The Journal of TRAUMA威 Injury, Infection, and Critical Care

Review Article

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
Xavier L. Griffin, BM, BCh, MA, MRCS and Rick Pullinger, FCEM

Background: Assessment of patients
in the emergency department who sustain
blunt abdominal trauma represents a sig-
nificant diagnostic challenge. Computed
tomography (CT) is increasingly used as
the principal investigation for these pa-
tients. A sensitive screening test could
safely reduce the use of CT.
Objectives: To appraise the evi-
dence supporting the use of diagnostic
peritoneal lavage and focused abdomi-
nal sonography for trauma as screening
tests in the emergency department to
reduce the use of CT in the initial assess-
ment of patients sustaining blunt ab-
dominal trauma.
Methods: A search of high-quality
evidence resources was performed, fol-
lowed by a hand search of the bibliogra-
phies of all relevant articles.
Results: Altogether, 55 articles were
found during the initial search, of which
23 were relevant. An additional 11 were
found by hand searching. Six relevant
original research articles were found.
Conclusion: Screening diagnostic
peritoneal lavage and selective CT is a safe
diagnostic strategy for the investigation of
blunt abdominal trauma. Further research
is needed to determine the role of focused
abdominal sonography for trauma scanning
in diagnostic protocols.
J Trauma. 2007;62:779 –784.

B
lunt abdominal trauma (BAT) is common and associ-
ated with significant morbidity and mortality. The rapid
and appropriate assessment of patients with BAT in the
emergency department (ED) is important to direct early de-
finitive management.
However, assessment of patients in the ED who sustain
BAT represents a significant diagnostic challenge. The diffi-
culty of making a full assessment from physical examination
(PE) alone is well recognized and has led to the develop-
ment of several modalities of investigation to assist in the
initial assessment. Recognized modalities include diagnos-
tic peritoneal lavage (DPL), focused abdominal sonogra-
phy for trauma (FAST), and computed tomography (CT).
The roles of DPL and FAST for investigation of the he-
modynamically unstable BAT patient are well established.
However, their roles in the hemodynamically stable patient
are less clear.
Early management of patients sustaining BAT depends
upon their hemodynamic stability. Patients who do not re-
spond to initial fluid resuscitation are candidates for early
laparotomy because further imaging is unsafe. However, in
Submitted for publication June 7, 2006.
Accepted for publication September 26, 2006.
Copyright © 2007 by Lippincott Williams & Wilkins, Inc.
From the Emergency Department (X.L.G.) and Emergency Medicine
(R.P.), John Radcliffe Hospital, Headington, Oxford.
Address for reprints: X.L. Griffin, Emergency Department, John Rad-
cliffe Hospital, Headley Way, Headington, Oxford OX3 9DU; email:
x.griffin@tiscali.co.uk.
DOI: 10.1097/01.ta.0000250493.58701.ad
the group of patients who are hemodynamically stable, there
is considerable variation in management. In the United King-
dom, CT is increasingly used as the primary modality of
investigation of these patients. CT is costly, time consuming,
and delivers a radiation dose that confers an additional life-
time risk of fatal cancer of 1 in 2,000.1 This has led some
centers to develop protocols for the initial assessment of
patients sustaining BAT using screening DPL or FAST, and
subsequent CT only when screening tests are positive.
The objective of this review is to appraise the evidence
supporting the use of DPL and FAST as screening tests
before CT in the initial assessment of hemodynamically sta-
ble BAT patients in the ED setting.
METHODS
A review of high-quality evidence resources (including
NeLH Guidelines Finder, National Guideline Clearinghouse,
E-Guidelines, E-Medicine, Clinical Evidence, Bandolier,
Trip Database, UpToDate, BestBETS, and Cochrane Library)
was performed to find existing robust, evidence-based proto-
cols for the initial assessment of patients with BAT by using
the search term “blunt abdominal trauma”.
For each investigation, a search strategy (“blunt abdom-
inal trauma OR blunt abdominal injur* OR intra-abdominal
trauma* OR intra-abdominal injur*” AND ([investigation]
OR [synonym]) was used to search the Cochrane Library,
NeLH, Embase, Medline, and UpToDate. After this search,
the bibliographies of relevant articles were hand searched.

Volume 62 • Number 3 779

 The Journal of TRAUMA威 Injury, Infection, and Critical Care
Diagnostic Peritoneal Lavage
DPL is effective in the diagnosis of hemoperitoneum as
an adjunct to PE. The sensitivity of DPL is between 92% and
98%.2–7 The complication rate of DPL is low and further
decreased using the open technique.8 –13 Disadvantages of
DPL include a high false positive rate and the technique does
not sample the retroperitoneal space.5,14,16 However, DPL is
the most sensitive test for mesenteric and hollow organ
injuries.17–19
Focused Abdominal Ultrasound for Trauma
FAST is a noninvasive bedside test that can be per-
formed in conjunction with resuscitation. Ultrasound is por-
table and can be repeated throughout resuscitation and during
any period of observation. Ultrasound in the trauma setting is
only reliable for detecting free intra-abdominal fluid.20 The
minimum detectable volume is considered to be in the region
of 200 mL.21 FAST has a sensitivity of between 73% and
88% and a specificity between 98% and 100% in this
context.22–33 Identification of hollow viscous injury and the
assessment of solid abdominal organs is not reliable with
ultrasound in the trauma setting.22,24,27,28,33–35
Computed Tomography
CT has a sensitivity of between 92% and 98% and a
specificity of 99% in the evaluation of BAT.36 CT has been
previously shown to miss hollow organ and mesenteric in-
jury. Hence, most centers recommend a period of inpatient
observation after a negative CT. However, a recent prospec-
tive, multi-center series demonstrated that CT has a high
enough negative predictive value to allow immediate dis-
charge from the ED.37 CT is also the only modality that is
able to assess the retroperitoneal structures and grade solid
organ injury.
RESULTS
Three good-quality literature reviews were found, which
suggested protocols for the investigation of BAT. An addi-
tional 52 original articles were found from the initial litera-
ture search, of which 31 were relevant. An additional 11
articles were found from the hand search of the bibliogra-
phies. Of these articles, there were six studies concerning the
complementary roles of DPL, FAST, and CT. Table 1 shows
a summary of the evidence.38
Discussion of Evidence
A diagnostic screening test should safely identify all
patients who require CT to define their intra-abdominal in-
jury. The number of CT scans performed, the rate of missed
injury, and the rate of nontherapeutic laparotomy are the key
outcome measures by which protocols incorporating these
screening tests can be compared. The literature search re-
turned two prospective, randomized trials and four cohort
studies.
780
Mele et al.
Mele et al.39 reported a cohort study in a US trauma
referral hospital. During a 1-year period, 167 patients suffer-
ing BAT, who were hemodynamically stable at presentation,
required further abdominal evaluation for clinically suspected
injury. Patients underwent either immediate CT or screening
DPL, followed by CT for those found to have hemoperito-
neum. Patients were not randomized but allocated to either
arm by clinician preference. All patients were admitted for a
period of observation.
Seventy-one patients were entered into the DPL/CT arm,
of those patients, 20 had a positive DPL. Ten of these patients
underwent immediate laparotomy. The remainder were fur-
ther assessed with CT, and of those patients, three required
laparotomy for intra-abdominal injuries. Overall, 13 patients
in the DPL/CT group underwent laparotomy, all of which
were therapeutic. All 51 patients with a negative DPL were
successfully managed conservatively without any require-
ment for further abdominal imaging. Of the 96 who under-
went immediate CT, 11 required laparotomy. There were
seven missed injuries in the CT group compared with none in
the DPL/CT group. The missed injures were four hollow
organ injuries, two splenic lacerations, and a diaphragmatic
rupture.
The main limitation in this study is the selection bias
introduced by the clinician who chose which group to allocate
each patient to. This led to a significant difference in the
injury severity score between the two groups: score of 22 in
the DPL/CT group and a score of 17 in the CT group ( p ⫽
0.01). This could account for the comparatively successful
conservative management of the DPL/CT group.
Gonzalez et al.
Gonzalez et al.40 presented a similar study based on a
prospective randomized format at a Level I US trauma center.
Hemodynamically stable patients who had reliable abnormal
abdominal examinations (Glasgow Coma Scale [GCS] score
⬎13), or had sustained BAT but had a GCS score ⱕ13 were
randomized to undergo DPL/CT or CT alone. A positive DPL
was defined as more than 20,000 red blood cells (RBCs)/mm3,
necessitating CT. Laparotomy was reserved for those patients
in whom CT demonstrated a hollow organ injury or free fluid
without solid organ injury; lavage fluid ⬎100,000 RBCs/mm3,
⬎500 white blood cells (WBCs)/mm3, or positive for biliru-
bin or vegetable matter.
Two hundred fifty-two patients met the entry criteria;
127 were randomized to the DPL/CT arm and 125 to the CT
arm. Of the 127 patients who underwent DPL, only 27 re-
quired CT. Eleven patients had an equivocal DPL (20,000 ⬍
RBCs/mm3 ⬍ 100,000), three of whom had solid organ
injuries. Of the remaining 16 patients, 10 had solid organ
injury and 5 had free fluid without solid organ injury. In total,
seven patients proceeded to laparotomy. There were no
known missed injuries or nontherapeutic laparotomies. Of the
125 patients who underwent CT alone, 22 had a positive
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Volume 62 • Number 3
Table 1 Summary of Emergency Department Studies of the Assessment of Patients Sustaining Blunt Abdominal Trauma
Level of
Study Objective Design Size (n) Entry Criteria Outcome Measures Principal Conclusion
Evidence38

Mele39 DPL ⫾ CT vs. CT Cohort 167 Adult, SBP ⱖ90, HR Laparotomy, inpatient stay, Reduction in CT use 2-
ⱕ120, clinical complications, ED with screening DPL,
suspicion of injury assessment time, no missed injuries at
inpatient stay 1 yr
Gonzalez40 DPL ⫾ CT vs. Randomized 252 Adult, SBP ⬎90, Sensitivity of DPL/CT, DPL/CT is cost effective 1-
DPL prospective abnormal or laparotomy rate, cost and safe
format unreliable effectiveness
abdominal
examination
Schreiber41 DPL ⫾ CT vs. Cohort 67 SBP ⱖ90, HR ⱕ110 Nontherapeutic Reduction in CT use and 2-
historical cohort laparotomy, cost nontherapeutic
laparotomy with
screening DPL
Rose23 FAST vs. control Randomized 208 Adult, US trauma Use of CT, time to FAST does reduce use 1-
prospective triage criteria laparotomy of CT
format
Shih42 FAST protocol vs. Cohort 167 Consecutive Nontherapeutic Reduced rate of 2-
historical cohort laparotomy, missed nontherapeutic
injury laparotomy, no
increase in rate of
missed injury
Branney43 FAST protocol vs. Cohort 1,002 Consecutive Use of DPL and CT Reduction in rate of CT 2-
historical cohort and DPL use
DPL, diagnostic peritoneal lavage; FAST, focused abdominal sonography for trauma; CT, computed tomography; SBP, systolic blood pressure; HR, heart rate; ED, emergency
department.

781
Are DPL or FAST Safe Screening Tests?
 The Journal of TRAUMA威 Injury, Infection, and Critical Care
finding mandating laparotomy, and there were 3 missed in-
juries requiring delayed laparotomy.
Gonzalez et al. have designed a robust study protocol but
did violate this on one occasion. Their data suggest that
complementary DPL and CT is a safe and effective way of
reducing use of CT.
Schreiber et al.
Schreiber et al.41 presented a cohort of 1,147 patients
sustaining BAT at a US Level I trauma center. All patients
requiring abdominal investigation underwent DPL as their
initial assessment. CT was reserved for those hemodynami-
cally stable patients who had a positive DPL for blood. Those
with a DPL positive for lymphocytes, fecal matter, amylase,
or organisms underwent laparotomy without further imaging.
Those patients with a negative DPL were observed.
Only the results for those patients who had a positive
DPL for blood were presented. There were 67 patients in this
group, of whom 38 underwent CT and 29 underwent imme-
diate laparotomy in violation of the protocol. Of the 38 in the
CT group, 5 underwent immediate laparotomy after CT and
an additional 6 underwent delayed laparotomy after a period
of observation. Of these, one laparotomy was nontherapeutic.
Of the 29 patients who underwent laparotomy directly after
DPL, 8 were not therapeutic.
Schreiber et al. demonstrated that CT reduces the rate of
nontherapeutic laparotomy in patients with a positive DPL.
These conclusions are drawn from the subgroup of patients
who violated the study protocol. Also those patients who
violated protocol had a significantly higher injury severity
score and this may have influenced the decision to proceed
directly to laparotomy. Furthermore, this study design does
not provide any information about the management of pa-
tients with a negative DPL; it is more a reflection of changing
surgical practice to conservatively manage abdominal injury
where possible.
Rose et al.
Rose et al.23 performed a prospective randomized study
at a US Level II trauma center. All patients entered into the
study met the American College of Surgeons Subcommittee
on Trauma’s critical trauma triage criteria for assessment at a
trauma center. Patients were randomized in blocks of 30 for
a FAST scan at arrival. Once patients were randomized to
FAST or control groups, physicians were free to appropri-
ately investigate them. The primary outcome measure was the
use of CT between the FAST and control groups.
Two hundred twelve patients were entered into the study.
One hundred four underwent FAST examination, 104 pa-
tients were entered into the control group, and 4 patients did
not complete the protocol. Thirty-seven patients underwent
further evaluation with CT in the FAST group compared with
54 in the control group ( p ⬍ 0.02). Three patients in the
FAST group had missed injuries, two of whom required
782
laparotomy. The rate of missed injury for the control group
was not stated.
The enrollment of patients into this study was not con-
secutive since not all ED clinicians were trained in the use of
ultrasound. Also, the authors are not explicit about the rate of
missed injuries in the control group, nor the rate of nonthera-
peutic laparotomy in either group. It is therefore difficult to
determine the sensitivity of this diagnostic protocol.
Shih et al.
Shih et al.42 compared a cohort of 167 patients using an
ultrasound-based diagnostic protocol in a trauma center in
China with a historical cohort in the same hospital. Ultra-
sound was used as a screening test in all patients. Unstable
patients with a positive ultrasound underwent immediate lap-
arotomy. CT was used to further assess those stable patients
with a positive ultrasound and an equivocal or negative PE or
X-ray (group A), and those with a negative ultrasound but
equivocal PE or X-ray (group B).
There were 44 patients in group A, 3 of whom quickly
became unstable and underwent laparotomy. Of the remain-
ing patients, 2 underwent immediate therapeutic laparotomy
for suspected injuries identified on CT, 38 patients were
managed successfully conservatively, and 1 failed conserva-
tive management and underwent a delayed laparotomy. There
were two nontherapeutic laparotomies and no missed injuries.
There were 23 patients in group B, one of whom became
unstable before CT and underwent repeat positive ultrasound
and laparotomy. Eighteen patients had a negative CT, and of
the four with injuries identified on CT, three underwent
laparotomy. There were no nontherapeutic laparotomies or
missed injuries.
In this study, ultrasound was not used to exclude intra-
abdominal pathological abnormalities when there was clin-
ical suspicion of injury, and thus it could not reduce CT
use. In those patients with a negative ultrasound and a
reliable negative PE, it did support the decision for con-
servative management. This may partly explain the reduc-
tion in nontherapeutic laparotomy in the study group
compared with the historical cohort (9.1% versus 32.2%;
p ⫽ 0.025). Importantly, the ultrasound examination used
in this study was not the routine FAST examination. The
time of ultrasound examination is not stated. This may
introduce bias since hemorrhage is a dynamic process.
Branney et al.
Branney et al.43 compared a consecutive cohort of 486
patients using an ultrasound-based pathway with a similar
historical cohort of 516 patients at a US Level I trauma
center. Ultrasound was used as an initial examination to
direct early laparotomy or further diagnostic testing. Patients
who were hemodynamically unstable with a positive ultra-
sound or had peritonitis on PE underwent laparotomy. Stable
patients with a positive ultrasound or who had unreliable PE
underwent further imaging with CT. The remaining patients
March 2007

with a negative ultrasound and a reliable PE were admitted
for observation.
There was a 74% reduction in use of DPL and a 58%
reduction in the use of CT in the protocol group compared
with the control group. Injury severity score, type of injury,
and rate of laparotomy were not significantly different be-
tween the two groups. Patients in the protocol group were
followed up for 6 months, during which time there were no
missed injuries.
It is not explicit whether there was a change in the rate of
nontherapeutic laparotomy between the groups. However,
Branney et al.43 were able to show that a clear algorithm
involving ultrasound as an early screening test does safely
reduce the rate of DPL and CT at their center. In this protocol
CT is only withheld from hemodynamically stable patients
with a normal PE and ultrasound. It is possible that the results
seen in this study may not transfer directly to practice in the
United Kingdom.
CONCLUSIONS
The evidence regarding the use of DPL and FAST as
screening investigations in patients sustaining BAT is lim-
ited. 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 and
has been incorporated into the recommendations for investi-
gation of blunt trauma by the American College of
Surgeons.44 The evidence reviewed here does not support the
use of this modality as a screening test to reduce the use of
CT. 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.
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