Emergency Medicine

ABDOMINAL AND PELVIC TRAUMA

240 Surgical Emergencies

(iii) Diagnostic peritoneal lavage (DPL)

(a) has largely been entirely superseded by FAST and CT scans

(b) may be used when the above are not available, to diagnose a

haemoperitoneum with unexplained hypotension, or other

suspected abdominal injury or when abdominal examination is:

• unreliable, due to coma, intoxication or spinal injury


• equivocal, due to fractured lower ribs, pelvis or lumbar spine


• impractical in planned extra-abdominal radiographic or
  surgical procedures.
  (c) infiltrate local anaesthetic with adrenaline (epinephrine), and
  then perform open dissection via a mini-laparotomy incision
  through all the layers of the abdominal wall
  (d) the procedure is positive if:


• 5–10 mL of frank blood or enteric contents are aspirated


• peritoneal lavage fluid effluent exits via a chest tube or
  bladder catheter


• laboratory analysis of lavage fluid shows >100 000 red blood
  cells/mm^3.
  (e) it is highly sensitive for intraperitoneal bleeding although it
  provides no indication about its source or volume, and misses
  retroperitoneal injury to the duodenum, pancreas, kidney
  and pelvis, or a diaphragm rupture.
  6 Involve the admitting surgical team at all stages of investigation, as the
  decision on emergency laparotomy is theirs.

Penetrating abdominal trauma

DIAGNOSIS

1 Penetrating abdominal injury may occur in stab wounds, industrial

incidents, road traffic crashes, explosions and gunshot wounds.

2 Gunshot wounds may be divided into three types:

(i) High-velocity wound

(a) the muzzle velocity of a bullet from a high-velocity rifle is

>1000 m/s

(b) a small entry wound is associated with gross internal tissue

damage from cavitation and a large exit wound.

(ii) Low-velocity wound

(a) the muzzle velocity from a hand gun reaches 250 m/s

(b) the bullet causes local internal damage by perforation and

laceration, often passing through several structures.

(iii) Shotgun wound

(a) usually fatal from a range of <3 m (10 ft), and causes

massive superficial internal damage from close range

(<7 m)