Diagnostic Peritoneal Lavage

A sensitive way to evaluate for intra-abdominal injury in the trauma patient


imagesIn Blunt Trauma


   imagesUnexplained hypotension


   imagesConcern for injury but no obvious indication for laparotomy and serial abdominal examinations are not practical (i.e., unconscious or under anesthesia)


   imagesEquivocal focused abdominal sonography for trauma (FAST) examination and concern for an intra-abdominal injury


   imagesPatient unsuitable for computed tomography (CT) in whom there is concern for intra-abdominal injury


   imagesConcern for mesenteric or hollow viscous injury not seen on CT


imagesIn Penetrating Trauma


   imagesAnterior abdominal stab wound and evidence of fascial penetration in the stable patient with no obvious indication for laparotomy


   imagesTo evaluate for hollow organ or diaphragmatic injury in the stable patient


CONTRAINDICATIONS



imagesAbsolute Contraindications


   imagesIndication for an emergent laparotomy


imagesRelative Contraindications


   imagesPrior abdominal surgery


   imagesSecond or third trimester of pregnancy—consider open technique with supraumbilical approach


   imagesMorbid obesity


   imagesSignificant ascites


   imagesCoagulopathy



imagesGeneral Basic Steps


   imagesPrepare patient


   imagesAnalgesia


   imagesTechnique


      imagesOpen


        imagesIncision


        imagesDissection


        imagesIncise fascia, then peritoneum


        imagesPlace dialysis catheter


      imagesClosed


        imagesNeedle into abdomen


        imagesThread guidewire


        imagesSmall skin incision


        imagesThread dialysis catheter


   imagesAspirate


   imagesLavage/Drainage of fluid


   imagesAnalysis of fluid


LANDMARKS



The incision should be made in the midline, one-third of the way between the umbilicus and pubic symphysis. In the pregnant patient or the patient with a pelvic fracture, the incision should be made in the midline, just above the umbilicus (FIGURE 16.1).


SUPPLIES



images1% Lidocaine with epinephrine, 20 mL with 25-gauge needle, 10-mL syringe


imagesSterile towels or drapes, sterile gown and gloves, mask, and eye protection


imagesPovidone–iodine (Betadine) solution or chlorhexidine


images11-Blade scalpel


imagesSyringe and needle (for closed technique)


imagesFlexible guidewire (for closed technique)


imagesTwo clamps and two retractors (for open technique)


imagesPeritoneal catheter


images1 L warm saline for infusion (for lavage)


imagesTubing to let lavage fluid drain


imagesSuture (for open technique)


TECHNIQUE



imagesPreparation


   imagesPlace a Foley catheter (unless contraindicated)


   imagesPlace a nasogastric tube (unless contraindicated) to suction to decompress the stomach


   imagesGather all instruments and sterile gown/gloves


   imagesSterilize the abdomen from costal margin to pubis and from flank to flank with povidone–iodine solution (Betadine) or chlorhexidine


   imagesDrape the area with sterile towels or drapes



images


FIGURE 16.1 Anatomical landmarks for diagnostic peritoneal lavage. (From VanDevander PL, Wagner DK. Diagnostic peritoneal lavage. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:358, with permission.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Diagnostic Peritoneal Lavage

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