abdominal trauma
TRANSCRIPT
Controversies in Controversies in Abdominal TraumaAbdominal Trauma
BY BY PROF/GOUDA PROF/GOUDA
ELLABBANELLABBAN
Controversies in Controversies in Emergency UltrasoundEmergency Ultrasound
Should EM physicians perform Should EM physicians perform ultrasound?ultrasound?
How should this work be funded?How should this work be funded? What new areas of use should be What new areas of use should be
explored?explored?
It isn’t rocket It isn’t rocket science ...science ...
RationaleRationale
24x7 access24x7 access Shorten the time to intervention in Shorten the time to intervention in
life threatslife threats Decrease the length of stay in the Decrease the length of stay in the
EDED Decrease the cost of care and Decrease the cost of care and
improve resource utilizationimprove resource utilization Improve diagnostic accuracyImprove diagnostic accuracy
Abdominal Trauma UltrasoundAbdominal Trauma UltrasoundAccuracyAccuracy
Sensitivity: 80% - 100%Sensitivity: 80% - 100% Specificity: 85% - 98%Specificity: 85% - 98% Intraperitoneal fluid: Intraperitoneal fluid:
– 82-98% sensitivity 82-98% sensitivity – 88-100% specificity88-100% specificity– Prospective trials: sensitivity 87-98%, specificity 99-Prospective trials: sensitivity 87-98%, specificity 99-
100% (Pearl, 1996) 100% (Pearl, 1996) Intraperitoneal injury:Intraperitoneal injury:
– 69-96% sensitivity69-96% sensitivity– 95-100% specificity95-100% specificity
Sensitivity/Volume of FluidSensitivity/Volume of FluidBranney, 1995Branney, 1995
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
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0 100 200 300 400 500 600 700 800 900 1000
Abdominal Trauma UltrasoundAbdominal Trauma UltrasoundLearning CurvesLearning Curves
12 non-radiologist scanners12 non-radiologist scanners 8 hours of didactics, 10 supervised exams8 hours of didactics, 10 supervised exams 50 practice exams on patients50 practice exams on patients Free Fluid: Sensitivity 68%; Specificity 98%Free Fluid: Sensitivity 68%; Specificity 98% Error rate from 17% to 5% after only 10 Error rate from 17% to 5% after only 10
examsexams 9.8% indeterminate scan rate9.8% indeterminate scan rate
(Shackford, et al)(Shackford, et al)
Abdominal Trauma UltrasoundAbdominal Trauma UltrasoundTraining RequiredTraining Required
No definite standardNo definite standard Didactic: 4-8 hours of trainingDidactic: 4-8 hours of training Supervised exams: 15Supervised exams: 15 Experiential: 20-50 examsExperiential: 20-50 exams
Is there still a place Is there still a place for DPL?for DPL?
Diagnostic Peritoneal Diagnostic Peritoneal LavageLavage
Component 1: Aspiration of 10cc of Component 1: Aspiration of 10cc of bloodblood– Indication for emergent laparotomy Indication for emergent laparotomy IFIF
hemodynamically unstablehemodynamically unstable Component 2: Lavage Component 2: Lavage
– >100,000 RBCs>100,000 RBCs– >20 IU Amylase (Alk Phos)>20 IU Amylase (Alk Phos)– >500 WBC>500 WBC– Bile, Gram StainBile, Gram Stain
Diagnostic Peritoneal Diagnostic Peritoneal LavageLavageProblemsProblems Non invasive management of Non invasive management of
abdominal traumaabdominal trauma Complications: 0.3%Complications: 0.3% More time consuming than More time consuming than
ultrasoundultrasound Less information than CT scanLess information than CT scan
Diagnostic Peritoneal Diagnostic Peritoneal LavageLavage
Sharp decrease in useSharp decrease in use– Increased availability of ultrasoundIncreased availability of ultrasound– Helical CT scans: faster and betterHelical CT scans: faster and better– Non invasive always winsNon invasive always wins
Diagnostic Peritoneal Diagnostic Peritoneal LavageLavageIndicationsIndications Hypotensive patient with a Hypotensive patient with a
negative FAST examnegative FAST exam Stab wound to the abdomenStab wound to the abdomen Gunshot wound to the abdomenGunshot wound to the abdomen
– DPL vs. LaparotomyDPL vs. Laparotomy
Prioritization in Prioritization in traumatrauma
Head InjuryHead Injury HypovolemiaHypovolemia
– Chest traumaChest trauma– Intraperitoneal Intraperitoneal
(Spleen, liver)(Spleen, liver)– Retroperitoneal Retroperitoneal
(Pelvis, renal)(Pelvis, renal) Occult lethal injuriesOccult lethal injuries
– Traumatic aortic Traumatic aortic injuryinjury
Head CTHead CT Chest x-rayChest x-ray Ultrasound/DPLUltrasound/DPL
Abd CTAbd CT
Chest CTChest CT Transesophageal Transesophageal
echoecho ArteriographyArteriography
Prioritization in Prioritization in traumatraumaTwo ContendersTwo Contenders Head InjuryHead Injury
– Most CNS deaths from head injury Most CNS deaths from head injury are due to a delay in decompressionare due to a delay in decompression
Intraperitoneal InjuryIntraperitoneal Injury– Injuries are amenable to therapyInjuries are amenable to therapy– Preventing prolonged hypovolemic Preventing prolonged hypovolemic
shock is critical to outcomeshock is critical to outcome
Prioritization in Prioritization in traumatrauma
Unstable with positive ultrasound Unstable with positive ultrasound Emergent Laparotmy + ICP Emergent Laparotmy + ICP boltbolt
Unstable with negative ultrasound Unstable with negative ultrasound DPL DPL if DPL if DPL ++LaparotomyLaparotomy
Stable with positive ultrasound Stable with positive ultrasound or DPLor DPL Head CT & Abdominal CT Head CT & Abdominal CT