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Home > Articles > Penetrating Abdominal Trauma: Guidelines for Evaluation

Abdominal Trauma
Evaluation of Penetrating Abdominal Trauma

Penetrating abdominal injury

The abdomen extends from the nipples to the groin crease anteriorly, and the tips of the scapulae to the gluteal skin crease inferiorly. Any penetrating injury to this area, or that may have traversed this volume, should be considered as a potential abdominal injury, and evaluated as such.

The incidence of penetrating injury will vary from hospital to hospital and region to region. Some institutions will have a very low incidence of penetrating trauma, and yet it is vital that penetrating injury is treated differently to blunt trauma. The mechanisms and physical characteristics of injury are different, as are the relevance and accuracy of investigations and the methods and timing of repair.

Priorities

Patients with significant penetrating abdominal injury tend to fall into 3 major categories:

Presentation

Injury Type

Management
priority

PulselessMajor vascular injuryEmergency
laparotomy
Consider ED
thoracotomy
Haemodynamically
unstable
Vascular and/or solid
organ injury

AND/OR

Haemorrhage from
other sites
Identify & control
haemorrhage
Haemodynamically
Normal
Hollow viscus injury
Pancreas or renal
Identify presence of
gastrointestinal,
diaphragmatic or
retroperitoneal
injury



The appropriate investigations and management pathway vary with each of these clinical presentations.

Pulseless

Patients who arrive without palpable pulses but with witnessed recent or current signs of life (eg. pulseless electrical activity) need immediate laparotomy in the operating room. The ability to transfer such a patient from the ambulance bay directly to the operating room and start the laparotomy within 5 minutes of arrival is vital if this is to have any chance of success.

A second option is to perform a thoracotomy in the emergency department and cross-clamp the aorta. This is a poor second choice option as it does not arrest haemorrhage, delays laparotomy, and opens a second body cavity which will contribute to further heat and blood loss. This manoeuver has a very low functional survivor yield, and yet remains the only hope for salvage in this group of patients where immediate access to an operating room is not available.

ABDO TRAUMA
PENETRATING INJURY


Stab abdomen &
evisceration

PENETRATING
ABDO INJURY

PRIMARY SURVEY
AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXPOSURE

ADJUNCTS
CXR
DPL
FAST
NG CATHETER
URINARY CATHETER

SECONDARY



clamshell thoracotomy &
laparotomy



Haemodynamically Unstable

Patients with penetrating trauma who are haemodynamically unstable require immediate operation. 'Haemodynamically unstable' includes non-responders and transient-responders to initial small-volume fluid bolus administration. Patients should be taken immediately to the operating room, without further unnecessary investigations or interventions.

The only decision to be made in these patients is where is the bleeding and this which cavity to expose first. Where there is a stab or gunshot wound obviously involving the abdomen, the decision is simple, and the patient has a laparotomy.

If there is a question about the abdomen being the source of the bleeding, Diagnostic Peritoneal Lavage (DPL) or FAST scan is used to determine the presence of free intra-peritoneal fluid. For the DPL, a positive aspiration of frank blood, or lavage fluid with a high red cell count (>100,000/ml) is required to confirm the presence of major intraperitoneal haemorrhage.

The decision to perform a laparotomy may be complicated if:

  • There are multiple stab wounds/gunshot wounds to multiple cavities.
  • The wounds are at, or cross, junctional zones (eg. costal margin, groin or buttock wounds).
  • There is evidence or the possibility of cardiac tamponade


The diagnosis of massive haemothorax may be made clinically, with a FAST scan, chest tube or Chest X-ray, depending on the degree of shock present and the rapidity with which such tests can be performed. Cardiac tamponade may be diagnosed with FAST or in the operating room with a pericardial window.

It is more important to take the patient to the operating room and commence surgery than to make a definitive diagnosis. If a thoracic injury is suspected during a laparotomy a hemithorax can be explored through the diaphragm or a formal thoracotomy, and a tamponade explored through a pericardial window and sternotomy.

There should be no delay in trying to resuscitate the patient prior to surgery.


Haemodynamically Normal

Patients with clinical signs of peritonitis, or with evisceration of bowel should be taken immediately to the operating room.

Currently there are several possible options for the evaluation of penetrating abdominal trauma in the haemodynamically normal trauma patient without signs of peritonitis. Many of these patients will have some superficial tenderness around the wound site, but no signs of peritoneal inflammation.

The goal of any algorithm for penetrating abdominal trauma should be to identify injuries requiring surgical repair, and avoid unnecessary laparotomy with its associated morbidity.

Adjuncts the the initial evaluation of the trauma patient can provide clues to significant intra-peritoneal injury:

  • Chest X-ray
    An erect chest radiograph may identify sub-diaphragmatic air. This must be interpreted with some caution in the absence of peritonitis, as air may be entrained into the peritoneal cavity with a stab or gunshot wound. However it certainly signals peritoneal penetration and warrants further investigation.
  • Nasogastric Tube
    Blood drained from the stomach will identify gastric injury.
  • Urinary catheter
    Macroscopic haematuria indicates a renal or bladder injury. Microscopic injury suggests but is not pathognomonic of ureteric injury.
  • Rectal examination
    Rectal blood indicates a rectal or signmoid penetration. Protoscopy & sigmoidoscopy should be performed (see below)


Options for evaluation

Further evaluation requires the use of one or more of the following diagnostic modalities:

  • Serial Physical Examination (PE)
  • Local Wound Exploration (LWE)
  • Diagnostic Peritoneal Lavage (DPL)
  • Ultrasound (FAST)
  • CT Scan
  • Laparoscopy
  • Laparotomy


These different methods, each discussed below, are by no means equal. The decision on which method, or combination of methods, to choose will depend primarily on hospital factors such as trauma patient load, access to in-patient beds, availability of in-house surgical teams, access to multislice CT scanners etc. Whichever decision tree is chosen should be accepted at a hospital-wide level. The practice should not change from surgeon to surgeon and day to day. The algorithm should be routinely audited for missed injuries, effectiveness and use of resources.

 

PE

LWEDPLFASTCT
Scan
LaparoscopyLaparotomy
Sensitivity (%)
(for therapeutic
intervention)
95-
97
7187-
100
46-
85
9750-100-
Specificity (%) 100 77 52-
89
48-
95
98 74-90-

NPV (%)

92 79 78-
100
60-
98
98 100 -
        
Requires awake,
cooperative
patient
+ --- - --
Invasive - ++- - +++
Requires
admission
+ +/--- - ++
Evaluates
retroperitoneum
+/- --- + -+
High clinical
workload
+ --- -+/-+/-
Complication
rate
-++/-- - +++
        

PE: Physical Exam; LWE: Local Wound Exploration; DPL: Diagnostic Peritoneal Lavage

Serial Physicial Examination

Serial physical examination has the best sensitivity and negative predictive value of all modalities for the evaluation of penetrating abdominal trauma.

The patient is admitted for observation for 24 hours. During this time the patient is has frequent (hourly), regluar checks of their haemodynamic status. The abdomen is examined routinely for signs of developing peritonitis. Ideally the same surgeon should examine the patient each time. If this is not possible, during a handover period both surgeons should examine the patient at the same time so they agree on the current status of the abdomen and whether there has been any progression in symptoms. The timing of examinations varies inthe literature, but should probably start out more frequently and then decrease over time. A suggested sequence of examination might be at 1, 4, 12 and 24 hours after the initial assessment. Some authors recommend examination every four hours.

If the patient develops signs of haemodynamic instability or peritonitis during this period of observation, a laparotomy is performed. If the patient is well the following day they start a normal diet, and are discharged once diet is tolerated and they have completed the observation period.

Patients who do not develop frank peritonitis, but who have persistent local symptoms of pain and tenderness, with perhaps a fever or tachycardia at 24 hours should be evaluated by another modality: CT Scan, laparoscopy or laparotomy.

The disadvantages of serial physicial exam are primarily the requirement to admit all patients with a penetrating injury, and the requirement for frequent haemodynamic and physical examinations. This usually requires the patient to be in a high dependency type setting, and requires a body of in-house surgeons to perform the serial evaluations.

Local Wound Exploration

Local wound exploration (LWE) requires a formal evaluation of a stab wound under local anaesthesia. This procedure is usually performed in the operating room, but is performed in the emergency department by some institutions. The wound is extended under local anaesthesia and the track followed through tissue layers.

Penetration of the anterior fascia is considered a positive LWE, as penetration of the peritoneum is difficult to identify. A positive LWE leads to either laparotomy or another diagnostic test such as DPL or laparoscopy.

When LWE is used alone to determine laparotomy, there will be a high non-therapeutic laparotomy rate. Even if the peritoneam is penetrated were used as a cut-off, many of these patients will have no intra-peritoneal injury, or an injury that does not require surgical intervention - most commonly omental laceration, mesenteric laceration or liver tears that have stopped bleeding.

Diagnostic Peritoneal Lavage

Diagnostic Peritoneal Lavage (DPL) involves passing a small catheter into the peritoneal cavity, usually at the umbilicus or just inferior to this. If blood can be aspirated through this catheter, this is referred to as a positive 'tap' or aspiration (DPA). If no blood can be aspirated a litre of warm crystalloid solution is run into the peritoneal cavity and then allowed to drain out. This lavage fluid is then sent to the laboratory for analysis of red cell count, white cell count and any bowel contents (faecal or food matter).

It is important to realise that the role of DPL in the haemodynamically stable patient is diffierent from that in the unstable patient. In the unstable patient the problem is one of major haemorrhage, and identifying the site of haemorrhage. DPL is used as an alternative to the FAST scan to identify intra-peritoneal haemorrhage (more often in blunt trauma). In the unstable patient one is searching for a lot of blood, so a positive DPL in this setting requires either a positive aspiration (DPA) or a high red-cell count (>100,000/ml).

The situation in penetrating abdominal trauma is very different. A haemodynamically unstable patient with an abdominal stab wound needs no further investigations and will proceed to laparotomy, as discussed above. So the role of DPL in the haemodynmically normal patient with penetrating abdominal injury is to identify hollow viscus injury (stomach, small bowel, colon) or diaphragmatic injury.

If faecal or food matter is seen on microscopy this is diagnostic. However this is rarely the case - and a decision to proceed to laparotomy is usually based on the red cell count. By necessity this must be lower than that looking for gross haemorrhage, so the threshold for the red cell count is set somewhere between 5000/ml and 20,000/ml. The lower the threshold, the more sensitive the test, but the higher the non-therapeutic laparotomy rate. Contamination from the insertion site of the DPL can lead to false positive results. Some units also use a white cell count >500/ml as a positive result - this value is probably too low and 3000/ml isprobably a better threshold for gastrointestinal tract injury.

The primary disadvantages of DPL are that it is invasive, does not evaluate the retroperitoneum, and has a signficiant false positive rate.

FAST

The role of FAST in penetrating trauma has not been fully evaluated. While FAST is sensitive for pericardial fluid, it appears to have a high false negative rate for intra-abdominal injury. This may improve if serial FAST scans are performed. Ultrasound as yet cannot detect the small amounts of fluid which may be associated with a hollow viscus injury.

  • A positive FAST indicates peritoneal penetration, but is poor at discriminating for injuries requiring intervention
  • A negative FAST does not exclude significant abdominal injury.

It is therefore impossible to recommend FAST as the only investigation for the assessment of penetrating intra-abdominal injury. It MAY have a role in combination with other investigations.

CT Scan

As the technology has improved, CT scanning is finding more and more of a role in the evaluation of penetrating abdominal injury. Most studies recommend a multidectector (multislice) scanner with triple-contrast protocol (intravenous, oral and rectal), although it is not clear how important the GI contrast is for the detection of bowel injury. Of all the diagnostic modalities listed, CT gives the best assessment of retroperitoneal structures.

The CT features of penetrating bowel injury are:

  • Signs of peritoneal violation
  • Free intra-peritoneal air
  • Free intra-peritoneal fluid
  • Wound track extending through peritoneum
  • Signs of bowel injury
  • Wound track extending to bowel wall
  • Bowel wall defect
  • Bowel wall thickening
  • Intra-luminal contrast leak
  • (not free intra-peritoneal air - may have been entrained through peritoneal wall)
  • Other signs of intra-peritoneal injury
  • Intravenous contrast extravasation
  • Diaphragmatic tear (especially on re-formats)

The use of CT for penetrating intra-abdominal injury remains in its infancy, and not all CT scanners have the resolution or software capabilities necessary to achieve the sensitivity and specificity rates quoted in the literature. Interpretation of the scans is also difficult and requires multiple passes on different 'window' settings by a trained and experienced trauma radiologist.

Laparoscopy

Laparoscopy is also a technology somewhat in its infancy, and remains very user dependent. A full trauma laparoscopy for the evaluation of penetrating injury requires general anaesthesia and complete examination of intra-peritoneal contents, including visualisation of the whole small bowel and intra-peritoneal colon. In most studies laparoscopy has a significant false negative, primarily from missed bowel injuries. Laparoscopy is also limited in the evaluation of retroperitoneal injury.

Laparoscopy is the diagnostic method of choice for the diagnosis of suspected diaphragmatic injury. Many diaphragmatic lacerations can alse be repaired via the laparoscope.

Laparoscopy may also have a role in patients who have localised tenderness or develop a white cell count or fever without generalised peritonitis after a period of clinical observation. Laparoscopy may be useful to confirm that a wound is tangential and does not enter the peritoneal cavity - although many of the methods above have advantages over laparoscopy for this indication.

Laparotomy

Exploratory laparotomy for all penetrating abdominal wounds still has a role in resource-limited environments, or occasionally in cases of multi-cavitary injuries. For most situations however the non-therapeutic laparotomy rate will be unacceptable high. With the incidence of complications with a negative laparotomy at of 12%-41%, with hospital stays of 4-8 days, , it is difficult to support such a strategy where adjunctive methods such as CT or DPL are available and serial physicial examination has such a low missed injury rate.

Recommended approaches

Which diagnostic tree a hospital chooses for the evaluation of penetrating injury will be dependent on numerous factors, including trauma patient load, surgical team availability and coverage, the availability of multidetector CT scanners and trauma radiologists, and access to the operating room and critical care beds.

Many different systems are used around the world. The following recommendations are in order of preference and are by no means the only possibilities. Each choice is associated with the caveats listed above.

  1. Serial physical examination

  2. Multidetector CT

  3. Local Wound Exploration AND either:

  • Diagnostic Peritoneal Lavage OR
  • Laparoscopy

Special Situations

Wounds to thoracoabdominal junction zone

Thoracoabdominal injuries need to be evluated for diaphragmatic injury. Where there is evidence of thoracic and abdominal injury there must, by definition, be an injury to the diaphragm. For example, if there is a right pneumothorax and a liver laceration, the diaphragm must also be torn.


R haemothorax from
R lower chest stab




+ liver injury = diaphragm injury



If the evidence for this is less clear, but diaphragm injury is still suspected, the options are ultrasound, MRI, CT or laparoscopy/thoracoscopy. All radiological studies may miss small diaphragmatic tears, and so laparoscopy / thoracoscopy remains the investigation of choice. Laparoscopy is preferred for left sided injuries, thoracoscopy or laparoscopy for right sided injuries. Diaphragmatic lacerations may also be repaired through a laparoscopic or laparoscope-assisted approach.

Flank or back wound

Flank or back wounds may be associated with injuries to retroperitoneal organs such as the colon, kidney and lumbar vessels - or more rarely the pancreas, aorta and inferior vena cava. Of these, the colon is the injury most often missed. Where colon injury is a possibility, the duration of serial physical examination is extended to 72 ours, watching for fever or a rise in the white cell count. An alternative is to perform a triple-contrast CT scan. Where the wound track extends up to the colon, or there is evidence of abnormal bowel wall thickening, laparotomy is indicated.

Wound to buttock or perineum

The most dangerous missed injury here is the occult rectal injury. Any penetrating injury to the gluteal region carries the risk of rectal injury. Digital rectal examination is inadequate and full proctoscopy and sigmoidoscopy should be performed, looking for the presence of blood and/or a mucosal tear.

References

Physical Examination

Velmahos GC, Demetriades D, Toutouzas KG et al. 'Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care?' Ann Surg. 2001;234:395-402

Demetriades D, Velmahos G, Cornwell E. 'Selective nonoperative management of gunshot wounds of the anterior abdomen.' Arch Surg. 1997;132:178-83

Leppaniemi AK, Haapiainen RK. 'Selective nonoperative management of abdominal stab wounds: prospective, randomized study.' World J Surg. 1996;20:1101-5

Shorr RM, Gottlieb MM, Webb K, Ishiguro L, Berne TV 'Selective management of abdominal stab wounds. Importance of the physical examination.' Arch Surg. 1988;123:1141-5

Demetriades D, Rabinowitz B. Indications for operation in abdominal stab wounds. 'A prospective study of 651 patients.' Ann Surg 1987;203 129-132

Demetriades D, Rabinowitz B. 'Selective conservative management of penetrating abdominal wounds: a prospective study.' Br J Surg. 1984;71:92-4

Nance FC, Martin HW, Johnson LW, et al. Surgical judgment in the management of penetrating wounds of the abdomen: Experience with 2,212 patients. Ann Surg 1974; 179: 639-646

Local Wound Exploration

Goldberger JH, Bernstein DM, Rodman GH Jr, Suarez CA. 'Selection of patients with abdominal stab wounds for laparotomy.' J Trauma. 1982 Jun;22(6):476-80.

Thompson JS, Moore EE, Van Duzer-Moore S, Moore JB, Galloway AC 'The evolution of abdominal stab wound management.' J Trauma. 1980;20:478-84

Diagnostic Peritoneal Lavage

Sriussadaporn S, Pak-art R, Pattaratiwanon M et al. 'Clinical uses of diagnostic peritoneal lavage in stab wounds of the anterior abdomen: a prospective study.' Eur J Surg. 2002;168:490-3

Nagy KK, Roberts RR, Joseph KT et al. 'Experience with over 2500 diagnostic peritoneal lavages.' Injury. 2000;31:479-82

Feliciano DV, Bitondo-Dyer CG. 'Vagaries of the lavage white blood cell count in evaluating abdominal stab wounds.' Am J Surg. 1994;168:680-3

Henneman PL, Marx JA, Moore EE, Cantrill SV, Ammons LA, 'Diagnostic peritoneal lavage: accuracy in predicting necessary laparotomy following blunt and penetrating trauma'. J Trauma 1990;30:1345-1355

FAST Ultrasound

Kirkpatrick AW, Sirois M, Ball CG et al. 'The hand-held ultrasound examination for penetrating abdominal trauma'. Am J Surg. 2004;187:660-5

Bokhari F, Nagy K, Roberts R et al. 'The ultrasound screen for penetrating truncal trauma.' Am Surg. 2004;70:316-21

Soffer D, McKenney MG, Cohn S. 'A prospective evaluation of ultrasonography for the diagnosis of penetrating torso injury.' J Trauma. 2004;56:953-7

Udobi KF, Rodriguez A, Chiu WC et al. 'Role of Ultrasonography in Penetrating Abdominal Trauma: A Prospective Clinical Study'. J Trauma 2001;50:475-479

Boulanger B, Kearney PA, Tsuei B,Ochoa JB, 'The Routine Use of Sonography in Penetrating Torso Injury Is Beneficial.' J Trauma 2001;51:320-325

Rozycki GS, Feliciano DV, Ochsner MG, et al. The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study. J Trauma. 1999;46:543–552

CT Scan

Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJ, Scalea TM. Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury--a prospective study in 200 patients. Radiology. 2004;231:775-84

K. Shanmuganathan, S.E. Mirvis, W.C. Chiu et al., 'Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy'. Am J Roentgenol 2001;177:1247–1256.

Ginzburg E, Carrillo EH, Kopelman T, et al. The role of computed tomography in selective management of gunshot wounds to the abdomen and flank. J Trauma 1998;45:1005-9.

Maldjian PD, Zurlo JV, Sebastiano L. Role of abdominal computed tomography in the evaluation and management of stab wounds to the back and flank. Emerg Radiol 1997;4:340-5.

Kirton OC, Wint D, Thrasher B, et al. 'Stab wounds to the back and flank in the hemodynamically stable patient: a decision algorithm based on contrast-enhanced computed tomography with colonic opacification'. Am J Surg. 1997;73:189–193

Laparoscopy

Leppaniemi A, Haapiainen R. 'Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study.' J Trauma. 2003;55:636-45

DeMaria EJ, Dalton JM, Gore DC, Kellum JM, Sugerman HJ. 'Complementary roles of laparoscopic abdominal exploration and diagnostic peritoneal lavage for evaluating abdominal stab wounds: a prospective study.' J Laparoendosc Adv Surg Tech A. 2000;10:131-6

Elliott DC, Rodriguez A, Moncure M et al. 'The accuracy of diagnostic laparoscopy in trauma patients: a prospective, controlled study.' Int Surg. 1998;83:294-8

Porter JM, Ivatury RR. 'The Role of Laparoscopy in the Management of Penetrating Trauma.' Semin Laparosc Surg. 1996;3:156-167

Sosa JL, Baker M, Puente I. 'Negative Laparotomy in Abdominal Gunshot Wounds: Potential Impact of Laparoscopy.' J Trauma. 1995; 38: 194-197

Laparotomy

Haan J, Kole K, Brunetti A, Kramer M, Scalea TM. 'Nontherapeutic laparotomies revisited.' Am Surg. 2003 Jul;69:562-5

Renz BM, Feliciano D. 'The length of hospital stay after an unnecessary laparotomy for trauma: A prospective study'. J Trauma 1996;40:187

Renz BM, Feliciano DV: Unnecessary laparotomy for trauma: A prospective study of morbidity. J Trauma 1995;38:350

Ross SE, Dragon GM, O’Malley KF, Rehm CG. Morbidity of negative coeliotomy in trauma. Injury. 1995;26:393–394

Lappaniemi A, Salo J, Haapiainen R. Complications of negative laparotomy for truncal stab wounds. J Trauma. 1995;38:54–58.

Weigelt JA, Kingman RG: Complications of negative laparotomy for trauma. Am J Surg 1988;156:544

Thoracoabdominal Injury

Leppaniemi A, Haapiainen R. 'Occult diaphragmatic injuries caused by stab wounds.' J Trauma. 2003 Oct;55:646-50

Murray JA; Demetriades D; Cornwell EE 3rd; Asensio JA et al. 'Penetrating left thoracoabdominal trauma: the incidence and clinical presentation of diaphragm injuries.' J Trauma 1997;43:624-6

Back & flank wounds

Maldjian PD, Zurlo JV, Sebastiano L. Role of abdominal computed tomography in the evaluation and management of stab wounds to the back and flank. Emerg Radiol 1997;4:340-5

.

Kirton OC, Wint D, Thrasher B, et al. 'Stab wounds to the back and flank in the hemodynamically stable patient: a decision algorithm based on contrast-enhanced computed tomography with colonic opacification'. Am J Surg. 1997;73:189–193

Burns RK; Sariol HS; Ross SE. 'Penetrating posterior abdominal trauma.' Injury 1994;25:429-31

Easter DW; Shackford SR; Mattrey RF. 'A prospective, randomized comparison of computed tomography with conventional diagnostic methods in the evaluation of penetrating injuries to the back and flank.' Arch Surg 1991;126:1115-9

Penetrating rectal injury

Fallon WF Jr, Reyna TM, Brunner RG, Crooms C, Alexander RH. 'Penetrating trauma to the buttock.' South Med J. 1988;81:1236-8

ABDOMINAL TRAUMA

PENETRATING INJURY

trauma.org 9:8, August 2004


gunshot flank


close range. unstable


liver injury


gunshot epigastrium
blood in NG tube



stomach injury


gunshot flank


necrotizing fasciitis
from gluteal stab &
missed rectal injury

Comments

vaibhav001, November 10, 2011

Are there any specific protocols/algorithmic charts From AIIMS for investigation & management stratergy for various trauma cases eg.mentioned below of as per recent advances??
e.g

1) Blunt Trauma to anterior abdomen
2) blunt trauma to flanks
3) Penetrating Injury anterior abdomen / flanks
4) cases with omental protrusion

for both stable & Unstable cases

What will be First investigation of choice / best investigation / best management for above cases..

what will be sequence of investigations adviced among X-Ray abdomen erect view, LWE , DPL , FAST, CECT , TRIPLE Contrast etc for above various cases ??

please help regarding this..
If there are any such protocols can u please mail me? my mail id : .(JavaScript must be enabled to view this email address)

Thanks..
Dr.Vaibhav A. Deshpande
Nashik,Maharashtra,India

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