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Volume 1 Issue 2 March 1996 Contents: This issue features contributions from:
INTRODUCTIONIt has been a very exciting month within South Western Sydney Area in Trauma. Of particular note has been the camaraderie within the Trauma Team and the co-operation of various disciplines in the promotion of a streamlined trauma system. In trauma rounds over the next few months there will be a significant input from Brain Injury, Rehabilitation, Pain Service and Injury Prevention.We have just settled into our new offices. I would welcome any input and letters or comments to subsequent months Grapevine. Michael Sugrue MEETINGSSWAN IV: The full program and registration forms will be available by the end of April.EMST: Liverpool Hospital will host its third EMST course in July. OUR FIRST 3 WEEKS IN LIVERPOOL HOSPITAL'S TRAUMA UNITA final Year Medical Student's perspective on Trauma Care "Down Under"Recently,during our five week trauma attachment to Liverpool, we again witnessed two more people given the chance to live. It never rains but it pours (weather too!), and the back-up Trauma Team was called in. There would have been nothing lacking had either of them died, and indeed, it is a credit to the teams involved that both left theatre for the ICU rather than the morgue. Every trauma call we have attended has been met with fluent, co-ordinated and timely action. Compared with our limited experience of trauma in the U.K., the protocols are comparable, but we have not yet seen communication and synchronisation to the level we have seen here. Continuing appraisal at the weekly Trauma Meeting is avidly attended by all those involved, from the paramedics to the ICU staff providing the continuing care. Do not expect a seat if you are late! Also, the fact that the meeting usually over-runs, indicates a willingness to constructively criticise and learn from past experience. Input is from all levels and is another illustration of commitment to provide the best trauma service for the Liverpool Area. We have been impressed by the friendliness of the staff, despite the cramped and frantic working conditions. Murphy's Law states that whenever we took time out for sightseeing (not in Liverpool!), a trauma would come in. Never the less,we have seen a wide variety of trauma, in a greater volume than that at home, with repeated demonstrations by the Trauma Teams of how it should be done. Lorraine Greasley & Catherine Tagg Final Year Medical Students St George Hospital, London. The Value of DPL in Patients with Pelvic FracturesDr. Ulvi BudakDPL has been used as a diagnostic tool in blunt abdominal trauma since 1965. It is an established adjunct in the evaluation of abdominal trauma with a diagnostic accuracy of 90-98%. However, its value in patients with pelvic fractures has been revisited consistently. Hubbard and colleagues (1) from Kentucky have stressed that DPL has a false positive rate of up to 28% in patients with pelvic fractures. A recent study from Mendez and colleagues (2) has shown the false positive result of DPL in patients with pelvic fracture to be 0.7% with a sensitivity of 94%. High false positive DPL results in the presence of pelvic fractures has been attributed to several factors: (A) dissection of the retroperitoneal or pelvic haematoma, which results from the pelvic fracture, into the preperitoneal space of the anterior abdominal wall and placement of the dialysis catheter into this haematoma at the time of DPL; (B) direct placement of the dialysis catheter into the retroperitoneal haematoma; (C) extravasation of the blood from a retroperitoneal haematoma into the peritoneal cavity through a tear in the peritoneum; and (D) time dependant diapedesis of RBC's across the peritoneal lining into the abdominal cavity. Accordingly, to avoid false positive results, performance of DPL as soon as possible after injury, the use of the open technique and the supraumbilical approach has been advocated. DPL has a recognised limitation in the detection of retroperitoneal, extraperitonal (eg bladder) and diaphragmatic injury. DPL should be employed selectively in patients with pelvic fracture. Haemodynamic instability, where you wish to determine whether bleeding is intra or extra peritoneal is one of the main advantages of DPL in pelvic trauma. Suspicion of associated abdominal trauma (equivocal physical examinationof abdomen) and the presence of extra-abdominal injury requiring surgery (ie severe head injury) are relative indications for DPL. Positive DPL results purely by RBC count should be re-evaluated. Diagnostic Peritoneal Lavage is reliable in the evaluation of blunt abdominal trauma and should remain a mainstay of diagnostic work-up in patients with or without a pelvic fracture. References: 1. Hubbard SG et al. Diagnostic Errors with Peritoneal Lavage in Patients with Pelvic Fractures. Arch Surg 1979; 114: 844-846 2. Mendez C et al. Diagnostic Accuracy of Peritoneal Lavage in Patientswih Pelvic Fractures. Arch Surg 1994; 129: 477-482. Editorial : The paper by Mendez and colleagues and Dr. Budak's review made me look back at the literature critically to see why this has come to be the case. Most recent view about DPL in pelvic trauma resulted from a paper published in 1979 by the group at Loiusville in which they identified 61 patients who had diagnostic lavageperformed for pelvic fracture, of whom 35 were positive, 10 of which were false positive. The 10 divided by 35 gave a 29% false positive rate, and that number has been widely quoted since as the error rate. One problem is definitional in that a false-positive rate is the number of false positives relative to the total positives. What weactually want to know is the number of false positives relative to the total patients lavaged. In Hubbard's paper, that rate was much smaller, about 16%. It still doesn't answer how a significant number of positives came to be reported but other papers since have parroted this number without actually examining new data. When one looks at the subsequent literature, critically, it appears that the false positive rate in no study has been as high as that reported in the 1979 study. The most recent study, for example, from Denver General in 1990, which looked at 74 patients with pevic fractures who had diagnostic lavage, appeared to have a false positive rate (relative to total patients lavaged) of about 3%. Even two chest drains do not preclude the development of a recurrent pneumothorax or haemothorax. In a patient with chest tubes in place the first thing one should check, when there is a rapid deterioration, is the patency of the chest drain. Is it still in the chest? Is it blocked? Is it kinked? Remember to place drains on low suction!
Trauma AlgorithmsSerious (unconscious) Head Injuries: When and how to evaluate the abdomen? If the patient with a serious head injury, GCS<8, is haemodynamically stable and has been since the injury, then the priority lies with the head injury management.
February's Case of the Month Revisited(Click to review the case scenario)CXR or Chest Drain ?The patient arrived in the resuscitation room 1 hour and 12 minutes after the accident. There was no indication for the immediate insertion of a chest drain because:Oxygen Saturation was 99% there were no signs of tension pneumothorax (ie no severe dyspnoea tracheal shift, hyperinflation of the chest wall, hypotension) Without these signs, tension pneumothorax is unlikely. Chest drains have a significant morbidity and their insertion should always be after evaluation of all the above key clinical parameters. In this case the CXR did demonstrate a pneumothorax, which in a trauma setting neccessitates a chest drain. Was the patient Haemodynamically Stable?It is occassionally difficult to determine if a patient is haemodynamically stable. This 23 year old has had a persistent tachycardia suggesting significant blood loss (in the abscence of hypotension , it would suggest 750 - 1,250 mls of blood loss). In addition, however, it should be remembered that 2,800 mls of fluid has been administered. The patient therefore could not be considered to be haemodynamically stable.How would you have progressed from where we left off?The patient was relatively unstable and had been in the resuscitation room for 40 minutes. A DPL was performed under local anaesthetic and was frankly positive with over 50 mls of frank blood returning. The patient was transferred to the operating theatre where a laparotomy revealed 1,000 mls of blood in the abdominal cavity from a splenic rupture and liver laceration. The splenic laceration was bleeding actively and after mobilisation of the spleen, a splenorrhaphy was performed using dexon mesh. The liver laceration was superfical and required the application of topical haemostatic agents only.Post-operatively, the chest drain was kept on low suction as this reduces the length of time they are required for. The patient made a slow recovery but was able to be discharged day 10.
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