drashishmahajan
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A 34-year-old man presents to the clinic, 24 hours after he was hit in the abdomen. He has had constant abdominal pain since the altercation. He denies nausea and vomiting. His abdomen is soft, painful to palpation mostly around the umbilicus. Rebound tenderness is also present. Bowel sounds are diminished. Rectal exam is normal. Abdominal x-ray, ultrasonogram (USG), and CT are unremarkable. His vitals are, BP: 120/70mm of Hg; PR: 90/min; Hct: 40%; serum Amylase: 53 U/L. Most appropriate management is:
A. Observation
B. Angiography
C. Contrast studies of GI tract
D. Diagnostic peritoneal lavage
E. Laparotomy
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| Guptashutosh
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he is hemodynamically stable so observation will be the better option....... if it was hemodynamically unstable or deterirating vital signs then option would be laprotomy ...
any better explanation is invited,
GL
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| CocaCola
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The above patient has peritoneal signs - rebound tenderness - therefore he should go to the ER
E. Laparotomy is my answer
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| sarika
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i will go for DPL
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| fox
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Since all tests are normal, I guess observation is the answer.
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| CocaCola
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All test aren't normal - physical exam yields rebound tenderness and decreased bowels - something is going on...
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| robin082006
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I GO WITH D
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| krsna
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D
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| webjeee
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ok to observe. vital is good, >24hr
soft, rebound but no guarding, not likely peritonitis
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| paviraj
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In usmle world DPL is ans, but a doubt y cant observation?
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| fox
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this q from UW really got me stumped. The answer given is DPL but Im really not convinced. UW argues that in the presence of symptoms of peritoneal irritation, even though usg & CT are clear, it warrants a DPL to figure out whats going on in there. When ultrasound & CT could not detect free fluid, how can u get fluid on DPL by just sticking in a needle? Beats me.
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| chemamr
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I doubt perit lavage could make a different dx if ct, us and xrays are normal.
Observation, I think.
Edited by chemamr on 02/12/07 - 02:02 PM
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| chemamr
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more opinions are welcome
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| lam79m
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"The abdomen should neither be ignored nor the sole focus of the treating physician and surgeon. In an unstable patient, the question of abdominal involvement must be expediently addressed. This is accomplished by identifying free intra-abdominal fluid using diagnostic peritoneal lavage (DPL) or the Focused Assessment with Sonography for Trauma (FAST) examination. The objective is to rapidly identify patients who need a laparotomy."
http://www.emedicine.com/MED/topic2804.htm
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| dr in trouble
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I think u shud observe the patient.
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| MAGY17
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a) observation
rememberthe patient with minor internal injuries who responds promptly to fluid resuscitation does not need surgery.
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| Justice
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Observation
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| sahota
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ALWAYS IT IS SAID THAT BLUNT TRAUMA IN ABDOMEN WITH PERITINEAL SIGNS SHOULD GO FOR SURGERY WHY CT OR USG WAS DONE
EXPLATORY LAPAROTOMY
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| r_albayunen
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people .. stable/unstable patients with a history of trauma with "Peritoneal signs" proceed with a Exploratory laparotomy!! you dont need DPL/US/CT, if patient has peritoneal signs EL.
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| ashfaque
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ans E> blunt abdominal trauma>Pain>rebound tendernesss> diminished bowel souds favours peritonitis. dont get trap by this question lets see what kaplan says"acute abdomen after blunt abdominal trauma mandates laprotomy"plus" solid organs will bleed when smashed (hemodynamicaly unstable):' and hollow viscus spills their contents(hemodynamically Stable) Both need laporotomy" plus Kaplan also says"hemodynamically stable patient ==get CT Sacn, if unstable and literally dying in your hand do DPL or FAST.
Hope this explanation serves the purpose
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| DrVirgo
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DPL first?
or
Laparotomy because signs of peritoneal irritation.
?
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| liliaeliz
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d because he is hemo stable
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| liliaeliz
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Im sorry it don`t matter in this case if is stable or unstable because there are sign of the peritoneal irritation , I`lldo exp.lap
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| DrVirgo
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Here is a summary of what to do in case of blunt trauma to the abdomen.
1. If Blunt trauma and signs of internal bleeding, hemodynamically STABLE
---CT Scan (can ONLY be done if patient is STABLE)
2. If Blunt trauma and hemodynamically UNSTABLE:
A) and no signs of peritoneal irritation ---DPL
i) if DPL Negative ---Observe
ii) if DPL Positive --- Exp. Lap
B) and signs of peritoneal irritation ---Exp Lap (even if stable)
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| Justice
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DrVirgo wrote:
Here is a summary of what to do in case of blunt trauma to the abdomen.
1. If Blunt trauma and signs of internal bleeding, hemodynamically STABLE
---CT Scan (can ONLY be done if patient is STABLE)
2. If Blunt trauma and hemodynamically UNSTABLE:
A) and no signs of peritoneal irritation ---DPL
i) if DPL Negative ---Observe
ii) if DPL Positive --- Exp. Lap
B) and signs of peritoneal irritation ---Exp Lap (even if stable)
What is the reason to do DPL in case of (-) signs of peritoneal irritation, even if hemodinamically unstable? What do we look at in this particular situation?
I remember (only remember) a similar Q in UW, and I guess the point was: if (+) signs and stable - do DPL, if unstable - do exp lap.
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