Blunt Abdominal Trauma A
Prospective Study With Selective
Waheed
\s=b\ To
Ahmad, MD, Hiram C. Polk, Jr,
Peritoneal
Lavage
MD
determine the effectiveness of clinical evaluation and
peritoneal lavage in blunt abdominal trauma, a prospective study was undertaken in 315 consecutive patients suspected of having this injury. Conscious patients with obvious physical findings were operated on without peritoneal lavage, and a diagnostic accuracy of 96% was achieved. In patients with altered states of consciousness, peritoneal lavage was studied prospectively for equivocal physical findings. An overall accuracy of 97% was achieved in such patients by peritoneal lavage. Peritoneal lavage was helpful in reducing the rate of normal findings at laparotomy by 50% in patients with altered states of consciousness and equivocal physical findings. Patients with normal findings on peritoneal lavage and subsequent deterioration had normal findings at laparotomy, which points to the value of further evaluation in such patients before laparotomy is carried out. Mortality is ultimately determined by the severity of the injury, despite early and definitive diagnosis and aggressive management.
(Arch Surg 111:489-492, 1976)
retrospective study from our institution on 63 consecutive patients having blunt abdominal trauma showed the diagnostic accuracy of clinical evaluation alone in conscious patients.1 However, difficulties were encoun¬ tered in making accurate diagnoses in patients with altered states of consciousness, or with equivocal physical findings. A prospective study was undertaken to evaluate diagnostic peritoneal lavage in such patients.
A
pyelograms, cystograms, and other roentgenographic examinations are done. In the present study, after initial resuscitation, all patients suspected of having blunt abdominal trauma were classified into three clinical groups on the basis of physical findings. Group 1 consisted of patients with exsanguinating hemorrhage from intraabdominal bleeding. Group 2 comprised patients who were conscious, alert, and had obvious physical findings of blunt abdominal trauma. All patients in groups 1 and 2 underwent laparotomy without peritoneal lavage. Group 3 included all patients with altered states of consciousness, and conscious patients with equivocal physical findings. All patients in group 3 underwent peritoneal lavage by the technique described by Root and associates7 and modified by Perry.' With the patient under local anesthesia, an infraumbilical midline incision was made and the peritoneum opened under direct vision before inserting the dialysis catheter. If no blood was recovered in the catheter, lavage with a balanced salt solution was carried out. Results of peritoneal lavage were considered abnormal if frank blood was recovered in the catheter on insertion, if grossly bloody fluid returned in the lavage fluid, if the red blood cell (RBC) count was greater than 100,000/cu mm, if the white blood cell (WBC) count was greater than 500/cu mm, or if high amylase, bile, or bacteria concentra¬ tions were present in the fluid. venous
RESULTS
.
CLINICAL EXPERIENCE
Hospital is the main trauma center for the Unique police cooperation exists in Louis¬ ville in transferring injured persons promptly to the Louisville General Hospital. On arrival in the emergency room, injuried persons are examined immediately for triage by the physician on duty. Trauma victims with serious injuries are transferred to a special room of the operating suite, maintained in readiness for that purpose. After adequate airway is assured and obvious bleeding stopped, fluid is started intravenously. Blood is drawn for complete blood cell count, typing, and cross matching. A Foley catheter and nasogastric tube are inserted. Thorough clinical examination is carried out. Roentgenographic examination of the abdomen and chest are performed in the operating room; intraLouisville General
greater Louisville
Accepted
area.
for publication Dec 15, 1975. From the Department of Surgery, Health Sciences Center, University of Louisville (Ky) School of Medicine. Read before the 83rd annual meeting of the Western Surgical Association, Colorado Springs, Colo, Nov 22, 1975. Reprint requests to Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40201 (Dr Polk).
During three-year period (1972 through 1974), a total of 315 consecutive patients suspected of having sustained blunt abdominal trauma were included in this prospective study. Twenty-three patients were not included in the study because the protocol instructions were not followed (Table 1). Fifteen patients were admitted with obvious exsanguination and underwent laparotomy without peri¬ toneal lavage. Forty-six patients were conscious, alert, and had physical findings suggestive of intra-abdominal injury. They also underwent operation without peritoneal lavage. Only two patients in this group had normal find¬ ings on laparotomy-a 96% diagnostic accuracy in conscious patients with obvious physical findings (Table 2). Two hundred fifty-two patients (Table 3) underwent peritoneal lavage. Altered states of consciousness were manifested in 141; one hundred eleven patients were conscious but had equivocal physical findings. Peritoneal lavage gave abnormal results in 110 patients. Findings in 104 patients were truly abnormal; of these, five had minor injuries. Six patients (2%) had falsely abnormal findings (Table 4). Peritoneal lavage results were considered normal in 142 patients, 140 confirmed as truly normal and two (1%) as falsely normal. One hundred thirty-one patients were apparently spared unnecessary operation. Nine patients in the truly normal group were operated on because of deteriorating condition; all of these had normal findings at a
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Table 1.—Fate of 23 Patients Not Included in the
Physical
No. of Patients
Status
Peritoneal
Conscious
Conscious; equivocal physical findings Altered state of consciousness Altered state of consciousness
Lavage
Laparotomy Findings
Mortality
Comments
Not done Not done
Normal Normal
None None
Paraplegic; needed lavage After repeated examinations; operated
Equivocal physical findings
on
abnormal,
100,000/cu mm) Gross blood in tubing
Retroperitoneal
injury
tear
Diapedesis?
hematoma
Retroperitoneal hematoma
laparotomy. An overall accuracy of 97% was thus achieved with peritoneal lavage, duplicating previous observations.7 Only two patients (1%) suffered complications resulting from peritoneal lavage. Only two complications were encountered in this study with peritoneal lavage—a definitely small risk. In one
15
at
Laparotomy
8
(26%)
to
Findings Operation Abnormal
165 17 severe
Findings
Results
(3%)
Severity
Severe *
(12%)
No. (%) of Deaths 41 (25)
7(41)*
extra-abdominal
injury.
According
to
Index Score 0-7
No. of Patients
of Deaths
8-18
92 90
0(0) 7(8) 41 (45)
>18
No.
(%)
Adapted from Kirkpatrick and Youmans.5
patient, a trocar was used blindly instead of having the peritoneum actually exposed before introducing the cathe¬ ter. This resulted in
Diapedesis?
121
31
No. of Patients
of Injury Minor Moderate
liga¬
Retroperitoneal
2
Table 7.—Outcome of Injury Victims Trauma Index Rating*
mesentery
mentum teres Done twice; injury to transverse mesocolon
61
(0%)
6.—Mortality According
All patients died of
Findings on
Findings on Peritoneal Lavage Gross blood in catheter
Results
0
Normal on
Laparotomy
No. of Patients
32
at
because of deterioration and
Table 4.—Details of Falsely Abnormal Findings
Normal
Patients with al¬ tered states of consciousness and conscious patients with
(N 252) 140(55%)* 2(1%: 99(40%) 6 (2%) 5(2%)
(N 111) 60(54%)
=
*
findings
Lavage in 252 Patients
Laparotomy
No. of Patients
Patients operated on without peri¬ toneal lavage in¬ cludes conscious patients with ob¬ vious physical
Overall accuracy, 96%.
:
Present Study: Regular Lavage
Lavage
No. (%) of Deaths
rotomy Findings 0(0)
Groups
Total
Laparotomy
Previous Study:
No. (%) With Normal Lapa¬
conscious with obvi¬ ous
on; needed lavage Expected negative laparotomy Pink peritoneal fluid normal by labora¬ tory study; patients operated on without waiting for results
6 normal
Í8 with minor injury 3 normal
Done
No. of Patients 15
Groups Exsanguinating Not exsanguinating;
2
Not done
Table 2.—Fate of Patients Operated Peritoneal Lavage
Study
a laceration of the transverse colon. In another patient, a small bowel laceration was inflicted because of scarring attributable to previous operation. Both these complications could have been avoided by proper use of the technique, and by avoiding peritoneal lavage in patients with previous abdominal operations. Hemoperitoneum marks the basis of abnormal findings on peritoneal lavage. In our study, 31% of the patients had gross blood in the catheter before balanced salt solution was instilled. Ten percent had return of the grossly bloody
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fluid in the tubing after instilling Ringer lactate solution. Only 1% of the patients went to operation on the basis of weakly abnormal peritoneal lavage findings (RBC count > 100,000/cu mm), and all had serious intra-abdom¬ inal injuries. Five patients had minor injuries despite gross blood in the catheter on insertion. We expected weakly abnormal peritoneal lavage findings in minor injuries, but found the contrary to be true. One explanation is that after minor injury (eg, small laceration of the liver or mesenterie tear), there is a rapid accumulation of a moderate amount of blood in the abdominal cavity and then the bleeding stops. None of the patients in our study underwent laparot¬ omy on the basis of high level of amylase or WBCs in the peritoneal fluid. The efficacy of these diagnostic factors in making decisions to operate is being questioned by others.' Six patients had falsely abnormal results, ie, showed abnormality where none existed. A number of factors contributed. Absolute hemostasis is essential to prevent blood contamination from skin and subcutaneous tissue. Cauterization is recommended to control small capillary hemorrhage. Gentle introduction of the catheter is impor¬ tant to prevent mesenterie or retroperitoneal injuries. Diapedesis in retroperitoneal hematoma was the possible cause of falsely abnormal peritoneal lavage findings in two
patients.
Table 5 compares the results of laparotomy in the in the retrospective study. A reduction of more than 50% in the rate of normal findings at laparotomy was achieved in patients with equivocal physical findings and altered states of consciousness. The mortality according to the findings at laparotomy is shown in Table 6. Outcome for the injury victims after application of trauma index is shown in Table 7.7'
prospective study with those
COMMENT
The diagnosis of blunt abdominal trauma in conscious, alert patients with obvious physical findings can be made with reasonable accuracy by clinical evaluation as shown by our study. The physical findings most reliable in conscious patients are (1) pain and tenderness, (2) a maximal point of tenderness, (3) pain on movement, and (4) rebound tender¬ ness. The diagnosis of blunt abdominal trauma by clinical evaluation alone in patients with altered states of consciousness or equivocal physical findings is extremely difficult, and bears a high potential for error. Peritoneal lavage was utilized only in the patients in group 3, and was helpful in avoiding unnecessary operation in 131 patients while pointing immediately to operation in others, thus precluding delay in diagnosis and management of blunt abdominal trauma. Twenty-three patients who were not included in the study served as an excellent concurrent control and as a guide to future management of blunt abdominal trauma. Paraplegic patients with blunt abdominal trauma are extremely difficult to evaluate; all such patients should have peritoneal lavage. Equally important is that any diagnostic test used should be carried out properly, with attention to all details. This instruction could have
prevented unnecessary operation in 11 of 23 patients. Eight patients with altered states of consciousness were operated on without peritoneal lavage. Operation could have been avoided in six of these difficult presentations if diagnostic peritoneal lavage had been done. Three patients with equivocal physical findings were observed and, after repeated examinations and delay, operation was perform¬ ed. Results of these laparotomies were normal, which points to the necessity of peritoneal lavage in equivocal cases.
The presence of absolutely normal lavage results excluded serious intra-abdominal injury in all patients with normal peritoneal lavage findings except two. Of the two patients with falsely normal results, one had splenic hematoma and the other had retroperitoneal injury to the duodenum. The value of peritoneal lavage is definitely limited in such injuries, and other tests, such as arterio¬ grams and upper gastrointestinal x-ray series with watersoluble contrast media, should be utilized. Nine patients, among 140 with normal peritoneal lavage results, who were operated on for deterioration needed further evaluation before laparotomy. In the presence of normal peritoneal lavage findings, it is essential to recognize that no serious life-threatening hemorrhage is occurring. Thus, any kind of deterioration should be carefully evaluated before lapa¬ rotomy. If there is a drop in the hemoglobin level, hemato¬ crit value, or blood pressure after adequate resuscitation, the patient probably should have an arteriogram to rule out intra-abdominal injury. In the presence of deteriorating physical condition only, a second peritoneal lavage some¬ times should be attempted, using the catheter as left in place. Deterioration because of head injury in patients with normal peritoneal lavage findings should be recog¬ nized and laparotomy avoided. An overall mortality of 26% may seem high when compared with other similar reports. Careful analysis of the 41 deaths showed that most deaths were in patients with scores on the trauma index of greater than 18, at which point a mortality of 50% or more is expected. All patients with blunt abdominal trauma who died had severe associated extra-abdominal injury; in 33% of the patients, these associated injuries were the direct cause of death. About 20% of the 41 patients died intraoperatively as a result of hypovolemia and vascular injuries, emphasizing the severity of these injuries. Injury to two or more intraabdominal organs was found in 71% of the 41 deaths. Thirty-three percent of the 41 patients who died had been struck by vehicles, resulting in severe, crushing, multiple
system injury.
SUMMARY 1. Clinical evaluation is accurate in conscious patients with obvious physical findings. 2. Accuracy of peritoneal lavage is high and results can be duplicated. 3. Peritoneal lavage is especially helpful in patients with equivocal physical findings and altered states of conscious¬ ness.
4. Patients with normal
lavage findings
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and clinical
deterioration should undergo further evaluation before laparotomy is done. 5. Mortality is often ultimately determined by severity of the injury, despite prompt diagnosis and aggressive
management. References 1. Ahmad W, Polk HC Jr: Blunt abdominal trauma: A study of relationbetween diagnosis and outcome. South Med J 66:1127-1130, 1973. 2. Root HD, Hauser CW, McKinley CR, et al: Diagnostic peritoneal
ship
lavage. Surgery 57:633-637, 1965. 3. Perry JF Jr: Blunt and penetrating abdominal injuries. Curr Probl Surg, 1970, pp 1-53. 4. Parvin S, Smith DE, Asher WM, et al: Effectiveness of peritoneal lavage in blunt abdominal trauma. Ann Surg 181:255-261, 1975. 5. Kirkpatrick JR, Youmans RL: Trauma index: An aide in the evaluation of injury victims. J Trauma 11:711-714, 1971. Discussion
William Olsen, MD, Ann Arbor, Mich: I think this study adds evidence to that produced by others, that peritoneal lavage is the most accurate single means whereby we can detect intra-abdom¬ inal injury after blunt trauma. When we consider the ease and safety of performing this test, it seems apparent that the test should be a mandatory part of the evaluation of all patients with blunt abdominal trauma and questionable intra-abdominal
injury.
Drs Ahmad and Polk apparently are better physical diagnosti¬ cians than we are. We have difficulty determining, when we first see these patients, which ones have injuries significant enough to require operation. In fact, when we looked at our clinical acumen prospectively, (Arch Surg 104:536, 1972), we found that when we were absolutely certain the patient needed an operation, on the basis of his physical findings, 20% did not have an injury that required operation. But if the abdominal signs were minimal, if the patients were unconscious, or if the findings were equivocal (the equivocal group made up almost half of our patients) about one third of patients had important injuries. We identified these promptly with lavage. I would like to add one word of caution. When we are performing lavage, we are not looking for blood in the peritoneal cavity. We are looking for injuries that require surgical treatment, and we are using the presence of blood only as an indicator. We have found that 30% of our patients who have blood detectable by lavage do not have an injury that requires operation. These injuries usually bleed only a small amount, and if we quantitate the amount of blood in the peritoneal cavity by a variety of means, we can avoid unnecessary operations. I have a little problem with the terminology "abnormal laparot¬ omy findings." We have now performed about 1,300 peritoneal lavages. We initially operated on all patients with small amounts of blood in the lavage fluid, and we found the source of the bleeding. Some had minimal bleeding from a contused omentum, a small mesenterie laceration, or retroperitoneal hematomas. Once we even detected bleeding from a ruptured Graafian follicle. However, the bleeding had stopped and operation was not neces¬ sary in many of these patients. It is extremely important to measure the amount of blood in the lavage fluid if we are to avoid unnecessary operation in patients with minimal hemorrhage from trivial injuries. The Louisville group apparently use the Minnesota technique of minilaparotomy to introduce the lavage catheter. We do not think this is necessary or desirable. We make an incision only in the skin and pass the catheter directly, with very few complications. We, too, are disenchanted with the reliability of a high amylase
concentration in the lavage fluid, because we have found a number of these patients who did not have pancreatic injury. I am a little concerned about Dr Ahmad's conclusion that he has avoided laparotomy in half of these patients. I am certain that if he didn't have lavage at his disposal, many of these patients who did not have abnormal physical findings probably would not have been operated on. In conclusion, I would agree with the authors that this is a necessary and desirable test. Robert Baker, MD, Chicago: As Carey, Shaftan, and others have shown, peritoneal lavage represents one of the real diag¬ nostic advances in management of blunt abdominal trauma in the last ten years. I would like to mention several points about the technique that have precipitated serious difficulty. These sound rather minor, but with this procedure minutiae may spell the difference between success and failure. For example, when we first commenced using peritoneal irrigation for diagnostic purposes, Ringer lactate solu¬ tion was administered as it came out of the bottle. We then found that one third of these patients developed progressive abdominal tenderness following the peritoneal lavage. The reason for this is that the Ringer lactate solution, as provided commercially in glass containers, has a pH in the range of 5. This is done so that the lactate does not polymerize during the heating process in sterili¬ zation. It is very important to buffer the Ringer lactate solution, for this purpose, by adding 25 ml of 7.5'» sodium bicarbonate to that fluid, raising the pH into the 8 to 8.5 range. This slightly alkaline fluid will not irritate the peritoneum, and will make the repeated physical examinations much easier to interpret. In addition, we have found that a plastic arterial catheter with side holes cut in it can be introduced over a central metal trocar, just as we do in the radial or femoral artery. We have abandoned the peritoneal dialysis catheter because it is tedious to insert, especially if the patient is unconscious or irrational and it is necessary to proceed with paracentesis as rapidly as possible. This arterial catheter with the side holes is introduced percutaneously into the peritoneal cavity with no local anesthesia. The accessory openings in the catheter discourage omentum or intestine from occluding the catheter, as frequently occurs with the use of the standard venous or arterial catheter. With this technique, simple aspiration and, if necessary, lavage can be done via the peritoneal catheter. If aspiration has an abnormal yield, it is not necessary, obviously, to proceed with the peritoneal lavage, but if the aspiration is normal, one can then irrigate with volumes between 250 and 500 ml. Since a simpler catheter is available, the peritoneal dialysis catheter is just too cumbersome, requiring a formal incision. There is one other concern, as Dr Ahmad emphasized. If the patient has had a recent, or even ancient, central abdominal incision, it is very hazardous to attempt peritoneal dialysis. It is quite one thing to introduce a small catheter lateral to the rectus sheath, and quite another to incise into what turns out to be a bound-down loop of intestine. The complication reported by Dr Ahmad is not uncommon, so we feel very strongly that a midline or paramedian incision extending across the midabdomen is a substantial contraindication to the use of this technique. One last point: despite Dr Olsen's comments, the conviction of all who are working with large numbers of trauma patients is that there is no substitute for frequent, repeated physical examination of the abdomen. I am sure that this is a truism that we all hear and that many of us, unfortunately, tend to ignore occasionally. Dr. Ahm"ad: I would like to point out that when I said that half of the patients were spared laparotomy, this has a background. Drs Griswold and Noer started the trauma service in the Greater Louisville area, and at that time patients underwent operation on just the slightest suspicion of abdominal injury.
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Prospective Study With Selective
Waheed
\s=b\ To
Ahmad, MD, Hiram C. Polk, Jr,
Peritoneal
Lavage
MD
determine the effectiveness of clinical evaluation and
peritoneal lavage in blunt abdominal trauma, a prospective study was undertaken in 315 consecutive patients suspected of having this injury. Conscious patients with obvious physical findings were operated on without peritoneal lavage, and a diagnostic accuracy of 96% was achieved. In patients with altered states of consciousness, peritoneal lavage was studied prospectively for equivocal physical findings. An overall accuracy of 97% was achieved in such patients by peritoneal lavage. Peritoneal lavage was helpful in reducing the rate of normal findings at laparotomy by 50% in patients with altered states of consciousness and equivocal physical findings. Patients with normal findings on peritoneal lavage and subsequent deterioration had normal findings at laparotomy, which points to the value of further evaluation in such patients before laparotomy is carried out. Mortality is ultimately determined by the severity of the injury, despite early and definitive diagnosis and aggressive management.
(Arch Surg 111:489-492, 1976)
retrospective study from our institution on 63 consecutive patients having blunt abdominal trauma showed the diagnostic accuracy of clinical evaluation alone in conscious patients.1 However, difficulties were encoun¬ tered in making accurate diagnoses in patients with altered states of consciousness, or with equivocal physical findings. A prospective study was undertaken to evaluate diagnostic peritoneal lavage in such patients.
A
pyelograms, cystograms, and other roentgenographic examinations are done. In the present study, after initial resuscitation, all patients suspected of having blunt abdominal trauma were classified into three clinical groups on the basis of physical findings. Group 1 consisted of patients with exsanguinating hemorrhage from intraabdominal bleeding. Group 2 comprised patients who were conscious, alert, and had obvious physical findings of blunt abdominal trauma. All patients in groups 1 and 2 underwent laparotomy without peritoneal lavage. Group 3 included all patients with altered states of consciousness, and conscious patients with equivocal physical findings. All patients in group 3 underwent peritoneal lavage by the technique described by Root and associates7 and modified by Perry.' With the patient under local anesthesia, an infraumbilical midline incision was made and the peritoneum opened under direct vision before inserting the dialysis catheter. If no blood was recovered in the catheter, lavage with a balanced salt solution was carried out. Results of peritoneal lavage were considered abnormal if frank blood was recovered in the catheter on insertion, if grossly bloody fluid returned in the lavage fluid, if the red blood cell (RBC) count was greater than 100,000/cu mm, if the white blood cell (WBC) count was greater than 500/cu mm, or if high amylase, bile, or bacteria concentra¬ tions were present in the fluid. venous
RESULTS
.
CLINICAL EXPERIENCE
Hospital is the main trauma center for the Unique police cooperation exists in Louis¬ ville in transferring injured persons promptly to the Louisville General Hospital. On arrival in the emergency room, injuried persons are examined immediately for triage by the physician on duty. Trauma victims with serious injuries are transferred to a special room of the operating suite, maintained in readiness for that purpose. After adequate airway is assured and obvious bleeding stopped, fluid is started intravenously. Blood is drawn for complete blood cell count, typing, and cross matching. A Foley catheter and nasogastric tube are inserted. Thorough clinical examination is carried out. Roentgenographic examination of the abdomen and chest are performed in the operating room; intraLouisville General
greater Louisville
Accepted
area.
for publication Dec 15, 1975. From the Department of Surgery, Health Sciences Center, University of Louisville (Ky) School of Medicine. Read before the 83rd annual meeting of the Western Surgical Association, Colorado Springs, Colo, Nov 22, 1975. Reprint requests to Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40201 (Dr Polk).
During three-year period (1972 through 1974), a total of 315 consecutive patients suspected of having sustained blunt abdominal trauma were included in this prospective study. Twenty-three patients were not included in the study because the protocol instructions were not followed (Table 1). Fifteen patients were admitted with obvious exsanguination and underwent laparotomy without peri¬ toneal lavage. Forty-six patients were conscious, alert, and had physical findings suggestive of intra-abdominal injury. They also underwent operation without peritoneal lavage. Only two patients in this group had normal find¬ ings on laparotomy-a 96% diagnostic accuracy in conscious patients with obvious physical findings (Table 2). Two hundred fifty-two patients (Table 3) underwent peritoneal lavage. Altered states of consciousness were manifested in 141; one hundred eleven patients were conscious but had equivocal physical findings. Peritoneal lavage gave abnormal results in 110 patients. Findings in 104 patients were truly abnormal; of these, five had minor injuries. Six patients (2%) had falsely abnormal findings (Table 4). Peritoneal lavage results were considered normal in 142 patients, 140 confirmed as truly normal and two (1%) as falsely normal. One hundred thirty-one patients were apparently spared unnecessary operation. Nine patients in the truly normal group were operated on because of deteriorating condition; all of these had normal findings at a
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Table 1.—Fate of 23 Patients Not Included in the
Physical
No. of Patients
Status
Peritoneal
Conscious
Conscious; equivocal physical findings Altered state of consciousness Altered state of consciousness
Lavage
Laparotomy Findings
Mortality
Comments
Not done Not done
Normal Normal
None None
Paraplegic; needed lavage After repeated examinations; operated
Equivocal physical findings
on
abnormal,
100,000/cu mm) Gross blood in tubing
Retroperitoneal
injury
tear
Diapedesis?
hematoma
Retroperitoneal hematoma
laparotomy. An overall accuracy of 97% was thus achieved with peritoneal lavage, duplicating previous observations.7 Only two patients (1%) suffered complications resulting from peritoneal lavage. Only two complications were encountered in this study with peritoneal lavage—a definitely small risk. In one
15
at
Laparotomy
8
(26%)
to
Findings Operation Abnormal
165 17 severe
Findings
Results
(3%)
Severity
Severe *
(12%)
No. (%) of Deaths 41 (25)
7(41)*
extra-abdominal
injury.
According
to
Index Score 0-7
No. of Patients
of Deaths
8-18
92 90
0(0) 7(8) 41 (45)
>18
No.
(%)
Adapted from Kirkpatrick and Youmans.5
patient, a trocar was used blindly instead of having the peritoneum actually exposed before introducing the cathe¬ ter. This resulted in
Diapedesis?
121
31
No. of Patients
of Injury Minor Moderate
liga¬
Retroperitoneal
2
Table 7.—Outcome of Injury Victims Trauma Index Rating*
mesentery
mentum teres Done twice; injury to transverse mesocolon
61
(0%)
6.—Mortality According
All patients died of
Findings on
Findings on Peritoneal Lavage Gross blood in catheter
Results
0
Normal on
Laparotomy
No. of Patients
32
at
because of deterioration and
Table 4.—Details of Falsely Abnormal Findings
Normal
Patients with al¬ tered states of consciousness and conscious patients with
(N 252) 140(55%)* 2(1%: 99(40%) 6 (2%) 5(2%)
(N 111) 60(54%)
=
*
findings
Lavage in 252 Patients
Laparotomy
No. of Patients
Patients operated on without peri¬ toneal lavage in¬ cludes conscious patients with ob¬ vious physical
Overall accuracy, 96%.
:
Present Study: Regular Lavage
Lavage
No. (%) of Deaths
rotomy Findings 0(0)
Groups
Total
Laparotomy
Previous Study:
No. (%) With Normal Lapa¬
conscious with obvi¬ ous
on; needed lavage Expected negative laparotomy Pink peritoneal fluid normal by labora¬ tory study; patients operated on without waiting for results
6 normal
Í8 with minor injury 3 normal
Done
No. of Patients 15
Groups Exsanguinating Not exsanguinating;
2
Not done
Table 2.—Fate of Patients Operated Peritoneal Lavage
Study
a laceration of the transverse colon. In another patient, a small bowel laceration was inflicted because of scarring attributable to previous operation. Both these complications could have been avoided by proper use of the technique, and by avoiding peritoneal lavage in patients with previous abdominal operations. Hemoperitoneum marks the basis of abnormal findings on peritoneal lavage. In our study, 31% of the patients had gross blood in the catheter before balanced salt solution was instilled. Ten percent had return of the grossly bloody
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fluid in the tubing after instilling Ringer lactate solution. Only 1% of the patients went to operation on the basis of weakly abnormal peritoneal lavage findings (RBC count > 100,000/cu mm), and all had serious intra-abdom¬ inal injuries. Five patients had minor injuries despite gross blood in the catheter on insertion. We expected weakly abnormal peritoneal lavage findings in minor injuries, but found the contrary to be true. One explanation is that after minor injury (eg, small laceration of the liver or mesenterie tear), there is a rapid accumulation of a moderate amount of blood in the abdominal cavity and then the bleeding stops. None of the patients in our study underwent laparot¬ omy on the basis of high level of amylase or WBCs in the peritoneal fluid. The efficacy of these diagnostic factors in making decisions to operate is being questioned by others.' Six patients had falsely abnormal results, ie, showed abnormality where none existed. A number of factors contributed. Absolute hemostasis is essential to prevent blood contamination from skin and subcutaneous tissue. Cauterization is recommended to control small capillary hemorrhage. Gentle introduction of the catheter is impor¬ tant to prevent mesenterie or retroperitoneal injuries. Diapedesis in retroperitoneal hematoma was the possible cause of falsely abnormal peritoneal lavage findings in two
patients.
Table 5 compares the results of laparotomy in the in the retrospective study. A reduction of more than 50% in the rate of normal findings at laparotomy was achieved in patients with equivocal physical findings and altered states of consciousness. The mortality according to the findings at laparotomy is shown in Table 6. Outcome for the injury victims after application of trauma index is shown in Table 7.7'
prospective study with those
COMMENT
The diagnosis of blunt abdominal trauma in conscious, alert patients with obvious physical findings can be made with reasonable accuracy by clinical evaluation as shown by our study. The physical findings most reliable in conscious patients are (1) pain and tenderness, (2) a maximal point of tenderness, (3) pain on movement, and (4) rebound tender¬ ness. The diagnosis of blunt abdominal trauma by clinical evaluation alone in patients with altered states of consciousness or equivocal physical findings is extremely difficult, and bears a high potential for error. Peritoneal lavage was utilized only in the patients in group 3, and was helpful in avoiding unnecessary operation in 131 patients while pointing immediately to operation in others, thus precluding delay in diagnosis and management of blunt abdominal trauma. Twenty-three patients who were not included in the study served as an excellent concurrent control and as a guide to future management of blunt abdominal trauma. Paraplegic patients with blunt abdominal trauma are extremely difficult to evaluate; all such patients should have peritoneal lavage. Equally important is that any diagnostic test used should be carried out properly, with attention to all details. This instruction could have
prevented unnecessary operation in 11 of 23 patients. Eight patients with altered states of consciousness were operated on without peritoneal lavage. Operation could have been avoided in six of these difficult presentations if diagnostic peritoneal lavage had been done. Three patients with equivocal physical findings were observed and, after repeated examinations and delay, operation was perform¬ ed. Results of these laparotomies were normal, which points to the necessity of peritoneal lavage in equivocal cases.
The presence of absolutely normal lavage results excluded serious intra-abdominal injury in all patients with normal peritoneal lavage findings except two. Of the two patients with falsely normal results, one had splenic hematoma and the other had retroperitoneal injury to the duodenum. The value of peritoneal lavage is definitely limited in such injuries, and other tests, such as arterio¬ grams and upper gastrointestinal x-ray series with watersoluble contrast media, should be utilized. Nine patients, among 140 with normal peritoneal lavage results, who were operated on for deterioration needed further evaluation before laparotomy. In the presence of normal peritoneal lavage findings, it is essential to recognize that no serious life-threatening hemorrhage is occurring. Thus, any kind of deterioration should be carefully evaluated before lapa¬ rotomy. If there is a drop in the hemoglobin level, hemato¬ crit value, or blood pressure after adequate resuscitation, the patient probably should have an arteriogram to rule out intra-abdominal injury. In the presence of deteriorating physical condition only, a second peritoneal lavage some¬ times should be attempted, using the catheter as left in place. Deterioration because of head injury in patients with normal peritoneal lavage findings should be recog¬ nized and laparotomy avoided. An overall mortality of 26% may seem high when compared with other similar reports. Careful analysis of the 41 deaths showed that most deaths were in patients with scores on the trauma index of greater than 18, at which point a mortality of 50% or more is expected. All patients with blunt abdominal trauma who died had severe associated extra-abdominal injury; in 33% of the patients, these associated injuries were the direct cause of death. About 20% of the 41 patients died intraoperatively as a result of hypovolemia and vascular injuries, emphasizing the severity of these injuries. Injury to two or more intraabdominal organs was found in 71% of the 41 deaths. Thirty-three percent of the 41 patients who died had been struck by vehicles, resulting in severe, crushing, multiple
system injury.
SUMMARY 1. Clinical evaluation is accurate in conscious patients with obvious physical findings. 2. Accuracy of peritoneal lavage is high and results can be duplicated. 3. Peritoneal lavage is especially helpful in patients with equivocal physical findings and altered states of conscious¬ ness.
4. Patients with normal
lavage findings
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and clinical
deterioration should undergo further evaluation before laparotomy is done. 5. Mortality is often ultimately determined by severity of the injury, despite prompt diagnosis and aggressive
management. References 1. Ahmad W, Polk HC Jr: Blunt abdominal trauma: A study of relationbetween diagnosis and outcome. South Med J 66:1127-1130, 1973. 2. Root HD, Hauser CW, McKinley CR, et al: Diagnostic peritoneal
ship
lavage. Surgery 57:633-637, 1965. 3. Perry JF Jr: Blunt and penetrating abdominal injuries. Curr Probl Surg, 1970, pp 1-53. 4. Parvin S, Smith DE, Asher WM, et al: Effectiveness of peritoneal lavage in blunt abdominal trauma. Ann Surg 181:255-261, 1975. 5. Kirkpatrick JR, Youmans RL: Trauma index: An aide in the evaluation of injury victims. J Trauma 11:711-714, 1971. Discussion
William Olsen, MD, Ann Arbor, Mich: I think this study adds evidence to that produced by others, that peritoneal lavage is the most accurate single means whereby we can detect intra-abdom¬ inal injury after blunt trauma. When we consider the ease and safety of performing this test, it seems apparent that the test should be a mandatory part of the evaluation of all patients with blunt abdominal trauma and questionable intra-abdominal
injury.
Drs Ahmad and Polk apparently are better physical diagnosti¬ cians than we are. We have difficulty determining, when we first see these patients, which ones have injuries significant enough to require operation. In fact, when we looked at our clinical acumen prospectively, (Arch Surg 104:536, 1972), we found that when we were absolutely certain the patient needed an operation, on the basis of his physical findings, 20% did not have an injury that required operation. But if the abdominal signs were minimal, if the patients were unconscious, or if the findings were equivocal (the equivocal group made up almost half of our patients) about one third of patients had important injuries. We identified these promptly with lavage. I would like to add one word of caution. When we are performing lavage, we are not looking for blood in the peritoneal cavity. We are looking for injuries that require surgical treatment, and we are using the presence of blood only as an indicator. We have found that 30% of our patients who have blood detectable by lavage do not have an injury that requires operation. These injuries usually bleed only a small amount, and if we quantitate the amount of blood in the peritoneal cavity by a variety of means, we can avoid unnecessary operations. I have a little problem with the terminology "abnormal laparot¬ omy findings." We have now performed about 1,300 peritoneal lavages. We initially operated on all patients with small amounts of blood in the lavage fluid, and we found the source of the bleeding. Some had minimal bleeding from a contused omentum, a small mesenterie laceration, or retroperitoneal hematomas. Once we even detected bleeding from a ruptured Graafian follicle. However, the bleeding had stopped and operation was not neces¬ sary in many of these patients. It is extremely important to measure the amount of blood in the lavage fluid if we are to avoid unnecessary operation in patients with minimal hemorrhage from trivial injuries. The Louisville group apparently use the Minnesota technique of minilaparotomy to introduce the lavage catheter. We do not think this is necessary or desirable. We make an incision only in the skin and pass the catheter directly, with very few complications. We, too, are disenchanted with the reliability of a high amylase
concentration in the lavage fluid, because we have found a number of these patients who did not have pancreatic injury. I am a little concerned about Dr Ahmad's conclusion that he has avoided laparotomy in half of these patients. I am certain that if he didn't have lavage at his disposal, many of these patients who did not have abnormal physical findings probably would not have been operated on. In conclusion, I would agree with the authors that this is a necessary and desirable test. Robert Baker, MD, Chicago: As Carey, Shaftan, and others have shown, peritoneal lavage represents one of the real diag¬ nostic advances in management of blunt abdominal trauma in the last ten years. I would like to mention several points about the technique that have precipitated serious difficulty. These sound rather minor, but with this procedure minutiae may spell the difference between success and failure. For example, when we first commenced using peritoneal irrigation for diagnostic purposes, Ringer lactate solu¬ tion was administered as it came out of the bottle. We then found that one third of these patients developed progressive abdominal tenderness following the peritoneal lavage. The reason for this is that the Ringer lactate solution, as provided commercially in glass containers, has a pH in the range of 5. This is done so that the lactate does not polymerize during the heating process in sterili¬ zation. It is very important to buffer the Ringer lactate solution, for this purpose, by adding 25 ml of 7.5'» sodium bicarbonate to that fluid, raising the pH into the 8 to 8.5 range. This slightly alkaline fluid will not irritate the peritoneum, and will make the repeated physical examinations much easier to interpret. In addition, we have found that a plastic arterial catheter with side holes cut in it can be introduced over a central metal trocar, just as we do in the radial or femoral artery. We have abandoned the peritoneal dialysis catheter because it is tedious to insert, especially if the patient is unconscious or irrational and it is necessary to proceed with paracentesis as rapidly as possible. This arterial catheter with the side holes is introduced percutaneously into the peritoneal cavity with no local anesthesia. The accessory openings in the catheter discourage omentum or intestine from occluding the catheter, as frequently occurs with the use of the standard venous or arterial catheter. With this technique, simple aspiration and, if necessary, lavage can be done via the peritoneal catheter. If aspiration has an abnormal yield, it is not necessary, obviously, to proceed with the peritoneal lavage, but if the aspiration is normal, one can then irrigate with volumes between 250 and 500 ml. Since a simpler catheter is available, the peritoneal dialysis catheter is just too cumbersome, requiring a formal incision. There is one other concern, as Dr Ahmad emphasized. If the patient has had a recent, or even ancient, central abdominal incision, it is very hazardous to attempt peritoneal dialysis. It is quite one thing to introduce a small catheter lateral to the rectus sheath, and quite another to incise into what turns out to be a bound-down loop of intestine. The complication reported by Dr Ahmad is not uncommon, so we feel very strongly that a midline or paramedian incision extending across the midabdomen is a substantial contraindication to the use of this technique. One last point: despite Dr Olsen's comments, the conviction of all who are working with large numbers of trauma patients is that there is no substitute for frequent, repeated physical examination of the abdomen. I am sure that this is a truism that we all hear and that many of us, unfortunately, tend to ignore occasionally. Dr. Ahm"ad: I would like to point out that when I said that half of the patients were spared laparotomy, this has a background. Drs Griswold and Noer started the trauma service in the Greater Louisville area, and at that time patients underwent operation on just the slightest suspicion of abdominal injury.
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