Docstoc

BAT

Document Sample
BAT Powered By Docstoc
					                                                      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.

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:16
posted:8/16/2012
language:English
pages:2