CAPÍTULO II: MARCO TEÓRICO
2.1. Hombre vs. Homosexualidad
Laparoscopy
Laparoscopy has been used in the hope of decreasing the rate of nontherapeutic laparotomies ( 94,95). Despite the fact that laparoscopy can directly visualize organs, it has not been shown to be superior to DPL in the initial evaluation of blunt abdominal trauma ( 25). Its greatest utility may be in the hemodynamically stable patient who was found to have hemoperitoneum by DPL or ultrasound (96).
Angiography
With the exception of patients with pelvic fractures, abdominal angiography and therapeutic embolization play minor roles in the evaluation and treatment of blunt abdominal trauma (97). On occasion, angiography has been used to localize intra-abdominal bleeding, and embolization has been used to control visceral
hemorrhage (93). Angiography clearly plays an important role in diagnosing and treating uncontrolled pelvic hemorrhage ( 80).
Other Studies
A variety of other tests are occasionally useful in the evaluation of blunt abdominal trauma. Endoscopic retrograde cholangiopancreatography (ERCP) is valuable only when a strong suspicion of pancreatic duct injury exists. During the 1970s, nuclear medicine studies were used to evaluate potential liver and spleen injuries, but they have been replaced by CT and are rarely performed today. While magnetic resonance imaging (MRI) can detect otherwise occult diaphragm rupture, it is not indicated in the acute situation due to lack of availability, high cost, and prolonged scanning times. Contrast duodenography clearly demonstrates the presence of duodenal hematoma and may be valuable in certain settings. One such scenario is the patient with persistent, unexplained vomiting after a blow to the upper abdomen.
The Pediatric Patient
Due to anatomic and physiologic differences, children tolerate nonoperative intervention better than adults ( 2,98,99 and 100). While DPL is sensitive for
hemoperitoneum in children, a positive lavage does not mandate laparotomy if the child is hemodynamically stable ( 101,101,102,103 and 104). Many children with a positive lavage may be managed nonoperatively. CT scans of the abdomen are better suited to nonoperative management in children with splenic injury and
hemoperitoneum. Serial hematocrits, repeated clinical examinations, and follow-up scans complement this approach (105). Recommendations for laparotomy include (a) children unresponsive to fluid resuscitation, (b) transfusion requirement >40 mL/kg of packed red blood cells during the first 36 to 48 hours, or (c) progressive abdominal findings (104,106). Nonoperative management requires intensive monitoring, preferably in a tertiary care setting, and may not be indicated in most rural or community hospitals.
Some authors have found abdominal CT insensitive in children. One study found CT to be only 67% sensitive for intra-abdominal injury compared to 94% with DPL (47). Most trauma centers use DPL only in hypotensive children who have multiple potential sources of blood loss, and who remain hypotensive despite aggressive resuscitation. DPL may also be indicated in children at high risk for pancreatic or intestinal injury ( 101).
Ultrasound has a growing role in the management of pediatric blunt abdominal trauma. Akgur used ultrasound in 68 children to determine the presence of free
intra-abdominal fluid and found it to be 100% sensitive and 98.3% specific (107). In this study, ultrasound was more sensitive than DPL. In another series, Luks found ultrasound to be 89% sensitive and 96% specific in detecting hemoperitoneum in children ( 100).
The Pregnant Patient
The evaluation of the traumatized pregnant woman is difficult for a variety of reasons. Due to peritoneal stretching, the peritoneum becomes less irritable and physical exam more unreliable. Up to 50% of pregnant women with massive hemoperitoneum have no peritoneal signs (109). Detection of shock is also problematic because a woman may lose up to 35% of blood volume before her blood pressure drops (110). Objective evaluation of the pregnant woman's abdomen is necessary for those with equivocal abdominal exams, persistent tachycardia, elevated base deficit, or major mechanism of injury (5). Unfortunately, there are no prospective studies comparing DPL, CT, and ultrasound in the evaluation of the pregnant patient with a traumatized abdomen. However, there is greater experience regarding the use of DPL than CT scanning (109,111 and 112). If DPL is to be safely used with a gravid uterus, the fully open supraumbilical technique is recommended.
CT of the abdomen is safe in the pregnant woman if the uterus is shielded and the scan is limited to the upper abdomen. This modified scan delivers less than 3000 millirads to the fetus, whereas pelvic CT results in 3000 to 9000 millirads, posing a significant fetal risk ( 113,114).
Ultrasound is particularly helpful in evaluating the pregnant woman with blunt abdominal trauma ( 39). In addition to safely detecting hemoperitoneum, ultrasound will establish fetal viability, gestational age, volume of amniotic fluid and detect up to 50% of abruptions. For these reasons, ultrasound is rapidly becoming the test of choice to evaluate the traumatized pregnant patient.
Patients with Pelvic Fractures
The management of the patient with an unstable pelvic fractures is complex. Hypotension may be secondary to hemoperitoneum and/or retroperitoneal bleeding. With hemoperitoneum, urgent laparotomy is necessary, but with retroperitoneal hemorrhage, an external fixator and possibly angiographic embolization are indicated.
While CT scanning can distinguish intraperitoneal from retroperitoneal hemorrhage and delineate complex pelvic fractures, it may result in a dangerous delay. The hypotensive patient with a complex pelvic fracture may benefit from peritoneal aspiration. If gross blood is returned, laparotomy is indicated, if the aspirate is negative, pelvic stabilization and angiography are indicated (115). Alternatively, ultrasound may provide rapid diagnosis of hemoperitoneum.
CONCLUSION
Emergency physicians have a number of objective means at their disposal to evaluate the multiply injured patient. The choice of DPL, CT, ultrasound, or some combination depends on a number of patient factors. The most important is hemodynamic stability. A bedside test, such as DPL or ultrasound, is the best way to determine the need for immediate laparotomy in the hypotensive patient. To a large extent, the utility of CT or ultrasound depends on the location and quality of equipment and the expertise of the interpreting physician. While DPL is criticized for being overly sensitive to minor intra-abdominal injuries, CT scan is more likely to miss a critical injury. While the role of serial ultrasound needs to be further explored, serial ultrasound combined with clinical criteria may obviate the need for DPL or CT in most cases. Because no test is infallible, the patient with a negative DPL, CT, or ultrasound should undergo a period of observation after a negative study.
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