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Fri Apr 24 12:34:03 BST 2009

Ron Karim and others,

  I'm not saying a positive DPL of 10k = injury, only penetration. So  
if you're going to operate because of penetration it's a good test.  
For example, historically all GSW to the abdomen with penetration  
required operative intervention. That is not necessarily the case  
today as there is selective non operative management of some GSW to  
the abdomen and that will probably increase over time. And as I said,  
at County, as I understand it, they would operate for penetration of a  
missile through the retroperitoneum into the peritoneum. If you  
wouldn't do that DPL is not a good test for that injury.

  Karim, I don't understand what you're saying re: sens/spec. DPL is  
highly sensitive and specific for assessing peritoneal penetration.  
Are you disputing that or are you saying that for some reason it's not  
so for assessing diaphragm penetration?

Peritoneal lavage in penetrating thoraco-abdominal trauma.

Merlotti GJ, Dillon BC, Lange DA, Robin AP, Barrett JA.
Trauma Unit, Cook County Hospital, Chicago, IL 60612.
Forty-five consecutive patients with penetrating thoraco-abdominal  
trauma underwent surgical exploration to evaluate the ability of  
peritoneal lavage to detect peritoneal penetration. Eight patients  
fulfilled standard criteria for operation and did not undergo lavage.  
The remaining 37 patients underwent diagnostic peritoneal lavage using  
a closed technique before exploratory laparotomy. Using 10,000 RBC/mm3  
as our previously established criterion for peritoneal penetration,  
there were seven true positive, one false positive, 28 true negative,  
and one false negative lavage for an overall accuracy of 94.6% with  
87.5% sensitivity and 96.6% specificity as determined by subsequent  
laparotomy. While 33% of this patient cohort were found to have  
significant injuries (four had isolated diaphragmatic injuries, all  
detected by peritoneal lavage), 67% were subjected to negative  
surgical exploration, as accurately predicted by peritoneal lavage.  
Negative laparotomy carried a 10.7% operative morbidity. Based on  
these data we advocate diagnostic peritoneal lavage in patients with  
thoraco-abdominal penetrating trauma who otherwise lack operative  
indications.

This work is 20 yrs old. Has this work been refuted? I understand most  
people don't do this and that laproscopy has the advantage of offering  
Dx and repair at the same sitting if there is an injury and that MDCT  
is looking good for making this Dx now. And for that matter a lot of  
people don't believe that non symptomatic isolated penetrating  
injuries to the diaphragm need to be chased after and fixed.
Rob

On Apr 24, 2009, at 6:55 AM, Gross, Ronald wrote:

> 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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