Clinical importance of intraperitoneal fluid in patients with blunt intra-abdominal injury

The purpose of this study was to determine the prevalence of intraperitoneal fluid (IF) in blunt trauma patients with intra-abdominal injuries, to determine the rate of exploratory laparotomy in patients with and without IF, and to identify the location of this IF. We retrospectively reviewed the records of 604 patients with intra-abdominal injuries after blunt trauma who were admitted to a level 1 trauma center over a 42-month period. Patients were considered to have intra-abdominal injuries if an injury to the spleen, liver, urinary tract, pancreas, adrenal glands, gallbladder, or gastrointestinal tract was identified on abdominal computed tomography (CT) or at exploratory laparotomy. Patients were considered to have IF if fluid was identified on abdominal CT or during exploratory laparotomy. In patients undergoing abdominal CT or abdominal ultrasound (US), the specific location of the IF was identified. Four hundred forty-three (73%, 95% confidence interval [CI] 69 - 77%) of the 604 patients with intra-abdominal injuries had IF. Patients with IF had an increased risk of laparotomy (344/443 [78%] v 44/161 [27%], odds ratio = 9.2, 95% CI 6.1-13.9). Of the 539 patients undergoing abdominal CT or abdominal US, IF was identified in 389 (72%) and was visualized in the following locations: 258 of 389 (66%) in Morison's pouch, 216 of 389 (56%) in the left upper quadrant, 187 of 389 (48%) in the pelvis, and 139 of 390 (36%) in paracolic gutters. Three patients with IF visualized solely in the paracolic gutters underwent laparotomy. The majority of patients with intra-abdominal injuries have IF, and these patients are more likely to undergo laparotomy. Morison's pouch is the most common location for IF to be detected with radiologic imaging. However, visualization of the paracolic gutters with abdominal US may detect IF in patients with intra-abdominal injuries that would otherwise not be detected by US.     

Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam

The multiple-view focused assessment with sonography for trauma (FAST) exam is an integral tool in the assessment of blunt abdominal trauma. A prospective observational study was performed to compute the average minimum volume of detectable intraperitoneal fluid with the pelvic views of the FAST exam. All adult patients from October 1999 to May 2001, who presented to the ED with blunt abdominal trauma and underwent a clinically indicated diagnostic peritoneal lavage (DPL), were candidates for admission to the pelvic ultrasound study. In the supine position, patients were administered lavage fluid in 100 cc increments until the examiner detected the fluid on ultrasound. An independent reviewer also examined the hard-copy ultrasound images for fluid detection. Patients were excluded if they had (1) a positive DPL for hemoperitoneum (defined as 10 cc of gross blood or >100,000 red blood cells/mL), (2) a positive initial ultrasound for free fluid, or (3) lacked sufficient hard-copy ultrasound images. The mean minimal volume of fluid needed for pelvic ultrasound detection by the examiner and reviewer was 157 and 129 cc (n = 7), respectively. The median quantity of fluid for ultrasound detection by both the examiner and reviewer was 100 cc. The pelvic views of the FAST exam identified a significantly smaller quantity of intraperitoneal fluid than previous studies of the right upper quadrant single-view exam.     

Free Fluid in Morison's Pouch on Bedside Ultrasound Predicts Need for Operative Intervention in Suspected Ectopic Pregnancy

Background Ectopic pregnancies are frequently present in women who present to the emergency department with pregnancy and abdominal pain or bleeding, a subset of whom may require operative intervention.
Objectives To prospectively determine if emergency physician (EP)-performed transabdominal pelvic ultrasonography (US) with determination of free abdominal fluid in the hepatorenal space predicted the need for operative intervention.
Methods Patients who were suspected to have an ectopic pregnancy were prospectively enrolled over a ten-month period. An EP-performed bedside transabdominal pelvic US that included a view of the hepatorenal space (Morison's pouch) for free fluid. The EP US was classified as intrauterine pregnancy (IUP) or no definitive IUP, with Morison's pouch classified as positive or negative. The majority of patients had a subsequent transvaginal pelvic US performed by the Department of Radiology. Patients were followed up for radiology results, need for operative intervention, and ultimate outcome of the pregnancy.
Results There were 242 patients enrolled, with an average time to complete the EP US of 4 minutes and 27 seconds. There were 28 ectopic pregnancies diagnosed (11.6%), of which 18 patients underwent operative intervention. Free fluid in Morison's pouch was identified in ten patients, nine of whom underwent operative intervention, yielding a positive likelihood ratio of 112 (95% confidence interval = 15 to 831) for patients with suspected ectopic pregnancy who required operative intervention.
Conclusions Free intraperitoneal fluid found in Morison's pouch in patients with suspected ectopic pregnancy may be rapidly identified at the bedside by EP-performed US and predicts the need for operative intervention.     

Operative versus nonoperative management of blunt abdominal trauma: Role of ultrasound-measured intraperitoneal fluid levels.

This study's objective was to analyze whether the quantity of free intraperitoneal fluid on ultrasonography, alone or in combination with unstable vital signs, is sensitive in determining the need for laparotomy in patients presenting with blunt trauma. Adult patients who presented with blunt abdominal trauma to 2 level I trauma centers were enrolled. Combined intraperitoneal fluid levels (anechoic stripe) of 5 intraperitoneal areas were measured and defined as small (< 1.0 cm), moderate (> 1.0 cm, < 3.0 cm), or large (> 3.0 cm). Unstable vital signs were defined as pulse > 100 bpm or systolic blood pressure < 90 mmHg. Exploratory laparotomy or computed tomography scan confirmed hemoperitoneum. Of 270 patients entered into the study, ultrasound detected free intraperitoneal fluid in 33 patients. Of the 18 patients with a large fluid accumulation, 16 underwent exploratory laparotomy (89% sensitivity), and all 8 patients with unstable vital signs underwent exploratory laparotomy (100% sensitivity). Of the 10 patients with a moderate fluid accumulation, 6 underwent exploratory laparotomy (60% sensitivity), and 4 of the 6 patients with unstable vital signs underwent exploratory laparotomy (67% sensitivity). A large intraperitoneal fluid accumulation on ultrasonography in combination with unstable vital signs, is sensitive for determining the need for exploratory laparotomy in patients presenting with blunt trauma.     

Ultrasound for the detection of intraperitoneal fluid: the role of Trendelenburg positioning

A prospective, observational study was performed to evaluate the role of Trendelenburg positioning in improving the sensitivity of the single-view ultrasound examination. Hemodynamically stable patients undergoing diagnostic peritoneal lavage (DPL) were assigned to one of two groups: supine or 5 degrees of Trendelenburg positioning. Baseline right intercostal oblique images of Morison's pouch were obtained followed by additional images for each 100 cc of lavage fluid instilled into the peritoneal cavity. The initial volume of fluid required to identify an anechoic stripe was recorded for each patient. Patients were excluded if they had (1) a positive DPL for hemoperitoneum (defined as 10 cc of gross blood or >100,000 red blood cells/microL), (2) positive baseline ultrasound study, (3) hemodynamic instability, or (4) lack of documentation (ie, baseline/subsequent hard copy images were not obtained or inadequately demonstrated anechoic stripe). The mean quantity of fluid for visualization of the anechoic stripe was 443.8 cc in the Trendelenburg group (n = 8) and 668.2 cc in the supine group (n = 11). These means were statistically different (P < .05, t test). The median amount of fluid needed for visualization of the anechoic stripe was 400 cc and 700 cc for the Trendelenburg and supine groups, respectively.     

Ultrasound detection of free intraperitoneal fluid associated with hepatic and splenic injuries

BACKGROUND: The objective of this study was to compare the sensitivity and specificity of 5 abdominal views for detecting free intraperitoneal fluid in trauma patients later diagnosed with hepatic or splenic injuries. METHODS: This retrospective study conducted over a 17-month period enrolled patients with trauma. A Focused Abdominal Sonogram for Trauma (FAST) examination was done using 5 abdominal views. Exploratory laparotomy or computed tomography (CT) confirmed the presence of intraperitoneal fluid and associated injuries. The sensitivity and specificity were determined. RESULTS: Of the 245 study patients, 29 had injuries to the liver or spleen or both. The 5-view FAST examination's sensitivity for detecting free intraperitoneal fluid associated with hepatic, splenic, or combined injuries was 77%, 90%, and 100%, respectively. The sensitivity of the single Morison's pouch view in detecting free intraperitoneal fluid associated with hepatic, splenic, or combined injuries was 38%, 20%, and 67%, respectively. CONCLUSION: For identifying free intraperitoneal fluid associated with hepatic or splenic injuries, no single view of the FAST examination could match the sensitivity provided by the 5-view technique.     

Emergency Physician Use of Ultrasonography in Blunt Abdominal Trauma

Objective: To evaluate the diagnostic utility of abdominal diagnostic ultrasonography (DUS) performed by emergency physicians for intraperitoneal fluid caused by blunt abdominal trauma (BAT). Methods: The design was a prospective, blind, observational study. During a 15-month period, a convenience sample of patients presenting to the ED with BAT necessitating CT scan of the abdomen, diagnostic peritoneal lavage (DPL), or laparotomy was studied. Scans were performed by an emergency medicine (EM) attending, or a resident supervised by an attending, using a real-time sector ultrasound scanner with a 3.5-MHz probe. Training in DUS included a 1-hour didactic session and 1 hour of practice on human volunteers. Free intraperitoneal fluid was defined as an anechoic stripe in the hepatorenal, bladder-rectal, or splenorenal space, and constituted a positive DUS study. Free intraperitoneal fluid detected on abdominal CT scan, DPL, and/or laparotomy was the criterion standard. Results: Of 110 patients scanned, 13 were excluded secondary to technical difficulty or lack of diagnostic follow-up modalities. Of the remaining 97 patients, there were 24 females and 73 males, ranging from ages 2 to 78 years. DUS detected intraperitoneal fluid in 21 subjects, including 3 false positives. There were 6 false-negative DUS examinations. DUS had a sensitivity of 75% (95% CI 53–90%), a specificity 96% of (95% CI 89–99%), and an accuracy of 91% (95% CI 83–96%). No false-positive or false-negative DUS study occurred after the first 67 cases. The mean interval for a DUS scan was 4.9 ± 2.9 minutes, ranging from 0.5 to 16 minutes, and the mean intervals were not different between the positive and the negative studies. The accuracies of DUS were similar in the pediatric patients, 97% (95% CI 83–100%), and in the adults, 88% (95% CI 78–95%). The hepatorenal view provided the highest sensitivity as well as the least number of uninterpretable scans of the 3 DUS views. Conclusion: Emergency physicians with minimal training can use DUS with fair sensitivity and good specificity and accuracy to detect free intraperitoneal fluid in both pediatric and adult BAT victims. The hepatorenal view provides the highest sensitivity for intraperitoneal fluid, although the 3-view series (with hepatorenal, bladder-rectal, and splenorenal spaces) can typically be performed within 5 minutes and may increase the specificity and accuracy.     

FAST (Focused Assessment With Sonography in Trauma) Accurate for Cardiac and Intraperitoneal Injury in Penetrating Anterior Chest Trauma

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.     

Tissue Harmonic Imaging Improves Organ Visualization in Trauma Ultrasound When Compared with Standard Ultrasound Mode

The focused abdominal sonography for trauma (FAST) examination is complicated by brightly lit trauma bays, limited time, and body habitus. Recently, new ultrasound (US) technology has become available that improves organ visualization in abdominal scans. OBJECTIVE: The hypothesis was that a new US mode, tissue harmonic (TH) imaging, improves visualization of critical organ relationships in the FAST examination by making use of previously unused frequencies. The authors performed a blind, prospective observational study to compare the images obtained in typical FAST views with those obtained in standard US and TH modes. METHODS: Blunt trauma patients presenting to a level I trauma center between April and September 2000 were enrolled on a convenience basis. Typical FAST views were obtained in standard and TH modes. The emergency ultrasonographer (EU) switched between modes for each view, optimizing the gain each time. Multiple digital still images were made with all indications of the mode used disguised. For each view on a patient, the best image in each mode was selected in a blinded fashion. Three experienced EUs, blinded to the mode used, rated each image pair for resolution, detail, and total image quality as previously defined on a ten-point Likert scale, 10 being the best for each category. Wilcoxon signed-ranks test, 95% confidence intervals (95% CIs), and interobserver correlation were calculated. RESULTS: A total of 76 image groups (39 of Morison's pouch, 20 splenorenal, and 17 bladder) from 52 patients were rated. Tissue harmonics produced improved resolution, detail, and quality when compared with the standard US mode, with median scores of 6.7 vs. 6.0, 6.7 vs. 6.0, and 6.3 vs. 6.0, respectively. The differences of 0.7 (95% CI = 0.4 to 0.93), 0.7 (95% CI = 0.4 to 0.93), and 0.33 (95% CI = 0.17 to 0.67) were statistically significant, with p = 0.0001, 0.0001, and 0.0003, respectively. There was good interobserver agreement (kappa = 0.74; 95% CI = 0.68 to 0.79). CONCLUSIONS: Tissue harmonics produced FAST images higher in detail, resolution, and total image quality than standard-mode US images.     

Is Closed Diagnostic Peritoneal Lavage Contraindicated in Patients with Previous Abdominal Surgery?

Objective: To compare the accuracies and complication rates of diagnostic peritoneal lavage (DPL) in trauma patients with and without previous abdominal surgery. Methods: A retrospective review of DPL accuracy and complication rate was performed using all ED trauma patients who underwent DPL during 1993 as identified by the trauma registry. Care was provided at a Level-1 trauma center, a 1,100-bed, central-city teaching hospital with an annual ED census of 84,000. Records were reviewed for a history of previous surgery, DPL results, complications, mechanism of injury, and location of abdominal scars. DPL was performed using the Seldinger technique with a standard Arrow Diagnostic Peritoneal Lavage Kit using an 8-Fr catheter. Rates for patient groups with and without previous abdominal surgery were compared using Fisher's exact test. A “misclassified” DPL was defined as either a positive DPL with negative laparotomy or a negative DPL with subsequent need for laparotomy. “Complications” were defined as iatrogenic injury during the procedure or inability to obtain return of fluid during the lavage. Results: A total of 372 DPLs were performed; 42 in patients with previous surgery and 330 in patients without prior surgery. The groups were similar with respect to proportion with blunt trauma (95% vs 97%), positive DPL (19% vs 19%), misclassified rate (2.4% vs 1.8%), and complication rate (2.4% vs 0.9%); no significant difference was found between groups. The previous abdominal surgeries were appendectomy (n = 20), tubal ligation (n = 5), abdominal hysterectomy (n = 4), cholecystectomy (nonlaparoscopic) (n = 4), pyloric stenosis (n = 1), uterine prolapse (n = 1), undescended testis (n = 1), partial gastrectomy (n = 1), and unknown (n = 5). The analysis had a 90% power of detecting a 10% difference between the 2 groups. Conclusion: The complication rate and accuracy of closed DPL in patients with previous abdominal surgery were similar to those for DPL performed in patients without previous abdominal surgery.     

Emergency Department Right Upper Quadrant Ultrasound Is Associated with a Reduced Time to Diagnosis and Treatment of Ruptured Ectopic Pregnancies

OBJECTIVE: To determine whether the time to diagnosis and treatment of patients with ruptured ectopic pregnancy is significantly less for patients who had emergency department (ED) right upper quadrant (RUQ) ultrasound (US) compared with those who had US in the radiology department. METHODS: The authors conducted a retrospective review of eligible patients presenting to an urban ED between January 1990 and December 1998. Patients were included in the study if they were seen in the ED, had a discharge diagnosis of ruptured ectopic pregnancy, were brought immediately to the operating room after a definitive diagnosis of ectopic pregnancy rupture was made, and had more than 400 mL of intraperitoneal blood found at the time of surgery. The ED, hospital, radiology, and operative records were reviewed to determine presenting vital signs, intraperitoneal blood loss, time to diagnosis, time to treatment, and type of US performed. RESULTS: There were 37 patients enrolled; 16 received ED RUQ US (group I) and 21 had a formal US in radiology (group II). The ages, pulses, systolic blood pressures, and volumes of hemoperitoneum were similar between the two groups. The average time to diagnosis from ED arrival was 58 minutes for group I (SD = 57; 95% CI = 28 to 87) and 197 minutes for group II (SD = 82; 95% CI = 162 to 232) (p < or = 0.0001). The average time to operative treatment was 111 minutes (group I) (SD = 86; 95% CI = 69 to 153) and 322 minutes (group II) (SD = 107; 95% CI = 270 to 364) (p < or = 0.0001), respectively. CONCLUSIONS: Patients with ruptured ectopic pregnancy, who were selected to have RUQ US performed in the ED by emergency physicians, had an average decrease in time to diagnosis of two and a quarter hours, and an average decrease in time to treatment of three and a half hours, compared with those having a formal pelvic US in the radiology department. Further prospective investigation is needed to determine whether ED RUQ US can safely expedite care of patients with suspected ectopic pregnancy.     

Thoracic point-of-care ultrasound is an accurate diagnostic modality for clinically significant traumatic pneumothorax

Objective

There are conflicting data regarding the accuracy of thoracic point-of-care ultrasound (POCUS) in detecting traumatic pneumothorax (PTX). The purpose of our study was to determine the accuracy of thoracic POCUS performed by emergency physicians for the detection of clinically significant PTX in blunt and penetrating trauma patients.

Methods

We conducted a retrospective institutional review board–approved study of trauma patients 15 years or older presenting to our urban Level I academic trauma center from December 2021 to June 2022. All study patients were imaged with single-view chest radiography (CXR) and thoracic POCUS. The presence or absence of PTX was determined by multidetector computed tomography (CT) or CXR and ultrasound (US) with tube thoracostomy placement.

Results

A total of 846 patients were included, with 803 (95%) sustaining blunt trauma. POCUS identified 13/15 clinically significant PTXs (defined as ≥35 mm of pleural separation on a blinded overread or placement of a tube thoracostomy prior to CT) with a sensitivity of 87% (95% confidence interval [CI] 58–97), specificity of 100% (95% CI 99–100), positive predictive value of 81% (95% CI 54%–95%), and negative predictive value of 100% (95% CI 99%–100%). The positive likelihood ratio was 484 and the negative likelihood ratio was 0.1. CXR identified eight (53%) clinically significant PTXs, with a sensitivity of 53% (95% CI 27%–78%) and a specificity of 100%, when correlated with the CT. The most common reason for a missed PTX identified on expert-blinded overread was failure to recognize a lung point sign that was present on US.

Conclusions

Thoracic POCUS accurately identifies the majority of clinically significant PTXs in both blunt and penetrating trauma patients. Common themes for false-negative thoracic US in the expert-blinded overread process identified key gaps in training to inspire US education and medical education research.     

Negative findings on laparotomy for trauma

A retrospective review of 428 exploratory laparotomies for trauma included 199 patients with blunt trauma, 96 with gunshot wounds, and 133 with stab wounds. In the blunt trauma group, 16 laparotomies (8%) showed no injury and 24 (12%) showed that no repair was needed. Physical examination (68 cases) and diagnostic peritoneal lavage (DPL) (121) were used as the primary indication for laparotomy. In the stab wound group, there was a high incidence of negative or nontherapeutic operation when proximity to the abdomen or deep fascial penetration was the indication for operation. Patients sustaining gunshot wounds had a 27% incidence of negative laparotomy, with proximity being the primary indication for operation. Two deaths in the negative laparotomy group occurred due to associated injuries. Complications were minimal. DPL has decreased the number of negative operations but has increased the nontherapeutic operations. The high incidence of negative laparotomy for stab wounds shows the need for selective management rather than routine exploration.     

A Prospective Comparison of Supine Chest Radiography and Bedside Ultrasound for the Diagnosis of Traumatic Pneumothorax

Background: Supine anteroposterior (AP) chest radiography may not detect the presence of a small or medium pneumothorax (PTX) in trauma patients. Objectives: To compare the sensitivity and specificity of bedside ultrasound (US) in the emergency department (ED) with supine portable AP chest radiography for the detection of PTX in trauma patients, and to determine whether US can grade the size of the PTX. Methods: This was a prospective, single‐blinded study with convenience sampling, based on researcher availability, of blunt trauma patients at a Level 1 trauma center with an annual census of 75,000 patients. Enrollment criteria were adult trauma patients receiving computed tomography (CT) of the abdomen and pelvis (which includes lung windows at the authors' institution). Patients in whom the examination could not be completed were excluded. During the initial evaluation, attending emergency physicians performed bedside trauma US examinations to determine the presence of a sliding lung sign to rule out PTX. Portable, supine AP chest radiographs were evaluated by an attending trauma physician, blinded to the results of the thoracic US. The CT results (used as the criterion standard), or air release on chest tube placement, were compared with US and chest radiograph findings. Sensitivities and specificities with 95% confidence intervals (95% CIs) were calculated for US and AP chest radiography for the detection of PTX, and Spearman's rank correlation was used to evaluate for the ability of US to predict the size of the PTX on CT. Results: A total of 176 patients were enrolled in the study over an eight‐month period. Twelve patients had a chest tube placed prior to CT. Pneumothorax was detected in 53 (30%) patients by US, and 40 (23%) by chest radiography. There were 53 (30%) true positives by CT or on chest tube placement. The sensitivity for chest radiography was 75.5% (95% CI = 61.7% to 86.2%) and the specificity was 100% (95% CI = 97.1% to 100%). The sensitivity for US was 98.1% (95% CI = 89.9% to 99.9%) and the specificity was 99.2% (95% CI = 95.6% to 99.9%). The positive likelihood ratio for a PTX was 121. Spearman's rank correlation showed at ρ of 0.82. Conclusions: With CT as the criterion standard, US is more sensitive than flat AP chest radiography in the diagnosis of traumatic PTX. Furthermore, US allowed sonologists to differentiate between small, medium, and large PTXs with good agreement with CT results.     

Patterns of fluid accumulation in splenic trauma: Demonstration by CT

Detection of hemoperitoneum in splenic trauma is as important as detection of the visceral injury itself. Observation of a consistent spectrum of fluid accumulation in patients with splenic trauma prompted us to investigate the patterns in more detail. Twenty-three computed tomographic (CT) scans in 20 patients were evaluated with respect to presence of fluid collections in various peritoneal and retroperitoneal compartments. These were correlated with severity of injury and operative and pathologic findings. Hemoperitoneum was detected in the pelvis (65%), paracolic gutters (52%), left subphrenic space (48%), perihepatic space (48%), Morison's pouch (17%) and in the lesser sac (9%). In addition to free fluid, pleural fluid (39%) and retroperitoneal hematoma in the left anterior pararenal space (13%) were also encountered. These ancillary findings may help to substantiate the diagnosis of splenic trauma in equivocal cases, particularly when the spleen itself is obscured by artifacts. Early detection may reduce mortality and morbidity associated with splenic trauma.     

Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage

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.     

The fast is positive,now what? Derivation of a clinical decision rule to determine the need for therapeutic laparotomy in adults with blunt torso trauma and a positive trauma ultrasound

INTRODUCTION: The object of this study was to derive a clinical decision rule for therapeutic laparotomy among adult blunt trauma patients with a positive abdominal ultrasound for trauma (FAST) examination. METHODS: We retrospectively reviewed the trauma registry and medical records of all critical trauma patients who underwent a FAST examination in the emergency department (ED) in a university Level I trauma center over a 3-year period. Blunt trauma patients aged >16 years who had a positive FAST examination (defined as the presence of intraperitoneal fluid) were eligible. We selected seven clinical and ultrasound variables available during ED resuscitation for analysis: age, presence of an episode of hypotension (systolic blood pressure <90 torr in the ED), presence of abdominal tenderness, chest injury, pelvic fracture, femur fracture, and FAST fluid location (right upper quadrant [RUQ] only; RUQ plus other location; other location only). The primary outcome variable was whether a laparotomy was performed and whether this laparotomy was needed to provide the definitive surgical intervention ("therapeutic laparotomy"). We analyzed the variables using binary recursive partitioning analysis to create a decision rule. RESULTS: There were 2336 FAST examinations performed during the study period, resulting in 230 (9.8%) positive examinations in patients meeting inclusion criteria. There were 135 patients who had therapeutic laparotomies and 95 who did not need laparotomy. The groups were similar in baseline characteristics. In the recursive partitioning analysis, the first node in the decision tree was the presence of fluid in the RUQ. Of the 144 patients with RUQ fluid, 105 (73%, 95% confidence interval [CI] 64%-80%) required therapeutic laparotomy. Of the 86 patients without RUQ fluid, 30 (35%, 95% CI 25%-46%) nevertheless required therapeutic laparotomies, and the variables blood pressure, femur fracture, abdominal tenderness, and age further divided these patient into high- and low-risk groups. Of the 12 patients without RUQ fluid who had normal blood pressures, no femur fractures, no abdominal tenderness, and were aged 60 years and younger, none (95% CI 0%-22%) required therapeutic laparotomy. In conclusion, given a positive FAST examination, the presence of fluid in the RUQ is an important predictor of the need for therapeutic laparotomy. CONCLUSION: In the absence of fluid in the RUQ, there are other clinical variables that may allow for the development of a clinical decision rule regarding the need for therapeutic laparotomy.     

Diagnosis of bowel and mesenteric injuries in blunt abdominal trauma: a prospective study

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.     

Diagnostic peritoneal lavage in evaluation of acute abdominal disease.

Diagnostic peritoneal lavage (DPL) is an established procedure in evaluation of trauma victims but is less well established for use in patients suspected of having acute intra-abdominal disease. Twenty-six seriously ill patients at our institution who had DPL for acute intra-abdominal disease form the basis of this report. Use of DPL indicated sepsis in ten patients; in seven of the ten, findings were confirmed at celiotomy or autopsy. Only one of the ten survived without laparotomy or confirmatory necropsy indicating the result of DPL had been false-positive. Sepsis was not indicated by DPL in 16 patients. Fourteen patients appeared to have true-negative results confirmed by operation (three patients), autopsy (four patients), or survival longer than two weeks (seven patients). Complications occurred in one patient whose DPL showed sepsis. Two patients with negative results of DPL died within two weeks of examination without confirmatory operation or autopsy and could not be evaluated. We therefore, consider the overall diagnostic accuracy in our patient group to be 95%. We recommend the use of DPL in patients suspected of an acute intra-abdominal disease process who are unable to undergo other evaluation for reasons such as critical illness.     

Free echogenic pelvic fluid: correlation with hemoperitoneum.

Echogenic fluid is an important extrauterine finding of ectopic pregnancy. The purpose of this study was to determine how accurately echogenic fluid correlates with hemoperitoneum at surgery. Transvaginal sonography was performed in 831 consecutive patients referred to rule out ectopic pregnancy over a 36 month period. Scans were retrospectively evaluated for the presence or absence and echogenicity of free pelvic fluid. Subsequently, 185 patients had a laparotomy or laparoscopy and had documentation of the presence or absence of hemoperitoneum. On transvaginal sonography 125 patients had echogenic fluid, 30 patients had anechoic fluid, and 30 patients had no fluid. Of the 125 patients with echogenic fluid, 122 (98%) patients had hemoperitoneum; none of the patients with anechoic fluid or no detected fluid had hemoperitoneum (0%). Echogenic fluid had a sensitivity of 100%, specificity of 95%, positive predictive value of 98%, and an accuracy of 98% for detecting hemoperitoneum. This study demonstrates that echogenic fluid detected by transvaginal ultrasonography accurately correlates with hemoperitoneum detected at surgery in patients with suspected ectopic pregnancy.