Imaging in Blunt Abdominal Trauma

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Imaging in Blunt Abdominal Trauma

• Stephen J. Wolf, MD
• Department of Emergency Medicine
• Denver Health Medical Center
• Denver, Colorado USA

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Imaging in Blunt Abdominal Trauma

• Blunt Abdominal Trauma
• Leading cause of morbidity and mortality in
  trauma
• Leading cause of intra-abdominal injuries
• Nineteen percent of intra-abdominal injuries have
  no pain

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Imaging in Blunt Abdominal Trauma

• Pre 1960s - Four quadrant paracentesis
• 1960s - Diagnostic Peritoneal Lavage (DPL)
• 1980s - Abdominal Computed Tomography Scan
• (CT Scan)
• 1990s - Focused Abdominal Sonography for Trauma
  (Fast Scan)

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Imaging in Blunt Abdominal Trauma Case
Presentation

• 20 year old male unrestrained driver of high
  speed MVA, complaining of abdominal pain.
• VS BP 90/40 HR 115 RR 20 SaO2 100
• Abd Diffusely Tender, no ecchymosis
• Pelvis Stable, Non-tender
• Rectal Hemoccult negative
• CTL C-spine, pCXR, Pelvis NL
• HCTHgb 44 / 13g/dl

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Imaging in Blunt Abdominal Trauma - DPL

• What is the diagnostic performance of DPL in
  diagnosing significant intra-abdominal injuries
  requiring intervention in blunt abdominal trauma?

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Imaging in Blunt Abdominal Trauma - DPL

• Sensitivity
• Hemoperitoneum 83 98 I,II,III
• Mean sensitivity 95 III
• Enteric injuries 82III
• Nontherapeutic laparotomies (False Positives)
• Rate 13 54 II,III

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Imaging in Blunt Abdominal Trauma - DPL

• Limitations
• Minimal bleeding II,III
• Retroperitoneal, diaphragmatic, enteric injuries
• Insensitive markers III
• Gram stain, amylase, alkaline phosphatase
• Significance of injury?
• Complications rate 1 2 II,III

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Imaging in Blunt Abdominal Trauma - DPL

• Level A recommendations. None specified.
• Level B recommendations.
• Diagnostic peritoneal lavage can be used to
  exclude hemoperitoneum in blunt abdominal trauma
  patients. Diagnostic peritoneal lavage does not
  define the extent of injury, has a 1 to 2
  complication rate, and may lead to nontherapeutic
  laparotomies.
• Level C recommendations.
• On the basis of consensus and current practice
  patterns, the initial choices for the evaluation
  of blunt abdominal trauma are CT and FAST,
  depending on the patients hemodynamic stability.

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Imaging in Blunt Abdominal Trauma CT Scan

• What is the diagnostic performance of CT in
  diagnosing significant intra-abdominal injuries
  requiring intervention in blunt abdominal trauma?
  

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Imaging in Blunt Abdominal Trauma CT Scan

• Sensitivity
• Solid organ injury 97 II,III
• Enteric injury 64 94 III
• Diaphragmatic injury 61 III
• Pancreatic injury 30 III

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Imaging in Blunt Abdominal Trauma CT Scan

• Level A recommendations. None specified.
• Level B recommendations.
• When either liver or spleen injury is suspected,
  CT can reliably exclude injuries that require
  emergent operative intervention. CT alone cannot
  be used to exclude either bowel, diaphragm, or
  pancreas injury.
• Abdominal CT accurately identifies hemoperitoneum
  among patients with blunt abdominal trauma.
• Level C recommendations. None specified.

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Imaging in Blunt Abdominal Trauma CT Scan

• Does oral contrast improve the diagnostic
  performance of CT in blunt abdominal trauma?

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Imaging in Blunt Abdominal Trauma CT Scan

• Proposed benefits of oral contrast
• Identifying extravasation, delineating mesentery,
  setting opacified bowel apart from hematomas and
  pancreatic injuries
• Proposed risks of oral contrast
• Vomiting, aspiration, delayed diagnosis.

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Imaging in Blunt Abdominal Trauma CT Scan

• Sensitivities oral vs no oral contrast
• Solid organ injuries 84.2 vs 88.9 II
• Enteric injuries 86 vs 100 II
• Intra-abdominal injuries 98.4 II
• Extravasation 2.9 enteric injuries III
• Aspiration 0 III

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Imaging in Blunt Abdominal Trauma CT Scan

• Level A recommendations. None specified.
• Level B recommendations.
• Oral contrast is not essential to the evaluation
  of blunt abdominal trauma.
• Level C recommendations. None specified.

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Imaging in Blunt Abdominal Trauma FAST Scan

• What is the diagnostic performance of FAST in
  diagnosing hemoperitoneum in blunt abdominal
  trauma?

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Imaging in Blunt Abdominal Trauma FAST Scan

• Sensitivity
• Hemoperitoneum 68 98 I,II,III
• Hemoperitoneum and hypotension 100 II
• Intraabdominal injuries 69 II
• Enteric injury 58 II

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Imaging in Blunt Abdominal Trauma FAST Scan

• Level A recommendations. None specified.
• Level B recommendations.
• FAST is useful as an initial screening
  examination to detect hemoperitoneum in blunt
  abdominal trauma patients.
• Level C recommendations. None specified.

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Imaging in Blunt Abdominal Trauma

• Thank You!