BAT by cuiliqing

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									                                                      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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