Laparotomy or External Fixation?
	Date: 04.04.97 21:56 From: Varit Nilpanit [vnilpani@suandok01.medicine.cmu.ac.th] I found a patient get car accident and came to ER. Physical exam reveal that blood pressure is drop ,with pelvic compression positive (suspect opened book injury of pelvis) . Diagnostic peritoneal lavage was performed at ER and positive. What operation should be done first? between 1. Emergency exploration to R/O intra-abdominal injury 2. Emergency external pelvic fixation. Thanks for your recommendation. Dr.Varit Nilpanit(vnilpani@medicine.cmu.ac.th) Suandok Hosp. Chiangmai Thailand
	Date: 04.04.97 10:25 From: Chris Taylor [chris@knakee.demon.co.uk] (2) - it bleeds, it only takes a few minutes to put the external fixator on, it may be the cause of the positive lavage and you may not find anything more on laparotomy. in other words: you already diagnosed one injury that may explain all physical findings - fix that before looking for the next. strictly speaking, I think the fixator should have gone on before even thinking of a lavage. in my experience, lavage is next to useless in the presence of a pelvic fracture: if it doesn't pour blood, you're none the wiser. if it does pour blood, the patient was usually so critical that you wouldn't have dared NOT to proceed to laparotomy to rule out haemorrhage. -- chris taylor consultant in A&E James Paget Hospital
	Date: 04.04.97 11:19 From: "Eric Frykberg M.D." Ideally a C-loop external fixator can be applied in the trauma center or on the O.R. table for pelvic fixation, but laparotomy must first be done to take care of the intr-abdominal source of hemorrhage--NOT to "R/O" hemorrhage, as you said, because you've already established with the DPL that it's there. If DPL grossly positive with hypotensive patient, then right to O.R. for lap--if positive only on counts, then pelvic angio or fixation as first step. Eric Frykberg, M.D. Jacksonville, Fl
	Date: 04.04.97 13:23 From: jbryan@zeta.org.au [Dr. Jon Ryan] Dr.Varit Nilpanit raises the issue of DPL in the presence of Pelvic Fractures. Below is a copy of an article from Liverpool Hospital (Sydney, Australia) Trauma Department's Newsletter "Trauma Grapevine" March 1996 on this subject. (Trauma Grapevine is available via our Web Site at http://www.med.unsw.edu.au/livtrauma ) The Value of DPL in Patients with Pelvic Fractures Dr. Ulvi Budak DPL has been used as a diagnostic tool in blunt abdominal trauma since 1965. It is an established adjunct in the evaluation of abdominal trauma with a diagnostic accuracy of 90-98%. However, its value in patients with pelvic fractures has been revisited consistently. Hubbard and colleagues (1) from Kentucky have stressed that DPL has a false positive rate of up to 28% in patients with pelvic fractures. A recent study from Mendez and colleagues (2) has shown the false positive result of DPL in patients with pelvic fracture to be 0.7% with a sensitivity of 94%. High false positive DPL results in the presence of pelvic fractures has been attributed to several factors: (A) dissection of the retroperitoneal or pelvic haematoma, which results from the pelvic fracture, into the preperitoneal space of the anterior abdominal wall and placement of the dialysis catheter into this haematoma at the time of DPL; (B) direct placement of the dialysis catheter into the retroperitoneal haematoma; (C) extravasation of the blood from a retroperitoneal haematoma into the peritoneal cavity through a tear in the peritoneum; and (D) time dependant diapedesis of RBC's across the peritoneal lining into the abdominal cavity. Accordingly, to avoid false positive results, performance of DPL as soon as possible after injury, the use of the open technique and the supraumbilical approach has been advocated. DPL has a recognised limitation in the detection of retroperitoneal, extraperitonal (eg bladder) and diaphragmatic injury. DPL should be employed selectively in patients with pelvic fracture. Haemodynamic instability, where you wish to determine whether bleeding is intra or extra peritoneal is one of the main advantages of DPL in pelvic trauma. Suspicion of associated abdominal trauma (equivocal physical examinationof abdomen) and the presence of extra-abdominal injury requiring surgery (ie severe head injury) are relative indications for DPL. Positive DPL results purely by RBC count should be re-evaluated. Diagnostic Peritoneal Lavage is reliable in the evaluation of blunt abdominal trauma and should remain a mainstay of diagnostic work-up in patients with or without a pelvic fracture. References: 1. Hubbard SG et al. Diagnostic Errors with Peritoneal Lavage in Patients with Pelvic Fractures. Arch Surg 1979; 114: 844-846 2. Mendez C et al. Diagnostic Accuracy of Peritoneal Lavage in Patientswih Pelvic Fractures. Arch Surg 1994; 129: 477-482. Editorial : Dr. Micael Sugrue The paper by Mendez and colleagues and Dr. Budak's review made me look back at the literature critically to see why this has come to be the case. Most recent view about DPL in pelvic trauma resulted from a paper published in 1979 by the group at Loiusville in which they identified 61 patients who had diagnostic lavageperformed for pelvic fracture, of whom 35 were positive, 10 of which were false positive. The 10 divided by 35 gave a 29% false positive rate, and that number has been widely quoted since as the error rate. One problem is definitional in that a false-positive rate is the number of false positives relative to the total positives. What weactually want to know is the number of false positives relative to the total patients lavaged. In Hubbard's paper, that rate was much smaller, about 16%. It still doesn't answer how a significant number of positives came to be reported but other papers since have parroted this number without actually examining new data. When one looks at the subsequent literature, critically, it appears that the false positive rate in no study has been as high as that reported in the 1979 study. The most recent study, for example, from Denver General in 1990, which looked at 74 patients with pevic fractures who had diagnostic lavage, appeared to have a false positive rate (relative to total patients lavaged) of about 3%. Regards JBR Dr. Jon Ryan Surgical Registrar Sydney Australia
	Date: 04.04.97 17:46 From: "Smith, J. Stanley, MD" [JStanley.Smith@hmc.psu.edu] The positive DPL requires exploration. Fixators are not appropriate for all pelvic fractures and the pelvic film needs to be done to determine indications for a fixatro. If the laparotomy is negative, proceed to angio or pack pelvis and apply PASG or fixator depending on status of posterior pelvis.
	Date: 05.04.97 10:35 From: "Eric Frykberg M.D." An observation from one who has been in this quandary a few times- My take is that this "false positive DPL" scenario is far overplayed in the setting of major pelvic fracture, and if you depend only on gross positivity rather than cell counts, it is a non-issue--especially if you take the precaution to make your insertion site supra- rather than infra-umbilically as recommended in ATLS--I've yet to encounter any significant problem with this highly written-about caution, and I doubt that patients in Jacksonville are any different than elsewhere. Contrary to one post I saw, it is extremely important to take care of treatable intra-peritoneal injuries FIRST, before addressing pelvic hemorrhage--think what a mistake it would be for the patient, never mind embarrassing for yourself, were you to spend a couple hours fixating the pelvis and doing a pelvic angio, only to have the patient bleed to death from a ruptured spleen! In most cases, the significant hemorrhage is from either one or the other, not both--if the rarity happens, and both are bleeding heavily, well, you can still only do one thing at a time, and we are not magicians! The most likely and treatable injury should be treated first. Another point is that this issue of false-positive DPL has been rendered obsolete also by the advent of ultrasound to evaluate the intra-peritoneal compartment--the pelvic hematoma does not interfere at all with this highly accurate modality. Eric Frykberg, M.D. Jacksonville, M.D.
	Date: 10.04.97 03:01 From: Mark Richardson [richardson_m"%MRGATE."AM.decnet@WHMC-LAFB.AF.MIL] Sir, I submit DPL then ex fix unless DPL is grossly positive.(supraumbilical of course)A negative or even cell count positive DPL would lend confidence to angio instead of OR as the next treatment should blood requirement continue.Thank you. Mark Richardson