Most often patients involved in major accidents sustain multiple trauma including trauma to the abdomen. When the patient has loss of consciousness due to head injury or has injury to the spine or when he is under the influence of alcohol, physical examination of the abdomen by itself will not indicate the underlying problems. Patient may have major injury to the spleen or liver or other organs and still may not show up on physical examination.
Routine abdominal investigations including CT scan and ultrasound have certain limitations including availability of equipment and expertise. These are time consuming procedures as well. Some times it becomes necessary to safely rule out any internal injury to the abdomen before the patient is taken to surgery for other problems like intracranial and skeletal injuries. The most sensitive and specific test that will indicate the presence or absence of intra-abdominal trauma is “diagnostic peritoneal lavage”.
To find out if there is enough blood in the peritoneal cavity to suspect a bleeding viscus
To find if there is any injury to the intestine
As a first step, the urinary bladder is decompressed by passing a Foley catheter and a nasogastric tube is passed to empty the stomach.
Preparation of the entire abdomen is done using Povidone Iodine solution
Sterile drapes are placed to provide exposure to the abdomen
1% xylocaine with adrenaline is injected in the midline between the umbilicus and suprapubic area about 1/3rd of the distance from the umbilicus.
In the anesthetized area of the midline a vertical skin incision is made with a 15 blade knife for about 2 cm and dissection is carried down to the fascia.
At this point, fascial edges are grasped with Alice forceps and gently pulled upwards and the incision is further deepened to get into the peritoneal cavity.
The dialysis catheter is passed through the opening in the peritoneal cavity and advanced towards the hollow of the pelvis.
The I.V. tube connected to the bottle or bag of Ringers Lactate or Normal Saline is now connected to the dialysis catheter.
The wound is closed with a stitch or two as necessary and about 10-ml/kg-body weight measured quantity of the fluid is rapidly let inside the peritoneal cavity.
The fluid inside the abdomen is now swished around by gentle agitation of the abdomen so that it is distributed all over the peritoneal cavity.
Once the desired amount of fluid has entered into the peritoneal cavity, it is allowed to stay for up to 10 minutes and then siphoned off by bringing the fluid bag or bottle down to the floor.
If the returning fluid is clear, obviously there is no gross internal injury to the abdomen and no major hemorrhage. However, certain tests have to be carried out.
The fluid has to be examined for RBC and WBC counts. More than 100,000 RBCs or 500 leukocytes/cumm would indicate that the test is positive. Similarly if gross intestinal contents like fiber etc., are identified under the microscope, it would indicate injury to the intestine. A positive result would mean that the patient would require laparotomy
The diagnostic catheter is removed, wound dressed and patient taken care of as indicated.
Limitations of the test:
Previous abdominal surgery and adhesions inside the peritoneal cavity will be a limiting factor and render the procedure unreliable? Peritoneal lavage does not rule out injuries to the retroperitoneal structures like pancreas or duodenum and also any small perforation of hollow viscus or diaphragmatic injury
Rarely peritonitis due to intestinal perforation from the procedure and from the catheter.
Injury to the urinary bladder if not emptied well.
False positive due to hemorrhage from the site of incision.
These complications, however, are rare.
In any multi-trauma situation the procedure has considerable advantages.
Given these limitations and complications still the test is a very valuable procedure and would come in handy for those family practitioners who deal with trauma care.
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