DrVirgo
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Justice wrote:
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.
Good question. I remember that UW Q also.
As UW explained it, if the patient has blunt trauma intraabdominal bleeding is possible. In a patient with NO signs of peritoneal irritation we STILL NEED TO DO DPL... This is because small lacerations of solid organs, mesentary, and serosa of hollow viscus may give little bleeding that may stop spontaneously.
Intrapertoneal fluid may not be detected by an ultrasound an dsmall perf. may not show as air under the diaphragm. But this small bleed can still cause peritonitis. Diagnose with a DPL. If negative, observe. If positive, do an exp. lap.
This is what I understood from the explanation. (but it can be confusing sometimes)
Please confirm if you agree. thanks.
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| Justice
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DrVirgo wrote:
Good question. I remember that UW Q also.
As UW explained it, if the patient has blunt trauma intraabdominal bleeding is possible. In a patient with NO signs of peritoneal irritation we STILL NEED TO DO DPL... This is because small lacerations of solid organs, mesentary, and serosa of hollow viscus may give little bleeding that may stop spontaneously.
Intrapertoneal fluid may not be detected by an ultrasound an dsmall perf. may not show as air under the diaphragm. But this small bleed can still cause peritonitis. Diagnose with a DPL. If negative, observe. If positive, do an exp. lap.
This is what I understood from the explanation. (but it can be confusing sometimes)
Please confirm if you agree. thanks.
So, in this case the DPL is a first step anyway... The Pt is stable, but he has guarding that a sign of peritoneal irritation. If DPL is positive, do exp lap.
What is worrisome to me is that if DPL is positive, it may (+) be due to a small laceration that stopped spontaneously, as said above... And which will never (hopefully) rebleed... Do we go for exp lap right away, or first observe??? I think the option of laparoscopy would make much more sense in a stable Pt with (+) peritoneal signs and (+) DPL in a STABLE PATIENT, AS IN OUR CASE... But if the Pt unstable, than we go for exp lap
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| DrVirgo
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Justice wrote:
So, in this case the DPL is a first step anyway... The Pt is stable, but he has guarding that a sign of peritoneal irritation. If DPL is positive, do exp lap.
What is worrisome to me is that if DPL is positive, it may (+) be due to a small laceration that stopped spontaneously, as said above... And which will never (hopefully) rebleed... Do we go for exp lap right away, or first observe??? I think the option of laparoscopy would make much more sense in a stable Pt with (+) peritoneal signs and (+) DPL in a STABLE PATIENT, AS IN OUR CASE... But if the Pt unstable, than we go for exp lap
DPL is NOT a first step in this case... please read what i wrote again.
To summarize: STABLE and NO SIGNS OF PERITONEAL IRRITATION --> DPL
IF SIGNS OF PERITONEAL IRRITATION --> EXP LAP ALWAYS!
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| DrVirgo
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Just to add, to clarify this point:
-DPL gives you a yes or no answer. Is there bleding in the abdomen or not?
-But when there IS CLEAR signs of peritoneal irritation like guarding or rebound, you know there is peritoneal irritation... you don't need to do a DPL. Therefore you do an exp. lap. to find the SOURCE (exp. lap tells us WHERE the bleeding is coming from) so it can be fixed.
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| Justice
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DrVirgo wrote:
STABLE and NO SIGNS OF PERITONEAL IRRITATION --> DPL
What is indication for DPL here? Just a history of blunt trauma? Following this strategy, all boxers and kick-boxers after the ring should be transferred into OR for DPL... Same for kids playing on streets...
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| DrVirgo
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Exploratory Laparotomy is the answer in this case! (NOT DPL)
IF SIGNS OF PERITONEAL IRRITATION --> EXP LAP ALWAYS!
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| DrVirgo
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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:
(He has signs of peritoneal irritation (rebound tenderness) and is stable (BP is 120/70), and CT was already done and was unremarkable...
next step: Exp. Lap)...
A. Observation
B. Angiography
C. Contrast studies of GI tract
D. Diagnostic peritoneal lavage
E. Laparotomy
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| Justice
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DrVirgo,
I see your point and do not argue with the statement that Pt with peritoneal signs should have exp lap. BUT I want to make sure I understand your other points including this: STABLE and NO SIGNS OF PERITONEAL IRRITATION --> DPL. Why not observation? What is indication for DPL here? Just history of blunt trauma???
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| Justice
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DrVirgo wrote:
Exploratory Laparotomy is the answer in this case! (NOT DPL)
IF SIGNS OF PERITONEAL IRRITATION --> EXP LAP ALWAYS!
In post #11 Fox gave right answer which is DPL.
If DPL positive (here I agree with you) you go for laparotomy. Otherwise, in a stable Pt, 24 hr after the trauma, going for exp lap right away is going to far...
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| DrVirgo
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Justice wrote:
DrVirgo,
I see your point and do not argue with the statement that Pt with peritoneal signs should have exp lap. BUT I want to make sure I understand your other points including this: STABLE and NO SIGNS OF PERITONEAL IRRITATION --> DPL. Why not observation? What is indication for DPL here? Just history of blunt trauma???
Ok so we are in agreement that peritoneal signs ---> Exp. Lap. (good!) 
To answer your question: "STABLE and NO SIGNS OF PERITONEAL IRRITATION --> DPL. Why not observation? What is indication for DPL here? Just history of blunt trauma???" --->>> Yes, according to UW.... as I explained in post 26 that there could be some "hidden" bleed not detected by CT or ultrasound so they say to do a DPL to find out if there is a bleed or not.
If DPL positive --> Exp. Lap.
IF DPL negative --> observe.
This is causing me some confusion as well because
Kaplan says if UNSTABLE and NO signs of per. irritation--->do DPL
UW says if STABLE and NO signs of per. irritation --> do DPL
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| DaddyO
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It seems to me that the consensus is that if the pt. is stable with peritoneal signs then do a DPL and if it is positive then go for exp. lap. If neg then observe. If pt is unstable with peritoneal signs then exp. lap stat.
My thought is...if a pt is stable with peritoneal signs and Abd. Xray, U/S, and CT show NO free fluid anywhere and cannot identify a bleed then how in the heck do you know where to insert the DPL needle??? Do you just stick and poke the pt. numerous times around the umbilicus to try and find a possible small bleed that might be leaking a small amount of fluid???
It seems to me that the best management would be to observe the pt and if the pt becomes unstable and declines then exp. lap. I would repeat U/S as well.
I just can't see sticking a pt. randomly in the abdomen wherever it hurts to see if fluid is removed.
I remember there was a case exactly like this on the NBC show "ER" and Kovac had this exact pt. and Lucian, the surgical attending, said since all of the signs were negative then the pt will be admitted and will go upstairs but no expl lap and DPL is NOT indicated because the pt was stable and CT and U/S were negative. There was a big debate between the two because Luca Kovac had a sixth sense about this pt and just felt that the pt had a bleed that went undetected and ordered Pratt to do the DPL against the orders of the attending; so an ER attending went against the surgical attending and did the DPL and it ended up being positive and the pt. went to surgery. Luca Kovac simply told his 2nd year resident, Pratt, that sometimes you get a sixth sense for some pts that you know need surgery even though all of the protocol says that it is not indicated.
See, an entire episode on "ER" was dedicated to this dilemma because it is unclear and not an exact science. And that is why it is in UsmleWorld because it is confusing and exactly why this type of question will be on the actual CK because they stray away from basic clinical diagnoses and do not want to give you clear cut questions that if you studied hard you should get right. They want to give you something that ER attendings and surgical attendings can't even get straight, and things that even 2nd year residents don't know what the correct answer is. Therefore, why would a 4th year medical student know exactly what to do.
This is how the CK is, it would be nice if they would ask straightforward questions that were a direct extension of basic clinical sciences and by straightforward I don't mean easy; I mean that if you spent 3 months studying you should be able to get it right not have 100 4th year students still not be able to come to the correct conclusion on what is the best answer. To ask questions that were not vague and had clear cut answers would be too fair and wouldn't present enough of a dilemma for 4th year med students because we all know that by this time in our careers we just haven't had enough challenges right. The CK really goes too far with their questions, if someone studies 8 hours a day for 3 months and can get 90% of your questions right then that is a good thing it doesn't mean you have to make the exam harder or raise the score...I really wonder what makes some of these people tick.
Cheers!
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| cirus
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stable or not, Rebound tenderness should have expl lap
if there fantastic word wasn't there, i would go for DPL
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| gr8doc
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Why not a contrast stuidy of the GIT ? He is definitely having the peritoneal signs which everyone has agreed. His vitals are pretty much stable after 24 hours which suggests that there is no active bleeding.
A blunt injury to the hollow viscus can explai the peritoneal signs he has along with the normal vitals.
& the only way to diagnose the viscus injury is to do a Contrast GI study.
Differences are welcome.
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| young_doc
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DaddyO wrote:
My thought is...if a pt is stable with peritoneal signs and Abd. Xray, U/S, and CT show NO free fluid anywhere and cannot identify a bleed then how in the heck do you know where to insert the DPL needle??? Do you just stick and poke the pt. numerous times around the umbilicus to try and find a possible small bleed that might be leaking a small amount of fluid???
I think you're confusing a Paracentesis with a DPL! In a DPL we infuse saline into the peritoneum, and then suck it up and look for the presence of blood in the saline. So we don't need to know "where the bleeding is".
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| k00l
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if there are no signs of peritoneal signs and pt is unstable one doesn't know whether source of bleeding is intra or retro peritoneal or is it somewhere else [e.g.chest]. Quick way of assessment is DPL. Exp Lap in retroperitoneal bleeding from large veins will be subjecting your unstable pt to major insult without any meaningful gain [in my own exp.]. correct me if i am wrong.
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| lena02
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hello
im new here
i read this question and was quiet confused but
in blunt abdominal trauma if the patient is awake and stable with slight abdominal findings you go for contrast CT
u dont opt to laprotomy only if the pt is hemodynamically unstable and since he was around for 24 hours then this irritation might be from small lacerations ie minimum bleeding that will resolve spontaneously.
another point is that DPL is no more widely used coz its less sensitive and specific plus it alters any CT scan results.
in this question its safer to say contrast studies and if this option wasnt available il go for observation . any other suggestions
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