technique for direct visualization of the peritoneum. Clips are placed to
grasp each side of the rectus fascia to lift it and advance the catheter cau-
dally into the peritoneum. The fully open technique is preferred when
more direct view is needed such as with pelvic fractures, pregnancy, prior
abdominal surgery, infections, and obesity.
■ In the closed technique, a guide needle is inserted into the peritoneal cav-
ity in the infraumbilical midline. The Seldinger (guidewire) method is
then used to allow over-the-wire placement of a catheter.
■ In the event of second- or third-trimester pregnancy, a suprauterine approach
is used. With pelvic fractures, a supraumbilical approach should be used.
■ Once cathether is in place, aspiration is attempted. If 10 mL of frank
blood is aspirated, the DPL is positive and terminated. If there is little or
no blood, the cavity is lavaged with 1 L of NS or LR in adults or 15 mL/kg
in children. Fluid is then allowed to return to bag by gravity.
COMPLICATIONS
Infection, hematoma, wound dehiscence, bowel/bladder/vascular injury
INTERPRETATION OFRESULTS
■ Immediate aspiration of 10 mL of bloodis considered positive.
■ RBC counts >100,000/mm^3 is considered positive after lavage with 1 L of NS.
■ When the diaphragm is at risk of injury as with penetrating chest trauma
the RBC criterion should be lowered to 5000/mm^3 to maximize sensitivity
for isolated injury to this structure.
A patient with known esophageal varices presents with hematemesis and
hypotension. After blood, antibiotics, octreotide, and proton pump inhibitor
the patient continues to bleed. Upper endoscopy is not available. What
other interventions should be considered?
Balloon tamponade of gastroesophageal varices may serve as a bridge to
upper endoscopy in patients with massive upper GI bleeds. Surgical consultation
should also be obtained for possible operative intervention.Balloon Tamponade of Gastroesophageal Varices
INDICATIONS
■ Patient with known portal hypertension or prior variceal hemorrhage with
substantial ongoing upper GI bleeding despite optimal medical therapy
and for whom endoscopy is unavailable
CONTRAINDICATIONS
■ Endoscopy readily available
TECHNIQUE
■ Sedation should be provided during procedure. Head of bed should be
elevated to 45°if possible or placed in left lateral decubitus position.
■ Stomach is evacuated with gastric lavage, NGT removed.
■ Currently there are two types of gastroesophageal balloon tamponade
(GEBT) tubes available: The three-lumen Sengstaken-Blakemore tube
(gastric balloon, esophageal balloon, and gastric aspiration) and the four-
lumen Minnesota tube (which adds an esophageal aspiration port).
PROCEDURES AND SKILLS