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Imaging in Blunt Abdominal Trauma

Imaging in Blunt Abdominal Trauma. Stephen J. Wolf, MD Department of Emergency Medicine Denver Health Medical Center Denver, Colorado USA. Imaging in Blunt Abdominal Trauma. Blunt Abdominal Trauma Leading cause of morbidity and mortality in trauma

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Imaging in Blunt Abdominal Trauma

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  1. Imaging in Blunt Abdominal Trauma Stephen J. Wolf, MD Department of Emergency Medicine Denver Health Medical Center Denver, Colorado USA

  2. Imaging in Blunt Abdominal Trauma • Blunt Abdominal Trauma • Leading cause of morbidity and mortality in trauma • Leading cause of intra-abdominal injuries • Nineteen percent of intra-abdominal injuries have no pain

  3. Imaging in Blunt Abdominal Trauma • Pre 1960’s - Four quadrant paracentesis • 1960’s - Diagnostic Peritoneal Lavage (DPL) • 1980’s - Abdominal Computed Tomography Scan (CT Scan) • 1990’s - Focused Abdominal Sonography for Trauma (Fast Scan)

  4. Imaging in Blunt Abdominal Trauma – Case Presentation • 20 year old male unrestrained driver of high speed MVA, complaining of abdominal pain. • VS: BP 90/40 HR 115 RR 20 SaO2 100% • Abd: Diffusely Tender, no ecchymosis • Pelvis: Stable, Non-tender • Rectal: Hemoccult negative • CTL C-spine, pCXR, Pelvis: NL • HCT:Hgb: 44% / 13g/dl

  5. Imaging in Blunt Abdominal Trauma - DPL • What is the diagnostic performance of DPL in diagnosing significant intra-abdominal injuries requiring intervention in blunt abdominal trauma?

  6. Imaging in Blunt Abdominal Trauma - DPL • Sensitivity: • Hemoperitoneum: 83 – 98% [I,II,III] • Mean sensitivity: 95% [III] • Enteric injuries: 82%[III] • Nontherapeutic laparotomies (False Positives): • Rate: 13 – 54% [II,III]

  7. Imaging in Blunt Abdominal Trauma - DPL • Limitations: • Minimal bleeding [II,III] • Retroperitoneal, diaphragmatic, enteric injuries • Insensitive markers [III] • Gram stain, amylase, alkaline phosphatase • Significance of injury? • Complications rate: 1 – 2 % [II,III]

  8. Imaging in Blunt Abdominal Trauma - DPL • Level A recommendations.None specified. • Level B recommendations. • Diagnostic peritoneal lavage can be used to exclude hemoperitoneum in blunt abdominal trauma patients. Diagnostic peritoneal lavage does not define the extent of injury, has a 1% to 2% complication rate, and may lead to nontherapeutic laparotomies. • Level C recommendations. • On the basis of consensus and current practice patterns, the initial choices for the evaluation of blunt abdominal trauma are CT and FAST, depending on the patient’s hemodynamic stability.

  9. Imaging in Blunt Abdominal Trauma – CT Scan • What is the diagnostic performance of CT in diagnosing significant intra-abdominal injuries requiring intervention in blunt abdominal trauma?

  10. Imaging in Blunt Abdominal Trauma – CT Scan • Sensitivity: • Solid organ injury: 97% [II,III] • Enteric injury: 64 – 94% [III] • Diaphragmatic injury: 61% [III] • Pancreatic injury: 30% [III]

  11. Imaging in Blunt Abdominal Trauma – CT Scan • Level A recommendations. None specified. • Level B recommendations. • When either liver or spleen injury is suspected, CT can reliably exclude injuries that require emergent operative intervention. CT alone cannot be used to exclude either bowel, diaphragm, or pancreas injury. • Abdominal CT accurately identifies hemoperitoneum among patients with blunt abdominal trauma. • Level C recommendations. None specified.

  12. Imaging in Blunt Abdominal Trauma – CT Scan • Does oral contrast improve the diagnostic performance of CT in blunt abdominal trauma?

  13. Imaging in Blunt Abdominal Trauma – CT Scan • Proposed benefits of oral contrast • Identifying extravasation, delineating mesentery, setting opacified bowel apart from hematomas and pancreatic injuries • Proposed risks of oral contrast • Vomiting, aspiration, delayed diagnosis.

  14. Imaging in Blunt Abdominal Trauma – CT Scan • Sensitivities: oral vs no oral contrast • Solid organ injuries: 84.2% vs 88.9% [II] • Enteric injuries: 86% vs 100% [II] • Intra-abdominal injuries: 98.4% [II] • Extravasation: 2.9% enteric injuries [III] • Aspiration: 0% [III]

  15. Imaging in Blunt Abdominal Trauma – CT Scan • Level A recommendations. None specified. • Level B recommendations. • Oral contrast is not essential to the evaluation of blunt abdominal trauma. • Level C recommendations.None specified.

  16. Imaging in Blunt Abdominal Trauma – FAST Scan • What is the diagnostic performance of FAST in diagnosing hemoperitoneum in blunt abdominal trauma?

  17. Imaging in Blunt Abdominal Trauma – FAST Scan • Sensitivity • Hemoperitoneum: 68 – 98% [I,II,III] • Hemoperitoneum and hypotension: 100% [II] • Intraabdominal injuries: 69% [II] • Enteric injury: 58% [II]

  18. Imaging in Blunt Abdominal Trauma – FAST Scan • Level A recommendations.None specified. • Level B recommendations. • FAST is useful as an initial screening examination to detect hemoperitoneum in blunt abdominal trauma patients. • Level C recommendations. None specified.

  19. Imaging in Blunt Abdominal Trauma Thank You!

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