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Fri Apr 24 11:55:59 BST 2009

Guys,
Maybe I am missing something......yes, DPL will tell you that there is AN injury.  In fact it is so sensitive and not specific that many folks were going to the OR for non-therapeutic laparotomies.  A positive DPL for "penetration" in the patient with no other injuries is going to take you to the OR for one of those non-therapeutic laparotomies.
Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert Smith
Sent: Friday, April 24, 2009 5:44 AM
To: Trauma and Critical Care mailing list
Subject: Re: trauma-list Digest, Vol 70, Issue 20-DPL

Tim,

The reason to use DPL to R/O diaphragmatic injuries is that you avoid
the OR/anesthesia event, if there is in fact no injury.

For the tracts of penetrating injuries perhaps we're agreeing? If the
information you get from the CT is unclear or you're not confident of
it because of the mechanism, then a DPL will answer the question of
penetration. This assumes that you will operate on a SW to the back
with a positive DPL indicating the missile has passed through the
retroperitoneum into the peritoneal cavity.

Rob

On Apr 24, 2009, at 4:45 AM, Dr Timothy Hardcastle wrote:

> Rob and Rob
>
> For the ?-penetrated diaphragm the Laparoscope is probably the way
> to go,
> but if this is not fairly easily accessible then DPL certainly is a
> viable
> option.
>
> For the other two scenarios you sketch I will agree that CT is the
> best
> option to follow the tract in the bullet injury group. It is not the
> best
> for stabs, however, with a higher "miss rate", particularly if there
> is
> not enteric contrast, which is not routine in most places anymore.
>
> Cheers
> Tim
> Dr T C Hardcastle
> M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
> Principal Specialist Trauma Surgeon /
> Honorary Lecturer University of KwaZulu-Natal Dept Surgery
> Deputy Director - IALCH Trauma Service
> Durban - South Africa
>
>> 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
>
>
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trauma-list Digest, Vol 70, Issue 20-DPL