Search

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.

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

The aim — to determine the sequence and scope of diagnostic measures in patients with thoracoabdominal injuries upon admission to the stages of medical evacuation of the II level of medical support, depending on the severity of the injury.Materials and methods. A retrospective analysis of 123 victims with gunshot thoracoabdominal wounds received during the operation of the combined forces (anti‑terrorist operation) in the East of Ukraine was carried out. The victims were divided into two groups: the main (n = 71), in which the diagnostic tactics depended on the severity of the injury according to the anatomical‑functional AdTS scale, and the comparison (n = 52), in which the diagnostic tactics depended on an empirical assessment of the injury severity. Groups on average age and injury severity were comparable. Clinical diagnostic methods and X‑ray imaging for chest, abdomen, spine, pelvis, and damaged limbs, FAST protocol ultrasonography, thoracopuncture/thoracocentesis, laparocentesis with diagnostic peritoneal lavage were used.Results and discussion. The introduction of ultrasonography according to the FAST protocol into the preoperative diagnostic algorithm in patients with thoracoabdominal wounds made it possible to reduce the time of preoperative diagnosis (by 12.2 min), the number of unjustified laparotomy and with high sensitivity to diagnose markers of damage to the organs of the chest (98.4 %) and abdominal (93, 8 %) of the cavity.Conclusions. FAST protocol ultrasonography is a non‑invasive fast (3 — 4 min) method for the diagnosis of thoracic and abdominal components of trauma with a sensitivity of 93.8 and 98.4 %, respectively, for identifying markers of damage to internal organs. The use of the FAST protocol reduced the time of preoperative diagnosis in severe and extremely severe victims with thoracoabdominal wounds by 1.4 times. Differential diagnostic tactics, depending on the severity of the injury, combined with the use of the FAST protocol, reduced the number of diagnostic errors by 19.1 %., Цель работы — определить последовательность и объем диагностических мероприятий у пострадавших с торакоабдоминальными ранениями при поступлении на этапы медицинской эвакуации II уровня медицинского обеспечения в зависимости от тяжести травмы.Материалы и методы. Проведен ретроспективный анализ 123 пострадавших с огнестрельными торакоабдоминальными ранениями, полученными в ходе проведения операции объединенных сил (антитеррористической операции) на Востоке Украины. Пострадавших разделили на две группы: основную (n = 71), в которой диагностическая тактика зависела от тяжести травмы по анатомо‑функциональной шкале AdTS, и сравнения (n = 52), в которой диагностическая тактика зависела от эмпирической оценки тяжести травмы. Группы по среднему возрасту и тяжести травмы были сопоставимы. Использовали клинические методы диагностики, рентгенографию грудной клетки, живота, позвоночника, таза и поврежденных конечностей, ультрасонографию по FAST‑протоколу, торакопункцию/ торакоцентез, лапароцентез с диагностическим перитонеальным лаважем.Результаты и обсуждение. Внедрение в дооперационный диагностический алгоритм у пострадавших с торакоабдоминальными ранениями ультрасонографии по FAST‑протоколу позволило сократить время дооперационной диагностики (на 12,2 мин), количество неоправданных лапаротомий и с высокой чувствительностью диагностировать маркеры повреждений органов грудной (98,4 %) и брюшной (93,8 %) полости.Выводы. Ультрасонография по FAST‑протоколу является неинвазивным быстрым (3 — 4 мин) методом диагностики торакального и абдоминального компонентов травмы с чувствительностью относительно выявления маркеров повреждения внутренних органов 93,8 и 98,4 % соответственно. Применение FAST‑протокола позволило сократить время дооперационной диагностики у тяжелых и крайне тяжелых пострадавших с торакоабдоминальными ранениями в 1,4 раза. Дифференциальная диагностическая тактика в зависимости от тяжести травмы в сочетании с использованием FAST‑протокола позволила уменьшить количество диагностических ошибок на 19,1 %., Мета роботи — визначити послідовність та обсяг діагностичних заходів у постраждалих з торакоабдомінальними пораненнями при надходженні на етапи медичної евакуації ІІ рівня медичного забезпечення залежно від тяжкості травми.Матеріали і методи. Проведено ретроспективний аналіз 123 постраждалих з вогнепальними торакоабдомінальними пораненнями, отриманими під час проведення операції об’єднаних сил (антитерористичної операції) на Сході України. Постраждалих розподілили на дві групи: основну (n = 71), в якій діагностична тактика залежала від тяжкості травми за анатомо‑функціональною шкалою AdTS, і порівняння (n = 52), в якій діагностична тактика залежала від емпіричної оцінки тяжкості травми. Групи за середнім віком і тяжкістю травми були порівнянними. Використовували клінічні методи діагностики, рентгенографію грудної клітки, живота, хребта, таза і пошкоджених кінцівок, ультрасонографію за FAST‑протоколом, торакопункцію/торакоцентез, лапароцентез з діагностичним перитоніальним лаважем.Результати та обговорення. Впровадження в доопераційний діагностичний алгоритм у постраждалих з торакоабдомінальними пораненнями ультрасонографії за FAST‑протоколом дало змогу скоротити час доопераційної діагностики (на 12,2 хв), кількість невиправданих лапаротомій та з високою чутливістю діагностувати маркери ушкоджень органів грудної (98,4 %) та черевної (93,8 %) порожнини.Висновки. Ультрасонографія за FAST‑протоколом є неінвазивним швидки м (3 — 4 хв) методом діагностики торакального та абдомінального компонентів травми з чутливістю щодо виявлення маркерів ушкодження внутрішніх органів 93,8 і 98,4 % відповідно. Застосування FAST‑протоколу дало змогу скоротити час доопераційної діагностики у тяжких та вкрай тяжких постраждалих з торакоабдомінальними пораненнями в 1,4 разу. Диференційна діагностична тактика залежно від тяжкості травми в поєднанні із використанням FAST‑протоколу дала змогу зменшити кількість діагностичних помилок на 19,1 %.

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.

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.

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.

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.

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.

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.

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.

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 Hemorrhage-related mortality (HRM) associated with pelvic fractures continues to challenge trauma care. This study describes the management and outcome of hemodynamically unstable patients with a pelvic fracture, with emphasis on primary intervention for hemorrhage control and HRM. Methods Blunt trauma patients [Injury Severity Score (ISS) >= 16] with a major pelvic fracture (Abbreviated Injury Score, pelvis >= 3) and hemodynamic instability [admission systolic blood pressure (SBP) = 6 units of packed red blood cells (PRBCs)/24 hours) were included into a 48-month (ending in December 2003) multicenter retrospective study of 11 major trauma centers. Data are presented as the mean +/- SD. Results A total of 217 patients (mean age 41 +/- 19 years, 71% male, ISS 42 +/- 16) were studied. The admission SBP was 96 +/- 37 mmHg and the Glascow Coma Scale (GCS) 11 +/- 5. Patients received 4 +/- 2 liters of fluids including 4 +/- 4 units of PRBCs in the emergency room (ER). In total, 69 (32%) patients died, among whom the HRM was 19%; 29% of the deaths were due to pelvic bleeding. Altogether, 120 of the 217 (55%) patients underwent focused abdominal sonography for trauma (FAST) or diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL); 60 of the 217 (28%) patients were found to have pelvic binding in the ER. In all, 53 of 109 (49%) patients had no bleeding noted at laparotomy, 26 of 106 (25%) had no abdominal findings, and 15 of 53 (28%) had had no prior abdominal investigation (FAST/DPL/computed tomography). Angiography was positive in 48 of 58 (83%) patients. The HRM was highest in patients with laparotomy as the primary intervention (29%) followed by the angiography group (18%), the combined laparotomy/pelvic fixation group (16%), and the pelvic fixation-only group (10%). Conclusion HRM associated with major pelvic trauma is unacceptably high especially in the laparotomy group. Hence, nontherapeutic laparotomy must be avoided, concentrating instead on arresting pelvic hemorrhage. Standards of care must be implemented and abided by

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.

Background The reported incidence of hollow viscus injuries (HVI) in blunt trauma patients is approximately 1 %. The most common site of injury to the intestine in blunt abdominal trauma (BAT) is the small bowel followed by colon, with mesenteric injuries occurring three times more commonly than bowel injuries. Isolated colon injury is a rarely encountered condition. Clinical assessment alone in patients with suspected intestinal or mesenteric injury after blunt trauma is associated with unacceptable diagnostic delays. Case presentation This is a case of a 31-year-old man, admitted to the emergency department after being the restrained driver, involved in a car accident. After initial resuscitation, focused assessment with sonography for trauma examination (FAST) was performed revealing a subhepatic mass, suspicious for intraperitoneal hematoma. A computed tomography scan (CT) that followed showed a hematoma of the mesocolon of the ascending colon with active extravasation of intravenous contrast material. An exploratory laparotomy was performed, hemoperitomeum was evacuated, and a subserosal hematoma of the cecum and ascending colon with areas of totally disrupted serosal wall was found. Hematoma of the adjacent mesocolon expanding to the root of mesenteric vessels was also noted. A right hemicolectomy along with primary ileocolonic anastomosis was performed. Patient’s recovery progressed uneventfully. Conclusion Identifying an isolated traumatic injury to the bowel or mesentery after BAT can be a clinical challenge because of its subtle and nonspecific clinical findings; meeting that challenge may eventually lead to a delay in diagnosis and treatment with subsequent increase in associated morbidity and mortality. Isolated colon injury is a rare finding after blunt trauma and usually accompanied by other intra-abdominal organ injuries. Abdominal ‘seatbelt’ sign, ecchymosis of the abdominal wall, increasing abdominal pain and distension are all associated with HVI. However, the accuracy of these findings remains low. Diagnostic peritoneal lavage, ultrasound, CT and diagnostic laparoscopy are used to evaluate BAT. Although CT has become the main diagnostic tool for this type of injuries, there are few pathognomonic signs of colon injury on CT. Given the potential for devastating outcomes, prompt diagnosis and treatment is necessary and high clinical suspicion is required.

Introduction: Trauma patients represent a heterogeneous group at risk for the development of both primary and secondary abdominal compartment syndrome (ACS). Our study aims at identifying these individuals early in their course and placing an intra-abdominal catheter to reduce intra-abdominal pressure before the serious hemodynamic consequences of ACS occur. Methods: During a 10-month period, 12 patients were identified who developed intra-abdominal hypertension. Patients who received 12 L or more of intravenous fluids in the first 24 hours of their resuscitation or received 500 mL/hr of intravenous fluids for more than 4 consecutive hours were considered at risk and had intra-abdominal pressure readings via bladder catheters every 4 hours. After resuscitation, patients were given a physical examination and intra-abdominal pressures were taken every 4 hours or when clinically necessary. When abdominal compartment pressures (ACPs) exceeded 20 mm Hg or the abdominal perfusion pressure (APP = mean arterial pressure-ACP) fell below 50 mm Hg, a diagnostic peritoneal lavage catheter was placed. Fluid volume and type drained, abdominal pressures, heart rate, mean arterial pressure, and pulmonary compliance were recorded. If adequate control of abdominal compartment pressures was not achieved, the patients were managed with a traditional decompressive laparotomy. Results: Readings taken 30 minutes after placement of the peritoneal catheter showed an average decrease in ACP of 8.0 mm Hg (p = 0.01); an increase in APP of 13.8 mm Hg (p = 0.14); an increase in static pulmonary compliance of 8.1 mL/ cmH 2 O (p = 0.16); and an increase in mean arterial pressure of 5.8 mm Hg (p = 0.52). Ten of the twelve patients were managed nonoperatively. Four patients failed to have their APP improve to >50 mm Hg with the catheter. Two of these patients underwent laparotomy, with one survivor and one mortality secondary to infarcted small bowel. Two did not undergo laparotomy, with one dying of cerebral herniation and the other having care withdrawn. Eight of the twelve patients required intra-abdominal catheters early in their admission (in the first 32 hours), with 7 of 8 surviving. Four patients received intra-abdominal catheters later than day 4 in their admission. All of those four patients died, three within 24 hours. Overall, 5 of the 12 patients died. Conclusions: Intra-abdominal catheter placement is a reasonable first step in the early management of ACS. It may prevent a portion of patients from progressing to hemodynamically significant ACS and prevent the complications of managing an open abdominal wound. Also, the late intra-abdominal hypertension may be a prognostic indicator of an impending rapid clinical deterioration. Further prospective investigation is warranted to determine whether this method reduces overall morbidity and mortality in critically ill patients.

Background: The prompt detection and accurate localization of abdominal injuries are difficult. Some diagnostic modalities, including laboratory tests, ultrasound, and diagnostic peritoneal lavage (DPL) were used to evaluate patients with blunt abdominal trauma, with various advantages and pitfalls. We aimed to evaluate the risk and benefit of using multidetector computed tomography (MDCT) as an initial assessment tool for proper diagnosis and treatment planning of patients with blunt abdominal trauma. Methods: Two hundred fifty-two patients with blunt abdominal trauma were prospectively enrolled. Multidetector computed tomography was performed during resuscitation. The risk and benefit of using MDCT in the diagnosis and planning of treatment were analyzed. Results: The time required for a MDCT examination averaged 10.2 minutes. Of the studies done, 224 revealed abdominal injuries. Of those, 34 were performed in patients with unstable hemodynamic status without adverse effect. Prompt diagnosis and proper treatment were given according to the MDCT findings. A total of 43 (17.1%) MDCTs showed contrast extravasation. Active bleeding was confirmed in all and treated with transarterial embolization (30) or surgery (13). Another 58 patients sustained bowel, mesenteric, or pancreatic injuries (BMPI) necessitating laparotomy. The sensitivity, specificity, and accuracy of MDCT in identifying patients with active bleeding or BMPI were all 100%. Conclusions: Multidetector computed tomography was useful as a second line initial assessment tool to identify injuries and determine treatment planning in blunt abdominal trauma patients. No increased risk was found if the facility is readily available, the protocol is well designed, and the patient is well prepared.

Purpose Currently, nonoperative management is the procedure of choice for solid organ injury in patients with a blunt abdominal trauma. Missed blunt bowel and mesenteric injuries (BBMIs) are possible because diagnosis is difficult. The aim of our study was to test a new algorithm for BBMI diagnosis using abdominal ultrasonography (AUS), computed tomography (CT), and diagnostic peritoneal lavage (DPL). Methods We reviewed cases of blunt abdominal injuries over a 10-year period, then we designed an algorithm that was prospectively tested in hemodynamically stable patients over a 2-year period. An abnormal AUS led to helical CT. When the CT showed more than 2 findings suggestive of BBMI, laparotomy was performed. In case of 1 or 2 abnormal CT findings, we performed a DPL and calculated the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid and divided this by the WBC/RBC ratio in peripheral blood. A ratio of 1 or higher was considered positive for BBMI, and a laparotomy was immediately performed. Patients with a ratio of less than 1 were managed nonoperatively. Results In the retrospective study, 26 (1%) of 2126 patients admitted to our trauma center for blunt trauma had a BBMI, including 15 (58%) diagnosed after a median delay of 24 hours. In the prospective study, 531 patients were admitted for blunt trauma with multiple injuries, including 131 with abdominal trauma. Computed tomography was performed in 40 patients. There were 2 criteria or more of BBMI in 1 patient, 0 criteria in 27 patients (with an uneventful follow-up), and 1 or 2 criteria in 12 patients who had DPL with a median ratio of 0.82 (ranges, 0.03-9). Five patients had a ratio of 1 or higher. They underwent immediate laparotomy. In all 5 cases, BBMI was found. The 7 patients who had a ratio of less than 1 were observed in ICU and treated for extra-abdominal injuries. No BBMI injury was missed in these patients. The accuracy of the algorithm was 100% (95% confidence interval, 0.99-1.00). Conclusion The proposed algorithm (based on AUS, CT, and DPL) had a high accuracy to diagnose BBMI while requiring the performance of DPL in only a few (2%) patients.

To determine whether interdepartmental educational and technical resources could be combined to successfully train surgery and emergency medicine residents in common diagnostic and therapeutic trauma skills outside the traditional hospital setting.Curriculum improvement survey.Surgical Skills Laboratory, Temple University School of Medicine, Philadelphia, Pennsylvania.A total of 35 surgery residents (PGY 1 to 5) and 26 emergency medicine residents (PGY 1 to 3).Emergency medicine attendings used human volunteers to train surgery residents in Focused Assessment with Sonography in Trauma (FAST). Trauma surgery attendings used a porcine model to teach emergency medicine residents tracheostomy, peripheral venous cutdown, diagnostic peritoneal lavage, tube thoracostomy, and bilateral thoracotomy. Upon completion of the courses, all residents were surveyed using a 5-point Likert scale to assess this teaching model.The percentage of residents reporting an improvement in knowledge levels after the course increased significantly (p0.003) for all skill modules (FAST, 14% vs 73%; tracheostomy, 20% vs 64%; peripheral venous cutdown, 25% vs 71%; diagnostic peritoneal lavage, 16% vs 60%; tube thoracostomy, 42% vs 92%; thoracotomy, 15% vs 42%). A significant (p0.05) increase in comfort levels during performance of the procedures in the clinical setting was also anticipated for all skills modules (FAST, 11% vs 60%; tracheostomy, 12% vs 50%; peripheral venous cutdown, 15% vs 31%; diagnostic peritoneal lavage, 12% vs 58%; tube thoracostomy, 35% vs 73%; thoracotomy, 0% vs 15%). PGY 1 to 4 surgery residents and PGY 1 and 2 emergency medicine residents perceived the greatest benefit (p0.05) from their respective courses. The overwhelming majority (89% to 100%) of surgery and emergency medicine residents felt the course was valuable and transferable to the clinical trauma setting.Interdepartmental collaboration between the Department of Surgery and Department of Emergency Medicine offered a unique training relationship that was a positive educational experience for all residents.

Abdominal trauma may be blunt or penetrating and generates injuries that vary from the insignificant to the immediately life threatening. Blunt trauma to the abdomen is most common in UK and is usually due to road traffic accidents. Penetrating trauma remains relatively rare in the UK, but is increasing in many urban areas. Penetrating trauma predominates in the USA and South Africa. The investigation of the traumatized abdomen includes repeat clinical examination and the use of adjuncts; the use and selection of adjunctive investigations is dependent on haemodynamic stability. Diagnostic peritoneal lavage is a highly sensitive examination for haemoperitoneum, but has largely been replaced by Focussed Abdominal Sonography for Trauma (FAST). CT is the first-line investigation in the stable patient because it allows quantification of the degree of organ damage and the possibility of conservative management. Laparoscopy is useful only when assessing peritoneal penetration or if diaphragmatic injury is suspected. Laparotomy remains the definitive abdominal examination, but mandatory laparotomy for abdominal penetrating injury has been abandoned in many large Trauma Centres in favour of selective conservatism. Laparotomy should proceed without prior investigation in an unstable patient with abdominal signs. The trauma laparotomy controls haemorrhage and minimizes contamination. All injuries may not be repairable at the initial laparotomy. Also, physiological status may be so deranged that damage control principles may need to be applied; the patient is returned to theatre after correction of all physiological parameters in the ICU. Temporary closure of the abdomen may be necessary because closure under tension predisposes to abdominal compartment syndrome (which is fatal in about 50% of cases in the UK).

Background An evaluation of hand-held ultrasonography (US) in the assessment of penetrating torso trauma has not yet been reported. Methods A 2.4 kg hand-held ultrasound device was used to examine penetrating trauma victims in an exam designated as the Hand-Held Focused Assessment with Sonography for Trauma (HHFAST). Results were compared with other US examinations including formal FAST (FFAST), computed tomography, diagnostic peritoneal lavage, operative and autopsy findings, and serial examination. Performance considered both the detection of fluid and injuries requiring intervention. Results The HHFAST was excellent for detecting free intraperitoneal fluid, which had 100% specificity for peritoneal penetration, but was only moderately sensitive for injuries requiring therapy. Conclusions Hand-held sonography can quickly detect intraperitoneal fluid, which has good test performance in determining the presence of an intra-abdominal injury. Negative FAST examinations after penetrating trauma should be followed up with another diagnostic modality.

Objective. To evaluate the FAST (focused assessment with sonography in trauma) examination for determining traumatic pericardial effusion and intraperitoneal fluid indicative of injury in patients with penetrating anterior chest trauma. Methods. An observational prospective study was conducted over a 30-month period at an urban level I trauma center. FAST was performed in the emergency department by emergency physicians and trauma surgeons. FAST results were recorded before review of patient outcome as determined by 1 or more of the following: thoracotomy, laparotomy, pericardial window, cardiologic echocardiography, diagnostic peritoneal lavage, computed tomography, and serial examinations. Results. FAST was undertaken in 32 patients with penetrating anterior chest trauma: 20 (65%) had stab wounds, and 12 (35%) had gunshot wounds. Sensitivity of FAST for cardiac injury (n = 8) in patients with pericardial effusion was 100% (95% confidence interval, 63.1%-100%); specificity was 100% (95% confidence interval, 85.8%-100%). The presence of pericardial effusion determined by FAST correlated with the need for thoracotomy in 7 (87.5%) of 8 patients (95% confidence interval, 47.3%-99.7%). One patient with a pericardial blood clot on cardiologic echocardiography was treated nonsurgically. FAST had 100% sensitivity for intraperitoneal injury (95% confidence interval, 63.1%-100%) in 8 patients with views indicating intraperitoneal fluid but without pericardial effusion, again with no false-positive results, giving a specificity of 100% (95% confidence interval, 85.8%-100%). This prompted necessary laparotomy in all 8. Conclusions. In this series of patients with penetrating anterior chest trauma, the FAST examination was sensitive and specific in the determination of both traumatic pericardial effusion and intraperitoneal fluid indicative of injury, thus effectively guiding emergent surgical decision making.

To determine the correlation between sonographic detection of free fluid in the left upper quadrant and blunt splenic injury.A retrospective review was conducted of all consecutive emergency blunt trauma sonograms obtained at a level I trauma center from January 1995 to January 2001. Data were collected on demographics, free fluid location, and patient outcome. Injuries were determined from computed tomography, diagnostic peritoneal lavage, laparotomy, or a combination thereof.A total of 4320 blunt trauma sonograms were obtained, and 596 patients (14%) had intra-abdominal injuries. The mean age was 33.7 +/- 19.1 years (range, 1-95 years), with 294 (49%) male and 302 (51%) female. There was no statistical difference between age, sex, or mechanism for all subgroups. There were 409 true-positive, 187 false-negative, 88 false-positive, and 3636 true-negative findings. Sensitivity of sonography for detecting all intra-abdominal injuries was 68%, and specificity was 97.6%; sensitivity for detecting isolated splenic injuries was 73.8%. Locations of free fluid in patients with nonsplenic injuries were compared with those in patients with splenic injuries. Isolated left upper quadrant free fluid was significantly associated with splenic injury (odds ratio = 3.0; P = .002), followed by diffuse free fluid (odds ratio = 2.1; P = .005). A subanalysis of isolated splenic injuries also revealed a significant association with left upper quadrant free fluid (odds ratio = 3.1; P = .007) and diffuse free fluid (odds ratio = 2.7; P = .0007).Free fluid in the left upper quadrant is significantly associated with splenic injury. This finding should triage patients more rapidly to computed tomography, angiography, embolization, and laparotomy.

Little is known about the presentation, management, outcome, and recurrence of hydatid cyst perforations. We reviewed the charts of all patients admitted to our emergency service for 7 years to identify patients who were surgically treated for intra-peritoneal hydatid cyst perforations. Twelve hydatid cysts were identified in 7 patients (5 males; median age 22 yr; range 8-67). The perforations occurred spontaneously in 5 patients, and were the result of mild trauma in 2 patients. Diagnostic tools included ultrasound (US, n = 4), computed tomography (CT, n = 3), and diagnostic peritoneal lavage (DPL, n = 1). The cysts were treated with radical (n = 3) or conservative (n = 9) operative techniques. Intra-cavitary and intra-abdominal spaces were washed in 6 and 5 patients, respectively. The median follow-up time was 41 months (range 3-58). Indirect hemagglutination test was positive in 3 patients, but CT confirmed cyst recurrence in only 2 of these patients. Both had had large cysts and had undergone conservative therapy (endocystectomy and external drainage). An intra-abdominal recurrence was observed in a patient whose abdomen had not been washed during surgery. In conclusion, patients with hydatid cyst perforations in our study generally presented with severe abdominal findings. US, CT, and DPL may be helpful for the diagnosis. Recurrence may be related to operative technique, location of the cyst, and abdominal wash during the surgery.

Abdominal paracentesis, the percutaneous removal of abdominal fluid for diagnostic and therapeutic purposes, provides a rapid, easy, and safe method of diagnosing diseases with abdominal effusion. Commonly diagnosed diseases include peritonitis, hemoperitoneum, uroabdomen, and neoplasia. Other indications for abdominal paracentesis include shock without a known apparent cause, undiagnosed disease within the abdominal cavity, suspicion of postoperative gastrointestinal wound dehiscence, blunt or penetrating abdominal injury, and refractory abdominal pain for which a cause cannot be determined. In such cases, simple abdominal paracentesis or four-quadrant paracentesis can be performed and requires minimal equipment. Diagnostic peritoneal lavage is indicated when peritonitis or other effusive disease is suspected, but other techniques have failed to provide a diagnostic sample. Both abdominal paracentesis and diagnostic peritoneal lavage are effective methods for the early detection of disease before overt clinical signs are present.

Clinical approach to a patient with acute abdominal distress involves decision making: whether to take a patient to surgery, or manage the patient medically. A thorough and systematic approach requires the use of diagnostic imaging modalities, including radiology and ultrasonography, performing diagnostic peritoneal lavage or abdominal paracentesis techniques, and bloodwork evaluation, including complete blood count and serum biochemistry profiles. In some cases, the results of diagnostic tests may lead to surgical versus medical management, particularly when a patient fails to respond to medical management alone. In other cases, such as GDV syndrome, penetrating abdominal wounds, pyometra, or uncontrolled abdominal hemorrhage, rapid surgical management is necessary for patient survival. This article describes a systematic approach to a small animal patient with acute abdomen.

Purpose: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Methods: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). Results: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Conclusion: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

Presentation of the dog with acute abdominal pain is common in veterinary practice. The general causes of abdominal pain include: distension of a hollow viscus or organ capsule; ischaemia; traction; and inflammation secondary to a variety of conditions. This chapter considers an approach to the acute abdomen, an approach to the swollen abdomen and surgical management. Quick Reference Guides: FAST scan; Abdominocentesis; Diagnostic peritoneal lavage.

Background: Pelvic fractures may be associated with significant hemorrhage. Although this hemorrhage may emanate from the pelvic vasculature, it may also be secondary to abdominal visceral injury. The purpose of this study was to determine factors associated with pelvic and/or abdominal visceral bleeding in hypotensive patients with pelvic fractures to guide the appropriate therapeutic intervention sequence for these difficult-to-manage patients. Methods: Medical records of all hypotensive (systolic blood pressure ≤ 90 mm Hg) patients with pelvic fractures seen at a Level I trauma center from January 1995 to December 1999 were evaluated. Records were abstracted for age, base deficit, 24-hour blood requirement, hemoperitoneum (positive ultrasound, diagnostic peritoneal lavage, or computed tomographic scan), abdominal hemorrhage discovered at celiotomy, pelvic hemorrhage discovered at angiography, emergency department disposition, Injury Severity Score, and mortality. Pelvic fracture categories were derived by adapting the Young-Burgess pelvic fracture classification scheme. Lateral compression (LC) I and anteroposterior compression (APC) I fractures were characterized as stable fracture patterns (SFPs), and APC II, APC III, LC II, LC III, and vertical shear were characterized as unstable fracture patterns (UFPs). Results: Of 231 hypotensive patients, 38 patients died in the emergency department, leaving 193 surviving initial resuscitation. One hundred seven patients stabilized (group I) and were transferred to the intensive care unit. Eighty-six patients (group II) required ongoing resuscitation and underwent celiotomy and/or angiography in an attempt to manage their hemorrhage. Within group II, in the SFP population, abdominal hemorrhage was responsible for hypotension in 34 of 40 (85%), and 10 patients died (25%). In patients with UFP injury, hemorrhage was predominantly from a pelvic source, as shown by 27 positive angiograms in the 46 patients (59%). Twenty-four of 46 (52%) UFP patients died. In patients with a UFP, 14 had both angiography and celiotomy. Four patients underwent angiography before celiotomy and one of four (mortality, 25%) died. In contrast, 10 patients underwent celiotomy before angiography and 6 of 10 died (mortality, 60%). Conclusion: Patients with signs of ongoing shock with SFP pelvic injury and hemoperitoneum require celiotomy as the initial intervention, as the hemorrhagic focus is predominantly intraperitoneal. In patients with UFP, even in the presence of hemoperitoneum, consideration should be given to angiography before celiotomy.

Aims : The aim of the study was to use the extensive experience of an Australian Level I trauma centre to develop guidelines for diagnosis and management of significant gastrointestinal tract injuries (GITIs). Methods : This was a retrospective study of 74 patients admitted to Westmead Hospital between 1985 and 1996 who had sustained major gastrointestinal tract (GIT) injuries following blunt trauma. The patients were identified from the trauma unit database. Clinical information was retrieved from the database and augmented by a review of the medical records. Results : Motor vehicle accidents were responsible for 55 (92%) admissions. Laparotomy was performed as a result of a positive diagnostic peritoneal lavage in 26 (35.1%) patients, abdominal signs in 20 (27%), diagnostic findings on computed tomography in 19 (25.7%), haemodynamic instability in eight (10.8%) and a positive contrast study in one (1.4%) patient. There was a total of 95 injuries: one gastric (1.1%), eight duodenal (8.4%), 64 small bowel (67.3%), two appendiceal (2.1%), 19 colonic (20%) and one rectal (1.1%). Thirty day mortality was 23% (17 patients). Seven (9.5%) patients died within 24 h of injury, three (4.1%) of which were directly related to the GIT. Ten (13.5%) patients died within 2 weeks of admission, three (4.1%) of which were attributable to the GIT. Thirty day GIT morbidity was 29.7% (22 patients). The development of GIT morbidity was significantly related to a delay to laparotomy of more than 24 h ( P =0.036) and tachycardia on presentation ( P =0.023). Associated injuries, injury severity scores (ISS) and age did not significantly impact on GITI related morbidity and mortality. Discussion : Major GITIs are associated with a high mortality due to the severity and complexity of associated injuries. Morbidity from GITIs correlates to delays in diagnosis and management.

I. STATEMENT OF THE PROBLEM Evaluation of patients who have sustained blunt abdominal trauma (BAT) may pose a significant diagnostic challenge to the most seasoned trauma surgeon. Blunt trauma produces a spectrum of injury from minor, single-system injury to devastating, multisystem trauma. Trauma surgeons must have the ability to detect the presence of intra-abdominal injuries across this entire spectrum. Although a carefully performed physical examination remains the most important method to determine the need for exploratory laparotomy, there is little Level I evidence to support this tenet. In fact, several studies have highlighted the inaccuracies of the physical examination in BAT. The effect of altered level of consciousness as a result of neurologic injury, alcohol, or drugs is another major confounding factor in assessing BAT. Because of the recognized inadequacies of physical examination, trauma surgeons have come to rely on a number of diagnostic adjuncts. Commonly used modalities include diagnostic peritoneal lavage (DPL) and computed tomographic (CT) scanning. Although not available universally, focused abdominal sonography for trauma (FAST) has recently been included in the diagnostic armamentarium. Diagnostic algorithms outlining appropriate use of each of these modalities individually have been established. Several factors influence the selection of diagnostic testing: type of hospital (i.e., trauma center vs. “nontrauma” hospital); access to a particular technology at the surgeon’s institution; and the surgeon’s individual experience with a given diagnostic modality. As facilities evolve, technologies mature, and surgeons gain new experience, it is important that any diagnostic strategy constructed be dynamic. The primary purpose of this study was to develop an evidence-based, systematic diagnostic approach to BAT using the three major diagnostic modalities: DPL, CT scanning, and FAST. This diagnostic regimen would be designed such that it could be reasonably applied by all general surgeons performing an initial evaluation of BAT.

Upon the treatment of abdominal stab wounds several modalities appear and may confuse the physician which one to prefer. The physician may utilize several diagnostic methods such as: computerized tomography, ultrasonography, sinography, local wound exploration, diagnostic peritoneal lavage, laparoscopy and laparotomy. Main controversial issues are: routine exploration versus selective approach, the timing for exploration of the abdomen and laparoscopy versus thoracoscopy for stable patients with insignificant injuries. Initial evaluation of the patient is universal and is the same as the general approach to the trauma victim. This review summarizes and compares several studies and techniques on this topic. The treatment of stable patients with insignificant stab injuries of the abdomen remains controversial. Management has evolved from prompt surgical exploration, towards more selective approaches (1–4). Knives and sharp objects or instruments mainly cause stab wounds. Almost one-third of such injuries never penetrate the peritoneal cavity, and only 50 % of those that penetrate require surgery.