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University Hospital 775 20 Olomouc, Czech Republic
We read with interest a perspective by McGahan and Richards [1] describing the role of emergent sonography in patients with blunt abdominal trauma. We agree with the statements made in the paper; however, the diagram showing a clinical algorithm, their figure 11, has at least two drawbacks. First, the possibility of sonography with negative findings not correlating with physical examination is omitted. Nevertheless, this problem is correctly described in the article. The authors state, "If the initial sonographic examination shows no abnormalities, but a strong clinical suggestion or laboratory evidence exists of solid or hollow organ injury in the abdomen, contrast-enhanced CT may be helpful." A similar recommendation is also included in the concluding sentences of the paper. Why wasn't this situation addressed in the diagram?
The second drawback is partly related to the previous one. In the case of negative findings on sonography and positive findings on physical examination or positive sonographic findings but a stable patient condition, too much time may elapse before CT is performed. When it is technically possible, we recommend performing CT immediately in these situations.
We agree with the authors that sonography is an expedient, noninvasive, low-cost method of triaging patients with blunt abdominal trauma. However, we think a better flow chart should be used such as the one by Bode et al. [2] in the same issue of the AJR.
References
University of California UC Davis Medical Center Sacramento, CA 95817
In reply to Dr. Herman's letter regarding the role of sonography in blunt abdominal trauma, we believe that our diagram and data regarding the sonography of blunt abdominal trauma are in basic agreement with him. First, the article emphasizes, "However, negative sonographic findings do not entirely exclude free fluid and may miss some solid organ or hollow viscus injuries" [1]. This problem is well illustrated in a number of publications, including one from our institution focusing on the use of sonography in renal trauma [2]. In that publication, only 35% of isolated renal injuries had associated free fluid on sonography. In only 22% of patients did sonographic examination detect a renal injury. Thus, definite limitations exist in the sonographic examination of patients with blunt abdominal trauma. Furthermore, others have confirmed that a lack of hemoperitoneum with significant intraperitoneal and retroperitoneal injuries may exist [3]. Thus, no time lapse occurs from sonography to CT. From a practical standpoint, only a few minutes are needed at our institution to transfer a patient to CT. We state in our article, "...if the patient is unresponsive, has worsening abdominal pain, or has abnormal laboratory findings..." then enhanced CT should be performed. We find sonography to be most useful with a trauma victim in whom significant free fluid is detected in an expedient fashion, allowing the patient to be immediately transported to the operating room. CT remains the gold standard for abdominal trauma, and the limitations of sonography in detecting free fluid or parenchymal and hollow viscus injuries must be clearly recognized [1].
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