Imaging in Blunt Abdominal Imaging in Blunt Abdominal TraumaTrauma

Stephen J. Wolf, MDStephen J. Wolf, MD

Department of Emergency MedicineDepartment of Emergency Medicine

Denver Health Medical CenterDenver Health Medical Center

Denver, Colorado USADenver, Colorado USA

Imaging in Blunt Abdominal Imaging in Blunt Abdominal TraumaTrauma

Blunt Abdominal TraumaBlunt Abdominal Trauma Leading cause of morbidity and mortality in Leading cause of morbidity and mortality in

traumatrauma

Leading cause of intra-abdominal injuriesLeading cause of intra-abdominal injuries

Nineteen percent of intra-abdominal injuries Nineteen percent of intra-abdominal injuries

have no painhave no pain

Imaging in Blunt Abdominal Imaging in Blunt Abdominal TraumaTrauma

Pre 1960’s - Four quadrant paracentesisPre 1960’s - Four quadrant paracentesis

1960’s - Diagnostic Peritoneal Lavage (DPL)1960’s - Diagnostic Peritoneal Lavage (DPL)

1980’s - Abdominal Computed Tomography Scan1980’s - Abdominal Computed Tomography Scan

(CT Scan)(CT Scan)

1990’s - Focused Abdominal Sonography for Trauma 1990’s - Focused Abdominal Sonography for Trauma

(Fast Scan)(Fast Scan)

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – Case PresentationTrauma – Case Presentation

20 year old male unrestrained driver of high speed MVA, complaining of abdominal pain. VS: BP 90/40 HR 115 RR 20 SaO2 100%

Abd: Diffusely Tender, no ecchymosis Pelvis: Stable, Non-tender Rectal: Hemoccult negative

CTL C-spine, pCXR, Pelvis: NL HCT:Hgb: 44% / 13g/dl

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma - DPLTrauma - DPL

What is the diagnostic performance of DPL What is the diagnostic performance of DPL

in diagnosing significant intra-abdominal in diagnosing significant intra-abdominal

injuries requiring intervention in blunt injuries requiring intervention in blunt

abdominal trauma? abdominal trauma?

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma - DPLTrauma - DPL

Sensitivity: Sensitivity: Hemoperitoneum: 83 – 98% [I,II,III]Hemoperitoneum: 83 – 98% [I,II,III] Mean sensitivity: 95% [III]Mean sensitivity: 95% [III] Enteric injuries: 82%[III] Enteric injuries: 82%[III]

Nontherapeutic laparotomies (False Nontherapeutic laparotomies (False Positives):Positives): Rate: 13 – 54% [II,III]Rate: 13 – 54% [II,III]

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma - DPLTrauma - DPL

Limitations:Limitations: Minimal bleeding [II,III]Minimal bleeding [II,III]

Retroperitoneal, diaphragmatic, enteric injuriesRetroperitoneal, diaphragmatic, enteric injuries

Insensitive markers [III]Insensitive markers [III] Gram stain, amylase, alkaline phosphataseGram stain, amylase, alkaline phosphatase

Significance of injury?Significance of injury? Complications rate: 1 – 2 % [II,III]Complications rate: 1 – 2 % [II,III]

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma - DPLTrauma - DPL

Level A recommendations.Level A recommendations. None specified.None specified. Level B recommendations.Level B recommendations.

Diagnostic peritoneal lavage can be used to exclude Diagnostic peritoneal lavage can be used to exclude hemoperitoneum in blunt abdominal trauma patients. hemoperitoneum in blunt abdominal trauma patients. Diagnostic peritoneal lavage does not define the extent of Diagnostic peritoneal lavage does not define the extent of injury, has a 1% to 2% complication rate, and may lead to injury, has a 1% to 2% complication rate, and may lead to nontherapeutic laparotomies. nontherapeutic laparotomies.

Level C recommendations.Level C recommendations. On the basis of consensus and current practice patterns, the On the basis of consensus and current practice patterns, the

initial choices for the evaluation of blunt abdominal trauma initial choices for the evaluation of blunt abdominal trauma are CT and FAST, depending on the patient’s hemodynamic are CT and FAST, depending on the patient’s hemodynamic stability.stability.

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – CT ScanTrauma – CT Scan

What is the diagnostic performance of CT What is the diagnostic performance of CT

in diagnosing significant intra-abdominal in diagnosing significant intra-abdominal

injuries requiring intervention in blunt injuries requiring intervention in blunt

abdominal trauma?abdominal trauma?

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – CT ScanTrauma – CT Scan

Sensitivity: Sensitivity:

Solid organ injury: 97% [II,III]Solid organ injury: 97% [II,III]

Enteric injury: 64 – 94% [III]Enteric injury: 64 – 94% [III]

Diaphragmatic injury: 61% [III]Diaphragmatic injury: 61% [III]

Pancreatic injury: 30% [III]Pancreatic injury: 30% [III]

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – CT ScanTrauma – CT Scan

Level A recommendations. Level A recommendations. None specified.None specified. Level B recommendations. Level B recommendations.

When either liver or spleen injury is suspected, CT can When either liver or spleen injury is suspected, CT can reliably exclude injuries that require emergent reliably exclude injuries that require emergent operative intervention. CT alone cannot be used to operative intervention. CT alone cannot be used to exclude either bowel, diaphragm, or pancreas injury.exclude either bowel, diaphragm, or pancreas injury.

Abdominal CT accurately identifies hemoperitoneum Abdominal CT accurately identifies hemoperitoneum among patients with blunt abdominal trauma.among patients with blunt abdominal trauma.

Level C recommendations. Level C recommendations. None specified.None specified.

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – CT ScanTrauma – CT Scan

Does oral contrast improve the diagnostic Does oral contrast improve the diagnostic

performance of CT in blunt abdominal performance of CT in blunt abdominal

trauma?trauma?

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – CT ScanTrauma – CT Scan

Proposed benefits of oral contrast Proposed benefits of oral contrast Identifying extravasation, delineating Identifying extravasation, delineating

mesentery, setting opacified bowel apart from mesentery, setting opacified bowel apart from

hematomas and pancreatic injurieshematomas and pancreatic injuries

Proposed risks of oral contrastProposed risks of oral contrast Vomiting, aspiration, delayed diagnosis.Vomiting, aspiration, delayed diagnosis.

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – CT ScanTrauma – CT Scan

Sensitivities: oral vs no oral contrastSensitivities: oral vs no oral contrast Solid organ injuries: 84.2% vs 88.9% [II] Solid organ injuries: 84.2% vs 88.9% [II] Enteric injuries: 86% vs 100% [II]Enteric injuries: 86% vs 100% [II] Intra-abdominal injuries: 98.4% [II]Intra-abdominal injuries: 98.4% [II]

Extravasation: 2.9% enteric injuries [III]Extravasation: 2.9% enteric injuries [III] Aspiration: 0% [III]Aspiration: 0% [III]

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – CT ScanTrauma – CT Scan

Level A recommendations. Level A recommendations. None specified.None specified.

Level B recommendations. Level B recommendations. Oral contrast is not essential to the evaluation Oral contrast is not essential to the evaluation

of blunt abdominal trauma.of blunt abdominal trauma.

Level C recommendations.Level C recommendations. None specified.None specified.

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – FAST ScanTrauma – FAST Scan

What is the diagnostic performance of What is the diagnostic performance of

FAST in diagnosing hemoperitoneum in FAST in diagnosing hemoperitoneum in

blunt abdominal trauma?blunt abdominal trauma?

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – FAST ScanTrauma – FAST Scan

SensitivitySensitivity

Hemoperitoneum: 68 – 98% [I,II,III]Hemoperitoneum: 68 – 98% [I,II,III]

Hemoperitoneum and hypotension: 100% [II]Hemoperitoneum and hypotension: 100% [II]

Intraabdominal injuries: 69% [II]Intraabdominal injuries: 69% [II]

Enteric injury: 58% [II]Enteric injury: 58% [II]

Imaging in Blunt Abdominal Imaging in Blunt Abdominal Trauma – FAST ScanTrauma – FAST Scan

Level A recommendations.Level A recommendations. None specified.None specified.

Level B recommendations.Level B recommendations. FAST is useful as an initial screening FAST is useful as an initial screening

examination to detect hemoperitoneum in blunt examination to detect hemoperitoneum in blunt abdominal trauma patients. abdominal trauma patients.

Level C recommendations. Level C recommendations. None specified. None specified.

Imaging in Blunt Abdominal Imaging in Blunt Abdominal TraumaTrauma

Thank You!Thank You!