Br. J. Surg. Vol. 62 (1975) 121-124
Abdominal lavage in blunt trauma W I L L I A M G I L L , H O W A R D R. C H A M P I O N , W I L L I A M B. L O N G , J O S E P H J A M A R T S A N D R. A D A M S C O W L E Y * SUMMARY
A technique for abdominal lavage is described and was used to evaluate the abdomen o f 6 7 1 multiple trauma victims, In 44 per cent (299 cases) there was a bloodstained return and these were regarded as positive. Patients with a positive result underwent exploratory laparotomy which revealed that 89 per cent had signiji’caiit intra-abdominal trauma requiring a surgical procedure, 8 per cent had trauma which did not require any active ~urgicalcorrection and3per cent had no abnormal jiwdings. Of all the lavages performed, there were 0.I I per cent false positive and 0.03 per cent false negative results. The value of the test in the context of multiple trauma is emphasized.
THEmortality rate in victims of blunt abdominal trauma remains unnecessarily high (Ah0 and Rasturia, 1971), partly as a result of the perpetuation of inappropriate medical teaching. The classic diagnostic approach of a clinical history proceeding to inspection, percussion, auscultation and palpation followed by special investigations has become almost obsolete in the evaluation of an abdomen in a multiple trauma patient. Needle abdominal paracentesis described by Neuhof and Cohen in 1926, while clearly a diagnostic advance, was associated with a high number of false negative results (Fitzgerald et al., 1960; Giacobine and Siler, 1960). The introduction of four-quadrant ‘tapping’ reduced the frequency of false negatives but did not eliminate them (Olsen and Hildreth, 1971). In 1965 Root et al. discussed abdominal lavage as a further diagnostic advance in abdominal trauma, but the technique failed to gain wide acceptance by those dealing with trauma victims. A slight modification of the technique of Root et al. ( I 965) has been employed in the Maryland Institute for Emergency Medicine during the past 2 years and the experience gained is described. Technique of abdominal lavage 1 . The bladder is emptied by Foley catheterization. 2. A nasogastric tube is inserted to empty the stomach. 3. A 5 x 7.5 cm area of skin in the midline below the umbilicus is prepared with Betadine solution and draped. 4. One per cent XyIocaine (and adrenaline) is used to infiltrate the midline for approximately 3 cm below the umbilicus and down to the peritoneum. 5. A midline subumbilical incision through skin and subcutaneous tissue is made for 2-4 cm depending on the patient’s obesity.
6. Meticulous haemostasis is mandatory and is aided by the adrenaline. 7. The preperitoneal space is entered through the linea alba. If the inferior rectus sheath is entered erroneously the muscle is deflected laterally and an entrance made through the posterior sheath. Improved visualization is obtained by grasping the cut edges of the posterior rectus sheath or linea alba and pulling upwards. 8. The peritoneum is exposed, grasped and tented with two Kelly clamps. 9. After ensuring that no adherent bowel is included in the clamps, a peritoneal purse string suture is placed around the Kelly clamps. 10. A 2-3-mm incision is made in the peritoneum. 11. A standard peritoneal dialysis catheter without the trocar is inserted through this incision into the peritoneal cavity and the purse string suture immediately tightened. 12. The catheter is gently aspirated and an obvious return of blood would obviate further evaluation. 13. If no bloodstained fluid is aspirated, 1000ml of sterile isotonic crystalloid solution are infused through the catheter by a routine intravenous infusion set. When the intraperitoneal infusion is complete the empty bottle is placed on the floor and the lavage fluid allowed to refill the bottle by gravity. 14. During the infusion the patient should be in a slight Trendelenburg position which is reversed when the infusate is returning to the bottle. 15. The wound is packed with gauze if surgery is to follow or sutured if the result is negative. Patients All admissions to the Maryland Institute for Emergency Medicine for the year 1973 were included in the study. During the first 6 months abdominal lavage was performed only for specific indications. Over the latter 6 months the examination was performed on all patients with blunt trauma. The technique described above was rigidly adhered to, and children were lavaged with 500 ml and adults with 1000 ml of crystalloid solution. Penetrating abdominal trauma was excluded from the study because of a different approach to this problem. When poor technique was recognized as a possible cause of a very faint discoloration in the returning fluid, a second litre of crystalloid solution was infused. Persisting or increasing discoloration in the return from the second bottle was required before the result
* Maryland Institute for Emergency Medicinc, University of Maryland Hospital, Baltimore, USA. 121
William Gill et al. Table I: NUMBER OF ABDOMINAL LAVAGES PERFORMED IN 1973 No. % o f total % of lavages Trauma admissions 83 1 100.0 Lavages performed 671 80.7 100~00 Negative lavages 372 55.23 Positive 1ava.ces 299 44.52 Table 11: SIGNIFICANCE OF ABDOMINAL PATHOLOGY IN 299 PATIENTS SUBJECTED TO LAPAROTOMY FOR POSITIVE ABDOMINAL, LAVAGE Findings at laparotomy Clinically significant Clinically insignificant Negative Total
No. 266 25
Table Ill : SIGNIFICANT ORGAN INJURY DETECTED IN 266 PATIENTS SUBJECTED TO LAPAROTOMY FOR POSITlVE ABDOMINAL LAVAGE Site of injury Spleen and splenic vessels Liver and hepatic veins Small or large bowel mesenteric vessel$ Pelvic vessels Large bowel Small bowel Bladder Inferior vena cdva Diaphragm Kidney Pancreas Duodenum Gallbladder Stomach Aorta Omental vessels Significant retroueritoneal haematoma
No. 107 102 42 38 29 26 10 10 10 10 10
5 5 4 1
Table 1V: FALSE RESULTS WITH ABDOMINAL LAVAGE No. of lavages Lavages performed 67 I False positive 8 0.110 False negative 2 0.03
was regarded as positive. When poor return of the fluid from the abdominal cavity occurred despite gentle adjustment of the catheter a second litre was also infused. All patients with bloodstaining of the lavage return were subjected to laparotomy. The intraperitoneal findings were classified as clinically significant when surgical correction or drainage was required, and clinically insignificant when the abnormal findings required no active therapy. A negative laparotomy indicates the total absence of traumatic intraperitoneal pathology and identifies a false positive result. An analysis was made of some of the factors likely to confuse a clinical attempt to evaluate the abdomen, and related specifically to associated central nervous system and thoracic trauma and the presence of alcohol in the blood. N o attempt was made to correlate the clinical findings with the lavage results and eventual pathology
or to correlate the degree of staining of the lavage return with the intra-abdominal pathology, as described by Olsen et al. (1972).
Results In the 12-month period studied, 943 patients were admitted to the Maryland Institute for Emergency Medicine of which 831 (88 per cent) were trauma victims transferred directly from the scene of the accident or from another hospital. Six hundred and forty-one (68 per cent) of these admissions arrived by helicopter. Abdominal lavage was performed in 671 patients to exclude traumatic intraperitoneal pathology. Three hundred and seventy-two (55-23 per cent) were found to be negative and 299 (44.52 per cent) positive (Table I). The latter 299 patients were subjected to exploratory laparotomy. In 266 (89 per cent) there were surgically significant lesions, and 8 (3 per cent) were negative (T&e IZI). The clinically significant findings are listed in Table 111. Twenty-five (8 per cent) patients had clinically insignificant findings at laparotomy. False negatives occurred in 2 instances (Table ZV). Of the 831 trauma admissions, 50 per cent showed alcohol in their blood on arrival and 25 per cent had over 0.15 mg/100 ml (the upper legal limit for driving in Maryland). Three hundred and forty-nine patients sustained central nervous system (CNS) injury with impaired consciousness, and 132 (38 per cent) of these required laparotomy for abdominal trauma. Almost half (44 per cent) of the patients with abdominal injury had a CNS injury. Two hundred and twenty-one patients sustained a thoracic injury and 124 were submitted to exploratory laparotomy. Thoracic trauma was present in 41 per cent of patients with abdominal injury, and 56 per cent of all the patients with thoracic injury underwent laparotomy. Multiple trauma involving the thorax, central nervous system and abdomen occurred in 50 patients; only 38 patients had isolated abdominal trauma, and 65 per cent of all the trauma patients had one or more fractures. Discussion Mortality from abdominal trauma is related not only to the severity of the injury and associated trauma but also to delay in diagnosis (Williams and Zollinger, 1959; McLeod and Brown, 1966; Bolton et a]., 1973). The difficulties of clinical diagnosis in the presence of head injury, alcoholic intoxication (Williams and Zollinger, 1959; Nicholson and Golden, 1966) and extra-abdominal trauma (Macbeth, 1966; Olsen and Hildreth, 1971) are well described. In the Institute’s special admitting areas, abdominal evaluation is limited to abdominal lavage after a cursory inspection for visible expansion. Radiological examination of the abdomen is not performed routinely and haemodynamic stabilization of the patient is clearly a priority. Because abdominal lavage is a routine part of our initial resuscitative and diagnostic effort, the mortality and morbidity related to delay in diagnosis are effectively removed. Meticulous technique in the performance of the lavage is essential for
Abdominal lavage in blunt trauma accuracy, and visceral damage is avoided by elevating the peritoneum before making the incision. A crystalclear return of lavage fluid is the only confirmation of a technically perfect lavage, and bloodstaining of the fluid means that blood from the incision has entered the peritoneal cavity during the catheter insertion or that intraperitoneal bleeding is present. Poor technique accounted for all our false positive results. Twenty-five (8 per cent) of our patients had exploratory laparotomy findings not requiring any further surgical procedure. Twenty of these had mildly positive lavage results, although the remainder showed deeper staining of the effluent. Various attempts to increase the accuracy of abdominal lavage include gradations based on red and white blood cell counts in the fluid, amylase estimations (Perry and Strak, 1972) and the presence of ammonia (Mansberger et al., 1959) to mention a few. We have found such scales to be too time-consuming in an emergency situation and to provide no useful additional information. Very weakly bloodstained lavage fluid not infrequently indicates a bowel perforation with minimal bleeding from the edges of the hole or may be the only clue to a ruptured duodenum or other retroperitoneal injury. It is for this reason that all bloodstained lavage results are regarded as an indication for exploratory laparotomy. In this context the deliberate acceptance of a number of exploratory laparotomies revealing ‘clinically insignificant’ pathology is necessary just as the negative laparotomy is acceptable in other situations when it is used as the final diagnostic manoeuvre. If anything, its use in the management of trauma is more essential because of the detrimental effect of delay in treatment. Constructive attention should be directed towards the false negative results obtained rather than the false positives because it is in these patients that a delay in diagnosis is likely to increase the mortality and morbidity. It is possible that previous surgery in the abdomen may result in the isolation of an injured viscus by fibrous adhesions and prevent adequate distribution of the instilled crystalloid solution. The presence of healed abdominal scars should consequently stimulate the surgeon to consider an alternative site for the lavage incision, and to agitate or promote movement of the abdomen to ensure good circulation of the fluid. The surgeon must also be wary of the potential danger of bowel perforation during the intraperitoneal introduction of the catheter. Trauma confined to the retroperitoneal space can never be excluded with certainty by abdominal lavage (Olsen and Hildreth, 1971), but to date this has not been a problem in our patient population. This may be related to the fact that the magnitude of trauma required to injure retroperitoneal structures produces associated intraperitoneal trauma which is detected by the lavage. In our experience, retroperitoneal hematomas almost always stain the lavage fluid even though covered by intact peritoneum. The 2 false negative results reported were patients in whom rupture of the left hemidiaphragm was apparent on chest X-ray, with translocation of the
stomach, colon and spleen into the chest. Both underwent laparotomy despite negative lavages, and in both instances splenic rupture was present. In one patient 500ml of blood were found in the thoracic cavity without spillage into the abdominal cavity-a presumed result of the herniation and negative intrathoracic pressure. The ruptured diaphragm thus presents a further weak area for lavage diagnosis, though it is unlikely to occur unless there has been a major disruptive force and other visceral injury, or to escape detection on chest X-rays. Abdominal lavage is still confused with abdominal ‘taps’ in the minds of many surgeons despite the ever increasing reports in the literature clarifying the procedure. Mis-statements in medical texts are numerous and reflect the inadequate experience of the authors in many cases. It has been stated that as little as 200 ml of blood in theperitoneal cavitymay be detected by lavage when quite clearly a few drops of blood introduced at the time of incision will give a false positive result. A1 present, we rely almost entirely on this procedure for our initial evaluation of the abdomen in blunt trauma victims and have had no cause for regret. We feel that knowledge of the value of this tool is lost in the midst of long descriptions of how to examine and assess the abdomen in this type of patient and that current texts have not yet fully appreciated the real value or import of the test. The time is overdue for change however much it saddens the traditional diagnostician’s heart. Acknowledgements This work was supported by grants from the US Army Material Systems Analysis Agency DAAD 05-73-C0032, and from the Office of the Surgeon General, US Army 3A 16 21 10A821. References AHO A. J. and RASTURIA R. D. (1 971) Closed abdominal injury. Observations of changes in material and activation of treatment. Acta Chir. Scand. 137, 429-435. BOLTON P . M., WOOD C. B. and QUARTEY-PAPATIA J. D . (1973) Blunt abdominal injury: a review of 59 consecutive cases undergoing surgery. Br. J. Surg. 60, 657-663. FITZGERALD J. D., CRAWFORD E. s. and DEBAKEY M. D. (1960) Surgical consideration of non-penetrating abdominal injuries: an analysis of 200 cases. Am. J. Surg. 100, 22-29. GIACOBINE J. w. and SILER v. E. (1960) Evolution of diagnostic abdominal paracentesis with experimental and clinical studies. Surg. Gynecol. Obstet. 110, 676-686. MACBETH R. A. (1966) Blunt abdominal trauma. Can. J. Surg. 9, 384-396. MCCLEOD R. A. and BROWN D. R. (1966) Non-penetrating abdominal trauma. Can. J. Surg. 9, 379-383. MANSBERGER A. R. jun., COWLEY R . A . , BESSMAN s. P. and BUXTON R. w. (1959) The origin and utilization of ammonia in strangulation obstruction of the small bowel. Ann. Surg. 150, 880-889. 123
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