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Fri Apr 24 11:58:02 BST 2009

It is good if the saline is pouring out through the chest tube....quite rare...

Where competent FAST is available in blunt trauma:
DPA (not DPL) has some limited role in haemodynamically unstable pelvic fracture patients to triage between abdomen and pelvis.
DPL (not DPA) has some limited role to exclude or diagnose hollow viscus injury in cases of haemodynamically normal intubated/head injured/intoxicated/uncooperative patient with some pockets of free fluid between the bowel loops without more suggestion of bowel injury. Here you test for AP, Amylase, WCC and not interested in the RBC.

Best Regards,

Zsolt Balogh

>>> Karim Brohi <karimbrohi at gmail.com> 04/24/09 8:46 PM >>>
Rob
I don't think that honestly in this day and age anyone uses DPL to
rule out diaphragmatic injuries.  It is neither sensitive nor
specific.  I'm not sure anywhere but Cook County really ever used it
like this?
Karim

On 04/24/2009, Robert Smith <rfsmithmd at comcast.net> wrote:
> 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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