https://www.east.org/education/practice-management-guidelines/blunt-abdominal-trauma,-evaluation-of

Thank you Dr. Vishnu Mani, does this guideline represent a consensus in the states?

its mostly hospital dependent

We rarely do DPL anymore for both blunt and penetrating trauma

FAST scan seems to be the choice with or without CT depending on the stability of the patient and/or direct laparotomy dealt case by case.

Dear Osaid,

ultrasound has outplaced DPL in most of all selective circumstances. Nevertheless, lack of ultrasound or lack of power in the absence of CT/MRI may be some of the fewer indications accepted world wide. Please keep in mind that your patient for DPL needs to be tubed (and probably ventilated) as no one will tolerate a tube on the peritoneum without narcosis. Doing a single peritoneal tap in a distending abdomen may prove blood in the abdomen, but please remember that the bowels are swimming on top of the blood and may be injured easily. And: after DPL any further ultrasound or CT proof of fluid or gas in the abdomen is useless - so have DPL as the last resort as it blinds further diagnostics. Furthermore, DPL is blind even for major injuries to  the retroperitoneal compartment. 

DPL is presently not routinely done as better option of Ultrasound and CT scan are now freely available even in remote areas. To some extent DPL is an invasive procedure and in most cases it is to be repeated as and when required. The guide line provided by Vishnu Mani is appropriate and feasible clinically

In the last twenty years in our emergency  hospital  we have performed only less than five DLP, I think. This extremely low number is explained because we have routinely performing FAST in the emergency department to all patients admitted with blunt  or open abdominal trauma. In some cases, when the diagnosis was uncertain we performed abdominal puncture under US guidance. Hemodinamic stable patients, in the last years, were referred to the CT scan for a thoroughly abdominal exam.

Indications for DPL in trauma? It depends on the criticality of trauma and if present a scenario of imminent impending CA. In such scenarios forget DPL, often even sonar. Nowadays, with the advent and refinements of echo has only two indications and both in a stable or compensated HS or in absence of other indications for a quick rush to OT: when you want to rule out intestinal perforation and when you need to exclude or confirm and distinguish an IA pool of fluid and if it is blood or else. Two caveats: in NOM of IA trauma, rarely-to-occasional even if penetrating trauma involving liver kidney and spleen or retroperitoneal haemorrhage, remember that it may take up to six hours for intestinal fluid or material to irritate the peritoneum and give clinical /tenderness/peritonitis and that clinical systemic sepsis of unknown origin, with kidney excluded and absence of IA haemathoma infection on imaging, may well be intestinal fluid sealed somewhere against the retroperitoneum. I saw a pt with GSW in the abdomen presenting "six days later the accident" with only an upper abdomen tenderness, a distended abdomen, and low fever, in otherwise good health walking pt? Because of pain in the back and the risk of the distended abdomen increasing in size on questioning, I explored the abdomen. A bullet in the retroperitoneum - seen on preop Xray - in a well-sealed pocket and some faecal material before the splenic flexure of the transverse colon is what I found in that Sudanese pt in North Kenya. I did nothing else than a good warm water cleaning and primary closure of the abdomen with full re-establishment of the patient. I left the bullet, more correctly I did not want t search for it. The possibility considered of a delayed LA caecostomy was considered but it went well.

Rarely performed, and superseded by more sensitive and specific modalitites! Its most important role is in a theory question paper for general surgical trainees...