Multiple Trauma (Blunt) Primary survey (ABC) Hx (mechanism of injury), Secondary survey Routine laboratory tests (a) Challenge Lactated Ringer 2L Trauma Series (X-ray)(b) Suspect abdominal trauma Stable Hemodynamics Unstable Hemodynamics abd echo abd echo Positive(c-2) Negative(c-1) (c-1) (c-2) Negative Positive Abd. CT (with IV contrast) Suspect Find other hollow organ extra-abdominal injury bleeder Negtive Solid organ Non-solid organ injury injury (mesentery or urinary bradder) or Hollow organ DPL injury Liver spleen Pancreas ≥ GrIII Positive(d-3) Negative(d-1) DPL Observation Bloody(d-2) Contaminated(d-3) (suspect hollow organ Non-op TX(e) injury) Fever, WBC↑ Hb↓ (-) 25cmH2O IAP >(+) Observation Laparoscope Celiotomy Suspect hollow organ Positive(d-3) DPL injury (a) Routine laboratory tests: ABG, CBC/DC, U/A, GOT, Amylase (b) Trauma series: C-spine (lat), CXR, Pelvis A-P. (c) Abd. echo: (1) Negative: 1. No fluid accumalation. (2) Positive examination: 1. Massive fluid or hemoperitoneum, as echo score ≧ 3 (Table 1) except liver or spleen injury. 2. Free air. 3. Soap-bubble sign. 4. Apparent peritoneal sing, etc. (d) DPL: (1) Negative: 1. Clear or gross less than 5ml blood in aspiration. 2. RBC < 10 5/mm3. 3. WBC < 500/mm3. 4. Amylase < 175u/dl. 5. No food debris, bile, or bacteria. (2) DPL:1. 20ml gross blood in aspiration, 2. RBC > 10 5/mm3. 3. WBC(D)/ RBC(D) ÷ WBC(B)/ RBC(B) < 1. 4. Amylase < 175 U/dl. 5. No food debris, biles, bacteria. (3) DPL: 1. Gram's stain(+), 2. Bile fluid (+), 3. food debris, 4. WBC(D)/ RBC(D) ÷ WBC(B)/ RBC(B) ≧ 1. 5. Amylase > 175 (4) DPL cell count ratio: WBC(L)/ RBC(L) ÷ WBC(B)/ RBC(B) > 1. WBC(L): WBC count in lavage fluid. RBC(L): RBC count in lavage fluid. WBC(B): Blood WBC count. RBC(B): Blood RBC count. (e) ICU care with BP, HR, Hb, HCT monitor and complete bed rest x 3 days Table 1 Ultrasonography points for the eveluation of intra-abdominal free fluid Points Morrison's pouch Significant* 2 Minimal + 1 Douglas's pouch Significant * 2 Minimal + 1 Perisplenic space 1 Paracolic gutter 1 Floating intestinal loops 2 * More than 2 mm of free fluid + Less than or equal to 2 mm of free fluid Reference (1) Mark M, Kim L, Diego N, et al: Can ultrasound replace diagnostic peritoneal lavage in the assessment of blunt trauma? J Trauma 370: 439, 1994. (2) Liu M, Lee CH, Peng FK: Prosterctive comparison of diagnostic peritoneal lavage, computed tomographic scarnning, and ultrasonography for the diagnosis of blunt abdominal trauma. J Trauma 35: 267, 1993. (3) Huang MS, Liu M, Wu JK et al: Ultrasonography for the evaluation of hemoperitoneum during resuscitation: a simple scoring system. J Trauma 36: 173, 1994. (4) Pachter HL, Hofstetter SR: Open and percutaneous para-centesis and lavage for abdominal trauma. Arch Surg 116: 318, 1981. (5) Fan JF, Chen RJ, Lin BC: Cell count ratio: New criterion of diagnostic peritoneal lavage for detection of hollow organ perforation. J Trauma 1998; 45: 540-544. (6) Chen RJ, Fan JF, Lin BC, et al: Selective application of laparoscopy and fibrin glue in the failure of nonoperative management of blunt hepatic trauma. J Trauma 1998; 44: 691-695.
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