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This is the most important source of preventable (but undiagnosed) trauma deaths. Patients with haemoperitoneum may have no abdominal signs and present with unexplained hypotension. ASSESSMENT History - steering wheel injuries and seat belt injuries may be associated with injuries to the pancreas and duodenum. The abdomen should be examined for external signs such as seat belt marks, tenderness and involuntary guarding. The presence or absence of bowel sounds is unhelpful. X-rays of the pelvis are mandatory. Tests of pelvic stability are inaccurate. Erect chest films are examined for lower rib fractures, thoracic bowel gas (ruptured diaphragm), displaced nasogastric tubes and the presence of free gas under the diaphragm. 20% of left lower rib fractures have splenic damage. 10% of right lower rib fractures have hepatic damage. Patients with obvious involuntary guarding will need laparotomy. Laparotomy Should Be Considered In All Patients Who Are Deteriorating Despite Adequate Fluid Resuscitation: better a negative laparotomy than a positive post-mortem. SUMMARY Clinically alert and stable: Observe Equivocal intra-abdominal signs of haemorrhage:Investigate - DPL or CT (It is current Trauma Department policy to favour DPL over CT scan). Shock with obvious signs of severe intra-abdominal injury: Cross Match Blood And Operate Immediately. DIAGNOSTIC PERITONEAL LAVAGE INDICATIONS - Assessment of the abdomen where there is an altered conscious state from injury, alcohol or drugs. - Fractured ribs or pelvis with aWominal tenderness. - Unexplained hypovolemia - Assessment of seat belt injuries to the abdomen. - Spinal cord lesions with aWominal anaesthesia - Persistent abdominal signs without adequate explanation. Contraindications include previous aabominal surgery and definitive clinical signs. PROCEDURE This can be performed as a sterile procedure in the emergency department by injecting local anaesthetic down to the peritoneum just below the umbilicus in the midline. A catheter is then inserted under direct vision into the peritoneal cavity. If suction with a syringe reveals frank blood, the test is positive and the catheter can be withdrawn. Otherwise, 1 litre of warmed 0.9% Saline solution is infused and the infusion set is then placed below the level of the patient. The patients bed should be placed in Trendelenberg and reverse Trendelenberg to aid mixing. A 'Lavage Pack' is available in resusc room and Operating theatres for testing the effluent. Present testing includes RBC, WCC, Alk Phos, Amylase and Gram stain. RESULTS When the Red Blood Cell count is greater than 100,000 per cubic mm the result is positive. and laparotomy should be performed. When the Red Cell count is between 50,000 - 100,000, the result is equivocal and the decision to operate is based on further investigations eg. CT scanning or on clinical grounds. When the Red Cell count is less than 50,000 this is considered negative but occasionally, due to technical reasons, an intra-abdominal injury can be missed and clinical suspicion should be maintained and the abdominal signs reviewed.
CT SCANNING Is useful in the assessment of-blunt abdominal trauma in the following situations: Patients in whom peritoneal lavage is contra-indicated, eg. extensive previous midline surgery and in children. Patients with suspected isolated solid organ injuries (eg. stable liver and spleen injuries). Patients with suspected retroperitoneal injuries eg. renal, pancreatic .
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