List Archives

Fri Apr 24 12:55:02 BST 2009

Yes, best to do it early and open in the unstable pt. so you can see  
you're sampling.

Rob
On Apr 24, 2009, at 7:42 AM, Gross, Ronald wrote:

> I would agree with your last statement but I am not sure I would  
> trust the DPL in the unstable pelvic fracture, especially if some  
> inexperienced person does the DPL below the umbilicus.  That being  
> said, I would also be concerned that the DPL is going to take you to  
> the OR for an intra-peritoneal rupture of the unstable open pelvic  
> fracture in a patient with no other need for laparotomy (unless, of  
> course you are going to have to pack the pelvis)
>
> Ron
> -----Original Message-----
> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org 
> ] On Behalf Of Zsolt Balogh
> Sent: Friday, April 24, 2009 6:58 AM
> To: karimbrohi at gmail.com; trauma-list at trauma.org
> Subject: Re: trauma-list Digest, Vol 70, Issue 20-DPL
>
> 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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