Controversies in Abdominal Trauma

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Controversies in Abdominal Trauma
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Controversies in Emergency Ultrasound

• Should EM physicians perform ultrasound?
• How should this work be funded?
• What new areas of use should be explored?

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FAST
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It isnt rocket science ...
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Rationale

• 24x7 access
• Shorten the time to intervention in life threats
• Decrease the length of stay in the ED
• Decrease the cost of care and improve resource
  utilization
• Improve diagnostic accuracy

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Abdominal Trauma UltrasoundAccuracy

• Sensitivity 80 - 100
• Specificity 85 - 98
• Intraperitoneal fluid
• 82-98 sensitivity
• 88-100 specificity
• Prospective trials sensitivity 87-98,
  specificity 99-100 (Pearl, 1996)
• Intraperitoneal injury
• 69-96 sensitivity
• 95-100 specificity

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Sensitivity/Volume of FluidBranney, 1995
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Abdominal Trauma UltrasoundLearning Curves

• 12 non-radiologist scanners
• 8 hours of didactics, 10 supervised exams
• 50 practice exams on patients
• Free Fluid Sensitivity 68 Specificity 98
• Error rate from 17 to 5 after only 10 exams
• 9.8 indeterminate scan rate
• (Shackford, et al)

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Abdominal Trauma UltrasoundTraining Required

• No definite standard
• Didactic 4-8 hours of training
• Supervised exams 15
• Experiential 20-50 exams

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Is there still a place for DPL?
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Diagnostic Peritoneal Lavage

• Component 1 Aspiration of 10cc of blood
• Indication for emergent laparotomy IF
  hemodynamically unstable
• Component 2 Lavage
• gt100,000 RBCs
• gt20 IU Amylase (Alk Phos)
• gt500 WBC
• Bile, Gram Stain

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Diagnostic Peritoneal LavageProblems

• Non invasive management of abdominal trauma
• Complications 0.3
• More time consuming than ultrasound
• Less information than CT scan

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Diagnostic Peritoneal Lavage

• Sharp decrease in use
• Increased availability of ultrasound
• Helical CT scans faster and better
• Non invasive always wins

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Diagnostic Peritoneal LavageIndications

• Hypotensive patient with a negative FAST exam
• Stab wound to the abdomen
• Gunshot wound to the abdomen
• DPL vs. Laparotomy

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Prioritization in trauma

• Head Injury
• Hypovolemia
• Chest trauma
• Intraperitoneal (Spleen, liver)
• Retroperitoneal (Pelvis, renal)
• Occult lethal injuries
• Traumatic aortic injury

• Head CT
• Chest x-ray
• Ultrasound/DPL
• Abd CT
• Chest CT
• Transesophageal echo
• Arteriography

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Prioritization in traumaTwo Contenders

• Head Injury
• Most CNS deaths from head injury are due to a
  delay in decompression
• Intraperitoneal Injury
• Injuries are amenable to therapy
• Preventing prolonged hypovolemic shock is
  critical to outcome

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Prioritization in trauma

• Unstable with positive ultrasound ? Emergent
  Laparotmy ICP bolt
• Unstable with negative ultrasound ? DPL ?
  if DPL ?Laparotomy
• Stable with positive ultrasound or DPL? Head CT
  Abdominal CT