern states, officially incorporated emergency physician (EP) performed FAST exams for critically injured blunt abdominal trauma (BAT) patients. Objective: We sought to determine the accuracy of EP performed FAST exams for severely injured patients with blunt abdominal trauma (BAT). Secondary objectives included trends in use of diagnostic peritoneal lavage (DPL) to identify hemoperitoneum after the implementation of the new protocol. Design: We conducted a retrospective chart review using the emergency department tracking system to identify all Emergency Severity Index (ESI) 1 trauma patients with BAT over a 26-month study period (July 1, 2011 to August 31, 2013). Hemodynamically unstable BAT patients who had a FAST exam performed were included for further analysis. Results of EP FAST exams and radiology department FAST exams were compared against peritoneal fluid analysis, computed tomography results, and operative findings, where available. Results: 185 patients met inclusion criteria. In total there were 33 true positive, 109 true negative, 2 false positive, 12 false negative, and 29 indeterminate examinations, for an overall sensitivity, specificity, and accuracy of 73%, 98%, and 91% respectively. EP performed FAST exams had a sensitivity, specificity and accuracy of 88% (95% CI 67 to 96 %), 98% (95% CI 87 to 99 %), and 94% for moderate to large amounts of intra-peritoneal hemorrhage. The overall use of DPL in the evaluation of critically ill blunt trauma patient decreased slightly with the protocol change, however this decrease was not significant (p=0.17). Conclusion: Our study demonstrated that emergency physicians are accurate in identifying hemoperitoneum in critically injured BAT patients. Secondary findings suggest that utilization of DPL in hemodynamically unstable BAT patients decreased modestly

Successful execution of emergency critical care procedures requires integrated knowledge of indications, contraindications, equipment, procedural steps, common pitfalls, and complications. The purpose of this chapter is to provide an integrated approach to emergency critical care procedures including surgical airway management, vascular access, tube thoracostomy, resuscitative thoracotomy, and diagnostic peritoneal lavage. Individual and team dynamics during emergency procedures are also discussed.

Diagnostic peritoneal lavage (DPL) is an invasive procedure, predominantly of historical significance, used to diagnose hemoperitoneum or bowel injury in patients who have experienced blunt or penetrating abdominal trauma. This procedure is now primarily used in hemodynamically unstable patients cared for in resource-constrained environments, to determine the need for exploratory laparotomy. Due to the rapidly progressing use of focused assessment with sonography for trauma (FAST) and computed tomography (CT), DPL is no longer considered the primary modality for diagnosing blood in the abdominal cavity and has been removed from ATLS guidelines. The only absolute contraindication is an obvious need for laparotomy. Relative contraindications include coagulopathy, prior abdominal surgeries, abdominal wall infections, pregnancy, and morbid obesity. DPL can be done via two different approaches: open or closed. The most common technique is closed with modified Seldinger technique. The procedure can be performed through either infraumbilical or supraumbilical locations. The most common location is infraumbilical. Positive findings during a DPL indicate a need for emergent exploratory laparotomy for the hemodynamically unstable patient. Positive findings include >10 cc of frank blood or enteric contents aspirated during phase 1 of the procedure or >100,000 RBC/mm3 and/or >500 WBC/mm3 during phase 2 of the procedure. When resources are limited, DPL can be a useful procedure when determining the need for exploratory laparotomy.

It has been suggested that diagnostic peritoneal lavage is now obsolete in UK hospitals with access to either skilled ultrasonography or emergency physician or surgeon-performed focused abdominal sonography in trauma. Diagnostic peritoneal lavage continues to be advocated and taught on Advanced Trauma Life Support courses. The aim of this study was to evaluate the experiences and attitudes of general-surgery trainees in one UK training region towards diagnostic peritoneal lavage and focused abdominal sonography in trauma in managing blunt abdominal trauma.An anonymous postal piloted questionnaire was sent to all 66 general surgery specialist trainees in one UK training region between January and March 2005.Out of 40 replies to the questionnaire (response rate 61%), 53% and 38% of surgical trainees had either never performed or never observed a diagnostic peritoneal lavage during their training. Thirteen trainees (33%) felt diagnostic peritoneal lavage to be obsolete and would never contemplate using it; 15 trainees (37%) might consider using diagnostic peritoneal lavage if computed tomography or ultrasonography were unavailable. Ten trainees (25%) felt that diagnostic peritoneal lavage had been superseded by computed tomography. Only 12 trainees (30%) had worked in a UK hospital with access to facilities for focused abdominal sonography in trauma and only seven trainees (18%) had received any training or experience in focused abdominal sonography in trauma.Surgical trainees in one UK training region lack skills in both diagnostic peritoneal lavage and focused abdominal sonography in trauma for managing blunt abdominal trauma and are therefore reliant upon the availability of prompt, skilled radiological assistance or emergency physician-provided focused abdominal sonography in trauma.

Assessment of patients in the emergency department who sustain blunt abdominal trauma represents a significant diagnostic challenge. Computed tomography (CT) is increasingly used as the principal investigation for these patients. A sensitive screening test could safely reduce the use of CT.To appraise the evidence supporting the use of diagnostic peritoneal lavage and focused abdominal sonography for trauma as screening tests in the emergency department to reduce the use of CT in the initial assessment of patients sustaining blunt abdominal trauma.A search of high-quality evidence resources was performed, followed by a hand search of the bibliographies of all relevant articles.Altogether, 55 articles were found during the initial search, of which 23 were relevant. An additional 11 were found by hand searching. Six relevant original research articles were found.Screening diagnostic peritoneal lavage and selective CT is a safe diagnostic strategy for the investigation of blunt abdominal trauma. Further research is needed to determine the role of focused abdominal sonography for trauma scanning in diagnostic protocols.