1. Controversies in Abdominal Trauma

2. Controversies in Emergency Ultrasound Should EM physicians perform ultrasound? Should EM physicians perform ultrasound? How should this work be funded? How should this work be funded? What new areas of use should be explored? What new areas of use should be explored?

4. It isn’t rocket science...

5. Rationale 24x7 access 24x7 access Shorten the time to intervention in life threats Shorten the time to intervention in life threats Decrease the length of stay in the ED Decrease the length of stay in the ED Decrease the cost of care and improve resource utilization Decrease the cost of care and improve resource utilization Improve diagnostic accuracy Improve diagnostic accuracy

6. Abdominal Trauma Ultrasound Accuracy Sensitivity: 80% - 100% Sensitivity: 80% - 100% Specificity: 85% - 98% Specificity: 85% - 98% Intraperitoneal fluid: Intraperitoneal fluid: –82-98% sensitivity –88-100% specificity –Prospective trials: sensitivity 87-98%, specificity 99-100% (Pearl, 1996) Intraperitoneal injury: Intraperitoneal injury: –69-96% sensitivity –95-100% specificity

7. Sensitivity/Volume of Fluid Branney, 1995

8. Abdominal Trauma Ultrasound Learning Curves 12 non-radiologist scanners 12 non-radiologist scanners 8 hours of didactics, 10 supervised exams 8 hours of didactics, 10 supervised exams 50 practice exams on patients 50 practice exams on patients Free Fluid: Sensitivity 68%; Specificity 98% Free Fluid: Sensitivity 68%; Specificity 98% Error rate from 17% to 5% after only 10 exams Error rate from 17% to 5% after only 10 exams 9.8% indeterminate scan rate 9.8% indeterminate scan rate (Shackford, et al) (Shackford, et al)

9. Abdominal Trauma Ultrasound Training Required No definite standard No definite standard Didactic: 4-8 hours of training Didactic: 4-8 hours of training Supervised exams: 15 Supervised exams: 15 Experiential: 20-50 exams Experiential: 20-50 exams

10. Is there still a place for DPL?

11. Diagnostic Peritoneal Lavage Component 1: Aspiration of 10cc of blood Component 1: Aspiration of 10cc of blood –Indication for emergent laparotomy IF hemodynamically unstable Component 2: Lavage Component 2: Lavage –>100,000 RBCs –>20 IU Amylase (Alk Phos) –>500 WBC –Bile, Gram Stain

12. Diagnostic Peritoneal Lavage Problems Non invasive management of abdominal trauma Non invasive management of abdominal trauma Complications: 0.3% Complications: 0.3% More time consuming than ultrasound More time consuming than ultrasound Less information than CT scan Less information than CT scan

13. Diagnostic Peritoneal Lavage Sharp decrease in use Sharp decrease in use –Increased availability of ultrasound –Helical CT scans: faster and better –Non invasive always wins

14. Diagnostic Peritoneal Lavage Indications Hypotensive patient with a negative FAST exam Hypotensive patient with a negative FAST exam Stab wound to the abdomen Stab wound to the abdomen Gunshot wound to the abdomen Gunshot wound to the abdomen –DPL vs. Laparotomy

15. Prioritization in trauma Head Injury Head Injury Hypovolemia Hypovolemia –Chest trauma –Intraperitoneal (Spleen, liver) –Retroperitoneal (Pelvis, renal) Occult lethal injuries Occult lethal injuries –Traumatic aortic injury Head CT Head CT Chest x-ray Chest x-ray Ultrasound/DPL Ultrasound/DPL Abd CT Abd CT Chest CT Chest CT Transesophageal echo Transesophageal echo Arteriography Arteriography

16. Prioritization in trauma Two Contenders Head Injury Head Injury –Most CNS deaths from head injury are due to a delay in decompression Intraperitoneal Injury Intraperitoneal Injury –Injuries are amenable to therapy –Preventing prolonged hypovolemic shock is critical to outcome

17. Prioritization in trauma Unstable with positive ultrasound  Emergent Laparotmy + ICP bolt Unstable with positive ultrasound  Emergent Laparotmy + ICP bolt Unstable with negative ultrasound  DPL  if DPL +  Laparotomy Unstable with negative ultrasound  DPL  if DPL +  Laparotomy Stable with positive ultrasound or DPL  Head CT & Abdominal CT Stable with positive ultrasound or DPL  Head CT & Abdominal CT