D.P.L. - Going Old School on Trauma

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Anyway, back to the matter at hand.  Diagnostic. Peritoneal. Lavage.  Yes, ok, everyone stop rolling their eyes.  I get it.  Many (moreso in our community rather than in the trauma world) now call DPL anachronistic with today's Emergency Department access to CT and FAST.  And as they should!  The test was a boon to trauma surgery when it was introduced in the 1960's but it is non-specific for intraperitoneal bleeding or diaphragmatic injury and insensitive for pneumoperitoneum.

However, in some cases your modern modalities may fail you.  An example might be a patient with evidence of intraperitoneal fluid with no visible solid organ damage (i.e. you suspect CT is not detecting a hollow viscus injury, which is something that should be promptly taken to the OR). Again, we're being honest here, it may not be a procedure that you ever have to do, but that doesn't get you off the hook of knowing it.

The "dipple" as I've heard it called is actually an aspiration and a lavage if you want to be technically correct in your description.  It can be done in a "semi-open" or "closed" technique, but for the purposes of this post we'll only cover the more EM-friendly, Seldinger-esque "closed" maneuver.

Think of it as a midline paracentesis, although you'll want to use a very small gauge needle.  Get sterile as you normally would, and give a generous amount of local anesthesia just inferior to the umbilicus.  The ideal entry site is in the midline here, as it is generally avascular, devoid of fat, and adherent to the peritoneum.  Once you puncture through, wire it, puncture the skin with a scalpel, and advance a catheter, directing it caudad either to the right or left.  Then, attach your tubing and aspirate for gross blood.  

If no gross blood, allow 1 L of either normal saline or Lactated Ringers to run in.  You can put a cuff on the bag to speed things up as this may take a while.  After it's all in, drop the bag on the floor and let the fluid run back out to gravity.  Some opt to roll the patient back and forth before this to make sure the lavage mixes in.  You don't need to wait until the entire liter comes back out--700 mL has traditionally been noted as adequate.  Send it off to the lab!

Here is an excellent primer from UCSD's Department of Trauma and Burn:

In terms of interpretation, let's just make it idiot proof:

1.) If you get over 10 mL of gross blood (or really any gross blood realistically), that's positive, you're done.
2.) In blunt trauma anywhere except the lower chest, you're positive if your RBC cell count is greater than 100,000.
3.) If there's blunt trauma to the low chest or a GSW, you need to drop that cutoff to 5,000.

If you did the DPL right, and there is no IPH, you really shouldn't see more than a few hundred RBC's in your sample.

Just as always, this post is meant to be for EDUCATIONAL PURPOSES ONLY.  Be a smart doc, and don't go claiming we told you it was a good idea to "dipple" all of your blunt trauma patients from here on out.

jps

Sources:

Griffin, X. L., & Pullinger, R. (2007). Are Diagnostic Peritoneal Lavage or Focused Abdominal Sonography for Trauma Safe Screening Investigations for Hemodynamically Stable Patients After Blunt Abdominal Trauma? A Review of the Literature. The Journal of Trauma, 62(3), 779–784. doi:10.1097/01.ta.0000250493.58701.ad

MD, Y.-C. W., MD, C.-H. H., MD, C.-Y. F., MD, C.-C. Y., MD, S.-C. W., & MD, R.-J. C. (2012). Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage. American Journal of Emergency Medicine, 30(4), 570–573. doi:10.1016/j.ajem.2011.02.014

Roberts and Hedge's Clinical Procedures in Emergency Medicine. Chapter 43.

UCSDTraumaBurn's YouTube Page

The Legendary Rectal Foreign Body Retrieval

If you ever want to hear a story about the "good old days" in the ED you should sit down with our former department chair.  He's a forty year veteran (i.e. he predates EM training) and has literally seen everything.  The other day he was passing through and I asked him point blank, "What's the biggest thing you've pulled out of a patient's rectum?"  He sat down, leaned back and without breaking stride he said, "It was a dill pickle.  Really got the fella up there.  And in my day we didn't use any sedation.  All you had was your metal anoscope, and whup, how's yer father--you shoved that thing up there and hoped you could see something."  So awesome.

All chuckles aside, and despite the fact that this is a coveted procedure, we are often left a bit befuddled when these actually do roll in.

Even if they're small, you need to always assume these FB's can perforate so they by definition need to come out.  A good history will give you a good understanding of what you're dealing with, although patients may not always be forthcoming with you (for obvious reasons).  Your DRE will be vital,  as anything low lying will have a much higher chance of being retrieved in the ED.  Finally a plain film of the abdomen is a quick and useful test you can order than can give you a lot of information, especially if the patient is being coy with you.

These situations are great opportunities for us to use our ability to MacGyver devices to our advantage, but some ground rules should be established before we get too cavalier.  If the patient is already peritonitic at presentation, stop what you're doing and call surgery as they may have perf'ed already.  Do the same if there is glass involved and you're pretty sure that something has shattered.

If you do decide to go after the FB, you'll need some sort of speculum.  A vaginal speculum with a light can actually serve as a decent substitute for an anoscope.  Once you have a good view you can try reaching with your bare fingers but a grabbing utensil like a ring forceps may come in handy.


Oh, and you'll need them comfortable as possible, which essentially means procedural sedation.  Ketamine will likely make your life a lot easier in these situations.  Typically patients are placed prone in a knee-chest position, or in a left lateral decubitus.

Often there's a lot of negative pressure working against you, so you may choose to employ a Foley catheter to pass distally to break this up.  An endotracheal tube can also achieve this goal, and it's less likely to bend.   Here's an awesome example illustrated by Dr. Whit Fisher:

If the FB is a jar or bottle with the open side down, you can employ another neat trick by placing a Foley or ETT into the object, and then injecting Plaster of Paris via the tube.  Once it solidifies around the tube, you have a nice handle to pull the object out with.

As always, these posts are for EDUCATIONAL PURPOSES ONLY.  The thought of a rectal FB may make you feel lighthearted and whimsical but you should never, ever treat them as such.  Finally, give these patients their dignity--don't be stupid and go posting pictures of their KUB on Instagram once you get home from your shift.


jps

Sources:

Cologne KG et al.  Rectal Foreign Bodies: What Is The Current Standard? Clin Colon Rectal Surg.  2012 Dec; 25(4): 214-8. 

Roberts and Hedges' Clinical Procedures in Emergency Medicine.  Chapter 45.

Procedurettes YouTube Page