Nonoperative management of blunt abdominal trauma: the role of sequential diagnostic peritoneal lavage, computed tomography, and angiography.

STUDY OBJECTIVE: To determine the usefulness of sequential nonoperative diagnostic studies in the evaluation and treatment of stable patients after blunt abdominal trauma. DESIGN AND SETTING: Retrospective review of a prospective treatment plan in a large urban Level I trauma center. PARTICIPANTS: Fifty-two patients deemed stable after initial evaluation following blunt abdominal trauma. INTERVENTIONS: Patients with a positive diagnostic peritoneal lavage for red blood cells underwent abdominal computed tomography (CT) scanning. If CT demonstrated a visceral injury, it was followed by diagnostic angiography. Attempts were made to treat on-going bleeding by transcatheter embolization. RESULTS: Fifteen patients had negative CT scans and were successfully observed. In the other 37 patients, CT identified 17 liver, 16 splenic, and eight kidney injuries; eight extra-peritoneal bleeds; and one mesenteric hematoma. Six of these patients were observed. Thirty underwent diagnostic angiograms. Twelve had no active bleeding, and all were observed successfully. Seventeen underwent successful embolization of the bleeding site(s). One had injuries not controllable by embolization and required exploration. Six patients required laparotomy later in their course, but none had intra-abdominal bleeding or a missed intestinal injury. Despite being performed after diagnostic peritoneal lavage, CT missed only two injuries. There was one main complication, delayed recognition of a diaphragmatic injury. Three patients died, two from multiple organ failure and one from a pulmonary embolus; none was believed to be related to this technique. With our algorithm, 45 patients (86%) were spared laparotomy. CONCLUSION: Diagnostic peritoneal lavage and CT are complementary when evaluating blunt abdominal trauma. Diagnostic peritoneal lavage is an effective screening tool. CT may be reserved for stable patients with a positive diagnostic peritoneal lavage to specify the organs injured. Bleeding often may be treated by embolization, limiting the rate of surgery.

Indications for barium enema preceding colostomy closure in trauma patients.

The need for a barium enema (BE) preceding colostomy closure is controversial. In the process of evaluating the usefulness of BE before closure of colostomies performed for colorectal injuries, we reviewed our experience with 84 trauma patients who underwent BE before colostomy closure. Patients who had their colonic injuries repaired or diverted during the initial procedure did not benefit from the precolostomy closure contrast study. In this group of patients artifacts on BE had to be ruled out by endoscopy or repeat radiography in 9.5% of patients. Barium enema was found beneficial in evaluating colorectal injuries below the peritoneal reflection in one out of 20 patients. However, since the rectal injuries are not usually explored and repaired during the initial procedure, investigation by endoscopy and contrast studies may still be indicated preceding colostomy closure.

Evaluation of occult cardiac injuries using subxiphoid pericardial window.

During 1987, we performed diagnostic subxiphoid pericardial windows on all stable patients with juxta-cardiac penetrating injuries. This excluded any patient with clinically diagnosed tamponade or shock. Fifty-one patients underwent subxiphoid diagnostic pericardiotomy for suspected cardiac injuries. Forty patients were normotensive on presentation and 11 experienced transient hypotension. All patients were easily resuscitated in the Emergency Department. The time from admission to operation ranged from 20 minutes to 6 hours (average, 2.5 hours). Twelve patients (23.5%) had hemopericardium at the time of subxiphoid diagnostic pericardiotomy (SDP), and cardiac injury was confirmed at sternotomy in all. Two patients (16%) in the positive group were admitted with systolic blood pressures less than 100 mm Hg compared to nine (23%) in the negative group. One patient had a systolic to diastolic pressure gradient less than 30. Central venous pressures in this group of patients ranged from 8 to 23 cm H2O. Nine patients who had pericardial window solely on the basis of location of the injury had positive findings. All nine patients were normotensive on admission, had CVP's less than 12, and had no other overt clinical signs of injury. This represents an overall occult injury rate of 17.6%. At sternotomy, there were eight ventricular, two pulmonary artery, one aortic root, and one atrial injury, all repaired. Two patients in this group had associated abdominal injuries as did 11 in the negative group, all of whom required operation, and may have explained the hypotension in negative patients. There were no complications of SDP and all negative patients were discharged on the second hospital day.(ABSTRACT TRUNCATED AT 250 WORDS)