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Fri Apr 24 00:12:29 BST 2009

Rob,

No not unstable. We have FAST. CT isn't good for picking up  
penetrating injuries to the diaphragm which, unlike blunt injuries,  
may often have no other signs. Fast isn't sensitive enough to pick up  
what would be the equivalent of a few cc of blood to give 10k rbc  
indicating penetration. The other two scenarios are when CT didn't  
answer the question of penetration.

Rob
On Apr 23, 2009, at 6:55 PM, Rob Ojala wrote:

> Dr Smith,
> Fortunately we don't see a huge amount of penetrating trauma, so my
> expertise for the DPL indications you quote is limited. I wonder for  
> the
> scenarios you quote....are we talking about patients who are too
> unstable to get a CT? [while I realise that CT has limited sensitivity
> for Diaphragmatic penetration- it can usually pick up secondary  
> features
> of injury [stranding /free fluid etc]].
> Do you have rapid bedside ultrasound available at your institution?
> If too unstable AND no FAST...perhaps DPA...but DPL??
>
> Regards,
> Rob Ojala
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert Smith
> Sent: Friday, 24 April 2009 4:29 a.m.
> To: Trauma and Critical Care mailing list
> Subject: Re: trauma-list Digest, Vol 70, Issue 20-DPL
>
> I thought Dr. McSwain's comments re: DPL were extremely well  
> expressed.
>
> I asked and at County DPL is still used in 3 instances: 1) penetrating
> thoraco-abdominal to determine diaphragmatic penetration 2) back and
> flank when it cannot be determined if the tract penetrates the
> peritoneal cavity 3) tangential gsw when peritoneal penetration is
> unclear. These indications are my understanding of what I was told. If
> they're incorrect in some detail, the fault is undoubtedly mine.
>
> Rob Smith
> On Apr 23, 2009, at 10:53 AM, Teperman, Sheldon wrote:
>
>> In short there is no role for DPL- lets expunge it from the record
>> books and delete it from ATLS.  We spend much more time talking
>> about it and then actually doing it. In the last 10 years at this
>> Level one center we have used it twice.  Both times was to use the
>> Catheter to warm a Hypothermic Pt until they were "warm" and dead.
>> Shel
>>
>> -----Original Message-----
>> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org
>> ] On Behalf Of trauma-list-request at trauma.org
>> Sent: Thursday, April 23, 2009 7:00 AM
>> To: trauma-list at trauma.org
>> Subject: trauma-list Digest, Vol 70, Issue 20
>>
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>> Today's Topics:
>>
>>  1. RE: The role of DPA in 2009 and beyond (Gross, Ronald)
>>  2. RE: The role of DPA in 2009 and beyond (McSwain, Norman E Jr.)
>>  3. The role of DPA in 2009 and beyond (Bevan Lowe) (navin goyal)
>>  4. Re: The role of DPA in 2009 and beyond (Bevan Lowe) (Karim Brohi)
>>
>>
>> ----------------------------------------------------------------------
>>
>> Message: 1
>> Date: Wed, 22 Apr 2009 07:10:48 -0400
>> From: "Gross, Ronald" <Ronald.Gross at baystatehealth.org>
>> Subject: RE: The role of DPA in 2009 and beyond
>> To: "'Trauma and Critical Care mailing list'" <trauma- 
>> list at trauma.org>
>> Message-ID:
>> 	<FD2BE6867A90F543AAD02E429F878633013B1FBC0B27 at bhsexc11.bhs.org>
>> Content-Type: text/plain; charset="us-ascii"
>>
>> Since 1995, when I began to use the FAST as a part of my primary
>> survey I have done no DPL's........
>>
>>
>> -----Original Message-----
>> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org
>> ] On Behalf Of Bevan Lowe
>> Sent: Wednesday, April 22, 2009 2:47 AM
>> To: trauma-list at trauma.org
>> Subject: The role of DPA in 2009 and beyond
>>
>> Is there any role of Diagnostic Peritoneal tap (DPA) or for that
>> matter DPL in the ED in the hypotensive blunt trauma pt when we have
>> FAST available these days?
>> Our approach is:- do a FAST, +ve OT, -ve repeat & look for other
>> cause, if still ? abdo bleed go to OT. Equivocal FAST go to OT. Some
>> surgeons are advocating DPA. Thoughts?
>>
>>
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>> ------------------------------
>>
>> Message: 2
>> Date: Wed, 22 Apr 2009 11:04:32 -0500
>> From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
>> Subject: RE: The role of DPA in 2009 and beyond
>> To: "Trauma and Critical Care mailing list" <trauma-list at trauma.org>
>> Message-ID:
>> 	<B79C02DCC4FA074DB02381DF1C5D60BA01D28503 at EX07.ad.tulane.edu>
>> Content-Type: text/plain; charset="iso-8859-1"
>>
>> Please do not confuse principles with preferences.
>>
>> I like DPL and use it but others may not. this does not mean that I
>> am wrong and that they are right or visa versa.  DPL is a test like
>> all tests. It has its good points and bad. The good is that it is
>> very accurate (~98% ). the bad is that it is very accurate (~98%).
>> It is so accurate in identifying the presence of blood it is overly
>> sensitive. If it is followed closely many patients with a small
>> amount of blood will get an operation that is not needed because the
>> hemorrhage has stopped. The is true of the latest generation of CT.
>> Many radiologists will identify things on the scan that do not
>> require surgery. All of these tests require clinical judgment. They
>> CANNOT be used in isolation of other physical examination and
>> laboratory findings.
>>
>> You should use the one the works best for YOU.
>>
>> the eye scan - looking at the patient, and the finger scan. -
>> physical examination with the fingers are both still a very
>> important part of patient assessment.
>>
>> Principle. determine what is going on in the abdomen
>> Preferences:
>> Situation - where are you and the patient Condition - what is the
>> current condition of the patient acute?, in shock? just needs to R/O
>> intraabdominal injury. What does the physical examination show?
>> Skill and experience. what the experience in your hospital with the
>> various tests? Example what is your %  accuracy with FAST. Not how
>> good in Dr Rozychi in Grady Hospital but how good are the
>> sonographies in YOUR hospital Resources - what tests does your
>> hospital have quickly available DPL? FAST? CT?
>>
>> Norman
>>
>> Norman McSwain MD
>> Trauma Director, Charity Hospital
>> Professor of Surgery, Tulane University
>> New Orleans LA
>> 504 988 5111
>> norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu>
>>
>> ________________________________
>>
>> From: trauma-list-bounces at trauma.org on behalf of Bevan Lowe
>> Sent: Wed 4/22/2009 1:47 AM
>> To: trauma-list at trauma.org
>> Subject: The role of DPA in 2009 and beyond
>>
>>
>>
>> Is there any role of Diagnostic Peritoneal tap (DPA) or for that
>> matter DPL in the ED in the hypotensive blunt trauma pt when we have
>> FAST available these days?
>> Our approach is:- do a FAST, +ve OT, -ve repeat & look for other
>> cause, if still ? abdo bleed go to OT. Equivocal FAST go to OT. Some
>> surgeons are advocating DPA. Thoughts?
>>
>>
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>> this email, including any attachment sent with it, may be subject to
>> a statutory duty of confidentiality if it relates to health service
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>> ------------------------------
>>
>> Message: 3
>> Date: Thu, 23 Apr 2009 10:15:13 +0530 (IST)
>> From: navin goyal <drnavingoyal at yahoo.co.in>
>> Subject: The role of DPA in 2009 and beyond (Bevan Lowe)
>> To: trauma-list at trauma.org
>> Message-ID: <110064.63554.qm at web94908.mail.in2.yahoo.com>
>> Content-Type: text/plain; charset=utf-8
>>
>> Dear Bevan ,
>> I am sorry I may be missing something but I could understand what do
>> you mean by equivocal FAST. We rarely use DPL . Last time I used it
>> was for an pelvic injury patient when my sonologist was unable to
>> tell me whether fluid is intra or extraperitoneal. We perform CT in
>> all FAST positive patients if feasible before shifting to OT to rule
>> out solid organ injury.
>> Thanks.
>> Dr. Navin Goyal
>> Trauma Surgeon
>> India
>>
>>
>>     From Chandigarh to Chennai - find friends all over India. Go to
> http://in.promos.yahoo.com/groups/citygroups/
>>
>> ------------------------------
>>
>> Message: 4
>> Date: Thu, 23 Apr 2009 08:55:56 +0100
>> From: Karim Brohi <karimbrohi at gmail.com>
>> Subject: Re: The role of DPA in 2009 and beyond (Bevan Lowe)
>> To: Trauma and Critical Care mailing list <trauma-list at trauma.org>
>> Message-ID:
>> 	<b8b351510904230055u3fed1fb5s2e8976f420d2e7a2 at mail.gmail.com>
>> Content-Type: text/plain; charset=ISO-8859-1
>>
>> Lots of places still do not have ultrasound in the resuscitation  
>> room.
>> Surely then, the continuing role for DPA is for the same indications
>> as FAST but where ultrasound is not readily available?
>>
>> (The converse of course is that FAST should be used when you would
>> previously have used DPA.  Otherwise these days it's going to be CT.
>> There's a lot of un-substantiated mission-creep with FAST)
>>
>> Karim
>>
>> 2009/4/23 navin goyal <drnavingoyal at yahoo.co.in>:
>>> Dear Bevan ,
>>> I am sorry I may be missing something but I could understand what
>>> do you mean by equivocal FAST. We rarely use DPL . Last time I used
>>> it was for an pelvic injury patient when my sonologist was unable
>>> to tell me whether fluid is intra or extraperitoneal. We perform CT
>>> in all FAST positive patients if feasible before shifting to OT to
>>> rule out solid organ injury.
>>> Thanks.
>>> Dr. Navin Goyal
>>> Trauma Surgeon
>>> India
>>>
>>>
>>> ? ? ?From Chandigarh to Chennai - find friends all over India. Go to
>>> http://in.promos.yahoo.com/groups/citygroups/
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