The Dominant Role of Paracentesis Technics in the Early Diagnosis of Blunt Abdominal Trauma
Richard D. Sloop, MD, Salem, Oregon
Diagnostic paracentesis with peritoneal lavage, when incorporated as part of the initial examination procedure upon blunt trauma victims, enables the sur-
geon to reach an accurate and definitive decision as to the need, or lack of need, for laparotomy, usually within a few minutes (l-151. But acceptance and application of the method by trauma surgeons, especially the occasional trauma surgeon, has been slow. The time-honored method of serial observation-or early laparotomy-continues to be unnecessarily employed. Additionally, current medical writings suggest that the various organ-imaging technics (arteriography, sonarography, and radionuclide imaging) have major roles in trauma diagnosis, resulting in application of these methods frequently in excess of their indications. A major factor in the lack of acceptance of peritoneal lavage is the burdensome nature of the described methods, most of which involve a “micro”-laparotomy technic for catheter placement [7,8,10,11], or percutaneous placement of a cumbersome trochar catheter [1,3,4,6]. To achieve its deserved acceptance, the method requires modification to provide rapidity and simplicity such that it becomes used as part of initial physical examination, and such that the surgeon will be motivated to its use in the two extremes of indications, that is, to produce immediate firm diagnosis when visceral injury is virtually obvious, and more importantly, possibility.
when such injury
seems only a remote
From the Department of Surgery, Salem Hospital, Salem, Oregon. Reprint requests should be addressed to Richard D. Sloop, MD, 560 Winter Street, SE, Salem, Oregon 97301. Presented at the Forty-Ninth Annual Meeting of the Pacific Coast Surgical Association, Newport Beach, California, February 19-22. 1978.
Volume 136, July 1878
The present report describes a simplified method of diagnostic paracentesis and lavage, and reports the experience with this method and other diagnostic aids in a large community hospital setting. Method Diagnostic paracentesis is accomplished at the time and place appropriate to circumstances, usually in the emergency center, but often in the x-ray department and elsewhere. Consent of patient or responsible party is not ordinarily obtained except to the extent that an alert individual is advised of the nature of his problem and the diagnostic measure that will be undertaken. A [email protected]
side-hole catheter-over-needle instrument is used ([email protected]
15 gauge, 4 inch thoracentesis catheterneedle, Becton-Dickinson). One or (usually) two catheters are placed percutaneously into the peritoneal cavity at umbilical level bilaterally in the region of the lateral margins of the rectus abdominis muscles. If clinical priorities so dictate, prior emptying of the bladder is not necessary. Nor is pregnancy considered a contraindication; the punctures are simply placed more cephalad, and in the case of third trimester pregnancy, the uterus is pushed away by a hand near the midline. When multiple scars of past abdominal operations are encountered, there is always at least one safe locus available for peritoneal puncture. Skin preparation is with a standard antiseptic solution; shaving is usually omitted and sterile draping is considered optional. A skin wheal is raised with 1 per cent lidocaine solution and infiltration carried to and through the peritoneum using a 22 or 25 gauge needle of appropriate length. The skin is pierced with a #ll blade and the catheterneedle assembly is inserted and advanced to the “pop” through peritoneum. The needle is withdrawn 1 cm within the catheter and the assembly advanced into the peritoneal cavity; if this is not free of resistance and pain, extraperitoneal position of the catheter tip must be suspected. The
Prime Indicators for Laparotomy-65
Indication Established at Initial Examination History and exam only Paracentesis positive Irrigation paracentesis Strong positive Trace-positive Aortogram Total Indication Not Establishedat Initial Examination Hidden blood loss when abdominal visceral injury not initially suspect (delayed paracentesis positive) Progressing retroperitoneal signs
Cases 2 29 28 1 61 (94%) 2
2 4 (6%)
needle is removed and the catheter is manipulated back and forth, again checking for lack of resistance. Blood often appears within the catheter; if this does not flow from the hub, it is considered as simply a product of needle-placement trauma. Blood flowing from a catheter in excess of 1 or 2 cc establishes the presence of hemoperitoneum; a sample is collected to confirm defibrination (nonclotting in 10 minutes) and the paracentesis is terminated. Those patients not demonstrating hemoperitoneum by simple paracentesis are subjected to peritoneal lavage by a “wash-through” technic. Physiologic saline solution is introduced through one of the peritoneal catheters via standard intravenous administration tubing until several cubic centimeters of the fluid flow from the second catheter; up to 1,000 cc may be used in adults and appropriately smaller volumes in children. After 100 to 200 cc have been instilled, check for backflow from the input catheter is usually made to verify intraperitoneal placement; preperitoneal or intraenteric placement often produces brief and vigorous backflow, the former producing trace-bloody fluid and the latter bile staining and/or particulate matter. If either is suspected, the catheter is repositioned. Return of crystal clear lavage fluid from the second catheter signifies absence of hemoperitoneum; return of 1 or 2 cc of bloody fluid followed by clear fluid indicates blood related only to trauma of needle placement. Return of homogeneously and grossly bloody lavage fluid denotes the presence of significant hemoperitoneum and is an indication for laparotomy. A “trace-positive” lavage is denoted by return of blood-tinged fluid that remains transparent to the extent that newsprint may be read through a 3 to 5 mm layer of the fluid; a more “scientific” quantitation of this parameter has not been found necessary. Rarely the retrieved lavage fluid is submitted to the clinical laboratory for amylase determination or Gram’s stain. Clinical
The present study includes my total blunt trauma experience from July 1970 through August 1977. Patients were seen in the course of duty rotation as surgeon-on-call to the Salem Hospital emergency center, or in the course
Trace-Positive Lavage Group: Management of 17 Cases
Visceral Arteriogram Negative Study Observed-no laparotomy Operated to control retroperitoneal hemorrhage Positive Study Abdominal Aortogram Operative repair of aorta Early Laparotomy without Observation (false-positive paracentesis) Observation without Study by Imaging Procedure Laparotomy not required Laparotomy for retroperitoneal injury Total Laparotomies
a 7 1 0 1 1 7 6 1 4
of surgical consultation requests to patients in various departments of the hospital. The number of patients involved is irretrievable since all manner of trauma, trivial through massive, are included. The intent is to identify all patients who had diagnosed, or should have had diagnosed, significant intraabdominal injury. Follow-up and identification of the latter group is considered to be complete. Patients who were suspected of having sustained abdominal trauma, but such injury not verified, were reviewed as to subsequent clinical course or autopsy findings. Any patients not suspect for abdominal trauma at initial examination, but who subsequently demonstrated an abdominal problem, would have been identified if they remained in Salem. An admittedly weak area of follow-up exists with the apparently trivially injured, transient accident victim who might turn up in a distant hospital with delayed manifestations of abdominal trauma. Results
Early Identification of Operative Cases. Sixty-five patients underwent laparotomy for blunt trauma during the study period. In sixty-one patients (94 per cent) the decision for laparotomy was made during the patient’s first examination (Table I); paracentesis aided this early decision in fifty-eight. Indications for operation were identified in two patients after periods of observation, and two did not become suspect for abdominal injury at initial examination. One of the latter was initially seen as an inpatient 18 hours after chest injury (4 rib fractures), was released home, and presented again eighteen days post injury with delayed hemorrhage from a splenic laceration. The second missed patient was seen 36 hours after admission to the orthopedic service, at which time abdominal injury was not thought to be present; continued unexljlained blood loss over two days led to paracentesis and removal of a transected spleen. In no patient was visceral arteriographic or other imaging technic findings instrumental in decision for laparotomy.
The American Journal of Surgery
Trace-Positive Lavage Group: Rationale for Observation without Use of Imaging Procedure (7 cases)
Difficult to accomplish imaging (multiple fractures) P’esumed lethal head injury Pegnancy Paracentesis suspect to be false-positive Clinical judgment (1 operated after 10 hours) -
2 1 1 1 2
Time Lapse to Operation. Among the sixty-one patients having laparotomy indication established a: first examination, time from emergency center admission or ward consultation to beginning of operation was less than 2 hours in 42 per cent, less than 3 hours in 69 per cent, and less than 4 hours in 86 per cent. Paracentesis and Lavage. Paracentesis with or without lavage was carried out on 131 patients, with the following results: 31 positive paracenteses; 28 positive lavages; 17 trace-positive lavages; and 55 negative lavages. All negative lavages were true-negative as confirmed by subsequent clinical course, by autopsy, and in one case by laparotomy incidental to median sternotomy for management of cardiac rupture (this case is not included among the 65 laparotomies to be d, scussed). The paracentesis catheter(s) yielded nonclotting bl.ood without need for irrigation in thirty-one patients. All were confirmed at laparotomy as truepositive, but in two the bleeding was from small liver lacerations that required no special attention; these are classified as “nontherapeutic” laparotomies. Lavage returns were grossly bloody in twenty-eight cases, all true-positives. One nontherapeutic laparotomy resulted, minor liver injury being the source of’ free blood. The precise number of unexpected results of paracentesis and lavage is not available, but the numerous instances in both directions are notable, amounting to an estimated 20 per cent. The frequency with which a seemingly normal abdomen yields free peritoneal blood and contains a lacerated spleen or liver is impressive. Trace-positive lavage occurred in seventeen cases. The crude method of quantitating trace versus strong lavage results was quite adequate because borderline situations did not occur. These cases sorted out as a special group in terms of management and results: The Trace-Positive Lavage Group. Management of these seventeen cases is summarized in Table II. Here occurred the only false-positive lavage of the series; this was early in the experience in a totally
Volume 136, July 1978
of Blunt Abdominal Trauma
Indications for Arteriography Paracentesis Result TraceStrong Negative Positive Positive
Neurologic Widened mediastinum Abdominal visceral Abdominal aorta Peripheral vascular
1 1 0 0 1
2 1 a 1 1
6 4 0 0 0
uncooperative young male who would not permit proper completion of the lavage procedure; laparotomy was done and no pathologic condition found. Three additional patients underwent operation and in each the “trace-positive” hemoperitoneum was confirmed. In each the blood source was contused posterior peritoneum. One patient underwent operation for clinically suspect and angiographically confirmed injury to the abdominal aorta; this was an isolated injury. The second patient was observed for 10 hours when decision for laparotomy was made on clinical grounds; operative findings were pancreatic laceration and intramural hematoma of duodenum. The third patient was operated on after 20 hours for control of continuing retroperitoneal hemorrhage from pelvic fractures. Further diagnostic measures were individualized in the remaining thirteen patients who did not undergo laparotomy. Seven had visceral angiography (all negative) and six were simply observed. The rationale for observation without use of imaging procedure is listed in Table III. Complications of Paracentesis and Lavage. One major complication was recognized, this being the one false trace-positive lavage which contributed to the decision to carry out laparotomy. Only one minor complication was identified: a catheter entered the left colon and lavage saline was instilled into the bowel; the mishap was recognized by return of particulate matter from the catheter and production of an urgent diarrhea; a fresh catheter was placed and the lavage was completed and proved negative; the patient suffered no ill effect. Angiography and Other Organ-Imaging Procedures. Arteriography was utilized for the indications
listed in Table IV. Excretory urography and cystography were done when hematuria was noted; indications to proceed with renal arteriography were not found in any patient. Diagnostic sonarography and radionuclide imaging were not utilized in this series. Characteristics of the Sixty-Five Laparotomy Cases. Age range of the sixty-five patients (43 male,
22 female) was seven to eighty-three
Distribution of Injuries and Mortality
Abdominal organ Spleen Liver Pancreas Bowel Thoracic Craniocerebral Major fracture Mortalitv
Clinically Obvious or ParacentesisPositive
Irrigation Strongly Positive
20 11 4 0 11 15 13 6
20 12 3 0 10 12 12 3
1 1 6 10 7 1
age, 26 years). Injury resulted from motor vehicle accident in most (48), with a smattering of sports and play accidents (5), industrial accidents (4), pedestrian injuries (2), falls (3), horse-kickings (2), and assault (1). Sites of injury and mortality are listed in Table V. Renal injuries are not listed because of the problem with parameter selection to define significant injury; only two kidneys were surgically exposed and one nephrorrhaphy was done. Among the mortalities, the abdominal injury was considered to be a major factor in outcome in two cases, and perhaps contributed in a third case. Blood Replacement in Operative Patients. Use of transfusion in the operative patients was examined and found too diverse to merit recording except for the experience with eleven patients having splenic injury as the only significant site of blood loss. Four of these were not transfused during their hospital course and the remainder were given 1 to 5 units of blood. Comments
In this blunt abdominal trauma series, early (first examination) recognition of injury requiring laparotomy was achieved very satisfactorily by the simple protocol of routine history, physical examination, and liberal use of diagnostic paracentesis and peritoneal lavage. More complex diagnostic procedures, notably arteriography, were used only in doubtful cases, but in none did arteriography or any other organ-imaging procedure yield indication for laparotomy. Failure of the examiner to suspect the possibility of abdominal injury and thus not carry out paracentesis was the only reason for delay in diagnosis of intraperitoneal injury (2 cases). For this reason and as advocated by others [8,11], paracentesis is done on the slightest suspicion of such injury. This policy includes any patient who has sustained sufficient
violence to have perhaps incurred abdominal injury, and who has either the slightest of abdominal physical findings or some compromise of responsiveness due to head injury, intoxication, or simply many other injuries. Ease and safety of paracentesis and gratifying results have fully justified this liberal use of the procedure. Conversely, this experience of complete reliability of negative “wash-through” lavage has greatly eased the management (and surgeon anxiety) of many traumatized patients. In addition to eliminating morbidity associated with delay in diagnosis, there have occurred several logistic dividends related to immediate identification of patients who will require laparotomy. This information allows prompt formulation of a definitive plan for diagnostic and therapeutic procedures. Order for preparation of the operating room and call-in of surgery personnel can be done early with confidence of their need, a matter of considerable significance in a community hospital. When dealing with multiple casualties, priority can immediately be assigned for utilization of limited surgical facilities and staff. Management of the trace-positive lavage case remains a problem for careful clinical judgment that cannot be “protocolized.” Others, most notably Olsen, Redman, and Hildreth , have discussed this problem. In this small series of seventeeen tracepositive cases, it is reassuring to note that none proved to have a hemorrhage-prone visceral injury. The three patients of the group who required operation were all identified by ordinary clinical signs: the first had abdominal aortic injury and the lavage result gave assurance that time could be taken for angiography before operation; the remaining two had initially apparent retroperitoneal injury, and brief periods of observation brought quantitation of the injury and indication for operation with good outcome. As the series progressed and the reliability of clinical signs was upheld in the trace-positive group, the use of arteriography decreased. Presently, organ-imaging is done selectively in this group and is primarily directed to the spleen; if clinical signs of leukocyte count suggest splenic injury, or if the injury was on the left, the spleen is imaged. Choice of imaging technic rests with the presence of other injuries; if arteriography is not needed at another organ, radionuclide scintography may be the method of choice. When there is readily apparent cause for a trace-positive lavage result, such as pelvic fracture, renal contusion, or apparent minor liver injury from right-sided trauma, a conservative diagnostic course is more frequently followed, relying upon continued observation.
The American Journal 01 Surgery
Early Diagnosis of Blunt Abdominal Trauma
The finding in the present series that organimaging in no instance provided indication for laparotomy (Olsen, Redman, and Hildreth  report 1 of 108) is undoubtedly a product of the small number of cases. But it does allow the conclusion that arteriography, radionuclide imaging, and sonarography all have very limited roles in early diagnosis of blunt abdominal injury. The role of these diagnostic modalities is restricted to the occasional situation of clnically suspect solid organ injury (most notably spleen and perhaps kidney) in which a trace quantity of intraperitoneal blood is demonstrated. With respect to arteriography, this conclusion is quite apart from that of Freeark . Further, in none of the present cases would operative management of visceral injury have been facilitated by the availability of an arteriogram; similarly, no injuries not discovered at laparotomy have become known. The method of paracentesis described has evolved from desire for a method of detecting free intraperitoneal blood that is rapid, safe, and sufficiently simple to encourage its routine use even in the most doubtful cases, and in the presence of a full bladder, a gravid uterus, or surgical scars. Rapidity and simplicity is provided by use of a plastic catheter-overneedle device that allows percutaneous placement. The commercial device described has provided adequate “feel” during catheter passage through the abdominal wall; ordinary catheter-over-needle venipuncture devices have not been satisfactory in this regard, and in addition they lack the essential side holes. (A homemade side-hole catheter needle has been described by Bivins, Jona, and Belin .) Peritoneal dialysis catheters have been excessively difficult to insert. Percutaneous placement of the catheter is of course a blind procedure, and thereby problems do arjse. Difficulty relates mainly to intraenteric and preperitoneal placement, both of which can produce misleading findings when lavage by single catheter is used. The two-catheter technic is recommended in order to avoid these important pitfalls. When lavage fluid is instilled in one catheter and retrieved from a second catheter on the opposite side of the abdomen, there can be no question that the retrieved fluid has passed through the peritoneal cavity. Further, with this “wash-through” technic there can be no doubt as to the significance of crystal clear lavage ret urn: there is no free blood in the peritoneal cavity.
Conversely, the most trivial quantity of free blood will be appreciated, and thus arises the possible criticism that the method is overly sensitive. Experience here is similar to that reported by others .
Volume 136, July 1978
None of .the four nontherapeutic laparotomies was related to this problem. The matter of oversensitivity must be acknowledged, but it can be kept in perspective by ordinary clinical judgment. Conclusion Hemoperitoneum in the blunt trauma victim is virtually a singular determinant of the need for laparotomy. Its demonstration, or proof of its absence, should be an early priority in managing suspect patients. After paracentesis, routine x-rays, and urologic x-ray studies, additional diagnostic methods short of laparotomy are seldom desirable and should be utilized with clinical judgment in special situations and in the light of paracentesis findings. Summary A simplified method of diagnostic abdominal paracentesis and lavage is described. Liberal application of this method as part of the initial physical examination of blunt trauma patients resulted in identification at first examination of 94 per cent (61 of 65) of those who were to have laparotomy. No case in the series was brought to laparotomy as the result of findings at arteriography, radionuclide imaging, or sonarography, and no intraabdominal problem was missed because of failure to use one of these organimaging .technics. The very limited role of these imaging procedures in early management of blunt abdominal trauma is discussed. References 1. Root HD, Hauser CW, McKinley CR, LaFave JW, Mendiola RP Jr: Diagnostic peritoneal lavage. Surgery 57: 633, 1965. 2. Berger WJ Jr: Evaluation of “intracath” method of abdominal paracentesis. Am Surg 35: 23, 1969. 3. Caffee HH, Benfield JR: Is peritoneal lavage for the diagnosis of hemoperitoneum safe? Arch Surg 103: 4, 197 1. 4. Olsen WR, Redman HC, Hildreth DH: Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 104: 536, 1972. 5. Perry JF Jr, Strate RG: Diagnostic peritoneal lavage in blunt abdominal trauma: indications and results. Surgery 71: 898, 1972. 6. Thai ER, Shires GT: Peritoneal lavage in blunt abdominal trauma. Am J Surg 125: 64, 1973. 7. Alho A. Tervo T: Diagnostic laparocentesis and peritoneal lavage in patients with multiple injuries. Acta Chir Stand 141: 53, 1975. 8. Gill W, Champion HR, Long WB, Jamaris J, Cowley RA: Abdominal lavage in blunt trauma. BrJ Surg 62: 121, 1975. 9. Parvin SP, Smith DE, Asher WM, Virgilio RW: Effectiveness of peritoneal lavage in blunt abdominal trauma. Ann Surg 181: 255, 1975. 10. Nicholas GG, DeMuth WW: Peritoneal lavage in diagnosis of intraperitoneal injury. Penn Medp 60, June 1975. 11. Engrav LH. Benjamin Cl, Strate RG, Perry JR Jr: Diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 15: 854, 1975.
12. Bivins BA, Jona JZ, Belin RP: Diagnostic peritoneal lavage in pediatric trauma. J Trauma 16: 739, 1976. 13. Powell RW, Smith DE, Zarins CK, Parvin S, Virgilio RW: Peritoneal lavage in children with blunt abdominal trauma. J Pediati Surg 11: 973, 1976. 14. Rao RN, Ravikumar TS: Diagnostic peritoneal tap. /n&mat Surg 62: 14, 1977. 15. Jergens ME: Peritoneal lavage. Am J Surg 133: 365, 1977. 16. Freeark RJz Role of angiography in the management of multiple injuries. Surg Gynecol Obstet 126: 761, 1969.
Discussion Robert C. Lim (San Francisco, CA): I enjoyed listening to Dr. Sloop’s presentation on his experience of peritoneal lavage. I agree that his method is simple and easy to perform. It is similar to the use of a peritoneal dialysis catheter which we prefer. The dialysis catheter has a larger bore and has more side holes. It also requires only one insertion site. The real controversy comes as to its indication. In Dr. Sloop’s series of 65 patients requiring laparotomy for blunt trauma, 58 had peritoneal paracentesis and/or lavage done. In contrast, during 1975-1976, 757 laparotomies were performed for trauma at the San Francisco General Hospital. Of these cases, 231 were done for blunt trauma; and peritoneal lavage was done in only 38 of the 231 patients. In this group of 231 patients, 189 had intraabdominal pathology necessitating surgical therapy, that is, injuries to the spleen, liver, pancreas, or bleeding from other sites;-42 patients had negative explorations. The majority of these patients had large retroperitoneal or pelvic hematomas from pelvic fractures. Only 1 patient had significant morbidity related to the negative laparotomy and no mortality was due to the laparotomy. In the 42 patients with negative explorations, 5 underwent peritoneal lavage. One of them had a negative lavage; however, because of change in clinical findings; exploratory laparotomy was done. Three patients had pink-colored fluid return, which was probably due to retroperitoneal or pelvic hematomas. One patient had an elevated amylase content in the lavage fluid. Laparotomy revealed no pancreatic or gastrointestinal disease. Our indication fo!: peritoneal lavage is limited to patients whose clinical findings are equivocal or whose associated injuries or drug indiscretion makes the abdominal findings difficult to interpret. We do ndt believe that peritoneal aspiration and lavage should be part of the initial physical examination. We believe that whenever it is contemplated, the surgeon must be consulted and appropriate abdominal x-ray studies should be completed first. The presence of free air would preclude doing the procedure; whereas the presence of free air after paracentesis of lavage would only
confuse the x-ray interpretation. In closing, I would like to underscore that peritoneal lavage should be regarded the same as any invasive test and that its indication should be clearly defined. Leon Morgenstern (Los Angeles, CA): My comments are intended neither to detract from nor to criticize Dr. Sloop’s fine paper and his expert use of a time-honored diagnostic technic in blunt abdominal trauma. I should rather like to introduce a new diagnostic concept now being developed by Dr. George Berci and resident colleagues in our section of Surgical Endoscopy. Its principle is the direct visualization of the peritoneal cavity by a miniature endoscope. (Slide) The equipment, which is designed for emergency room use, consists of a small trocar, no larger than the standard paracentesis trocar, a hand insufflator to induce pneumoperitoneum, a miniaturized telescope, and a fiberoptic light source. An even smaller “needle-telescope” is in the process of development. (Movie) This film strip shows the excellent visualization of the intraperitoneal structures (shown here in the experimental animal). Note the omental wrapping of the trocar, which could interfere with fluid retrieval. Note the excellent visualization of the lateral peritoneal gutter, where blood collects preferentially in visceral bleeding. As yet we do not have sufficient clinical experience with this method to recommend it for routine use. It is, however, just on the horizon as another effective tool in the diagnosis of intraabdominal injury. Richard D. Sloop (closing): I want to thank Dr. Lim and Dr. Morgenstern for their comments. Dr. Lim pointed out something that I think was obvious to everyone, that is, the author was enthusiastic about using the method, and therefore there were only two patients with laparotomies who were simply taken directly to the operating room without sticking a needle into their peritoneum. But I would like to point out that this work is in a community hospital. The operating room is not staffed 24 hours a day. The operating room staff needs to be called in at night, and the benefit of liberally using paracentesis in the case that is almost obvious has really been quite marked; the “almost obvious” case is far more common than the “obvious” case. One is pretty sure they need to be operated on, but in 10 minutes we can&now this positively, and we can call the crew. With multiple casualties, this becomes extremely important. Often it turns out the other way around. The multiply traumatized patient who seems obviously to have an abdominal injury frequently does not have one, and thereby laparotomy is avoided.
Tha Amarlcan Jcurnal cl Surf