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
UCSDTraumaBurn's YouTube Page
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