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Does anyone feel that DPL is an invaluable tool in the assessment of abdominal trauma?
Or, do you feel that in this day and age of FAST and 64 slice CTs, DPL is an unnecessary surgical extravagance frought with false positive results and risks of infection??
Or, do you feel that both have their own time and place... If so, when and where?
Edited by maroju on 02-02-2008 18:30
I still think there is place for DPL, when there is no imaging available either FAST/CT and there is convinvcing h/o and clinical signs i woould got for DPL.But in the current training DPL is falling out of place as most of the truama cases are routed to Taruma centers with imaging facilities.
FAST is the best tool in skilled hands.I accept with the low sensitivties of FAST scan but the specifitcity and negative preditive value is high which makes me think twice to do DPL on the patient.
If a patient comes with blunt abdmonial trauma and hemodynamically stable and FAST scan/CT is availble i would go for CT scan.

The evidence regarding the use of DPL and FAST as
screening investigations in patients sustaining BAT is limited.The most robust studies concern the use of DPL as a
screening test before CT.The available evidence suggests
that this is a safe and sensitive diagnostic approach.
The use
of CT is reduced and the rate of missed injuries is not
significantly higher in the reported series.

FAST scanning is becoming increasingly utilized.
FAST may support a decision to proceed to laparotomy
without the need to undergo DPL, but it cannot be used to
safely rule out the need for further investigation on the basis
of currently available evidence.

Thanks Stemlyns.
I think I would agree with some of your observations.
DPL as screening tool before CT!!!... could you reference it? I guess you are referring to the haemodynamically normal and stable patient. Where would FAST fit in then? (assuming the trauma centre in question has access to all these modalities 24/7. The choice would become very obvious if the centre doesn't have a certain diagnostic test).
What about penetrating abdominal trauma?
Has anyone got access to a departmental guideline/pathway /protocol?
Edited by maroju on 10-02-2008 14:52
Our centre has a high resolution ultrasound scanner for exculsive use in the ED. FAST scans are done and repeated as frequently as necessary by the EM residents. Our CT scanner which is very close to the ED, can slice through the entire abdomen and pelvis in 10secs flat. (This means a hemodynamically unstable patient has to be stabilzed for just a few minutes to get the scan).

In this setup, neither us nor any surgeon has felt the need to perform the DPL in any patient since the last 2 1/2 years

But we havent conducted any formal studies to justify this protocol.
Its been accepted all over that FAST is superior to DPL both in terms of being quick and accurate as well as being non-invasive. With high resolution USG machines and CT scanners, I don't feel the need to DPL to be used in an ER
But do also remember that no matter how high the resolution of the machines is, it is only going to be as good as the operator!!!

That begs the question as to who should be scanning? Why not employ a sonographer (who presumably would have done thousands of them!!!)

More importantly, it boils down to the availability of resources too.

i do agree...that a sonogrpher is always the best choice and also the first choice if he's available 24/7...but no harm in doing a FAST urself and picking up the gross abnormalities...and taking the patient early for a laparotomy...rather than either making the patient go thru DPL or instead wait for a sonographer off hours....or even overnight in some hospitals.....just so that he can pick up some finer abnormalities...
Agreed that FAST wins over DPL hands down when available... However, this is what I was implying in my previous post...

Does it make better sense to employ a sonographer, who is available 24/7. The expense and hassle of training a 'doctor' fully to the extent of being 'FAST competent', who would only be doing it occassionally (hence possibly less sensitivity), why not have a person who is better at it. There is also this money one could potentially save by avoiding 'litigations' and the likes...

Just a thought guys, don't aim your guns at me!!!
sonographer is not better than a trained EM physician for doing FAST, or for reading a CT contrast.
medline documents the sensitivity and specificity of EM physician done FAST scans as superior or equal to that of radiologists.
Believe me...i teach FAST scans, and they are way easy to do accurately, than to actually pick the phone call someone from his resting room.
As far as litigation is concerned....
hmm interesting question.
Australia and US have a formal accredition course for FAST scans.
We have embarked on the same lines, although.. accredition will take time to come.
those interested can contact dr. imron subhan, hes one of the chief faculties for the ultrasound course done by Apollo Hospital. We just finished 2 courses a couple of months back in hyderabad and kolkata.
Another one should be in the pipeline soon.
And leave footprints in the sands of time.......
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