blunt truma abdomen hemo UNstable - pinkypossible

[ArchivalUser]

hypetensive,flat neck veins,what is the NBS?

FSAT/DPL
Ex .laprotomy?

UW in many qs says go with Ex lap and other half of qs says DPL....

can some one throw some light on this

thanks a lot.

[ArchivalUser]

Dear Pinky
For blunt abdominal trauma :
If the pt is unstable = FAST or DPL
If the pt is stable = CT scan

[These tests make the surgeon decide what to do and where to do and what to look far]
Unstability is no doubt one indication of Laprotomy but usually FAST or DPL is done before laprotomy.

Not every unstable pt needs laprotomy e.g Large pelvic hematoma (Ex fixation + angiographic embolization).

If FAST ,(+) -----------> Laprotomy
If FAST (-) -----------> REsuscitation and if becomes stable ---------> CT

[ArchivalUser]

if on PE it's an acute abdomen or any sign of peritoneal irritation - Explore Lap
but if there's no PE on the abdomen on the case - FSAT/ DPL

[ArchivalUser]

thanks angel man.....

"Unstability is no doubt one indication of Laprotomy but usually FAST or DPL is done before laprotomy." I understand this concept.....but in some qs they give that pt is not responding to fliid resacitaiojn of 2L and then the ans woule be Exp Lap, not dpl/fast even though dpl was there in the choice.

so is there any indication like pt not responing to intial fluid , with no other injuirs, but abo trauma, will go for .Exp LAp ?

then
"Not every unstable pt needs laprotomy e.g Large pelvic hematoma (Ex fixation + angiographic embolization)"

this u will think of doing only after ruling out interaperietoneal bleed by fast/dpl , rt?

[ArchivalUser]

Hii pinky!!
I think we should give blood transfusion followed by dpl

DPL is indicated in blunt trauma as follows:
-------------------------------------------------

Patients with a spinal cord injury

Those with multiple injuries and unexplained shock

Obtunded patients with a possible abdominal injury

Intoxicated patients in whom abdominal injury is suggested

Patients with potential intra-abdominal injury who will undergo prolonged anesthesia for another procedure

An indication for immediate blood transfusion is hemodynamic instability despite the administration of 2 L of fluid to adult patients; this instability indicates ongoing blood loss.

Indications for laparotomy in a patient with blunt abdominal injury include the following:
-----------------------------------------------------------------------------------------------------


Signs of peritonitis

Uncontrolled shock or hemorrhage

Clinical deterioration during observation

Hemoperitoneum findings after FAST or DPL examinations

Finally, surgical intervention is indicated in patients with evidence of peritonitis based on physical examination findings

[ArchivalUser]

Actually if the patient is stable then CT is the test of choice. Not FAST /DPL
Let us suppose a patient becomes stable after rescusitation ,there is no sense in doing DPL/FAST.
These tests are performed because these are
-quick
-can be done bedside .

The scenario which USMLE is giving is :
If the patient is unstable ,try to resuscitate :
If resuscitated = FAST /DPL (Here my objection is why not CT ??)
If not = Laprotomy

Secondly what I have given is taken from : Emergent management of trauma by Scaletta

[ArchivalUser]

hii angleman the reason for not being CT is :

In [blunt abdominal trauma patients] is [computed tomography scanning better than diagnostic peritoneal lavage] at [identifying intraabdominal injury]?

Comment(s)
Independantly, DPL results in a high rate on non-theraputic laparotomies. While it has the advantages of rapidity and that fact that it is more cost effective, it cannot accurately diagnose retroperitoneal injury. Similarly, CT scans have been shown to produce more false positive and negative results when performed as the only diagnostic modality. Therefore, many studies advocate the use of the two methods in conjunction with one another.

Clinical bottom line :
---------------------
DPL may be used alone in haemodynamically unstable patients, those with concomitant head or chest injuries and those with open fractures. CT should be used in the inital evaluation of haemodynamically stable patients.

hope this clears

Godbless

[ArchivalUser]

thanks cancer.....can u please tell the sourse of this info, .......all looks so new to me


yes if there is a choice for BT, u will surel go with that....

what I am confused is what to be done first in an unstable pt, ie NBS? fast/dpl OR ex.lap....

About the indiactions of lap staraight away is Signs of peritonitis , (gaurding and rigidity)

the conditins u mentioned like Uncontrolled shock or hemorrhage and Clinical deterioration during observation , whjat the NBS?

DPL
EXp Lap


thanks a lot

[ArchivalUser]

emedicine : http://www.emedicine.com/MED/topic2804.htm

pinky thanks for bringing up such a nice discussion

Goodluck and Godbless

[ArchivalUser]

thanks guys for the all the inputs.


So bottom line is
------------------------
pt stable.......CT

If the patient is unstable ,try to resuscitate (2l of fliuds,if not better and Blood tranfusion is an option we can choose that)

If resuscitated = FAST /DPL

If not = Laprotomy


these 2 comes in not resuscitable catogory..
# Uncontrolled shock or hemorrhage

# Clinical deterioration during observation


thanks