Marcello della Corte wrote:
>I do not see the reason to do a DPL in a patient that already had a
US-scan. The problem with DPL is that it is not as repeatable as US scan
and does not detect any retroperitoneal source of bleeding. US-scan
compares well to DPL in terms of sensitivity, in experienced hands.<
U/S is very user dependent and in the UK currently radiology controlled. Is
it available in the Resuscitation Room around the clock? I accept the
desire to be non-invasive but specificity (negatives that are really
negative) is what is required here.
>I would rather be inclined to follow the ACS recommendation to do a repeat
US scan after 30 minutes, to detect a low rate bleeding with progressive
haemoperitoneum.<
Rescanning may be an option, but in 30 minutes I would hope that this
patient would be under drapes in theatre.
>A typical example of organ lesion that can cause a delayed haemoperitoneum
is the splenic rupture, which can be contained by the capsule for hours
(and in certain circumstances days). US-scan should be better than DPL at
detecting them.<
This was not at issue here. This is a time critical patient in which the
surgical decisions had to be made promptly.
Double contrast CT is the ideal option for identifying abdominal pathology
but the delays inherent in administration of oral contrast and the
"doughnut of death" make it a less than ideal option in this sort of
situation (where haemodynamic stability is absent). A haematoma that is
contained in a stable patient is different to small bowel perforation in
terms of need for laparotomy.
I stand by my contention that DPL and theatre are the correct actions in
MOST British hospitals under the circumstances presented in this case. The
DPL may be more appropriately done by the surgeons in theatre under
anaesthetic than the ED. FAST ultrasonography done by British ED physicians
is not widespead and is certainly not accepted by the Royal College of
Radiologists.
I apologise for not providing references to support this position. They're
all in shipping crates on their way to the UK :-(
Best wishes,
Darren Walter
SpR Emergency Medicine
Yorkshire Region
(currently with 3 weeks left on secondment in Sydney, Australia)
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