Category Archives: General

DPL: A Dying Art?

October 30, 2012 The Trauma Pro Leave a comment

Diagnostic peritoneal lavage (DPL) was invented by David Root at this hospital (Ancker Hospital, which then became St. Paul Ramsey, now Regions Hospital) in the 1960’s. It enjoyed its heyday during the 70’s and 80’s, when it was done hundreds of times per year at most major trauma hospitals. Now, we do it about 5 times per year. What happened?

As you know, DPL is a qualitative test. It gives a yes/no answer to the question “does this patient need an operation?” based on red and white blood cell counts. During the mid-1980s, CT scanning was introduced, which provides much more quantitative information about injuries in the abdominal cavity. The improved ability to diagnose abdominal injury, especially solid organ injury, has led to the demise of DPL.

Most solid organ injury results in some free blood in the peritoneal cavity. It doesn’t take much blood (10 cc of whole blood mixed with 1 liter of infused crystalloid) to exceed the threshold of 100,000 RBC per ml of aspirate that will send the surgeon off to the OR. Therefore, pretty much any liver or spleen laceration would have to be taken to the OR based on a DPL.

But we know that very few liver/spleen injuries actually need an operation. So DPL cannot be used, or the negative laparotomy rate for blunt trauma would escalate. The other downside to DPL is that it’s not possible to get all of the infused crystalloid back out of the abdomen. This leads to a confusing amount of free fluid seen on any CT scan done after a DPL.

So DPL is now down but not out. Some practical pointers:

DPL should be used primarily as a backup to an equivocal or unbelievable FAST exam in an unstable patient. An example would be a patient who is hypotensive, has a negative FAST and no other obvious bleeding sources.
Remember to insert a gastric tube and urinary catheter so the stomach and bladder are decompressed before the procedure. The easiest way to remember this is to tape these catheters to the DPL procedure tray.
A DPL is actually 2 procedures: peritoneal tap and lavage. Once the catheter is in, it should be aspirated. If 10cc of gross blood is returned, the test is positive and the patient needs to go immediately to OR.
For blunt trauma, the threshold for RBC per µl is 100,000. The threshold for WBC is 500 per µl. If particulate material or weird colors are seen (stool or bile), the test is also considered positive. Send the sample for cell counts only. Don’t send for any other assays (e.g. amylase).
For penetrating trauma, the thresholds have never been well defined. A number around 25,000 RBC per µl probably provides the best balance between sensitivity and negative laparotomy rate.

Reference: Diagnostic peritoneal lavage. HD Root, CW Hauser, CR McKinley, JW LaFave, RP Mendiola Jr. Surgery 57(5):633-637, 1965.

General

Pigtail Catheters Instead Of Chest Tubes?

October 29, 2012 The Trauma Pro Leave a comment

Traditionally, hemothorax and pneumothorax in trauma has been treated with chest tubes. I’ve previously written about some of the debate regarding using smaller tubes or catheters. A paper that will be presented at the EAST meeting in January looked at pain and failure rates using 14Fr pigtail catheters vs 28Fr chest tubes.

This was a relatively small, prospective study, and only 40 of 74 eligible patients were actually enrolled over 20 months at a Level I trauma center in the US. Pain was measured using a standard Visual Analog Scale, as was complication and failure rate, tube duration and hospital stay.

The following interesting findings were noted:

Chest wall pain was similar. This is expected because the underlying cause of the pneumothorax, most likely rib fractures, is unchanged.
Tube site pain was significantly less with the pigtail
The failure rate was the same (5-10%)
Complication rate was also the same (10%)
Time that the tube was in, and hospital stay was the same

Bottom line: There may be some benefit in terms of tube site pain when using a smaller catheter instead of a chest tube. But remember, this is a very small study, so be prepared for different results if you try it for your own trauma program. If you do choose to use a smaller tube or catheter, remember to do so only in patients with a pure pneumothorax. Clotted blood from a hemothorax will not be completely evacuated.

Related posts:

Reference: A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, 2013.

General

Why Do Trauma Patients Get Readmitted?

October 25, 2012 The Trauma Pro Leave a comment

Readmission of any patient to the hospital is considered a quality indicator. Was the patient discharged too soon for some reason? Were there any missed or undertreated injuries? Information from the Medicare system in the US (remember, this represents an older age group than the usual trauma patient) indicates that 18% of patients are readmitted and 13% of these are potentially preventable.

A non-academic Level II trauma center in Indiana retrospectively reviewed their admissions and readmissions over a 3 year period and excluded patients who were readmitted on a planned basis (surgery), with a new injury, and those who died. This left about 5,000 patients for review. Of those, 98 were identified as unexpected readmissions.

There were 6 major causes for readmission:

Wound (23) – cellulitis, abscess, thrombophlebitis. Two thirds required surgery, and 4 required amputation. All of these amputations were lower extremity procedures in obese or morbidly obese patients.
Abdominal (16) – ileus, missed injury, abscess. Five required a non-invasive procedure (mainly endoscopy). Only 2 required OR, and both were splenectomy for spleen infarction after angioembolization.
Pulmonary (7) – pneumonia, empyema, pneumothorax, effusion. Two patients required an invasive procedure (decortication, tube placement).
Thromboembolic (4) – DVT and PE. Two patients were admitted with DVT, 2 with PE, and 1 needed surgery for a bleed due to anticoagulation.
CNS (21) – mental status or peripheral neuro exam change. Eight had subdural hematomas that required drainage; 3 had spine fractures that failed nonoperative management.
Hematoma (5) – enlargement of a pre-existing hematoma. Two required surgical drainage.

About 14% of readmissions were considered to be non-preventable by a single senior surgeon. Wound complications had the highest preventability and CNS changes the lowest. Half occurred prior to the first followup visit, which was typically scheduled 2-3 weeks after discharge. This prompted the authors to change their routine followup to 7 days.

Bottom line: This retrospective study suffers from the usual weaknesses. However, it is an interesting glimpse into a practice with fewer than the usual number patients lost to followup. The readmission rate was 2%, which is pretty good. One in 7 were considered “preventable.” Wounds and pulmonary problems were the biggest contributors. I recommend that wound and pulmonary status be thoroughly assessed prior to discharge to bring this number down further. Personally, I would not change the routine followup date to 1 week, because most patients have far more complaints that are of little clinical importance than compared to 2 weeks after discharge.

Reference: Readmission of trauma patients in a nonacademic Level II trauma center. J Trauma 72(2):531-536, 2012.

General

Can Lead Poisoning Occur After A Gunshot?

October 24, 2012 The Trauma Pro Leave a comment

This is a fairly common question from victims of gunshots and their families. As you know, bullets are routinely left in place unless they are superficial. It may cause more damage to try to extract one, especially if it has come to rest in a deep location. But is there danger in leaving the bullet alone?

One of the classic papers on this topic was published in 1982 by Erwin Thal at Parkland Hospital in Dallas. The paper recounted a series of 16 patients who had developed signs and symptoms of lead poisoning (plumbism) after a gunshot or shotgun injury. The common thread in these cases was that the injury involved a joint or bursa near a joint. In some cases the missile passed through the joint/bursa but came to rest nearby, and a synovial pseudocyst formed which included the piece of lead. The joint fluid bathing the projectile caused lead to leach into the circulation.

The patients in the Parkland paper developed symptoms anywhere from 3 days to 40 years after injury. As is the case with plumbism, symptoms were variable and nonspecific. Patients presented with abdominal pain, anemia, cognitive problems, renal dysfunction and seizures to name a few.

Bottom line: Any patient with a bullet or lead shot that is located in or near a joint or bursa should have the missile(s) promptly and surgically removed. Any lead that has come to rest within the GI tract (particularly the stomach) must be removed as well. If a patient presents with odd symptoms and has a history of a retained bullet, obtain a toxicology consult and begin a workup for lead poisoning. If levels are elevated, the missile must be extracted. Chelation therapy should be started preop because manipulation of the site may further increase lead levels. The missile and any stained tissues or pseudocyst must be removed in their entirety.

Reference: Lead poisoning from retained bullets. Ann Surg 195(3):305-313, 1982.

General

How Long Should We Watch Intracerebral Hemorrhage?

October 23, 2012 The Trauma Pro Leave a comment

Patients with traumatic brain injury (TBI) severe enough to cause bleeding are usually admitted to the hospital for observation and in many cases, repeat CT scanning. Those with small intracranial hemorrhages (ICH) may experience progression of the bleeding, and a small percentage of cases may need operative intervention (1-3%). Questions we typically face are, how long should we watch for progression, and how often should we scan?

A retrospective cohort study was carried out at UMD-NJ, looking for answers for a specific subset of these patients. Specifically, they had to have a mild blunt TBI (loss of consciousness and/or retrograde amnesia, GCS in the ED of 13-15) and a positive head CT. They classified any type of hemorrhage into or around the brain as positive.

During a 3 year period, 474 adults were enrolled but only 341 were eligible for the study. They were excluded due to previous injury, presence of a mass (not trauma), need for immediate neurosurgical intervention, or failure to get a second CT scan. The authors found:

7% of patients were taking anticoagulants! This is surprisingly high. Interestingly, 15 were subtherapeutic, 3 were therapeutic and 2 were supratherapeutic.
Subarachnoid hemorrhage was the most common finding on CT (54%). Intraparenchymal hemorrhage was next most common (48%) Many patients had more than one type of bleed.
The injury worsened between the first and second scans in 31% of patients. This number increased to 46% in patients taking anticoagulants.
About 97% of bleeds stopped progressing by 24 hrs post-injury.

Bottom line: Most centers are probably overdoing the observation and repeat scan thing. More than two thirds of bleeds are stable by the first scan (first and second scans identical), and nearly all stop progressing within 24 hours. It’s very likely that patients who are not on anticoagulants and who have a stable neuro exam and stable symptoms can get just one scan and 24 hours of observation. Persistent headache, nausea, failure to ambulate well, or other symptoms warrant a repeat scan and longer observation.

Related posts:

Reference: The temporal course of intracranial haemorrhage progression: How long is observation necessary? Injury 43(12):2122-2125, 2012.

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