DPL, FAST, Abdominal CT When, Why and How?

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???????

• ??? ??
• ??? ???
• ??????????????

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• ??????????????????????
• ???????
• Physical Examination
• DPL
• FAST
• Abdominal CT

?
?
?
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Scenario XY

• 19???????????????, ???80/40 mmHg, ??115, ?????
  ??2000ml?????????, ????????????

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Scenario XX

• 31????????????????, ???130/60 mmHg, ??95, ??????
  ?????, ??????????????? ??????, ????????????

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??????

• DPL
• Sonographic survey (FAST)
• CT

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DPL

• Diagnostic Peritoneal Lavage
• ???????
• ????, ??????
• ?????
• ?????

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Open method
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• DPA
• A
• Closed
• method

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????

• Open and closed techniques
• Catheter inserted into the abdomen, aspirate
• Positive if gross blood, bile, food, stool
• If aspirate negative, lavage with 1 liter NS
• positive
• Lavage fluid gt 100,000 RBC/mm3,
• gt500 WBC/mm3,
• Bacteria on Gram stain

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Abdominal CT

• Computed tomography, CAT scan
• ???????, ??????
• ???, ????
• ????, ????, ????

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CAT scan
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FAST

• Focused Abdominal Sonography for Trauma
• ???, ????
• ?????
• ?????
• ??????????

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FAST

• ?????????
• ??????????, ???????????????
• Basic 4 views
• ??? Cardiac (subxyphoid) view
• ??? RUQ view (Morrisons pouch)
• ??? LUQ view (splenorenal space)
• ??? Suprapubic view (Cul-de-Sac)

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Typical 4 views
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RUQ view

• Longitudinal scan
• Transverse scan
• Intercostal scan
• Hypochondral scan
• Morison pouch
• May observe pleural space

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• 10 is identified with infusing 400ml saline
• 97 is noted with infusing 1L saline

Branney et al. J Trauma 1995
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LUQ view

• Longitudinal scan
• Transverse scan
• Intercostal scan
• Hypochondral scan
• Spleen may be obscured during deep inspiration
• May observe pleural space simultaneously

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Subcapsular hematoma
Pleural effusion
Same Victim
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Subxyphoid view

• Pericardiac sac
• Echogenesity of blood
• Pericardial effusion?
• Heart movement?
• Decompressive measure

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Echo guided pericardiocentesis

• Equipment
• 16-gauge short-bevel large-bore needle
• 30- or 50-mL syringe
• Echo- guided
• Local anesthesia
• Sterile supplies and povidone-iodine solution

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Suprapubic view

• Longitudinal scan
• Transverse scan
• Best viewed under full bladder
• Physiologic fluid

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Physiologic ascites
massive pelvic fluid
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EFAST

• Extended FAST scan
• Detect thoracic lesion
• Focus on occult pneumothorax (OPTX)
• Gliding pleura signs

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Lung Sliding
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• Lung point

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Hemothorax

• Right or left Intercostal view
• Subcostal view

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Blunt cardiac injury

• Pericardial effusion and Wall motion
• Valve injuries ( regurgitate )

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FAST or not?

• 100 victims of penetrating torso trauma assessed
  by our trauma teams. 48 stab wounds, 51 gunshot
  wounds, and 1 puncture wound..
• The overall accuracy of the US examination in
  penetrating torso trauma was 87, with a
  sensitivity of 64 and a specificity of 96. The
  positive predictive value was 86 and negative
  predictive value was 87...
• The US examination lacks sensitivity to be used
  alone in determining operative interventionRarely
  does US information contribute to the management
  of patients with penetrating abdominal injuries
• A PROSPECTIVE EVALUATION OF
  ULTRASONOGRAPHY DIAGNOSIS OF PENETRATING
  ABDOMINAL INJURY Dror Soffer MD, Mark McKenney et
  al. Ann Emerg Med 2003

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FAST or not?

• 149 patients with suspicion for abdominal trauma
  were evaluatedleaving 134 patients for analysis.
  
• There were 111 true negative FAST exams, 5 true
  positives, 17 false negatives, and 2 false
  positives.
• Chi-square analysis showed significant
  discordance between FAST and CT (plt0.001).
• Utilization of FAST as a screening tool for BAI
  in hemodynamically stable trauma patients results
  in under-diagnosis of intraabdominal injury
• Patients with suspected abdominal trauma should
  undergo routine CT scanning.
• Not So Fast! M.T. Miller, ND, M.D.
  Pasquale et al. J Trauma 2002

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Pitfall

• Operator-dependent skill
• Reliable?
• Sensitivity
• Missed injuries
• Pelvic fluid
• Full Bladder
• Serial examination
• Delayed onset
• Subcutaneous emphysema
• Gas block

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The new ABCs

• Admit
• Begin
• CT scan

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???????

• When?
• Why?
• Why not?

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DPL

• When
• ????YES?NO???
• Hemodynamic instability
• ????????CT ???
• Rare these days
• ?????????????

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DPL

• Why
• Quick decisions
• Looking primarily for gross blood

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DPL

• Why not
• ??????
• Possible complication
• ????????????
• Non-therapeutic lap rate app 30!
• ????????????

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FAST

• When
• ????YES?NO???
• Hemodynamic instability
• ??????????
• Detect for fluid

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FAST

• When
• 69 patients with initial BPlt 90 mmHg
• 22 with positive FAST
• 19(86)needed a laparotomy
• 47 with negative FAST
• 0(0) needed a laparotomy

Wherrett LJ. J Trauma 1996
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FAST

• Why
• ???????
• ???????

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FAST

• Why
• Can be done rapidly!
• Positive FAST
• Time required 19/-5 sec.
• Just for internal bleeding or cardiac tamponade
• Negative FAST
• Time required 154/-13 sec.

Wherrett LJ. J Trauma 1996
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FAST

• Why not
• ?????????
• ????????
• ?????????
• ??????????

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Abdominal CT

• Why
• ????????
• Solid organ, retroperitoneum, fluid
• ????
• ????

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Accuracy Vs. Sensitivity
???Accuracy ???Sensitivity
DPL 98 99
FAST 96 75-93
ABD CT 99 99
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Portable CAT scan HMC Seattle
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Abdominal CT

• When
• ????????
• ????????????
• ?????????CT??
• ?????????

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Abdominal CT

• Why not
• ????
• ??????????CT?????
• ???????
• ??CT????????

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Abdominal CT

• Why not
• Multi-institutional study for small bowel injury
• 13 without CT findings
• 21 with solid organ injuries
• 33 with peritoneal signs

Fakhry J Trauma 2003
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Digest time

• ???????????
• ?????????
• ???????

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???? A
?????
??????? ???()
?????? ???(-)
????
???? ????
?????? ??????
??
FAST Pericardial view
CT
Your choice
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???? B
???? ??????? ???(/-)
FAST ?? ?????DPL
????()
????(-)
Resuscitation Other injury?
????
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???? C
???? ?????? ???(-)
CT Scan
????(-)
????()
Solid organ injury Retroperitoneal injury
Observation LOC?DPL
(-) OBS/Tx
() Exp-lap?
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• Can you make your decision now?

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Scenario XX

• 52???????????????, ???80/40 mmHg, ??115, ?????
  ??2000ml?????????, ????????????

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???? B
???? ??????? ???(/-)
Hemodynamic Instablity
FAST Free fluid()
FAST ?? ?????DPL
????()
????(-)
Resuscitation Other injury?
????
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Scenario XY

• 31????????????????, ???130/60 mmHg, ??95, ??????
  ?????, ??????????????? ??????, ????????????

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???? A
Stable Vital signs
?????
??????? ???()
?????? ???(-)
????
???? ????
?????? ??????
??
FAST Pericardial view
CT
Your choice
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Conclusion

• Dont get ABC syndrome
• Good Decision ? Favorable outcome
• Good Practice ? Favorable outcome
• Time pressure?Bedside survey

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THANK YOU!