Controversies in Controversies in Abdominal TraumaAbdominal Trauma

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

1

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