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PRACTICE MANAGEMENT GUIDELINES FOR THE EVALUATIO

OF BLUNT ABDOMINAL TRAUMA

EAST Practice Management Guidelines Work Group

William S. Hoff, MD,1 Michelle Holevar, MD,2 Kimberly K. Nagy, MD,3

Patterson, MD,4 Jeffrey S. Young, MD,5 Abenamar Arrillaga, MD,6 Mi

Najarian, DO,7 Carl P. Valenziano, MD8

1Brandywine Hospital, Coatesville, PA

2Mount Sinai Hospital, Chicago, IL

3Cook County Hospital and Rush University, Chicago, IL

4Wright State University, Dayton, OH

5University of Virginia Health System, Charlottesville, VA

6Greenville Memorial Hospital, Greenville, SC

7Lehigh Valley Hospital, Allentown, PA

8Morristown Memorial Hospital, Morristown, NJ

Address for Correspondence:

William S. Hoff, MD, FACSBrandywine Hospital - Department of Traumatology201 Reeceville RoadCoatesville, PA 19320



PRACTICE MANAGEMENT GUIDELINES FOR THE EVALUATIONOF BLUNT ABDOMINAL TRAUMA

I. Statement of the problem

Evaluation of patients who have sustained blunt abdominal traumapose a significant diagnostic challenge to the most seasoned trauma surtrauma produces a spectrum of injury from minor, single-system injury to multi-system trauma. Trauma surgeons must have the ability to detect the intra-abdominal injuries across this entire spectrum. While a carefull

physical examination remains the most important method to determine texploratory laparotomy, there is little Level I evidence to support this tenseveral studies have highlighted the inaccuracies of the physical examinatio2 The effect of altered level of consciousness as a result of neurologic injurdrugs, is another major confounding factor in assessing BAT.

Due to the recognized inadequacies of physical examination, traumhave come to rely on a number of diagnostic adjuncts. Commonly useinclude diagnostic peritoneal lavage (DPL) and computed tomography (CTnot available universally, focused abdominal sonography for trauma recently been included in the diagnostic armamentarium. Diagnosticoutlining appropriate use of each of these modalities individually have been Several factors influence the selection of diagnostic testing: (1) type of hotrauma center vs. “non-trauma” hospital; (2) access to a particular technsurgeon’s institution; (3) the surgeon’s individual experience with a givemodality. As facilities evolve, technologies mature and surgeons gain new

it is important that any diagnostic strategy constructed be dynamic.The primary purpose of this study was to develop an evidence-baseddiagnostic approach to BAT utilizing the three major diagnostic modalities: iand FAST. This diagnostic regimen would be designed such that it could bapplied by all general surgeons performing an initial evaluation of BAT.

II. Process

A. Identification of referencesA MEDLINE search was performed using the key words “abdominal

the subheading “diagnosis”. This search was limited further to (1) clinic(2) published in English, (3) publication dates January 1978 through FebThe initial search yielded 742 citations. Case reviews, review articles, manalyses, editorials, letters to the editor, technologic reports, pediatric se



Articles were distributed among subcommittee members for formal rereview data sheet was completed for each article reviewed which summariz

conclusions of the study, and identified any deficiencies in the study. Furtheclassified each reference by the methodology established by the Agency foCare Policy and Research (AHCPR) of the U.S. Department of Health and HServices as follows:

Class I: Prospective, randomized, double-blinded studyClass II: Prospective, randomized, non-blinded trialClass III: Retrospective series, meta-analysisFollowing review by the subcommittee, references were excluded bas

design or invalid conclusions. An evidentiary table was constructed using th101 references: Class I (20); Class II (32); Class III (49). Recommendationbased on studies included in the evidentiary table.

III. Recommendations

A. Level I1. Exploratory laparotomy is indicated for patients with a positive DPL.2. CT is recommended for the evaluation of hemodynamically stable patien

equivocal f indings on physical examination, associated neurologic injuryextra-abdominal injuries. Under these circumstances, patients with a neshould be admitted for observation.

3. CT is the diagnostic modality of choice for nonoperative management ofvisceral injuries.

4. In hemodynamically stable patients, DPL and CT are complementary dia

modalities.

B. Level II1. FAST may be considered as the initial diagnostic modality to exclude

hemoperitoneum. In the presence of a negative or indeterminate FAST and CT have complementary roles.

2. When DPL is used, clinical decisions should be based on the presence blood on initial aspiration (i.e., 10 ml) or microscopic analysis of lavage

3. In hemodynamically stable patients with a positive DPL, follow-up CT scbe considered, especially in the presence of pelvic fracture or suspectedthe genitourinary tract, diaphragm or pancreas.

4. Exploratory laparotomy is indicated in hemodynamically unstable patienpositive FAST. In hemodynamically stable patients with a positive FASTCT permits nonoperative management of select injuries.



2. Patients with seatbelt sign (SBS) should be admitted for observation andphysical examination. Detection of intraperitoneal fluid by FAST or CT i

with SBS mandates either DPL to determine the nature of the fluid or exlaparotomy.

3. CT is indicated for the evaluation of suspected renal injuries.4. A negative FAST should prompt follow-up CT for patients at high risk for

intraabdominal injuries (e.g., multiple orthopedic injuries, severe chest wneurologic impairment).

5. Splanchnic angiography may be considered in patients who require angthe evaluation of other injuries (e.g., thoracic aortic injury, pelvic fracture

IV. Scientific Foundation

A. Diagnostic Peritoneal Lavage (DPL)DPL was introduced by Root in 1965 as a rapid and accurate method

the presence of intra-abdominal hemorrhage following trauma.3 Subsequehave confirmed the eff icacy of DPL in diagnosing abdominal hemorrhage assuperiority over physical examination alone.4 The accuracy of DPL has be

between 92% and 98%.5, 6, 7, 8, 9, 10 The high sensitivity of DPL is due tsignificant false positive rate of the technique.11, 12, 13 Several authors hhighlighted the importance of interpreting DPL results in the context of the oclinical condition of the patient. A positive DPL does not necessarily mandaimmediate laparotomy in the hemodynamically stable patient.12, 14, 15, 16been shown to be more efficient than CT scan in identifying patients that reqsurgical exploration.17

The complication rate associated with DPL is quite low.18 The incidecomplications is lower for open DPL compared with to the closed techniqueclosed DPL can be performed more rapidly.19, 20, 21, 22 Studies designedthe ability of physicians to estimate the red blood cell (RBC) count in DPL fdemonstrated the poor sensitivity of visual inspection.23, 24, 25 A positive on microscopic analysis of lavage fluid, has been defined as > 105 RBC/mmbeen recommended that patients with RBC counts in the equivocal range (i75,000 RBC/mm3) undergo additional diagnostic testing, such as CT scann

The false positive rate for DPL is increased in patients with pelvic fra27 In order to avoid sampling the retroperitoneal hematoma, a suprpa-umbapproach has been recommended, theoretically reducing the chances of a fresult.28

The advantages of DPL for detection of hollow visceral injuries havedemonstrated.29, 30 Two studies which advocate analysis of DPL fluid for a

lk li h h i i h i i j i h b di d



significant injuries to retroperitoneal structures. False positive results may presence of pelvis fractures. Hemodynamically stable patients with equivoc

are best managed by additional diagnostic testing to avoid unnecessary lap

B. Computed Tomography (CT)Routine use of CT for the evaluation of BAT was not initially viewed w

overwhelming enthusiasm. CT requires a cooperative, hemodynamically stIn addition, the patient must be transported out of the trauma resuscitation radiographic suite. Specialized technicians and the availability of a radiologinterpretation were also viewed as factors which limited the utility of CT for t

patients. CT scanners are now available in most trauma centers and, with thelical scanners, scan time has been significantly reduced. As a result, CT an accepted part of the traumatologist’s armamentarium.

The accuracy of CT in hemodynamically stable blunt trauma patientswell established. Sensitivity between 92% and 97.6% and specificity as highas been reported in patients subjected to emergency CT.38, 39 Most authrecommend admission and observation following a negative CT scan.40, 41study of 2774 patients, the authors concluded that the negative predictive v

(99.63%) of CT was sufficiently high to permit safe discharge of BAT patiena negative CT scan.42

CT is notoriously inadequate for the diagnosis of mesenteric injuries also miss hollow visceral injuries. In patients at risk for mesenteric or hollowinjury, DPL is generally felt to be a more appropriate test.37, 43 A negativesuch a patient cannot reliably exclude intra-abdominal injuries.

CT has the unique ability to detect clinically unsuspected injuries. In444 patients in whom CT was performed to evaluate renal injuries, 525 concabdominal and/or retroperitoneal injuries were diagnosed. Another advantascanning over other diagnostic modalities is its ability to evaluate the retropstructures.40 Kane performed CT in 44 hemodynamically stable blunt traumfollowing DPL. In 16 patients, CT revealed significant intra-abdominal or reinjuries not diagnosed by DPL. Moreover, the findings on CT resulted in a mto the original treatment plan in 58% of the patients.44

C. Focused Abdominal Sonography for Trauma (FAST)In recent years, focused abdominal sonography for trauma (FAST) has a useful diagnostic test in the evaluation of BAT. The advantages of theexamination have been clearly established. FAST is noninvasive, may be eperformed and can be done concurrently with resuscitation. In addition, theis portable and may be easily repeated if necessary.45, 46, 47, 48 In most FAST b l d i hi i Th i



the FAST examination cannot be used to reliably grade solid organ injuries.in the hemodynamically stable patient, a follow-up CT scan should be obtai

nonoperative management is contemplated.59 FAST compares favorably with more traditionally utilized diagnostic t

hemodynamically stable patient with BAT, FAST offers a viable alternative tDPL may also be used as a complementary examination in the hemodynampatient in the presence of an equivocal or negative ultrasound with strong csuspicion of visceral injury.61, 62 FAST has demonstrated utility in hemodystable patients with BAT.58, 60, 63 In addition, ultrasound has been showncost-effective when compared to DPL or CT.45, 47, 60

Overall, FAST has a sensitivity between 73% and 88%, a specificity 98% and 100% and is 96% to 98% accurate.46, 50, 57, 58, 64, 65 This levaccuracy is independent of the practitioner performing the study. Surgeonsmedicine physicians, ultrasound technicians and radiologists have equivalen53, 64, 65, 66

D. Other Diagnostic ModalitiesAs interest in laparoscopic procedures has increased among genera

there has been speculation regarding the role of diagnostic laparoscopy (Devaluation of BAT. One of the potential benefits postulated is the reductionnontherapeutic laparotomies. With modification of the technique to includeinstruments, portable equipment and local anesthesia, DL may be a useful initial evaluation of BAT. Although there are no randomized, controlled studcomparing DL to more commonly utilized modalities, experience at one instminilaparoscopy demonstrated a 25% incidence of positive findings on DL, successfully managed nonoperatively and would have resulted in nontheraplaparotomies.67

Although its ultimate role remains unclear, another modality to be cothe diagnostic evaluation of BAT is visceral angiography. This modality madiagnostic value when employed in conjunction with angiography of the pelvor when other diagnostic studies are inconclusive.68

V. Summary

Injury to intra-abdominal viscera must be excluded in all victims of BAexamination remains the initial step in diagnosis but has limited utility undecircumstances. Thus, various diagnostic modalities have evolved to assist tsurgeon in the identification of abdominal injuries. The specific tests selecteon the clinical stability of the patient, the ability to obtain a reliable physical



diagnostic choice is between CT or FAST (with CT in a complementary roleHemodynamically unstable patients may be initially evaluated with FAST or

VI. Future Investigation

Recent literature is replete with studies that emphasize the many advultrasound in the valuation of BAT. Although this technology is becoming mavailable to trauma surgeons, for a variety of reasons, it has not become unavailable in all centers. Continued research addressing the utility of FAST, emphasis on its advantages specific to resource utilization, is suggested. I

studies should be designed to more closely evaluate the feasibility of FASTdiagnostic test in hemodynamically stable patients. Perhaps safe strategiesnonoperative management of solid visceral injuries could be developed whiFAST alone, such that the number of CT scans could be reduced.



VII. References

1. Rodriguez A, DuPriest RW Jr., Shatney CH: Recognition of intra-abdomblunt trauma victims. A prospective study comparing physical examinatperitoneal lavage. Am Surg 48: 457-459, 1982.

2. Schurink GW, Bode PJ, van Luijt PA, et al: The value of physical examindiagnosis of patients with blunt abdominal trauma: a retrospective study261-265, 1997.

3. Root HD, Hauser CW, McKinley CR, et al: Diagnostic peritoneal lavage633-637, 1965.

4. Bivins BA, Sachatello CR, Daughtery ME, et al: Diagnostic peritoneal lasuperior to clinical evaluation in blunt abdominal trauma. Am Surg 44: 631978.

5. Smith SB, Andersen CA: Abdominal trauma: the limited role of peritoneaAm Surg 48: 514-517, 1982.

6. Henneman PL, Marx JA, Moore EE, et al: Diagnostic peritoneal lavage: predicting necessary laparotomy following blunt and penetrating trauma30: 1345-1355, 1990.

7. Krausz MM, Manny J, Austin E, et al: Peritoneal lavage in blunt abdominSG & O 152: 327-330, 1981.

8. MooreJB, Moore EE, Markivchick VJ, et al: Diagnostic peritoneal lavageabdominal trauma: superiority of the open technique at the infraumbilicaTrauma 21: 570-572, 1981.

9. Jacob ET, Cantor E: Discriminate diagnostic peritoneal lavage in blunt ainjuries: accuracy and hazards. Am Surg 45: 11-14, 1979.

10. Fischer RP, Beverlin BC, Engrav LH, et al: Diagnostic peritoneal lavageyears and 2586 patients later. Am J Surg 136: 701-704, 1978.

11. Bilge A, Sahin M: Diagnostic peritoneal lavage in blunt abdominal traumSurg 157: 449-451, 1991.

12. DeMaria EJ: Management of patients with indeterminate diagnostic perilavage results following blunt trauma. J Trauma 31: 1627-1631, 1991.

13. Van Dongen LM, de Boer HH: Peritoneal lavage in closed abdominal inj16: 227-229, 1985.

14. Day AC, Rankin N, Charlesworth P: Diagnostic peritoneal lavage: integrclinical information to improve diagnostic performance. J Trauma 32: 5215. Barba C, Owen D, Fleiszer D, et al: Is positive diagnostic peritoneal lava

absolute indication for laparotomy in all patients with blunt trauma? TheGeneral Hospital experience. Can J Surg 34: 442-445, 1991.

16. Drost TF, Rosemurgy AS, Kearney RE, et al: Diagnostic peritoneal lavag



19. Lopez-Viego MA, Mickel TJ, Weigelt JA: Open versus closed diagnosticlavage in the evaluation of abdominal trauma. Am J Surg 160: 594-597,

20. Cue JI, Miller FB, Cryer HM,III, et al: A prospective, randomized comparbetween open and closed peritoneal lavage techniques. J Trauma 30: 81990.

21. Wilson WR, Schwarcz TH, Pilcher DB: A prospective randomized trial oLazarus-Nelson vs. the standard peritoneal dialysis catheter for peritoneblunt abdominal trauma. J Trauma 27: 1177-1180, 1987.

22. Felice PR, Morgan AS, Becker DR: A prospective randomized study evaperiumbilical versus infraumbilical peritoneal lavage: a preliminary repor

combined hospital study. Am Surg 53: 518-520, 1987.23. Gow KW, Haley LP, Phang PT, et al: Validity of visual inspection of diag

peritoneal lavage fluid. Can J Surg 39: 114-119, 1996.24. Wyatt JP, Evans RJ, Cusack SP: Variation among trainee surgeons in in

diagnostic peritoneal lavage fluid in blunt abdominal trauma. J Royal Co(Edin) 37: 104-106, 1992.

25. Driscoll P, Hodgkinson D, Mackway-Jones K: Diagnostic peritoneal lavabut is it positive? Injury 23: 267-269, 1992.

26. Mendez C, Gubler KD, Maier RV: Diagnostic accuracy of peritoneal lavapatients with pelvic fractures. Arch Surg 129: 477-482, 1994.

27. Hubbard SG, Bivins BA, Sachatello CR, et al: Diagnostic errors with perlavage in patients with pelvic fractures. Arch Surg 114: 844-846, 1979.

28. Cochran W, Sobat WS: Open versus closed diagnostic peritoneal lavagmultiphasic prospective randomized comparison. Ann Surg 200: 24-28,

29. Meyer DM, Thal ER, W eigelt JA, et al: Evaluation of computed tomogradiagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 29: 111989.

30. Burney RE, Mueller GL, Coon WW, et al: Diagnosis of isolated small bofollowing blunt abdominal trauma. Ann Emerg Med 12: 71-74, 1983.

31. McAnena OJ, Marx JA, Moore EE: Peritoneal lavage enzyme determinatfollowing blunt and penetrating abdominal trauma. J Trauma 31: 1161-1

32. McAnena OJ, Marx JA, Moore EE: Contributions of peritoneal lavage endeterminations to the management of isolated hollow visceral abdomina

Ann Emerg Med 20: 834-837, 1991.33. Megison SM, Weigelt JA: The value of alkaline phosphatase in peritoneAnn Emerg Med 19: 503-505, 1990.

34. D’Amelio LF, Rhodes M: A reassessment of peritoneal lavage leukocyteblunt abdominal trauma. J Trauma 30: 1291-1293, 1990.

35. Soyka JM, Martin M, Sloan EP, et al: Diagnostic peritoneal lavage: is an



38. Peitzman AB, Makaroun MS, Slasky BS, et al: Prospective study of comtomography in initial management of blunt abdominal trauma. J Trauma

592, 1986.39. Webster VJ: Abdominal trauma: Pre-operative assessment and postopeproblems in intensive care. Anaest Int Care 13: 258-262, 1985.

40. Lang EK: Intra-abdominal and retroperitoneal organ injuries diagnosed ocomputed tomograms obtained for assessment of renal trauma. J Traum1168, 1990.

41. Matsubara TK, Fong HM, Burns CM: Computed tomography of abdomenmanagement of blunt abdominal trauma. J Trauma 30: 410-414, 1990.

42. Livingston DH, Lavery RF, Passannante MR, et al: Admission or observnecessary after a negative abdominal computed tomographic scan in pasuspected blunt abdominal trauma: Results of a prospective, multi-institJ Trauma 44: 272-282, 1998.

43. Nolan BW , Gabram SG, Schwartz RJ, et al: Mesenteric injury from blunttrauma. Am Surg 61: 501-506, 1995.

44. Kane NM, Dorfman GS, Cronan JJ: Efficacy of CT following peritoneal laabdominal trauma. J Comp Asst Tomo 11: 998-1002, 1987.

45. Branney SW, Moore EE, Cantrill SV, et al: Ultrasound based key clinicareduces the use of hospital resources for the evaluation of blunt abdomiJ Trauma 42: 1086-1090, 1997.

46. Healey MA, Simons RK, Winchell RJ, et al: A prospective evaluation of ultrasound in blunt trauma: Is it useful? J Trauma 40: 875-883, 1996.

47. Glaser K, Tschmelitsch J, Klingler P, et al: Ultrasonography in the manablunt abdominal and thoracic trauma. Arch Surg 129: 743-747, 1994.

48. Liu M, Lee CH, P’eng FK: Prospective comparison of diagnostic peritoncomputed tomographic scanning, and ultrasonography for the diagnosisabdominal trauma. J Trauma 35: 267-270, 1993.

49. Boulanger BR, McLellan BA, Brenneman FD, et al: Emergent abdominaas a screening test in a new diagnostic algorithm for blunt trauma. J Tra867-874, 1996.

50. Boulanger BR, Brenneman FD, McLellan BA, et al: A prospective study oabdominal sonography after blunt trauma. J Trauma 39: 325-330, 1995.

51. Ma OJ, Kefer MP, Mateer JR, et al: Evaluation of hemoperitoneum usingvs. multiple-view ultrasonographic examination. Acad Emerg Med 2: 58152. Rozycki GS, Ochsner MG, Jaffin JH, et al: Prospective evaluation of sur

of ultrasound in the evaluation of trauma patients. J Trauma 34: 516-52753. Branney SW, Wolfe RE, Moore EE, et al: Quantitative sensitivity of ultra

detecting free intraperitoneal fluid. J Trauma 39: 375-380, 1995.



57. Smith SR, Kern SJ, Fry WR, et al: Institutional learning curve of surgeontrauma ultrasound. Arch Surg 133: 530-536, 1998.

58. McKenney MG, Martin L, Lentz K, et al: 1000 consecutive ultrasounds foabdominal trauma. J Trauma 40: 607-612, 1996.59. Chambers JA, Pilbrow WJ: Ultrasound in abdominal trauma: an alternat

peritoneal lavage. Arch Emerg Med 5: 26-33, 1988.60. McKenney KL, McKenney MG, Nunez DB, et al: Cost reduction using ul

blunt abdominal trauma. Emerg Radiol 4: 3-6, 1997.61. Kimura A, Otsuka T: Emergency center ultrasonography in the evaluatio

hemoperitoneum: A prospective study. J Trauma 31: 20-23, 1991.

62. Gruessner R, Mentges B, Duber C, et al: Sonography versus peritoneal blunt abdominal trauma. J Trauma 29: 242-244, 1989.

63. Rothlin MA, Naf R, Amgwerd M, et al: Ultrasound in blunt abdominal andtrauma. J Trauma 34: 488-495, 1993.

64. Kern SJ, Smith RS, Fry WR, et al: Sonographic examination of abdominsenior surgical residents. Am Surg 63: 669-674, 1997.

65. Rozycki GS, Ochsner MG, Schmidt JA, et al: A prospective study of surgperformed ultrasound as the primary adjuvant modality for injured patien

assessment. J Trauma 39: 492-500, 1995.66. McKenney M, Lentz K, Nunez D, et al: Can ultrasound replace diagnost

lavage in the assessment of blunt trauma? J Trauma 37: 439-441, 199467. Berci G, Sackier JM, Paz-Partlow M: Emergency laparoscopy. Am J Sur

335, 1991.68. Ward RE: Study and management of blunt trauma in the immediate pos

period. Rad Clin NA 19: 3-7, 1981.



1 2

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I DE L I NE S F ORT HE E

VAL UAT I O N OF B L U N

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I

C l o s e d D P L s u p er i or t o o p enD

P L . O p en or s emi - o p en t e c h n

i q u e

r e c omm en d e d f or p a t i en t s i nw

h om c l o s e d D P L i s c on t r ai n d i c a t e d .

D a y A C

1 9 9 2

D i a gn o s t i c p er i t on e al l av a g e:

i n t e gr a t i onwi t h c l i ni c al i nf or m a t i on t o

i m pr ov e d i a gn o s t i c p er f or m

an c e.

J T r a um a 3 2 : 5 2 - 5 7

I

C om b i n a t i on of c l i ni c al ev al u a t i on an d D P L r e d u c e s r a t e of n on

-

t h er a p e u t i c l a p ar o t omi e s , b u t i n c r e a s e s t h en um b er of mi s s e d

i n j ur i e s .T h eh i gh e s t a c c ur a c y

( 9 5 % ) i s o b t ai n e d b y c om b i n a t i o

n of

c i r c ul a t or y a s s e s s m en t an d D P

L .

T s oP

1 9 9 2

S on o gr a ph y i n b l un t a b d omi n al

t r a um a: a pr el i mi n ar y pr o gr e s s r e p or t .

J T r a um a 3 3 : 3 9 -4 4

I

U S s en s i t i v e ( 9 1 % ) f or d e t e c t i o

n of f r e ef l ui d b u t l e s s s en s i t i v e

( 6 9 % ) f or i d en t i f i c a t i on of f r e ef l ui d pl u s or g an d i s r u p t i on. U S d

o e s

n o t r ul e o u t or g ani n j ur y i n t h e

a b s en c e of h em o p er i t on e um.

L i uM

1 9 9 3

P r o s p e c t i v e c om p ar i s on of d i a gn o s t i c

p er i t on e al l av a g e , c om p u t e d

t om o gr a ph i c s c anni n g , an d

ul t r a s on o gr a ph y f o

r t h e d i a gn o s i s of

b l un t a b d omi n al t r a um a.

J T r a um a 3 5 : 2 6 7

-2 7 0

I

S en s i t i v i y an d s p e c i f i c i t y of U

S i s c om p ar a b l e t o C T or D P L .F al s e

n e g a t i v e s i d en t i f i e d u s i n g C T ( 1 ) an d U S ( 3 ) i n t h e pr e s en c e of

i n t e s t i n al p er f or a t i on s .D ef i n e d

c om pl em en t ar y r ol e s of U S , C T

an d

D P L i n ev al u a t i on of B A T .

R o t h l i nMA

1 9 9 3

U l t r a s o un d i n b l un

t a b d omi n al an d

t h or a c i c t r a um a.

J T r a um a 3 4 : 4 8 8

-4 9 5

I

U S h i gh l y s en s i t i v e ( 9 8 .1 % ) an

d s p e c i f i c ( 1 0 0 % ) f or i d en t i f i c a t i on of

i n t r a- a b d omi n al f l ui d . S p e c i f i c

i t y r em ai n s h i gh ( 9 9 . 6 % ) b u t

s en s i t i v i t y d e c r e a s e s ( 4 3 . 6 % ) f

or d i a gn o s i s of s p e c i f i c or g an

l e s i on s .R e c omm en d 1 ) C T t o

i d en t i f y s p e c i f i c or g ani n j ur y ,2

)

s er i al U S ev er y 1 -2 h r s f or f i r s

t 6 h r s , t h en ev er y 1 2 h r s f or 2 d

a y s .

R oz y c k i G S

1 9 9 3

P r o s p e c t i v e ev al u a

t i on of s ur g e on s ”

u s e of ul t r a s o un d i n t h e ev al u a t i on of

t r a um a p a t i en t s .

J T r a um a 3 4 : 5 1 6

- 5 2 7

I

I nmi x e d b l un t ( 8 4 % ) / p en e t r a

t i n g ( 1 6 % ) p o p ul a t i on , U S h a s 7

9 . 0 %

s en s i t i v i t y an d 9 5 . 6 % s p e c i f i c i t y .A d j u s t e d s en s i t i v i t y f or b l un t

t r a um ai s 8 4 . 0 %. U S i n d i c a t e d

f or 1 ) b l un t t h or a c o a b d omi n al i n

j ur y ;

2 ) s u s p e c t e d p er i c ar d i al t am p o

n a d e ; 3 ) m ul t i - s y s t emi n j r u y wi t h

unk n own e t i ol o g y of h y p o t en s i on ; 4 ) pr e gn an t t r a um a p a t i en t .

G ol e t t i O

1 9 9 4

T h er ol e of ul t r a s on o gr a ph y i n b l un t

a b d omi n al t r a um a: r e s ul t s i n2 5 0

c on s e c u t i v e c a s e s

.

J T r a um a 3 6 : 1 7 8

-1 8 1

I

Ov er al l s en s i t i v i t y of U S 8 6 .7 %

.I n t r a p er i t on e al f l ui d v ol um e s

? 2 5 0

ml c or r el a t e s wi t h h i gh unn e c e

s s ar y l a p ar o t om y r a t ewh en

d i a gn o s e d b y U S ; s u g g e s t 2 5 0

ml a s t h r e s h ol d f or n on

- o p er a t i v e

m an a g em en t u s i n g U S . U S - g

ui d e d p ar a s c en t e s i s al l ow s s af e

n on-

o p er a t i v em an a g em en t i n pr e s en c e of s m al l v ol um e of f l ui d .

H u an gM

1 9 9 4

U l t a s on o gr a ph y f o

r t h e ev al u a t i on of

h em o p er i t on e um d

ur i n gr e s u s c i t a t i on:

a s i m pl e s c or i n g s

y s t em.

J T r a um a 3 6 : 1 7 3

-1 7 7

I

U S 1 0 0 % s p e c i f i c f or d i a gn o s i s of h em o p er i t on e um. S c or i n g

s y s t em d ev el o p e d t o pr e d i c t pr

e s en c e of h em o p er i t on e um an d

n e e d f or s ur g er y ; U S s c or e

? 3 c or r e s p on d s t o >1 0 0 0 ml b l o o d wi t h

8 4 % s en s i t i v i t y ,7 1 % s p e c i f i c i t y an d 7 1 % a c c ur a c y .



1 4

M c K enn e y M

1 9 9 4

C an ul t r a s o un d r e pl a c e d i a gn o s t i c

p er i t on e al l av a g ei n t h e a s s e s s m en t

of b l un t t r a um a?

J T r a um a 3 7 : 4 3 9

-4 4 1

I

C om p ar i s on of U S wi t h D P L , C

T s c an an d ex pl or a t or y l a p ar o t om y

i n2 0 0 p a t i en t s wi t h B A T . U S 8 3 % s en s i t i v e ,1 0 0 % s p e c i f i c an d

9 7 % a c c ur a t e.

B r ann e y S W

1 9 9 5

Q u an t i t a t i v e s en s i t i v i t y of ul t r a s o un d

i n d e t e c t i n gf r e ei n

t r a p er i t on e al f l ui d .

J T r a um a 3 9 : 3 7 5

- 3 8 0

I

P r o s p e c t i v e s t u d y of U S p er f or m e d i n p a t i en t s f ol l owi n gD P L wi t h

n o a s pi r a t i on of gr o s s b l o o d . U

S d em on s t r a t e d 9 7 % s en s i t i v i t y

an d

d e t e c t e d m e anf l ui d v ol um e of

6 1 9 ml . U S s c r e en s h o ul d b ei n

i t i al

b r an c h p oi n t i nB A T al g or i t h m.

R oz y c k i G S

1 9 9 5

A pr o s p e c t i v e s t u d

y of s ur g e on-

p er f or m e d ul t r a s o un d a s t h e pr i m ar y

a d j uv an t m o d al i t y f or i n j ur e d p a t i en t

a s s e s s m en t .

J T r a um a 3 9 : 4 9 2

- 5 0 0

I

A s s e s s m en t of s ur g e on- p er f or m e d U S i n 3 7 1 p a t i en t s ( 2 9 5 b l u

n t /

7 6 p en e t r a t i n g ) . U S i s an a c c u

r a t em o d al i t y ( 8 1 . 5 % s en s i t i v i t y ;

9 9 .7 % s p e c i f i c i t y ) wh i c h m a y

b e p er f or m e d b y s ur g e on s .

R e c omm en d r e p e a t U S a t 1 2

-1 4 h r s i f i ni t i al ex ami s n e g a t i v e

.

T h om a s B

1 9 9 7

U l t r a s o un d ev al u a t i on of b l un t

a b d omi n al t r a um a: pr o gr am

i m pl em en t a t i on ,i n

i t i al ex p er i en c e ,

an d l e ar ni n g c ur v e

.

J T r a um a4 2 : 3 8 4

- 3 9 0

I

U S ex ami n a t i on s p er f or m e d i n

3 0 0 p a t i en t s b y s ur g e on s an d

t r a um af el l ow s wi t h r ev i ew of f al s e ( - ) an d f al s e ( + ) b y r a d i ol o gi s t .

D em on s t r a t e d 8 1 . 0 % s en s i t i v i t y an d 9 9 . 3 % s p e c i f i c i t y .A c c ur a c y

pl a t e a u s af t er 1 0 0 ex ami n a t i on

s .P r o j e c t e d c o s t s av i n g s of

$ 4 1 , 0 0 0 .

M c K enn e y M G

1 9 9 8

C an s ur g e on s ev al u a t e em er g en c y

ul t r a s o un d s c an s f or b l un t a b d omi n al

t r a um a?

J T r a um a4 4 : 6 4 9

- 6 5 3

I

P r o s p e c t i v e s t u d y of 1 1 2 F A S T

ex ami n a t i on s p er f or m e d an d i ni t i al l y

i n t er pr e t e d b y s ur g e on s wi t h f i n

al i n t er pr e t a t i on b y r a d i ol o gi s t .N

o

f al s en e g a t i v e s ,2 f al s e p o s i t i v e s r e c or d e d . G o o d a gr e em en t

b e t w e eni n t er pr e t a t i on b y s ur g e

on an d r a d i ol o gi s t ( 9 9 % ) .

J a c o b E T

1 9 7 9

D i s c r i mi n a t e d i a gn

o s t i c p er i t on e al

l av a g ei n b l un t a b d

omi n al i n j ur i e s :

a c c ur a c y an d h az a

r d s .

A m S ur g e on4 5 : 1

1 -1 4

I I

D P L 9 3 .4 % a c c ur a t ei n pr e d i c t i on of p o s i t i v e ex pl or a t or y

l a p ar o t om y an d 9 6 . 6 % a c c ur a t ei n pr e d i c t i on of n e g a t i v e

ex pl or a t or y l a p ar o t om y i n p a t i en t s wi t h mi l e or e q ui v o c al c l i ni c al

f i n d i n g s .

B u t t er w or t h J F

1 9 8 0

D e t e c t i on of o c c ul t a b d omi n al t r a um a

i n p a t i en t s wi t h s ev er eh e a d i n j ur i e s .

L an c e t 2 : 7 5 9 -7 6 2

I I

D P L r e c omm en d e d f or t r a um a

p a t i en t s wh o ar e un a b l e t o o b e y

s i m pl e c omm an d s s e c on d ar y t

o c l o s e d h e a d i n j ur y t o ex c l u d e

o c c ul t i n t r a- a b d omi n al i n j ur y .

A l y on oD

1 9 8 2

R e a p pr ai s al of d i a gn o s t i c p er i t on e al

l av a g e c r i t er i af or

o p er a t i oni n

p en e t r a t i n g an d b l un t t r a um a.

S ur g er y 9 2 : 7 5 1 -7

5 7

I I

I n b l un t t r a um a , t h eh i gh e s t l ev

el of a c c ur a c y i s a c h i ev e d wi t h

s t an d ar d d i a gn o s t i c c r i t er i a: D P

L -R B C >1 0 0 K / mm 3 ; D P L -WB

C >

5 0 0 / mm 3

K u s mi n s k y R E

1 9 8 2

T h e p o t en t i al v al u e

of en d o t ox i n

-

am y l a s e d e t e c t i on

i n p er i t on e al

l av a g ef l ui d .


5 9 - 3 6 2

I I

D e t e c t i on of am y l a s e or en d o t o

x i ni nD P L f l ui d i s v al u a b l ei n t h e

d e t c t i on of p an c r e a t i c an d g a s t r oi n t e s t i n al i n j ur i e s .

R o d r i g u ez A

1 9 8 2

R e c o gni t i on of i n t r a- a b d omi n al i n j ur y

i n b l un t t r a um av i c t i m s .A

pr o s p e c t i v e s t u d y c om p ar i n g ph y s i c al

ex ami n a t i onwi t h p

er i t on e al l av a g e.


5 7 -4 5 9

I I

F i n d i n g s onP E unr el i a b l ei n c o

n s c i o u s , or i en t e d p a t i en t s wi t h B

A T

r e s ul t i n gi n p o t en t i al f or mi s s e d

i n t r a- a b d omi n al i n j ur i e s .D P L

h i gh l y a c c ur a t e an d s en s i t i v ef or d e t e c t i on oni n t a

- a b d omi n al

i n j ur i e s .



1 5

K umi n s k y R E

1 9 8 4

T h ev al u e of s e q u en t i al p er i t on e al

pr of i l ei n b l un t a b d

omi n al t r a um a.

A m S ur g e on 5 0 : 2

4 8 -2 5 3

I I

A d d i t i on of en d o t ox i ni nD P L f l ui d al l ow s s af en on

- o p er a t i v e

m an a g em en t i nh em o d y n ami c

al l y s t a b l eB A T p a t i en t s wi t h D P

L

R B C c o un t >1 0 0 K / mm 3 .

D av i s R A

1 9 8 5

T h e u s e of c om p u t er i z e d ax i al

t om o gr a ph y v er s u s p er i t on e al l av a g e

i n t h e ev al u a t i on of b l un t a b d omi n al

t r a um a.

S ur g er y 9 8 : 8 4 5 - 8

5 0

I I

H i gh s en s i t i v i t y an d s p e c i f i c i t y

d o c um en t e d f o

r D P L c om p ar e d wi t h

C T i nB A T : c o s t of C T 8 x c o s t

of D P L . C T a s t h e s ol e d i a gn o s

t i c

m o d al i t y i nh em o d y n ami c al l y s t a b l e p a t i en t s wi t h B A T a d d s c o s

t ,

t i m e an d r i s k of mi s s e d i n j ur y w

i t h o u t pr ov i d i n g s i gni f i c an t a d d i t i on al

i nf or m a t i on.

P ei t z m anA B

1 9 8 6

P r o s p e c t i v e s t u d y

of c om p u t e d

t om o gr a ph y i ni ni t i al m an a g em en t of


J T r a um a

2 6 : 5 8 5 - 5 9 2

I I

C T d em on s t r a t e d t o b y h i gh l y s

en s i t i v e ( 9 7 . 6 % ) an d s p e c i f i c

( 9 8 .7 % ) f or t h e d i a gn o s i s of i n t

r a- a b d omi n al i n j ur i e s i n

h em o d y n ami c al l y s t a b l e p a t i e

n t s . C T p er mi t s s af en on- o p er a

t i v e

m an a g em en t of s ol i d v i s c er al i n j ur i e s .

G om ez GA

1 9 8 7

D i a gn o s t i c p er i t on e al l av a g ei n t h e

m an a g em en t of b l un t a b d omi n al

t r a um a: ar e a s s e s s m en t .

J T r a um a2 7 : 1 - 5

I I

D P L i s an a c c ur a t ei n d i c a t or of s i gni f i c an t i n t r a

- a b d omi n al i n j ur y a s

d o c um en t e d b y ex pl or a t or y l a p ar o t om y i n p a t i en t s wi t h B A T .

P a gl i ar el l o G

1 9 8 7

A b d omi n o p el v i c c om p u t er i z e d

t om o gr a ph y an d o p en p er i t on e al

l av a g ei n p a t i en t s wi t h b l un t

a b d omi n al t r a um a: a pr o s p e c t i v e

s t u d y .

C an J S ur g er y 3 0 : 1 0 -1 3

I I

C T l e s s s en s i t i v ewh en c om p ar e d wi t h D P L .A gr e em en t b e t w e

en

D P L an d C T d em on s t r a t e d i n 5

3 %.D P L s u p er i or t o C T f or

ev al u a t i on of B A T .

C h am b er s J A

1 9 8 8

U l t r a s o un d i n a b d o

mi n al t r a um a: an

al t er n a t i v e t o p er i t o

n e al l av a g e.

A r c h E m er gM e d 5 : 2 6 - 3 3

I I

U S i s ar el i a b l e d i a gn o s t i c t e c h

ni q u ef or d e t e c t i on of f r e e

i n t r a p er i t on e al f l ui d b u t i s unr el i a b l ef or gr a d i n g s p e c i f i c i n j ur i e s .

F r am e S

1 9 8 9

C om p u t e d t om o gr a ph y v er s u s

d i a gn o s t i c p er i t on e

al l av a g e:

u s ef ul n e s s i ni mm e d i a t e d i a gn o s i s of


A nnE m er gM e d 1

8 : 5 1 3 - 5 1 6

I I

D P L s af er an d m or e a c c ur a t e t h an C T i n t h e ev al u a t i on of B A T

.

Gr u e s s n er R

1 9 8 9

S on o gr a ph y v er s u s p er i t on e al l av a g e

i n b l un t a b d omi n al t r a um a.

J T r a um a2 9 : 2 4 2 -2 4 4

I I

U l t r a s o un d pr ef er r e d i ni t i al s c r e eni n gm e t h o d c om p ar e d t oD P L

f or

ev al u a t i on of B A T .H ow ev er ,D

P L h a s c om pl em en t ar y r ol ei n t h e

pr e s en c e of i n d e t er mi n a t e U S .

M c k er s i eR C

1 9 8 9

I n t r a- a b d omi n al i n j ur y f ol l owi n g b l un t

t r a um a.I d en t i f y i n g t h eh i gh -r i s k

p a t i en t u s i n g o b j e c

t i v er i s k f a c t or s .

A r c h S ur g er y 1 2 4 : 8 0 9 - 8 1 3

I I

P r e s en c e of ( 1 ) c h e s t i n j ur y ; ( 2

) b a s e d ef i c i t <

- 3 . 0 ; ( 3 ) h y p o t e

n s i on

on ar r i v al ; ( 4 ) pr eh o s pi t al h y p o t

en s i on ; ( 5 ) p el v i s f r a c t ur e

s i gni f i c an t l y c or r el a t e d wi t h i n t r a- a b d omi n al i n j ur y .D P L , U S , or C T

r e c omm en d e d i n t h e pr e s en c e

of on e of t h e s er i s k f a c t or s .

M e y er D M

1 9 8 9

E v al u a t i on of c om p u t e d t om o gr a ph y

an d d i a gn o s t i c p er i t on e al l av a g ei n


J T r a um a2 9 : 1 1 6 8 -1 1 7 0

I I

C T s c an s i gni f i c an t l y l e s s s en s

i t i v e t h anD P L i nB A T p a t i en t s w

i t h

e q ui v o c al f i n d i n g s onP E ( 7 4 . 3 %v s 9 5 . 9 % ) . C T unr el i a b

l ef o

r

i d en t i f i c a t i on of s m al l i n t e s t i n al

i n j ur i e s i n t h e a c u t e s t a g e of

ev al u a t i on.



1 6

C u e J I

1 9 9 0

A pr o s p e c t i v e ,r an d omi z e d

c om p ar i s on b e t w e en o p en an d

c l o s e d p er i t on e al l av a g e t e c h ni q u e s .

J T r a um a 3 0 : 8 8 0 - 8 8 3

I I

O p enD P L t ak e s l on g er t o p er f or mwi t h b e t t e

r r e t ur n of l av a g e

f l ui d .

T i m e c on s i d er a t i on an d i m pr ov

e d p a t i en t t ol er an c e j u s t i f i e s u s e

of

c l o s e d C P L .

L o p ez -V i e g o

MA

1 9 9 0


d d i a gn o s t i c

p er i t on e al l av a g ei n t h e ev al u a t i on of


A m J S ur g er y 1 6 0

: 5 9 4 - 5 9 6

I I

O p enD P L h a s f ew er c om pl i c a

t i on s .B e c a u s ei t m a y b e p er f or m e d

f a s t er , c l o s e d D P L i s r e c omm e

n d e d wi t h c onv er s i on t o o p en

t e c h ni q u ei f c om pl i c a t i on s o c c ur .

B i l g eA

1 9 9 1

D i a gn o s t i c p er i t on e al l av a g ei n b l un t


E ur J S ur g er y 1 5 7

: 4 4 9 -4 5 1

I I

D P L i s h i gh l y a c c ur a t ef or t h e d i a gn o s i s of f r e ei n t r a p er i t on e al

b l o o d , b u t i s ov er l y s en s i t i v ei n

t h a t i t i s un a b l e t o d i s t i n g ui s h

c l i ni c al l y uni m p or t an t am o un t s

of i n t r a p er i t on e al b l o o d .

R e c omm en d a d d i t i on al d i a gn o s t i c s t u d i e s i nh em o d y n ami c al l y

s t a b l e p a t i en t s wi t h B A T t or e d

u c ei n c i d en c e of unn e c e s s ar y

l a p ar o t omi e s .

D r o s t T F

1 9 9 1

D i a gn o s t i c p er i t on e al l av a g e.L i mi t e d

i n d i c a t i on s d u e t o ev ol v i n g c on c e p t s

i n t r a um a c ar e.

A m S ur g e on 5 7 : 1

2 6 -1 2 8

I I

N on- t h er a p e u t i c ex pl or a t or y l a p

ar o t om y p er f or m e d i n1 / 3 B A T

p a t i en t s b a s e d onD P L r e s ul t s . ( + ) D P L n o t ar el i a b l e pr e d i c t or of

s i gni f i c an t i n t r a- a b d omi n al i n j u

r y , e s p e c i al l y i nl i e u of n on

- o p er a t i v e

m an a g em en t pr o t o c ol s .

H of f m annR

1 9 9 2

B l un t a b d omi n al t r a um ai n c a s e s of

m ul t i pl e t r a um a ev al u a t e d b y

ul t r a s on o gr a ph y : a

pr o s p e c t i v e

an al y s i s of 2 9 1 p a t i en t s .

J T r a um a 3 2 : 4 5 2 -4 5 8

I I

D o c um en t e d h i gh s en s i t i v i t y ( 8

9 % ) an d s p e c i f i c i t y ( 9 7 % ) f or U S

i n

p a t i en t s wi t h I S S >2 0 .F al s en

e g a t i v er e s ul t s l i mi t e d b y

s ur v ei l l an c e of i n d e t er mi n a t e U

S wi t h D P L , C T , or ex pl or a t or y

l a p ar o t om y .

B o ul an g er B R

1 9 9 3

T h e c l i ni c al s i gni f i c an c e of a c u t e

h y p er am y l a s emi a af t er b l un t t r a um a.

C an J S ur g er y 3 6 : 6 3 - 6 9

I I

A d mi s s i on s er um am y l a s el ev e

l s s h o ul d n o t b y u s e d t o d e t er mi n e

c l i ni c al or r a d i o gr a ph i c ev al u a t i on of p a t i en t s wi t h B A T .

F or s t er R

1 9 9 3

U l t r a s on o gr a ph y i n

b l un t a b d omi n al

t r a um a: i nf l u en c e of t h ei nv e s t i g a t or s ’

ex p er i en c e.

J T r a um a 3 4 : 2 6 4 -2 6 9

I I

U S p er f or m e d b y s ur g e on s h a s

h i gh s en s i t i v i t y ( 9 6 % ) an d

s p e c i f i c i t y ( 9 5 % ) wi t h a s h or t l e

ar ni n g ph a s e.

J af f i n J H

1 9 9 3

A l k al i n e ph o s ph a t a

s el ev el s i n

d i a gn o s t i c p er i t on e

al l av a g ef l ui d a s a

pr e d i c t or of h ol l ow

v i s c er al i n j ur y .

J T r a um a 3 4 : 8 2 9 - 8 3 3

I I

R o u t i n em e a s ur em en t of al k al i n e ph o s ph a t a s ei nD P L f l ui d i s n o t

c o s t - ef f e c t i v e.

Gl a s er K

1 9 9 4

U l t r a s on o gr a ph y i n

t h em an a g em en t

of b l un t a b d omi n al an d t h or a c i c

t r a um a.

A r c h S ur g er y 1 2 9 : 7 4 3 -7 4 7

I I

R e t r o s p e c t i v er ev i ew of U S p er f or m e d a s t h ei ni t i al d i a gn o s t i c

m o d al i t y i n1 1 5 1 p a t i en t s . U S pr ov i d e s r e s ul t s s i mi l ar t o C T an d

D P L ( 9 9 % s en s i t i v i t y ; 9 8 % s p e

c i f i c i t y ) a t l e s s c o s t an d wi t h o u t

c om pl i c a t i on s . U S i n a c c ur a t e

i n d i a gn o s i s of s m al l b ow el

p er f or a t i on s .



1 7

M a O J

1 9 9 5

E v al u a t i on of h em o p er i t on e um u s i n g

a s i n gl e-v s m ul t i p

l e-v i ew

ul t r a s on o gr a ph i c ex ami n a t i on.

A c a d E m er gM e d

2 : 5 8 1 - 5 8 6

I I

C om p ar i s on of s i n gl e-v i ew ( r i g

h t i n t er c o s t al o b l i q u e ) wi t h m ul t i p

l e-

v i ew U S . S en s i t i v i t y gr e a t er wi t h m ul t i pl e

-v i ew U S ( 8 7 %v s 5 1 % ) .

S p e c i f i c i t y 1 0 0 %wi t h b o t h t e c h

ni q u e s .

N a g y K K

1 9 9 5

A s pi r a t i on of f r e e b

l o o d f r om t h e

p er i t on e al c av i t y d o

e s n o t m an d a t e

i mm e d i a t el a p ar o t o

m y .

A m S ur g e on 6 1 : 7

9 0 -7 9 5

I I

C om p ar i s on of a s pi r a t i on of gr o s s b l o o d onD P L t o a c t u al c l i ni c

al

r e s ul t s i n 5 6 6 p a t i en t s wh o s u s t ai n e d b l un t an d p en e t r a t i n g

a b d omi n al t r a um a.A s pi r a t i on of < 5 ml f r e e b l o o d a s s o c i a t e d w

i t h

>2 0 %n on- t h er a p e u t i c l a p ar o t om y r a t e.

B o ul an g er B R

1 9 9 5

A pr o s p e c t i v e s t u d

y of em er g en t

a b d omi n al s on o gr a

ph y af t er b l un t

t r a um a.

J T r a um a 3 9 : 3 2 5 - 3 3 0

I I

C om p ar i s on of U S wi t h D P L an

d C T f or d e t e c t i on of i n t r a p er i t on e al

f l ui d . U S p er f or m e d i nm e an t i m e of 2 . 6 mi n s wi t h 8 1 % s en s i t i v i t y ,

9 8 % s p e c i f i c i t y an d 9 6 % a c c ur

a c y . U S i s ar a pi d , a c c ur a t e

ex ami n a t i onf or i ni t i al ev al u a t i on of f r e ei n t r a p er i t on e al f ol l owi n g

B A T .

B o ul an g er B R

1 9 9 6

E m er g en t a b d omi n

al s on o gr a ph y a s

a s c r e eni n g t e s t i n

an ew d i a gn o s t i c

al g or i t h mf or b l un t

t r a um a.

J T r a um a4 0 : 8 6 7 - 8 7 4

I I

D e s c r i p t i on of a d i a gn o s t i c al g

or i t h m u s i n g U S i nB A T .

D o c um en t e d 9 4 % a c c ur a c y i n4 0 0 p a t i en t s s t u d i e d ; U S ex am

c om pl e t e d i n < 3 mi n s ( 8 2 % ) . U S i s ar a pi d an d a c c ur a t e

d i a gn o s t i c m o d al i t y .

G owK W

1 9 9 6

V al i d i t y of v i s u al i n s p e c t i on of

d i a gn o s t i c p er i t on e al l av a g ef l ui d .

C an J S ur g er y 3 9 : 1 1 4 -1 1 9

I I

D e t er mi n e pr e d i c t i v ev al u e of v i s u al i n s p e c t i on of D P L f l ui d f or

i d en t i f i c a t i on of i n t r a- a b d omi n al i n j ur y .V i s u al i n s p e c t i onf o un d

t o

h av e g o o d N P V ( 9 8 . 9 % ) b u t p o

or P P V ( 5 2 . 0 % ) .H em o d y n ami c

al l y

s t a b l e p a t i en t s wi t h ( + ) D P L b y v i s u al i n s p e

c t i on s h o ul d h av ef l ui d

t e s t e d b ef or e ex pl or a t or y l a p ar o

t om y .

H e al y MA

1 9 9 6

A pr o s p e c t i v e ev al u a t i on of

a b d omi n al ul t r a s o u

n d i n b l un t t r a um a:

I s i t u s ef ul ?

J T r a um a4 0 : 8 7 5 - 8 8 3

I I

A s s e s s m en t of a c c ur a c y of t e c

h ni c i an- p er f or m e d U S i n ev al u a

t i on

of 7 9 6 p a t i en t s wi t h B A T . U S

d em on s t r a t e d 8 8 .2 % s en s i t i v e ,

9 7 .7 % s p e c i f i c ,7 2 . 3 %P P V an

d 9 9 .2 %N P V .A c c ur a c y of U S

c on s i s t en t wi t h o t h er d i a gn o s t i c

m o d al i t i e s .

M c K enn e y M G

1 9 9 6

1 0 0 0 c on s e c u t i v e ul t r a s o un d s f or


J T r a um a4 0 : 6 0 7 - 6 1 0

I I

A s s e s s m en t of u t i l i t y of U S i n p

a t i en t s wi t h i n d i c a t i on s f or D P L or

C T . U S d em on s t r a t e d 8 8 % s e

n s i t i v i t y , 9 9 % s p e c i f i c i t y , 9 7 %

a c c ur a c y . ( + ) U S i nh em o d y n ami c al l y un s t a b l e p a t i en t s or i n t h e

pr e s en c e of d e c r e a s i n gh em a t o c r i t m an d a t e s ex pl or a t or y

l a p ar o t om y . C T s c anf ol l owi n g ( + ) U S i nh em o d y n ami c al l y s t a b

l e

p a t i en t s p er mi t s s el e c t i onf or n on- o p er a t i v em an a g em en t .

B r ann e y S W

1 9 9 7

U l t r a s o un d b a s e d k e y c l i ni c al

p a t h w a y r e d u c e s t h e u s e of h o s pi t al

r e s o ur c e s f or t h e e

v al u a t i on of b l un t


J T r a um a4 2 : 1 0 8 6 -1 0 9 0

I I

P r o s p e c t i v e ,n on-r an d omi z e d s t u d y of U S pr o t o c ol f or ev al u a t i on of

B A T c om p ar e d wi t h r e t r o s p e c t i v e c on t r ol s u s i n g C T an d D P L .

D e c r e a s e d u s e of D P L an d C T

b y 7 4 % an d 5 8 %r e s p e c t i v el y

wi t h o u t mi s s e d i n j ur i e s . U S s a

f e an d c o s t - ef f e c t i v e d i a gn o s t i c

m o d al i t y f or ev al u a t i on of B A T .

M c E l v e enT S

1 9 9 7

T h er ol e of ul t r a s on o gr a ph y i n b l un t

a b d omi n al t r a um a: a pr o s p e c t i v e

s t u d y .

A m S ur g e on 6 3 : 1

8 4 -1 8 8

I I

C om p ar i s on of s ur g e on- p er f or

m e d U S t o C T an d D P L i n 8 2

p a t i en t s wi t h B A T . U l t r a s o un d

f o un d t o b e 8 8 % s en s i t i v e , 9 8 %

s p e c i f i c , 9 6 % a c c ur a t e ; N P V =

9 7 % , p o s i t i v e pr e d i c t i v ev al u e ( P

P V )

= 9 3 %. U S a c c ur a t e an d m a y

b e p er f or m e d wi t h mi ni m al t r ai ni n g.



1 8

B l ow O

1 9 9 8

S p e e d an d ef f i c i en

c y i n t h e

r e s u s c i t a t i on of b l u

n t t r a um a p a t i en t s

wi t h m ul t i pl ei n j ur i e

s : t h e

a d v an t a g e

of d i a gn o s t i c p er i t o

n e al l av a g e ov er

a b d omi n al c om p u t e d t om o gr a ph y .

J T r a um a4 4 : 2 8 7 -2 9 0

I I

S en s i t i v i t y an d s p e c i f i c i t y of D P

L s i mi l ar t o C T s c ani n p a t i en t s

wi t h

h em o d y n ami c i n s t a b i l i t y , s ev er eT B I or m ul t i pl ei n j ur i e s .D P L i s

m or e ef f i c i en t an d m a y b e p er f or m e d wi t h l ow er c o s t .

L i v i n g s t onD H

1 9 9 8

A d mi s s i on or o b s e

r v a t i oni s n o t

n e c e s s ar y af t er an

e g a t i v e a b d omi n al

c om p u t e d t om o gr a

ph i c s c ani n

p a t i en t s wi t h s u s p e

c t e d b l un t

a b d omi n al t r a um a:

r e s ul t s of a

pr o s p e c t i v e ,m ul t i -i n s t i t u t i on al t r i al .

J T r a um a4 4 : 2 7 3 -2 8 2 .

I I

S t u d y d em on s t r a t e s 9 9 . 6 3 %n e

g a t i v e pr e d i c t i v ev al u e ( N P V ) f or C T

s c an p er f or m e d i n2 7 7 4 p a t i en t s f ol l owi n g b l un t a b d omi n al t r a um a

( B A T ) . C T s c an d e t e c t e d 2 2 / 2

5 h ol l owv i s c er al i n j ur i e s .P a t i en

t s

wi t h ( - ) C T s c anm a y b e s af el y

d i s c h ar g e d .

F i s c h er R P

1 9 7 8

D i a gn o s t i c p er i t on e

al l av a g e: f o ur t e en

y e ar s an d 2 , 5 8 6 p a

t i en t s l a t er .

A m J S ur g er y 1 3 6 : 7 0 1 -7 0 4

I I I

Or g an- s p e c i f i c a c c ur a c y of D P

L d o c um en t e d f or s pl e en ( 9 8 . 5 %

) ,

l i v er ( 9 7 .1 % ) , s m al l b ow el ( 9 1 . 3

% ) ,i n t r a p er i t on e al b l a d d er ( 6 6 .

7 % ) ,

an d d i a ph r a gm ( 5 9 .1 % ) . C om p

ar e d wi t h h i s t or i c al c on t r ol s ,D P

L

d e c r e a s e d r a t e of unn e c e s s ar y

l a p ar o t m y f r om1 3 % t o 6 % an d

d e c r e a s e d m or t al i t y f r om4 6 .4 %

t o 3 0 %.D e c r e a s e d m or t al i t y

pr e s um e d d u e t o d e c r e a s e d i n c i d en c e of mi s s e d i n j ur y wi t h c l i n

i c al

o b s er v a t i on al on e.

H u b b ar d S G

1 9 7 9

D i a gn o s t i c er r or s w

i t h p er i t on e al

l av a g ei n p a t i en t s w

i t h p el v i c

f r a c t ur e s .

A r c h S ur g er y 1 1 4 :

8 4 4 - 8 4 6

I I I

A c c ur a c y of D P L s i gni f i c an t l y r e d u c e d i n t h e pr e s en c e of a p el v

i s

f r a c t ur e.A d d i t i on al d i a gn o s t i c

t e s t s r e c omm en d e d

i n

h em o d y n ami c al l y s t a b l e p a t i en t s wi t h p el v i s f r a c t ur e an d ( + ) D P L .

B a gw el l C E

1 9 8 0

B l un t a b d omi n al t r a um a: ex pl or a t or y

l a p ar o t om y or p er i t on e al l av a g e?

A m J S ur g er y 1 4 0 : 3 6 8 - 3 7 3

I I I

D P L s h o ul d b e c on s i d er e d m an

d a t or y i nh em o d y n ami c al l y s t a b l e

p a t i en t s wi t h al t er e d m en t al s t a

t u s or m ul t i pl ei n j ur i e s .

R o b b s J V

1 9 8 0

B l un t a b d omi n al t r a um awi t h j e j un al

i n j ur y : ar ev i ew.

J T r a um a2 0 : 3 0 8 - 3 1 1

I I I

C l i ni c al f i n d i n g s of p ai n , t en d er n e s s , g u ar d i n g , a b s en t b ow el

s o un d s , an d h y p ov ol emi a c or r e

l a t ewi t h j e j un al i n j ur

y .

P ar a s c en t e s i s ( i . e.f o ur - q u a d r an t a s pi r a t i on ) r e c omm en d e d i n

p a t i en t s wi t h m ul t i pl ei n j ur i e s , c

on c omi t an t c l o s e d h e a d i n j ur y , o

r

i m p ai r e d l ev el of c on s c i o u s n e s s .I f p ar a s c en t e s i s i s n e g a t i v e ,D

P L

i s i n d i c a t e d .

S h er w o o d R

1 9 8 0

Mi ni l a p ar o s c o p y f o

r b l un t a b d omi n al

t r a um a.


6 7 2 - 6 7 3

I I I

Mi ni -l a p ar o s c o p y al l ow s d i r e c t v i s u al i z a t i on of t h e ex t en t an d

s o ur c e of h em or r h a g ei nB A T p

a t i en t s wi t h ( 1 ) al t er e d s en s or i um ,

( 2 ) m ul t i - s y s t em t r a um a , ( 3 ) un

ex pl ai n e d h y p o t en s i on , or ( 4 )

e q ui v o c al f i n d i n g s onP E .I n a

d d i t i on , t h e c l i ni c al i m p or t an c e o

f

i n t r a- a b d omi n al h em or r h a g em

a y b e d e t er mi n e d .

W ar d R E

1 9 8 1

S t u d y an d m an a g e

m en t of b l un t

t r a um ai n t h ei mm e d i a t e p o s t -i m p a c t

p er i o d .

R a d C l i nN A 1 9 : 3

-7

I I I

S pl an c h ni c an gi o gr a ph y s h o ul d

b e c on s i d er e d a s a

c om pl em e

n t t o

D P L i n p a t i en t s wi t h ( 1 ) p el v i s f r a c t ur e s , ( 2 ) i n d i c a t i on s f or t h or a

c i c

a or t o gr a ph y , an d ( 3 ) p er pl ex i n g

a b d omi n al f i n d i n g s .



1 9

A l y on oD

1 9 8 2

S i gni f i c an c e of r e p e a t i n g d i a gn o s t i c


S ur g er y 9 1 : 6 5 6 - 6 5 9

I I I

R e p e a t D P L p er f or m e d a t 1 -2

h r s h a s ah i gh d e gr e e of s en s i t i v

i t y ,

s p e c i f i c i t y an d a c c ur a c y i n p a t i en t s wi t h i n d e t er mi n a t ei ni t i al D P L

( i . e.D P L -R B C = 5 0 -1 0 0 K / mm 3 ; D P L -WB C =1 0 0 - 5 0 0 / mm 3 ) .

S mi t h S B

1 9 8 2

A b d omi n al t r a um a: t h el i mi t e d r ol e of


A m S ur g e on4 8 : 5 1 4 - 5 1 7

I I I

H i gh d e gr e e of a c c ur a c y d em on s t r a t e d wi t h P E i n p a t i en t s c a p a

b l e

of ar el i a b l eP E .D P L i s v er y s e

n s i t i v e an d i s a s s o c i a t e d wi t h ah

i gh

n on- t h er a p e u t i c l a p ar o t m y r a t e

B er c i G

1 9 8 3

E m er g en c y mi ni l a p

ar o s c o p y i n


A n u p d a t e.

A m J S ur g er y 1 4 6 : 2 6 1 -2 6 5

I I I

L a p ar o s c o p y s af er ,f a s t er , an d

m or e a c c ur a t e t h anD P L .

I d en t i f i c a t i on of i n t r a- a b d omi n al b l o o d wi t h o u t ani d en t i f i e d i n j ur y

p er mi t s n on- o p er a t i v em an a g em en t an d d e c r e a s e s t h er a t e of

unn e c e s s ar y ex pl or a t or y l a p ar o t omi e s .

B ur n e y R E

1 9 8 3

D i a gn o s i s of i s ol a t e d s m al l b ow el

i n j ur y f ol l owi n g b l un t a b d omi n al

t r a um a.

A nnE m er gM e d 1

2 : 7 1 -7 4

I I I

A b d omi n al p ai nw a s a uni v er s a

l s y m p t omi n p a t i en t s wh o

c omm uni c a t e. O t h er pr e d i c t i v e

f i n d i n g s onP E i n c l u d e d d i f f u s e

a b d omi n al t en d er n e s s , a b d omi n al r i gi d i t y , an d a b s en c e of b ow

el

s o un d s .D P L w a s t h em o s t s en s i t i v e d i a gn o s t i c m o d al i t y f or s m

al l

b ow el i n j ur y .

S o d er s t r om C A

1 9 8 3

T h e d i a gn o s i s of i n

t r a- a b d omi n al

i n j ur y i n p a t i en t s wi t h c er v i c al c or d

t r a um a.

J T r a um a2 3 : 1 0 6 1

-1 0 6 5

I I I

A l l s i gni f i c an t i n t r a- a b d omi n al i n j ur i e s d i a gn o s e d b y D P L i n p a t i en t s

wi t h c er v i c al c or d i n j ur i e s .R e c

omm en d D P L t o ex c l u d ei n t r a

-

a b d omi n al i n j ur y i nB A T p a t i en t s wi t h c on c omi t an t c er v i c al c or d

i n j ur i e s .

B er r y T K

1 9 8 4


al l av a g ei n b l un t

t r a um a p a t i en t s wi t h c o a g ul o p a t h y .

A nnE m er gM e d 1

3 : 8 7 9 - 8 8 0

I I I

A c c ur a c y of D P L n o t d i mi ni s h e

d b y pr e s en c e of c o a g ul o p a t h y .

E x pl or a t or y l a p ar o t om y i s i n d i c a

t e d i n p a t i en t s wi t h ( + ) D P L wi t h

p o s t - t r a um a t i c c o a g ul o p a t h y .

M u s t ar d R A

1 9 8 4

B l un t s pl eni c t r a um

a: d i a gn o s i s an d

m an a g em en t .

C an J S ur g er y 2 7 :

3 3 0 - 3 3 3

I I I

D P L d i a gn o s t i c i n 8 6 p a t i en t s w

i t h s pl eni c i n j ur y d o c um en t e d b y

ex pl or a t or y l a p ar o t om y .

M c L el l anB A

1 9 8 5

A n al y s i s of p er i t on e al l av a g e

p ar am e t er s i n b l un t a b d omi n al

t r a um a.

J T r a um a2 5 : 3 9 3 - 3 9 9

I I I

B a s e d on s i gni f i c an t n um b er of t h er a p e u t i c l a p ar o t o omi s ,D P L R B C

c o un t >2 0 K / mm 3 r e c omm en d e d a s i n d i c a t i onf or ex pl or a t or y

l a p ar o t om y .

T r o o s k i n S Z

1 9 8 5

P er i t on e al l av a g ei n

p a t i en t s wi t h

n or m al m en t a t i on a

n d h em a t ur i a af t er

b l un t t r a um a.

S , G & O1 6 0 : 1 4 5 -1 4 7

I I I

D P L r ev e al s i n j ur i e s wh i c h r e q u

i r e s ur g er y i n4 5 % of B A T p a t i en t s

wi t h n or m al m en t a t i on an d h em

a t ur i a.D P L r e c omm en d e d i n

p a t i en t s wi t h B A T wh o pr e s en t

wi t h h em a t ur i ai n t h e pr e s en c e o

f

n or m al n e ur ol o gi c ex ami n a t i on.

V anD on g en

L M

1 9 8 5

P er i t on e al l av a g ei n c l o s e d

a b d omi n al i n j ur y .

I n j ur y 1 6 : 2 2 7 -2 2 9

I I I

D P L m a y b e ov er l y s en s i t i v ei n


W e b s t er V J

1 9 8 5

A b d omi n al t r a um a: pr e- o p er a t i v e

a s s e s s m en t an d p o s t o p er a t i v e

pr o b l em s i n j n t en s i v e c ar e.

A n a e s t & I n t C ar e

1 3 : 2 5 8 -2 6 2

I I I

C T s c anh a s s i gni f i c an t l y i m p a

c t e d t h e u s e of o t h er d i a gn o s t i c

m o d al i t i e s i n t h e ev al u a t i on of h

em o d y n ami c al l y s t a b l e p a t i en t s w

i t h

B A T .



2 0

R y an J J

1 9 8 6

C r i t i c al an al y s i s of o p en p er i t on e al

l av a g ei n b l un t a b d

omi n al t r a um a.

A m J S ur g er y 1 5 1 : 2 2 1 -2 2 3

I I I

F al s e p o s i t i v er a t ef or p er i t on e

al l av a g eh i gh er t h an pr ev i o u s l y

r e p or t e d ( s en s i t i v i t y = 8 3 % ) r e s ul t i n gi n2 7 %n on

- t h er a p e u t i c

l a p ar o t om y r a t e.

K an eN M

1 9 8 7

E f f i c a c y of C T f ol l o

wi n g p er i t on e al

l av a g ei n a b d omi n a

l t r a um a.

J C om pA s s t T om o1 1 : 9 9 8 -1 0 0 2

I I I

C T r ev e al e d s u b s t an t i al i n t r a- a b d omi n al or r e t r o p er i t on e al i n j ur i e s

i n1 / 3 p a t i en t s wh o un d er w en t C

T f ol l owi n gD P L . C T

r e c omm en d e d wh en c l i ni c al s t a

t u s e q ui v o c al r e g ar d l e s s of D P L

r e s ul t s .

P a t t y nP

1 9 8 9

P er i t on e al l av a g e a

f t er a b d omi n al

t r a um a: i n d i c a t i on s

, t e c h ni q u e ,

r e s ul t s .

I n t S ur g er y 7 4 : 1 7 -1 9

I I I

B a s e d onh i gh s en s i t i v i t y ( f al s e

n e g a t i v er a t e=1 % ) an d l ow

i n c i d en c e of c om pl i c a t i on s ( 0 . 5

% ) ,D P L r e c omm en d e d f or t h e


W eni n g J V

1 9 8 9

E v al u a t i on of ul t r a s

o un d ,l av a g e , an d


ph y i n b l un t


S ur gE n d o s c o p y 3

: 1 5 2 -1 5 8

I I I

D em on s t r a t e d 8 4 % s en s i t i v i t y a

n d 9 7 % s p e c i f i c i t y f or U S i n

ev al u a t i on of B A T . U S i s ar el i a b l e ,f a s t an d r e p e a t a b l e d i a gn o s

t i c

m o d al i t y .

C er al d i C M

1 9 9 0

C om p u t er i z e d t om o gr a ph y a s an

i n d i c a t or of i s ol a t e d

m e s en t er i c i n j ur y .

A c om p ar i s onwi t h


A m S ur g e on 5 6 1 : 8 0 6 - 8 1 0

I I I

S en s i t i v i t y of C T i n a d e q u a t e t o

r el i a b l y ex c l u d em e s en t er i c i n j ur y .

D P L r e c omm en d e d a s am or e s en s i t i v e d i a gn o s t i c m o d al i t y .

D ’ A m el i oL F

1 9 9 0

A r e a s s e s s m en t of

t h e p er i t on e al

l av a g el e uk o c y t e c o un t i n b l un t


J T r a um a 3 0 : 1 2 9 1

-1 2 9 3

I I I

E l ev a t e d D P L f l ui d WB C c o un t ( > 5 0 0 / mm

3 ) h a s on d i a gn o s t i c

v al u ei n t h e e ar l y ( <4 h r s ) p o s t

-i n j ur y p er i o d .I s ol a t e d el ev a t i on of

D P L WB C c o un t m a y b em or e

u s ef ul i n d el a y e d s e t t i n g

or i n t h e

pr e s en c e of e q ui v o c al P E .

D av i s J W

1 9 9 0

C om pl i c a t i on s i n ev al u a t i n g


d i a gn o s t i c

p er i t on e al l av a g ev er s u s

c om p u t er i z e d ax i al t om o gr a ph y .

J T r a um a 3 0 : 1 5 0 6

-1 5 0 9

I I I

S i gni f i c an t l y l ow er c om pl i c a t i on

r a t ef or D P L c om p ar e d t o C T s c an

( 0 . 9 %v s 3 .4 % ) wi t h n o d i f f er en

c ei n pr ev en t a b l e d e a t h s .

H enn em anP L

1 9 9 0


al l av a g e:

a c c ur a c y i n pr e d i c t

i n gn e c e s s ar y

l a p ar o t om y f ol l owi n

g b l un t an d

p en e t r a t i n g t r a um a

.

J T r a um a 3 0 : 1 3 4 5

-1 3 5 5

I I I

S emi - o p enD P L 9 6 % a c c ur a t e

f or pr e d i c t i on of n e e d f or ex pl or

a t or y

l a p ar o t om y i nB A T an d 9 2 % a c

c ur a t ei n t h e pr e s en c e of p el v i c

f r a c t ur e.

H awk i n s ML

1 9 9 0

I s d i a gn o s t i c p er i t o

n e al l av a g ef or

b l un t t r a um a o b s ol e t e?

A m S ur g e on 5 6 : 9 6 - 9 9

I I I

E a s e , s af e t y ( 1 % c om pl i c a t i onr a t e ) an d a c c ur a c y of D P L

( 9 7 % )

j u s t i f y c on t i n u e d u s ei n ev al u a t i on of B A T .

J a c o b s D G

1 9 9 0

P er i t on e al l av a g ew

h i t e c o un t : a

r e a s s e s s m en t .

J T r a um a 3 0 : 6 0 7 - 6 1 2

I I I

I s ol a t e d el ev a t i on of D P L WB C

c o un t > 5 0 0 / mm

3 n o t s p e c i f i c

f or

d i a gn o s i s of i n t r a- a b d omi n al i n

j ur y . S p e c i f i c i t y i n c r e a s e s wi t h

r e p e a t D P L .



2 1

L an gE K

1 9 9 0

I n t r a- a b d omi n al an d r e t r o p er i t on e al

or g ani n j ur i e s d i a gn

o s e d on d y n ami c


m s o b t ai n e d f or

a s s e s s m en t of r en al t r a um a.

J T r a um a 3 0 : 1 1 6 1

-1 1 6 8

I I I

C T s c anh el pf ul i n t h e d i a gn o s i s of un s u s p e c t e d a b d omi n al or

r e t r o p er i t on e al i n j ur i e s i n t h e ev al u a t i on of p a t i en t s f or r en al t r a um

a.

P a t i en t s wi t h ( - ) C T m a y b e s af el y o b s er v e d .

M a t s u b ar aT K

1 9 9 0

C om p u t e d t om o gr a

ph y of a b d om en

( C T A ) i nm an a g em

en t of b l un t


J T r a um a 3 0 : 4 1 0 -4 1 4

I I I

C T i s av al u a b l e d i a gn o s t i c m o

d al i t y i nh em o d y n ami c al l y s t a b l e

p a t i en t s wi t h B A T i f p er f or m e d

c or r e c t l y an d i n t er pr e t e d a c c ur a t

el y .

P a t i en t s wi t h ( - ) C T s h o ul d b e a

d mi t t e d f or o b s er v a t i on.

M e gi s on S M

1 9 9 0

T h ev al u e of al k al i n

e ph o s ph a t a s ei n


A nnE m er gM e d 1 9 : 5 0 3 - 5 0 5

I I I

M e a s ur em en t of al k al i n e ph o s ph a t a s ei nD P L f l ui d a d d s n o

d i a gn o s t i c a d v an t a g ei ni d en t i f i c a t i on of i n t e s t i n al i n j ur y .

S o y k a J M

1 9 9 0


al l av a g e: i s an

i s ol a t e d WB C c o un

t gr e a t er t h an or

e q u al t o 5 0 0 / mm 3 pr e d i c t i v e of i n t r a-

a b d omi n al i n j ur y r e

q ui r i n g c el i o t om y

i n b l un t t r a um a p a t i en t s ?

J T r a um a 3 0 : 8 7 4 - 8 7 9

I I I

I s ol a t e d el ev a t i on of D P L WB C

c o un t > 5 0 0 / mm

3 s h o ul d n o t b

e an

i n d i c a t i onf or ex pl or a t or y l a p ar o t om y i nB A T .

B ar b a C

1 9 9 1

I s p o s i t i v e d i a gn o s t i c p er i t on e al

l av a g e an a b s ol u t e

i n d i c a t i onf or

l a p ar o t om y i n al l p a

t i en t s wi t h b l un t

t r a um a?


4 4 2 -4 4 5

I I I

I mm e d i a t e ex pl or a t or y l a p ar o t om

y n o t n e c e s s ar i l y m an d a s t e d i n

t h e

pr e s en c e of ( + ) D P L .A d d i t i on al d i a gn o s t i c s t u d i e s s h o ul d b e

c on s i d er e d i nh em o d y n am

i c al l y s t a b l e p a t i en t s wi t h ( + ) D P L .

B er c i G

1 9 9 1

E m er g en c y L a p ar o

s c o p y .

A m J S ur g er y 1 6 1 : 3 3 2 - 3 3 5

I I I

D i a gn o s t i c l a p ar o s c o p y ( D L ) i s

av i a b l e d i a gn o s t i c m o d al i t y i n t h e

ev al u a t i on of B A T .D L l ow er s i n c i d en c e of n on

- t h er a p e u t i c

ex pl or a t or y l a p ar o t om y .

D av i s J W

1 9 9 1

B a s e d ef i c i t a s ani n d i c a t or of

s i gni f i c an t a b d omi n

al i n j ur y .

A nnE m er gM e d 2 0 : 8 4 2 - 8 4 4

I I I

B a s e d ef i c i t ( B D ) <- 6 . 0 i s a s en s i t i v ei n d i c a t or of i n t r a- a b d om

i n al

i n j ur y i nB A T .D P L or C T r e c omm en d e d f or p a t i en t s wi t h

B D

<- 6 . 0 .

D eM ar i aE J

1 9 9 1

M an a g em en t of p a t i en t s wi t h

i n d e t er mi n a t e d i a gn o s t i c p er i t on e al

l av a g er e s ul t s f ol l owi n g b l un t t r a um a.

J T r a um a 3 1 : 1 6 2 7

-1 6 3 1

I I I

I n d e t er mi n a t eD P L c or r el a t e s w

i t h i n j ur i e s t h a t m a y b em an a g e d

n on- o p er a t i v el y . C T r e c omm en

d e d f ol l owi n gi n d e t e

r mi n a t eD

P L

r a t h er t h anr e p e a t D P L .

F r y er J P

1 9 9 1


al l av a g e a s an

i n d i c a t or f or t h er a p e u t i c s ur g er y .


4 7 1 -4 7 6

I I I

S i x t y -f i v e p er c en t ( 6 5 % ) of p a t i en t s wh o un d er w en t ex pl or a t or y

l a p ar o t om y f or ( + ) D P L h a d t h er a p e u t i c l a p

ar o t mi e s .

M c A n en a O J

1 9 9 1

C on t r i b u t i on s of p e

r i t on e al l av a g e

enz y m e d e t er mi n a t i on s t o t h e

m an a g em en t of i s o

l a t e d h ol l ow

v i s c er al a b d omi n al

i n j ur i e s .

A nnE m er gM e d 2 0 : 8 3 4 - 8 3 7

I I I

E l ev a t i on of D P L f l ui d am y l a s e

i s h i gh l y s p e c i f i c f or i s ol a t e d s m al l

b ow el i n j ur y .R e c omm en d r o u t i n e enz y m e d e t er mi n a t i on s f or D

P L

ef f l u en t a s am ar k er f or s m al l b

ow el i n j ur y .



2 2

M c A n en a O J

1 9 9 1

P er i t on e al l av a g e e

nz y m e

d e t er mi n a t i on s f ol l o

wi n g b l un t an d

p en e t r a t i n g a b d omi n al t r a um a.

J T r a um a 3 1 : 1 1 6 1

-1 1 6 4

I I I

E l ev a t e d am y l a s e an d

al k al i n e

ph o s ph a t a s el ev el s i nD P L f l ui d

i n c r e a s e s i n d ex of s u s pi c i onf or pr e s en c e of a s m al l b ow el i n j ur y i n

p a t i en t s wi t h ( - ) D P L b y R B C c o un t .

M ur eA J

1 9 9 1

S er um am y l a s e d e t er mi n a t i on an d

b l un t a b d omi n al t r a

um a.

A m S ur g e on 5 7 : 2 1 0 -2 1 3

I I I

S er um am y l a s eh a s p o or s en s i t i v i t y , s p e c i f i c i t y an d P P V f or t h e

d i a gn o s i s of i n t r a- a b d omi n al i n j ur y .R o u t i n e s er um am y l a s eh a s n o

v al u ei n t h e ev al u a t i on of B A T .

P er ez F G

1 9 9 1

E v al u a t i on of t h e a b d om eni n

i n t ox i c a t e d p a t i en t s

: i s c om p u t e d

t om o gr a ph y s c an o

r p er i t on e al l av a g e

al w a y s i n d i c a t e d ?

A nnE m er gM e d 2 0 : 5 0 0 - 5 0 2

I I I

L e g al l y i n t ox i c a t e d p a t i en t s wi t h

n or m al m en t a t i onm a y b er el i a b l y

a s s e s s e d b y ph y s i c al ex ami n a t i on.E l ev a t e d s er um e t h an ol d o e s

n o t m an d a t e C T or D P L .

S ah d ev P

1 9 9 1

E v al u a t i on of l i v er f

un c t i on t e s t s i n

s c r e eni n gf or i n t r a- a b d omi n al i n j ur i e s .

A nnE m er gM e d 2 0 : 8 3 8 - 8 4 1

I I I

E l ev a t e d l i v er f un c t i on t e s t s a s s

o c i a t e d wi t h i n j ur y t o t h el i v er .

P a t i en t s wi t h el ev a t e d l i v er f un c

t i on t e s t s s h o ul d un d er g o C T s c an.

D a y A C

1 9 9 2


al l av a g e:

i n t e gr a t i onwi t h c l i n

i c al i nf or m a t i on t o

i m pr ov e d i a gn o s t i c

p er f or m an c e.

J T r a um a 3 2 : 5 2 - 5

7

I

C om b i n a t i on of c l i ni c al ev al u a t i on an d D P L r e d u c e s r a t e of n on

-

t h er a p e u t i c l a p ar o t omi e s , b u t i n

c r e a s e s t h en um b er of mi s s e d

i n j ur i e s .T h eh i gh e s t a c c ur a c y ( 9 5 % ) i s o b t ai n e d b y c om b i n a t i on of

c i r c ul a t or y a s s e s s m en t an d D P L .

D r i s c ol l P

1 9 9 2


al l av a g e: i t ’ s r e d

b u t i s i t p o s i t i v e?

I n j ur y 2 3 : 2 6 7 -2 6 9

I I I

V i s u al a s s e s s m en t of D P L f l ui d

R B C - c o un t i n a c c ur a t e.

K n u d s onMM

1 9 9 2

H em a t ur i a a s a pr e

d i c t or of

a b d omi n al i n j ur y af

t er b l un t t r a um a.

A m J S ur g er y 1 6 4 : 4 8 2 -4 8 5

I I I

H em a t ur i ai s am ar k er f or r en al

or ex t r a

-r en al i n t r a- a b d omi n al

i n j ur y . C T r e c omm en d e d i n t h e

pr e s en c e of h em a t ur i awi t h s h o

c k .

P a t t i m or eD

1 9 9 2

T or s oi n j ur y p a t t er n

s an d

m e c h ani s m s i n c ar c r a s h e s : an

a d d i t i on al d i a gn o s t i c t o ol .

I n j ur y 2 3 : 1 2 3 -1 2 6

I I I

I n j ur i e s t o t h e s pl e en ,l i v er , p el v

i s an d a or t am or el i k el y wi t h s i d e

i m p a c t c om p ar e d t of r on t i m p a c t c ol l i s i on s .

W y a t t J P

1 9 9 2

V ar i a t i on am on g t r a

i n e e s ur g e on s i n

i n t er pr e t i n g d i a gn o s t i c p er i t on e al

l av a g ef l ui d i n b l un t a b d omi n al

t r a um a.

J R o y al C ol l S ur g ( E d i n ) 3 7 : 1 0 4 -1 0 6

I I I

E s t i m a t i on of D P L R B C - c o un t

b y v i s u al i n s p e c t i oni n a c c ur a t e

c om p ar e d t omi c r o s c o pi c an al y s i s .R e c omm en d q u an t i t a t i v e c e

l l

c o un t v s v i s u al a s s e s s m en t of D P L f l ui d t o m ak e d e c i s i on on

m an a g em en t .

B ar onB J

1 9 9 3

N on o p er a t i v em an a

g em en t of b l un t


t h er ol e of

s e q u en t i al d i a gn o s t i c p er i t on e al

l av a g e , c om p u t e d t

om o gr a ph y , an d

an gi o gr a ph y .

A nnE m er gM e d 2 2 : 1 5 5 6 -1 5 6 2

I I I

C om b i n e d m o d al i t i e s of C T s c a

n an d an gi o gr a ph y i n

h em o d y n ami c al l y s t a b l e p a t i en t s wi t h ( + ) D P L r e d u c e s t h en on

-

t h er a p e u t i c l a p ar o t om y r a t e.



2 3

B o d eP J

1 9 9 3

A b d omi n al ul t r a s o u

n d a s ar el i a b l e

i n d i c a t or f or c on c l u

s i v el a p ar o t om y i n


um a.

J T r a um a 3 4 : 2 7 - 3

1

I I I

U S d em on s t r a t e d h i gh s en s i t i v i t y ( 9 2 . 8 % ) an d s p e c i f i c i t y ( 1 0 0 %

) .

R o u t i n e U S r e c omm en d e d f or 1

) a b d omi n al f i n d i n g s n o t i ni t i al l y

f el t

t ow ar r an t i mm e d i a t el a p ar o t om

y ,2 ) e q ui v o c al r e s ul t s oni ni t i al U

S ,

3 ) d e t er i or a t i n g c l i ni c al s i t u a t i on

.

V i s v an a t h anR

1 9 9 3

B l un t a b d omi n al t r a um a-i n j ur y

a s s e s s m en t i nr el a t i on t o e ar l y

s ur g er y .

J R o y al C ol l S ur g ( E d i n ) 3 8 : 1 9 -2 2

I I I

D P L h i gh l y s en s i t i v e ( 9 5 % ) wi t h

8 1 % s p e c i f i c i t y an d 8 9 % a c c ur a c y .

C om b i n a t i on of D P L an d U S f a c i l i t a t e s e ar l y a s s e s s m en t an d

m an a g em en t of a b d omi n al i n j ur i e s .

M en d ez C

1 9 9 4

D i a gn o s t i c a c c ur a c

y of p er i t on e al

l av a g ei n p a t i en t s w

i t h p el v i c

f r a c t ur e s .


4 7 7 -4 8 1

I I I

R e gi s t r y s t u d y of 2 8 6 o p enD P L

s p er f or m e d i n p a t i en t s wi t h B A T i n

t h e pr e s en c e of a p el v i s f r a c t ur e. O p enD P L a c c ur a t em o d al i t y

( 9 4 % s en s i t i v i t y ; 9 9 % s p e c i f i c i t y ) f or ev al u a t i on of p a t i en t s wi t h

m ul t i pl ei n j ur i e s ,i n c l u d i n g p el v i s f r a c t ur e s .

T i b b s P A

1 9 8 0

D i a gn o s i s of a c u t e

a b d omi n al i n j ur i e s

i n p a t i en t s wi t h s pi n al s h o c k : v al u e of

d i a gn o s t i c p er i t on e al l av a g e.

J T r a um a2 0 : 5 5 - 5

7

I I I

D P L r e c omm en d e d f or ex c l u s i o

n of i n t r a- a b d omi n al i n j ur i e s i n

s pi n al c or d i n j ur e d p a t i en t s wi t h

c om pl e t en e ur ol o gi c d ef i c i t .

B ar onB J

1 9 9 3

N on o p er a t i v em an a

g em en t of b l un t


t h er ol e of

s e q u en t i al d i a gn o s t i c p er i t on e al

l av a g e , c om p u t e d t om o gr a ph y , an d

an gi o gr a ph y .

A nnE m er gM e d 2 2 : 1 5 5 6 -1 5 6 2

I I I

C om b i n e d m o d al i t i e s of C T s c a

n an d an gi o gr a ph y i n

h em o d y n ami c al l y s t a b l e p a t i en t s wi t h ( + ) D P L r e d u c e s t h en on

-

t h er a p e u t i c l a p ar o t om y r a t e.

M en d ez C

1 9 9 4

D i a gn o s t i c a c c ur a c

y of p er i t on e al

l av a g ei n p a t i en t s wi t h p el v i c

f r a c t ur e s .


4 7 7 -4 8 1

I I I

R e gi s t r y s t u d y of 2 8 6 o p enD P L

s p er f or m e d i n p a t i en t s wi t h B A T i n

t h e pr e s en c e of a p el v i s f r a c t ur e. O p enD P L a c c ur a t em o d al i t y

( 9 4 % s en s i t i v i t y ; 9 9 % s p e c i f i c i t y ) f or ev al u a t i on of p a t i en t s wi t

h

m ul t i pl ei n j ur i e s ,i n c l u d i n g p el v i s f r a c t ur e s .

Gr i e s h o pN A

1 9 9 5

S el e c t i v e u s e of c o

m p u t e d

t om o gr a ph y an d d i a gn o s t i c p er i t on e al

l av a g ei n b l un t a b d omi n al t r a um a.

J T r a um a 3 8 : 7 2 7 -

7 3 1

I I I

R e gi s t r y r ev i ew of 9 5 6 h em o d y n ami c al l y s t a b l e p a t i en t s wi t h

r el i a b l en e ur ol o gi c ex ami n a t i on s ( G C S >1 1 ) .P a t i en t s wi t h

a b n or m al P E , c h e s t i n j ur y or gr o s s h em a t ur i ah av eh i gh i n c i d en c e

of i n t r a- a b d omi n al i n j ur y wh i c h

r e q ui r e ex pl or a t or y l a p ar o t om y .N o

C T r e q ui r e d i n p a t i en t s wi t h n or

m al P E ,n o c h e s t i n j ur y an d n o

h em a t ur i a.E l ev a t e d b l o o d al c o

h ol d o e s n o t al t er a c c ur a c y of P E .

N ol anB W

1 9 9 5

M e s en t er i c i n j ur y f r om b l un t


A m S ur g e on 6 1 : 5 0 1 - 5 0 6

I I I

R ev i ew of 2 7 p a t i en t s wi t h m e s en t er i c i n j ur y f ol l owi n gB A T . C T

p er f or m e d i n1 0 p a t i en t s ; f ai l e d

t o d e t e c t m

e s en t er i c i n j ur y i n7

.

H i gh i n d ex of s u s pi c i onr e q ui r e d t oi d en t i f y p a t i en t s wi t h m e s en t er i c

i n j ur y . C T s c ani s i n s uf f i c i en t d

i a gn o s t i c m o d al i t y f or t h i s i n j ur y

an d

m a y r e s ul t i nmi s s e d i n j ur i e s t o

m e s en t er y an d s m al l b ow el .



2 4

C h an d l er C F

1 9 9 7

S e a t b el t s i gnf ol l ow

i n g b l un t t r a um ai s

a s s o c i a t e d wi t h i n c r e a s e d i n c i d en c e

of a b d omi n al i n j ur y .

A m S ur g e on 6 3 : 8 8 5 - 8 8 8

I I I

E v al u a t i on of s e a t b el t s i gn ( S B S

) a s pr e d i c t or of i n t r a

- a b d omi al

i n j ur y i n1 4 p a t i en t s . S en s i t i v i t y

f or s ol i d v i s c er al i n j ur i e s w a s 8 5

%

an d 1 0 0 %wi t h C T c an an d D P

L r e s p e c t i v el y ; s en s i t i v i t y f or h ol l ow

v i s c er al i n j ur i e s w a s 3 3 % an d 1

0 0 %r e s p e c t i v el y .N e g a t i v e C T

s c ani n p a t i en t s wi t h S B S m an d

a t e s a d mi s s i on an d o b s er v a t i on.

F r e ef l ui d on C T s c anw ar r an t s

f ur t h er i nv e s t i g a t i on ( i . e.D P L or

ex pl or a t or y l a p ar o t om y ) .

K er n S J

1 9 9 7

S on o gr a ph i c ex ami n a t i on of

a b d omi n al t r a um a b

y s eni or s ur gi c al

r e s i d en t s .

A m S ur g e on 6 3 : 6 6 9 - 6 7 4

I I I

E v al u a t i on of f o c u s e d a b d omi n al s on o gr a ph y f or t r a um a ( F A S T )

f ol l owi n gP E i n 5 1 8 p a t i en t s ( 9 2

.4 % b l un t / 7 . 6 % p en e t r a t i n g

) .

F A S T ex ami n a t i on7 3 . 3 % s en s i t i v e , 9 7 . 5 % s p e c i f i c wi t h 9 8 . 3 %N P V

an d 9 6 .1 %P P V .L ow s en s i t i v i t

y d u e t omi s s e d h ol l owv i s c er al

i n j ur i e s .

M c K enn e y K L

1 9 9 7

C o s t r e d u c t i on u s i n

g ul t r a s o un d i n


um a.

E m er gR a d i ol o g y 4

: 3 - 6

I I I

C om p ar i s on of 6 2 6 p a t i en t s ( G

r o u p1 ) ev al u a t e d wi t h C T an d D

P L

wi t h 5 6 4 p a t i en t s ( Gr o u p2 ) . U s

e of D P L an d C T d e c r e a s e d b y

9 4 % an d 6 3 %r e s p e c t i v el y i n Gr o u p2 .D e c r e a s e d c o s t / p a t i en t b y

$ 1 7 0 .R e c omm en d U S a s t h ei ni t i al d i a gn o s t i c t e s t of c h oi c ei n

B A T wi t h unr el i a b l eP E . U S r e pl a c e s D P L an d al l ow s m or e

r e s o ur c e- ef f i c i en t u s e of C T s c an.

P or t er R S

1 9 9 7

U s e of ul t r a s o un d t o d e t er mi n en e e d

f or l a p ar o t om y i n t r a um a p a t i en t s .

A nnE m er gM e d 2 9

: 3 2 3 - 3 3 0

I I I

R e t r o s p e c t i v er ev i ew of t e c h ni c i an- p er f or m e d U S i n1 6 3 1 p a t i

en t s

wi t h o u t c on t r ol s . S en s i t i v i t y an d

s p e c i f i c i t y of U S 9 3 % an d 9 0 %

r e s p e c t i v el y . U S s af e an d c o s t

- ef f e c t i v e d i a gn o s t i c m o d al i t y i n

t h e


S c h ur i nk GW

1 9 9 7

T h ev al u e of ph y s i c

al ex ami n a t i oni n

t h e d i a gn o s i s of p a t i en t s wi t h b l un t


ar e t r o s p e c t i v e

s t u d y .

I n j ur y 2 8 : 2 6 1 -2 6 5

I I I

R e t r o s p e c t i v e s t u d y of ph y s i c al

ex ami n a t i on ( P E ) i n2 0 4 p a t i en t s

wi t h B A T .P a t i en t s wi t h i s ol a t e d T B I ,l ow

-i m p a c t r i b p ai n ,i s ol a

t e d

a b d omi n al t r a um am a y b e ev al u

a t e d wi t h P E pl u s ul t r a s o un d ( U S )

wi t h > 8 5 %N P V .H i gh er i n c i d e

n c e of i n t r a- a b d omi n al i n j ur y i n

t h e

pr e s en c e of l owr i b f r a c t ur e s an

d h i gh - en er g y i m p a c t , t h er ef or e

f ol l ow- u p C T s c anr e c omm en d e d i n pr e s en c e of n or m al U S .

S h er b o ur n e C D

1 9 9 7

V i s c er al i n j ur y wi t h o u t

h em o p er i t on e um: a

l i mi t a t i on of

s c r e eni n g a b d omi n al s on o gr a ph y f or

t r a um a.

E m er gR a d i ol o g y 4

: 3 4 9 - 3 5 4

I I I

R ev i ew of 1 9 6 p a t i en t s wi t h i n t r a- a b d omi n al i n j ur y ; 5 0 / 1 9 6 ( 2 6 %

)

h a d n oh em o p er i t on e um.F i f t e e

n of 5 0 p a t i en t s h a d (

- ) F A S T

ex ami n a t i on. U S m a y f ai l t o d e t e c t i n t r a

- a b d omi n al i n j ur i e s i n

t h e

a b s en c e of h em o p er i t on e um.

T ak i s h i m aT

1 9 9 7

S er um am y l a s el ev el on a d mi s s i oni n

t h e d i a gn o s i s of b l u

n t i n j ur y t o t h e

p an c r e a s .

A nn S ur g er y 2 2 6 : 7 0 -7 6

I I I

S er um am y l a s e el ev a t e d i n 8 4 %

of p a t i en t s wi t h p an c r e a t i c i n j ur y a t

pr e s en t a t i on ; el ev a t e d i n7 6 % (

< 3 h r s p o s t -i n j ur y ) an d 1 0 0 % ( > 3

h r s p o s t -i n j ur y ) . S er um am y l a s

em u s t b em e a s ur e d a t l e a s t 3 h

r s

p o s t -i n j ur y t o av oi d mi s s e d i n j ur i e s .



2 5

B uz z a s GR

1 9 9 8

A c om p ar i s on of s o

n o gr a ph i c

ex ami n a t i on s f or t r a um a p er f or m e d

b y s ur g e on s an d r a d i ol o gi s t s .

J T r a um a4 4 : 6 0 4 - 6 0 8

I I I

C om p ar i s on of F A S T p er f or m e d b y s ur gi c al r e s i d en t s ( Gr o u pA )

an d U S t e c h ni c i an s / r a d i ol o gi s t s

( Gr o u pB ) . S en s i t i v i t y 7 3 . 3 % an

d

7 9 . 5 %f or Gr o u pA an d B r e s p e

c t i v el y . S p e c i f i c i t y 9 7 . 5 % an d

9 9 . 3 %f or Gr o u pA an d B r e s p e

c t i v el y .

S en s i t i v i t y i m pr ov e d wi t h

ex c l u s i on of h ol l owv i s c er al i n j ur i e s .

S mi t h S R

1 9 9 8

I n s t i t u t i on al l e ar ni n g c ur v e of

s ur g e on- p er f or m e d

t r a um a

ul t r a s o un d .

A r c h S ur g1 3 3 : 5 3 0

- 5 3 6

I I I

S en s i t i v i t y an d s p e c i f i c i t y of F A S T ex ami n a t i on7 3 % an d 9 8 %

r e s p e c t i v el y an d m a y b el e ar n e

d wi t h o u t s i gni f i c an t l e ar ni n g c ur v e.

M o d al i t y unr el i a b l ef or d e t e c t i on

of h ol l owv i s c er al i n j ur i e s .

- C o

-E v -



2 6

E v

al u

a t i on

of B l un

t

A b d o mi n

al T r a

u m a:

U n

s t a b l eP

a t i en

t

H em o d y n ami c al l y U n s t a b l e?

F r e e

f l ui d i d en t i f i e d ?

E x pl or a t or y

l a p ar o t om y .

on t i n u er e s u s c i t a t i on

v al u a t e o t h er p o t en t i al

s o ur c e s of s h o c k

-R e p e a t ul t r a s o un d

-D P L .

-A s pi r a t i on of

gr o s s b l o o d

-R B C >1 0 0 K / mm 3

-WB C > 5 0 0 / mm 3

-P ar t i c ul a t em a t t er

-B i l e

?

- C on t i n u er e s u s c i t a t i on

-E v al u a t e o t h er

p o t en t i al s o ur c e s of

s h o c k

-R e p e a t D P L .

U S

D

P L

N o

N o



2 7

* C T s c anm a y b e el e c t e d

b a s e d oni n s t i t u t i on al ex p e

r i en c e or c l i ni c al s u s pi c i on

of i n t r a

- a b d omi n al i n j ur

y .

E v

al u

a t i on

of B l un

t A

b d o

mi n

al T r a

u m a:

S t a b l e

H em o d y n ami c al l y

S t a b l e

R el i a b l eP E ?

-A b d t en

d er n e s s

-M ul t i r i b f x s

-A b d w al l c on t u s i on

-E q ui v o c al f i n d i n g s

?

-A d

mi t

- S er

i al P E

C T

S c an

or

U S ?

F r e e


C T S c an

S ol i d

V i s c er al I n j ur y ?

C on s

i d er

ex pl o

r a t or y

l a p ar o t om y

C on s i d er

n on- o p er a t i v e

m an a g em en t

-R e p e a t U S

- O b s er v a t i on

- C T

s c an*

H ol l ow

v i s c er al i n j ur y ?

E x pl or a t or y

l a p ar o t om y

F r e e


S

ol i d

v i s c er al i n j ur y ?

C on s i d er

ex pl or a t or y

l a p ar o t om y

-

A d mi t

- S

er i al P E

Y e s

N o

N o

U S

C T S c an

Y e s

N o

Y e s

N o

N o

Y e s

N o

blunt abdomen

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