ORIGINAL CONTRIBUTION alkaline phosphatase, peritoneal lavage; peritoneal lavage
The Value of Alkaline Phosphatase in Peritoneal Lavage The accuracy of peritoneal lavage for diagnosis of intra-abdominal injury in trauma is limited by its relative lack of sensitivity for hollow viscus injury. Peritoneal lavage in the dog indicates that alkaline phosphatase is an early mqrker,of intestinal injury If these results were confirmed in human patients, alkaline phosphatase determination would improve lavage sensitivity for hollow viscus injuries. A study was conducted to determine the usefulness of alkaline phosphatase in lavage in human beings. Alkaline phosphatase was measured in all trauma lavage samples sent for laboratory assay during a one-year period. Two hundred ninety-two lavages were performed: 25 were positive by laboratory criteria, and 66 were grossly positive. There were 13 intestinal injuries - nine were grossly positive, and four were diagnosed by laboratory results. Three of these four patients with intestinal injuries had elevated lavage alkaline phosphatase. All three (lavaged from 30 minutes to two hours after injury) also had elevated white blood cells or bile in the lavage fluid. The remaining intestinal injury was diagnosed by lavage bile but had no elevation of alkaline phosphatase (lavaged 15 minutes after injury). Two patients with elevated alkaline phosphatase in otherwise negative law~ges were observed for at least five days; neither demonstrated any evidence of intra-abdominal injury. We conclude that alkaline phosphatase is no better than traditional determinants of intestinal injury in peritoneal lavage. In no patient was alkaline phosphatase helpful in diagnosing a hollow viscus injury, and its use would have prompted two unnecessary laparotomies. These data do not support the use of lavage alkaline phosphatase to identify hollow viscus injuries. [Megison SM, Weigelt JA: The value of alkaline phosphatase in peritoneal lavage. Ann Emerg Med May 1990; 19:503-505.]
Stephen M Megison, MD John A Weigelt, MD, FACS Dallas, Texas From the Department of Surgery, Trauma and Critical Care Section, The University of Texas Southwestern Medical Center, Dallas. Received for publication July 19, 1989. Revision received October 30, 1989. Accepted for publication January 8, 1990. Presented at the Society for Academic Emergency Medicine Annual Meeting in San Diego, May 1989. Address for reprints: John A Weigelt, MD, Department of Surgery, Trauma and Critical Care Division, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, Texas 75235-9031.
INTRODUCTION Diagnostic peritoneal lavage (DPL) is often used to diagnose intra-abdominal injury after trauma. The accuracy of lavage is limited by its relative lack of sensitivity for hollow viscus injuries. To improve the diagnostic efficiency of peritoneal lavage for hollow viscus injuries, Marx et al studied alkaline phosphatase in lavage fluid in dogs with intestinal injuries. 1 Lavage fluid alkaline phosphatase was elevated significantly earlier than white or red blood cell counts after intestinal injury. It is possible that testing lavage fluid for alkaline phosphatase will identify intestinal injuries earlier and improve the accuracy of DPL for these injuries. We have studied alkaline phosphatase in DPL in human beings to test this hypothesis. METHODS All patients presenting to Parldand Memorial Hospital from October 1, 1987, through October 25, 1988, who required DPL for trauma were entered into the study, which was approved by the Southwestern Medical School Institutional Review Board for Human Experimentation. Peritoneal lavage was performed in patients with abdominal stab wounds when local exploration failed to demonstrate that the wound was superficial. Patients with gunshot wounds to the abdomen were not lavaged. Patients with blunt abdominal trauma were lavaged if they complained of abdominal tenderness or impaired mental status prevented adequate assessment of
19:5 May 1990
Annals of Emergency Medicine
503/29
ALKALINE PHOSPHATASE Megison & Weigelt
the abdomen by physical examination. Peritoneal lavage was performed on each patient using standard technique, and lavage effluents were assayed for red blood cells, white blood cells, amylase, bile, and alkaline phosphatase. Alkaline phosphatase was determined by a colorimetric assay of cleavage of paranitrophenolphosphate. Grossly positive peritoneal lavages (those that returned free-flowing blood) were not assayed. Peritoneal lavage was considered positive for both blunt or penetrating trauma by laboratory criteria if RBCs were more than 100,000/mm 3, WBCs were more than 500/mm 3, if amylase was elevated, or if bile was present in the sample. Patients with positive peritoneal lavage underwent exploratory laparotomy, and the operative findings were recorded. Elevation of alkaline phosphatase was not considered an indication for exploration if the remainder of the lavage was considered negative. Patients with negative peritoneal lavages were admitted and observed for 24 hours before discharge.
RESULTS Two hundred ninety-two patients underwent peritoneal lavages. There were 250 men (86%) and 42 women (14%) in the study. The mechanism of injury was blunt in 68% of patients and penetrating in 32%. Patient ages ranged from 5 to 71 years old, with 69% of patients between 20 and 39 years old. There were 201 negative (69%) and 91 positive lavages (31%). Sixty-six of the 91 positive lavages were grossly positive (73%), whereas 25 (27%) were positive by laboratory criteria. Thirteen intestinal injuries were discovered at exploration in the 91 patients with positive lavages; nine were associated with grossly positive lavages, and four were diagnosed by laboratory assay. Only two of the nine patients with intestinal injuries and grossly p o s i t i v e lavages had other injuries to explain the lavage results. These injuries included a liver laceration (one patient) and an omental laceration (one patient). Of the four intestinal injuries identified by laboratory criteria, three were found to have elevated alkaline phosphatase. These three patients also had elevated bile or WBCs in the lavage effluent. One patient was la30/504
FIGURE. Interpretive criteria for
DPL. vaged 30 minutes after injury, and the o t h e r two were lavaged two hours after injury. The remaining intestinal injury was identified by bile in the lavage fluid but had no elevation of alkaline phosphatase. This patient was lavaged within 15 minutes of injury. Alkaline phosphatase was elevated in two patients who had otherwise negative lavage results. Each of these patients was admitted for other injuries and observed for at least five days; neither demonstrated any evidence of intra-abdominal injury. DISCUSSION DPL is extremely accurate in determining the presence of intra-abdomihal injuries after stab wounds and blunt trauma to the abdomen.2, 3 A set of interpretive criteria for DPL is listed (Figure). Despite the high accuracy, injuries to the diaphragm and bowel can be missed by DPL. 4 The WBC count is used to detect small bowel injuries but may not turn positive until three hours after injury, s This is not very helpful in evaluating patients seen shortly after abdominal trauma. A lower RBC count is suggested as a method to identify patients with hollow viscus injuries. 6 0 r e s k o v i c h and associates found in a study of patients with abdominal stab wounds that 92% of patients with lavage RBC counts of more than 50,000/ m m 3 had an intraperitoneal injury, w h e r e a s no p a t i e n t s w i t h RBC counts of less than 1,000/mm 3 had an organ injury. In patients with RBC counts between 1,000 and 50,000/ m m 3, 43% had an organ injury and 59% had a hollow viscus injury. These authors concluded that exploratory l a p a r o t o m y s h o u l d be performed for RBC counts of more than 1,000/mm 3 in patients with abdominal stab wounds. Thal reviewed 213 patients with abdominal stab wounds managed with RBC counts of 100,000/mm 3 as positive. 7 Three of nine patients with false-negative lavages had hollow viscus injuries, but lowering the positive lavage c o u n t to 1 , 0 0 0 / m m 3 would have increased the negative exploration rate to 36%. It is evident that neither the WBC nor the RBC Annals of Emergency Medicine
Positive Aspiration of > 10 mL of blood Lavage fluid exits chest tube RBC > lO0,O00/mm 3 WBC > 500/mm 3 Amylase > laboratory normal for serum Bile in lavage fluid Negative RBC < 50,O00/mm 3 WBC < lO0/mm 3 Amylase normal range for serum No bile Indeterminant Catheter fills with blood RBC > 50,000 but < lO0,O00/mm 3 WBC > 100 but < 500/ram 3
c o u n t can reliably d e t e c t h o l l o w viscus injuries early without an unacceptable negative laparotomy rate. Alkaline phosphatase is present in small bowel secretions and may allow earlier diagnosis of bowel injuries by DPL. Marx and associates studied the usefulness of alkaline phosphatase in lavage fluid for assessing the presence of hollow viscus injury. 1 Twenty-nine mongrel dogs were subjected to partial transection of the small intestine or colon. Control animals had exploratory laparotomy only. Peritoneal lavage then was performed. At one hour after injury, the lavage RBC count, WBC count, and amylase levels were all within normal limits in all animals. The alkaline phosphatase levels in the lavage fluid were markedly elevated in the animals with small intestine or colon injuries but not in the control animals. These data suggest that lavage alkaline phosphatase levels may be helpful in early identification of patients with hollow viscus injuries. Unfortunately, our evaluation of lavage alkaline phosphatase in patients did not produce similar results. In no patient with an intestinal injury was the lavage alkaline phosphatase helpful in identifying an intestinal injury. All intestinal injuries were diagnosed by traditional lavage criteria despite two of the patients being lavaged within 30 minutes of 19:5 May 1990
injury. In addition, if an isolated elev a t i o n of a l k a l i n e p h o s p h a t a s e had been considered an indication for abdominal exploration, two unnecessary l a p a r o t o m i e s w o u l d h a v e been performed. Statistical analysis was not possible because of the small n u m b e r of our patients (four) in w h o m alkaline phosphatase m i g h t have been useful. W i t h o u t a m u l t i c e n t e r trial, achievi n g s t a t i s t i c a l s i g n i f i c a n c e at t h e p r e s e n t r a t e of p a t i e n t e n r o l l m e n t w o u l d r eq u i r e a n o t h e r te n years of s t u d y (assuming an 80% s e n s i t i v i t y of DPL for h o l l o w viscus injuries). These data derhonstrate that alkaline phosphatase offers no advantage over the m o r e traditional criterion of a positive DPL for detecting the prese n c e of i n t r a - a b d o m i n a l i n j u r y . A lower RBC count to d e t e r m i n e holl o w viscus injuries is also n o t supported. At the present time, we suggest t h a t t h e criteria listed (Figure) c o n t i n u e to be used as p o s i t i v e par a m e t e r s for DPL after a b d o m i n a l trauma. I n t e r p r e t a t i o n of th e s e data
19:5 May 1990
m u s t be made on a clinical basis.
to identify hollow viscus injuries.
CONCLUSION D PL has b e e n a r e l i a b l e t o o l to evaluate patients for intra-abdominal t r a u m a d e s p i t e its r e l a t i v e l a c k of sensitivity for h o l l o w viscus injuries. A l k a l i n e p h o s p h a t a s e has b e e n reported in animals to be an early indic a t o r of i n t e s t i n a l i n j u r y to be included in the peritoneal lavage to increase its sensitivity. We m e a s u r e d a l k a l i n e p h o s p h a t a s e in p a t i e n t s in e v e r y p e r i t o n e a l lavage for t r a u m a sent to the laboratory during the oneyear study period. In no instance was alkaline phosphatase helpful in identifying an i n t e s t i n a l i n j u r y even t h o u g h t w o p e r i t o n e a l lavages were performed w i t h i n 30 m i n u t e s of injury. All intestinal injuries were diagnosed by traditional lavage criteria or by a grossly positive lavage. A l k a l i n e phosphatase offers no advantage over m o r e traditional determ i n a n t s of intra-abdominal injury in DPL, and this study does not support the use of lavage alkaline phosphatase
REFERENCES
Annals of Emergency Medicine
I. Marx JA, Moore EE, Bar-Or D: Peritoneal lavage in penetrating injuries of the small bowel and colon: Value of enzyme determinations. Ann Emerg Med 1983;12:68-70. 2. Fischer RP, BeverlinBC, Engrav LH, et al: Diagnostic peritoneal lavage: Fourteen years and 2,586 patients later. Am J Surg 1978;136: ~ 701-704. 3. Feliciano DV, Bitondo CG, Steel G, et al: Five-hundred open taps or lavages in patients with abdominal stab wounds. Arn J Surg 1984;148:772-777. 4. Jackson GL, Thal ER: Management of stab wounds to the back and flank. J Trauma 1979; 19:660-664. 5. Root HD, Harris CW, McKinley CR, et al: Diagnostic peritoneal lavage. Surgery 1965;57: 633-637. 6. Oreskovich MR, Carrico CJ: Stab wounds of the anterior abdomen: Analysis of a management plan using local wound exploration and quantitative peritoneal lavage. Ann Surg 1983; 198:411-419. 7. Thai ER: Peritoneal lavage: Reliability of RBC count in patients with stab wounds to the chest. Arch Surg 1984;I19:579-584.
505/31
The Value of Alkaline Phosphatase in Peritoneal Lavage The accuracy of peritoneal lavage for diagnosis of intra-abdominal injury in trauma is limited by its relative lack of sensitivity for hollow viscus injury. Peritoneal lavage in the dog indicates that alkaline phosphatase is an early mqrker,of intestinal injury If these results were confirmed in human patients, alkaline phosphatase determination would improve lavage sensitivity for hollow viscus injuries. A study was conducted to determine the usefulness of alkaline phosphatase in lavage in human beings. Alkaline phosphatase was measured in all trauma lavage samples sent for laboratory assay during a one-year period. Two hundred ninety-two lavages were performed: 25 were positive by laboratory criteria, and 66 were grossly positive. There were 13 intestinal injuries - nine were grossly positive, and four were diagnosed by laboratory results. Three of these four patients with intestinal injuries had elevated lavage alkaline phosphatase. All three (lavaged from 30 minutes to two hours after injury) also had elevated white blood cells or bile in the lavage fluid. The remaining intestinal injury was diagnosed by lavage bile but had no elevation of alkaline phosphatase (lavaged 15 minutes after injury). Two patients with elevated alkaline phosphatase in otherwise negative law~ges were observed for at least five days; neither demonstrated any evidence of intra-abdominal injury. We conclude that alkaline phosphatase is no better than traditional determinants of intestinal injury in peritoneal lavage. In no patient was alkaline phosphatase helpful in diagnosing a hollow viscus injury, and its use would have prompted two unnecessary laparotomies. These data do not support the use of lavage alkaline phosphatase to identify hollow viscus injuries. [Megison SM, Weigelt JA: The value of alkaline phosphatase in peritoneal lavage. Ann Emerg Med May 1990; 19:503-505.]
Stephen M Megison, MD John A Weigelt, MD, FACS Dallas, Texas From the Department of Surgery, Trauma and Critical Care Section, The University of Texas Southwestern Medical Center, Dallas. Received for publication July 19, 1989. Revision received October 30, 1989. Accepted for publication January 8, 1990. Presented at the Society for Academic Emergency Medicine Annual Meeting in San Diego, May 1989. Address for reprints: John A Weigelt, MD, Department of Surgery, Trauma and Critical Care Division, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, Texas 75235-9031.
INTRODUCTION Diagnostic peritoneal lavage (DPL) is often used to diagnose intra-abdominal injury after trauma. The accuracy of lavage is limited by its relative lack of sensitivity for hollow viscus injuries. To improve the diagnostic efficiency of peritoneal lavage for hollow viscus injuries, Marx et al studied alkaline phosphatase in lavage fluid in dogs with intestinal injuries. 1 Lavage fluid alkaline phosphatase was elevated significantly earlier than white or red blood cell counts after intestinal injury. It is possible that testing lavage fluid for alkaline phosphatase will identify intestinal injuries earlier and improve the accuracy of DPL for these injuries. We have studied alkaline phosphatase in DPL in human beings to test this hypothesis. METHODS All patients presenting to Parldand Memorial Hospital from October 1, 1987, through October 25, 1988, who required DPL for trauma were entered into the study, which was approved by the Southwestern Medical School Institutional Review Board for Human Experimentation. Peritoneal lavage was performed in patients with abdominal stab wounds when local exploration failed to demonstrate that the wound was superficial. Patients with gunshot wounds to the abdomen were not lavaged. Patients with blunt abdominal trauma were lavaged if they complained of abdominal tenderness or impaired mental status prevented adequate assessment of
19:5 May 1990
Annals of Emergency Medicine
503/29
ALKALINE PHOSPHATASE Megison & Weigelt
the abdomen by physical examination. Peritoneal lavage was performed on each patient using standard technique, and lavage effluents were assayed for red blood cells, white blood cells, amylase, bile, and alkaline phosphatase. Alkaline phosphatase was determined by a colorimetric assay of cleavage of paranitrophenolphosphate. Grossly positive peritoneal lavages (those that returned free-flowing blood) were not assayed. Peritoneal lavage was considered positive for both blunt or penetrating trauma by laboratory criteria if RBCs were more than 100,000/mm 3, WBCs were more than 500/mm 3, if amylase was elevated, or if bile was present in the sample. Patients with positive peritoneal lavage underwent exploratory laparotomy, and the operative findings were recorded. Elevation of alkaline phosphatase was not considered an indication for exploration if the remainder of the lavage was considered negative. Patients with negative peritoneal lavages were admitted and observed for 24 hours before discharge.
RESULTS Two hundred ninety-two patients underwent peritoneal lavages. There were 250 men (86%) and 42 women (14%) in the study. The mechanism of injury was blunt in 68% of patients and penetrating in 32%. Patient ages ranged from 5 to 71 years old, with 69% of patients between 20 and 39 years old. There were 201 negative (69%) and 91 positive lavages (31%). Sixty-six of the 91 positive lavages were grossly positive (73%), whereas 25 (27%) were positive by laboratory criteria. Thirteen intestinal injuries were discovered at exploration in the 91 patients with positive lavages; nine were associated with grossly positive lavages, and four were diagnosed by laboratory assay. Only two of the nine patients with intestinal injuries and grossly p o s i t i v e lavages had other injuries to explain the lavage results. These injuries included a liver laceration (one patient) and an omental laceration (one patient). Of the four intestinal injuries identified by laboratory criteria, three were found to have elevated alkaline phosphatase. These three patients also had elevated bile or WBCs in the lavage effluent. One patient was la30/504
FIGURE. Interpretive criteria for
DPL. vaged 30 minutes after injury, and the o t h e r two were lavaged two hours after injury. The remaining intestinal injury was identified by bile in the lavage fluid but had no elevation of alkaline phosphatase. This patient was lavaged within 15 minutes of injury. Alkaline phosphatase was elevated in two patients who had otherwise negative lavage results. Each of these patients was admitted for other injuries and observed for at least five days; neither demonstrated any evidence of intra-abdominal injury. DISCUSSION DPL is extremely accurate in determining the presence of intra-abdomihal injuries after stab wounds and blunt trauma to the abdomen.2, 3 A set of interpretive criteria for DPL is listed (Figure). Despite the high accuracy, injuries to the diaphragm and bowel can be missed by DPL. 4 The WBC count is used to detect small bowel injuries but may not turn positive until three hours after injury, s This is not very helpful in evaluating patients seen shortly after abdominal trauma. A lower RBC count is suggested as a method to identify patients with hollow viscus injuries. 6 0 r e s k o v i c h and associates found in a study of patients with abdominal stab wounds that 92% of patients with lavage RBC counts of more than 50,000/ m m 3 had an intraperitoneal injury, w h e r e a s no p a t i e n t s w i t h RBC counts of less than 1,000/mm 3 had an organ injury. In patients with RBC counts between 1,000 and 50,000/ m m 3, 43% had an organ injury and 59% had a hollow viscus injury. These authors concluded that exploratory l a p a r o t o m y s h o u l d be performed for RBC counts of more than 1,000/mm 3 in patients with abdominal stab wounds. Thal reviewed 213 patients with abdominal stab wounds managed with RBC counts of 100,000/mm 3 as positive. 7 Three of nine patients with false-negative lavages had hollow viscus injuries, but lowering the positive lavage c o u n t to 1 , 0 0 0 / m m 3 would have increased the negative exploration rate to 36%. It is evident that neither the WBC nor the RBC Annals of Emergency Medicine
Positive Aspiration of > 10 mL of blood Lavage fluid exits chest tube RBC > lO0,O00/mm 3 WBC > 500/mm 3 Amylase > laboratory normal for serum Bile in lavage fluid Negative RBC < 50,O00/mm 3 WBC < lO0/mm 3 Amylase normal range for serum No bile Indeterminant Catheter fills with blood RBC > 50,000 but < lO0,O00/mm 3 WBC > 100 but < 500/ram 3
c o u n t can reliably d e t e c t h o l l o w viscus injuries early without an unacceptable negative laparotomy rate. Alkaline phosphatase is present in small bowel secretions and may allow earlier diagnosis of bowel injuries by DPL. Marx and associates studied the usefulness of alkaline phosphatase in lavage fluid for assessing the presence of hollow viscus injury. 1 Twenty-nine mongrel dogs were subjected to partial transection of the small intestine or colon. Control animals had exploratory laparotomy only. Peritoneal lavage then was performed. At one hour after injury, the lavage RBC count, WBC count, and amylase levels were all within normal limits in all animals. The alkaline phosphatase levels in the lavage fluid were markedly elevated in the animals with small intestine or colon injuries but not in the control animals. These data suggest that lavage alkaline phosphatase levels may be helpful in early identification of patients with hollow viscus injuries. Unfortunately, our evaluation of lavage alkaline phosphatase in patients did not produce similar results. In no patient with an intestinal injury was the lavage alkaline phosphatase helpful in identifying an intestinal injury. All intestinal injuries were diagnosed by traditional lavage criteria despite two of the patients being lavaged within 30 minutes of 19:5 May 1990
injury. In addition, if an isolated elev a t i o n of a l k a l i n e p h o s p h a t a s e had been considered an indication for abdominal exploration, two unnecessary l a p a r o t o m i e s w o u l d h a v e been performed. Statistical analysis was not possible because of the small n u m b e r of our patients (four) in w h o m alkaline phosphatase m i g h t have been useful. W i t h o u t a m u l t i c e n t e r trial, achievi n g s t a t i s t i c a l s i g n i f i c a n c e at t h e p r e s e n t r a t e of p a t i e n t e n r o l l m e n t w o u l d r eq u i r e a n o t h e r te n years of s t u d y (assuming an 80% s e n s i t i v i t y of DPL for h o l l o w viscus injuries). These data derhonstrate that alkaline phosphatase offers no advantage over the m o r e traditional criterion of a positive DPL for detecting the prese n c e of i n t r a - a b d o m i n a l i n j u r y . A lower RBC count to d e t e r m i n e holl o w viscus injuries is also n o t supported. At the present time, we suggest t h a t t h e criteria listed (Figure) c o n t i n u e to be used as p o s i t i v e par a m e t e r s for DPL after a b d o m i n a l trauma. I n t e r p r e t a t i o n of th e s e data
19:5 May 1990
m u s t be made on a clinical basis.
to identify hollow viscus injuries.
CONCLUSION D PL has b e e n a r e l i a b l e t o o l to evaluate patients for intra-abdominal t r a u m a d e s p i t e its r e l a t i v e l a c k of sensitivity for h o l l o w viscus injuries. A l k a l i n e p h o s p h a t a s e has b e e n reported in animals to be an early indic a t o r of i n t e s t i n a l i n j u r y to be included in the peritoneal lavage to increase its sensitivity. We m e a s u r e d a l k a l i n e p h o s p h a t a s e in p a t i e n t s in e v e r y p e r i t o n e a l lavage for t r a u m a sent to the laboratory during the oneyear study period. In no instance was alkaline phosphatase helpful in identifying an i n t e s t i n a l i n j u r y even t h o u g h t w o p e r i t o n e a l lavages were performed w i t h i n 30 m i n u t e s of injury. All intestinal injuries were diagnosed by traditional lavage criteria or by a grossly positive lavage. A l k a l i n e phosphatase offers no advantage over m o r e traditional determ i n a n t s of intra-abdominal injury in DPL, and this study does not support the use of lavage alkaline phosphatase
REFERENCES
Annals of Emergency Medicine
I. Marx JA, Moore EE, Bar-Or D: Peritoneal lavage in penetrating injuries of the small bowel and colon: Value of enzyme determinations. Ann Emerg Med 1983;12:68-70. 2. Fischer RP, BeverlinBC, Engrav LH, et al: Diagnostic peritoneal lavage: Fourteen years and 2,586 patients later. Am J Surg 1978;136: ~ 701-704. 3. Feliciano DV, Bitondo CG, Steel G, et al: Five-hundred open taps or lavages in patients with abdominal stab wounds. Arn J Surg 1984;148:772-777. 4. Jackson GL, Thal ER: Management of stab wounds to the back and flank. J Trauma 1979; 19:660-664. 5. Root HD, Harris CW, McKinley CR, et al: Diagnostic peritoneal lavage. Surgery 1965;57: 633-637. 6. Oreskovich MR, Carrico CJ: Stab wounds of the anterior abdomen: Analysis of a management plan using local wound exploration and quantitative peritoneal lavage. Ann Surg 1983; 198:411-419. 7. Thai ER: Peritoneal lavage: Reliability of RBC count in patients with stab wounds to the chest. Arch Surg 1984;I19:579-584.
505/31
