Use of ultrasound to determine need for laparotomy in trauma patients.

STUDY OBJECTIVE: To determine whether abdominal ultrasound can be used routinely as the primary screening test to identify the need for laparotomy in trauma patients. METHODS: Ultrasound was used at a Level II trauma center as a primary screening test for evaluation of intraabdominal injury. We reviewed the charts of all patients from trauma codes presenting between January 1, 1991, and December 31, 1993, to determine the results of abdominal ultrasound evaluation and to learn whether laparotomy was required. RESULTS: A total of 2,013 trauma patients presented during the study interval. Ultrasound was performed in 1,631 patients as the primary screening test for abdominal injury (mean time after arrival, 22.9 minutes), abdominal computed tomography (CT) was performed as the primary screen on 8 (mean time, 68.6 minutes), and 93 patients underwent both ultrasound and CT of the abdomen. Of 86 patients requiring laparotomy who were screened by ultrasound, 80 had positive diagnostic findings, for a sensitivity of 93.0%. Of the 1,545 ultrasound-screened patients who did not require laparotomy, 1,390 had negative findings, for a specificity of 90.0%. None of the patients with negative ultrasound results died or sustained identifiable mortality as a consequence of their negative scans. CONCLUSION: Ultrasound is a sensitive and specific test with which to evaluate trauma patients for abdominal injury requiring surgery. Routine abdominal ultrasound can be performed at the bedside in the emergency department as a timely, noninvasive diagnostic test. This use of a screening abdominal ultrasound examination can improve clinical decision-making for the use of emergency laparotomy. Ultrasound may be a better alternative to CT or diagnostic peritoneal lavage for the initial screening evaluation of abdominal trauma.

Pediatric trauma triage: review of 1,307 cases.

To assess patterns of pediatric trauma triage and patient transfer to the pediatric trauma centers, the records of 1,307 patients 14 years old or less who were admitted or died during resuscitation at eight Level II Trauma Centers from January 1987 through December 1988 were reviewed retrospectively. Cases were analyzed according to the following criteria: age, diagnosis, mechanism of injury, admitting service, pediatric trauma score (PTS), length of stay in the intensive care unit (ICU) and in the hospital, and outcome. Forty-three patients were transferred to pediatric trauma centers based on local criteria. Of the remaining 1,264 patients kept at the Level II Trauma Centers, the average patient age was 8.34 year; PTS, 9.74; and length of stay, 4.46 days. Two hundred fifty-eight patients (19.7%) required ICU care for an average length of stay of 2.86 days. Twenty-four patients (1.8%) died; all 24 had a PTS less than or equal to 8. In comparing the data to the guidelines in Appendix J of the American College of Surgeons' Hospital and Prehospital Resources for Optimal Trauma Care of the Injured Patient for transfer to a Level I Pediatric Trauma Center, we found that children with a PTS greater than 8 and who either require ICU care and/or have altered states of consciousness can safely be treated in the adult ICU of a Level II Trauma Center.

The risk of improperly staging Hodgkin's disease with partial splenectomy.

Partial splenectomy has been proposed for staging Hodgkin's disease, but the risk of thereby missing limited splenic involvement is unknown. To assess that risk, we reviewed all spleens removed during staging laparotomies for Hodgkin's disease at our institution, assessing splenic weight, the characteristics of all nodules, and grossly visible subcapsular disease. Among 180 spleens, 65 had splenic disease. Fifty-three had six or more nodules; for 49 of those, other abdominal involvement had been present or the disease was so diffuse that staging by partial splenectomy would have been correct. The remaining 12 spleens (18%) contained five or fewer nodules. Eleven had no grossly visible subcapsular nodules, and five of the 11 were associated with no other abdominal involvement. In four of those five, the disease was localized to one area in such a way that it could have been missed by partial splenectomy. All positive spleens averaged 415 g; the four spleens with localized involvement averaged 287 g. Thus, in four of 65 patients, a few splenic nodules in a localized distribution not visible grossly were the only evidence of abdominal Hodgkin's disease, and if partial splenectomy had been done there would have been a 6.2 per cent risk of understaging their Hodgkin's disease.