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(CLINICAL PRACTICE ARTICLE)
BLUNT ABDOMINAL TRAUMA;
ROLE OF ULTRASONOGRAPHY VS FOUR QUADRANT
DR. GHULAM MURTAZA
MBBS, FCPS (Surgery)
Independent Medical College, Faisalabad.
DR. ABID RASHEED
MBBS, FCPS (Surgery)
Independent Medical College, Faisalabad.
DR. M. ABID BASHIR
MBBS, FCPS (Surgery)
Assistant Professor of Surgery
Independent Medical College, Faisalabad.
Prof. Dr. Riaz Hussain
FRCS, FCPS (Surgery)
Professor of Surgery PMC Faisalabad.
Copyright: 10th October, 2004.
ABSTRACT ... firstname.lastname@example.org Objective: (1) To define the role of ultrasonography and four quadrant
tap in deciding the treatment plan (conservative/operative) in blunt abdominal trauma . (2) To find out the specificity and
sensitivity of ultrasonography and four quadrant tap in blunt abdominal trauma. Design: Prospective study. Setting:
Allied Hospital Faisalabad. Period: From Jan 2001 to Jan 2002. Materials and methods: Fifty patients irrespective
of age, sex and mode of blunt injury included in the study. All the patients presented in emergency ward with blunt
abdominal trauma underwent ultrasonography & four quadrant tap. Results: In 30 out of 50(60%) patients, the
abdominal ultrasonography showed positive findings with the sensitivity of 90.62%, the specificity 94.44% and accuracy
92%. Four quadrant tap was positive in 29 patients out of 50(58%) with 87.09% sensitivity, 89.47% specificity and 88%
accuracy. Conclusion: Four quadrant tap is as effective as ultrasonography to pick up the intra-peritoneal fluid in the
assessment of blunt abdominal trauma patient but with slightly less sensitivity, specificity and accuracy.
Keywords: Blunt abdominal trauma, Four quadrant tap, Ultrasonography
Blunt abdominal trauma is one of the most common
causes of abdominal injuries and is usually associated
with multi-organ injury. Unrecognized abdominal trauma
is distressingly common cause of preventable death after
trauma . Majority of patients can be saved from morbidity
and mortality by appropriate resuscitation and timely
decision. Evaluating patients who have sustained blunt
abdominal trauma remain one of the most challenging
and resource intensive aspect of acute trauma care.
The basic tools for the initial evaluation of a blunt
abdominal trauma patient are history and clinical
examination. Unfortunately these are not always
conclusive. Associated injuries often cause tenderness
and spasm in the abdominal wall and make diagnosis
difficult. Lower rib fracture, pelvic fracture and abdominal
wall contusions may mimic the signs of peritonitis.
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Powell et al has reported 65% accuracy rate of clinical
evaluation alone in series of 955 patients with abdominal
In an unstable patient, the question of abdominal
involvement must be expediently addressed. This is
accomplished by identifying free intra abdominal fluid
using four quadrant tap, diagnostic peritoneal lavage
(DPL) and focused assessment with sonography for
trauma (FAST) examination. The objective is to rapidly
identify patients who need a laparotomy .
Computerized tomography is also invaluable in picking
up intra abdominal injuries but it is relatively expansive,
not readily available and requires haemodynamically
stable patients that can be transported to CT scan room .
Diagnostic peritoneal lavage is invasive and time
consuming. Further more it is difficult to perform in
obese, pregnant and patients with history of multiple
abdominal surgeries .
Ultrasonography is a rapid, economical, safe, non-
invasive, method of investigation in the initial assessment
of a patient with blunt abdominal trauma. It can also be
repeated when required even at bedside and need for
laparotomy in patients with a negative ultrasonography is
rare . It is increasingly being used with portable
apparatus by emergency room surgeons to provide a
speedy survey of the injured abdomen . The American
College of Surgeons has included the use of ultrasound
in the advanced trauma life support . Four quadrant tap
is also quick, simple method and it can be performed with
few complications .
1.To define the role of ultrasonography and Four
Quadrant tap in deciding the treatment plan
(conservative/operative) in blunt abdominal
2. To find out the specificity and sensitivity of
ultrasonography and four quadrant tap in blunt
PATIENTS AND METHODS
Fifty consecutive patients with blunt abdominal trauma
who presented to the Emergency Department Allied
hospital Faisalabad from 2001 to 2002 were included in
After resuscitation, all patients were evaluated by
history, clinical examination and with baseline
investigations. Ultrasonography and four quadrant tap
was also performed in all patients.
Technique of four quadrant tap.
After skin preparation with pyodine, an 18-gauge short
bevel spinal needle was attached to a 20cc syringe and
inserted through the abdominal wall after prior infiltration
of the site with a local anesthetic agent (2% xylocaine).
Suction was applied to the syringe as the needle was
slowly advanced into the abdomen at the sites just below
the costal cartilage lateral to rectus sheath on both sides
of upper abdomen and in both iliac fossae. Return of
non-clotted blood or intestinal contents was considered
Age range was 6-50 years with maximum patients
belonging to21-30 year group(Table I).
Table I Distribution of age
Age in yearsNo. of cases % age
0-10 02 04%
11-20 14 28%
21-30 22 44%
In 30 (60%) patients the abdominal ultrasonography was
positive, but in one patient (2%), laparotomy was
negative. Therefore, it was true positive in 29(58%)
patients. Free intra-peritoneal fluid was ruled out in
20(40%) patients, but 3(6%) patients out of these
deteriorated and had to be operated. It means
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ultrasonography was false negative in 6% patients.
Four quadrant tap was positive in 29(58%) patients. But
it was false positive in two (4%) patients. It means that it
was true positive in 27(54%) patients. Four quadrant tap
was negative in 21(42%) patients. Four (8%) patients out
of these 21 deteriorated and had to be operated.
Remaining 17 patients were successfully managed
conservatively. In 17(34%) patients out of 27, with four
quadrant tap frank blood came out. In remaining 10
patients, intestinal contents were found, in three of them
bile was mixed with intestinal contents.
Ultrasonography has a sensitivity of 87%, specificity of
100% and an overall accuracy of 96% for detecting free
intra-peritoneal fluid. It has been found that in individual
organ injury, its sensitivity is 92.4% for liver, 90% for
spleen, 92.2% for kidneys, 71.4% for pancreas and
34.7% for intestines. So ultrasonography is reliable for
detection and identification of solid organ injuries despite
its poor sensitivity for intestinal injuries .
Four quadrant tap is a useful diagnostic modality, but
only for those cases of abdominal trauma in which after
physical examination, the examiner continues to suspect
intra-abdominal haemorrhage . The abdominal tap has
been particularly useful as a diagnostic adjunct for
comatose patients with head injury in whom tap is
simple, economical and quick with relatively few
complications and can be performed any where .
In our study, the sensitivity of abdominal ultra-
sonography in the detection of intra- peritoneal fluid was
90.62%, the specificity 94.44% and the accuracy was
92%. The positive predictive value was 96.66% and
negative predictive value was 94.44%.
These findings are comparative with the results of other
studies. In a study done by Yoshii et al in 1998, the
sensitivity, specificity and accuracy of ultrasonography
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in blunt abdominal trauma patients was 94.6%, 95% and
94.9% respectively . Abu-Zaiden et al, in 1996 have
mentioned a sensitivity, specificity and accuracy of 85%,
100% and 96% respectively for ultrasonography in blunt
abdominal trauma According to the study by Lentz et al,
the ultrasonography was 87% sensitive, 100% specific
and 96% accurate in picking up the free intra peritoneal
fluid in blunt trauma victims .
In our study every patient underwent four quadrant taping
after abdominal ultrasonography. It was 87.09%
sensitive, 89.47% specific and 88% accurate with
positive predictive value of 93.1% and negative predictive
value of 98.47%. Mansoor et al conducted a study on 50
patients of blunt abdominal trauma in Apr. 2000. They
found that four quadrant tap was true positive in 92% of
cases and false positive rate was 8% . The results of
this study are comparable with our study where it was
true positive in 93.1% of cases and false positive in 7%
cases. Park concluded in 1991 that the false negative
rates of four quadrant tap ranges from 5-25% in different
series of patients presented with blunt abdominal
trauma . In our study, the false negative rates were 8%.
The four quadrant tap was positive in 29 patients out of
50. In 27 patients, it was found to be true positive
confirmed by laparotomy and in two patients laparotomy
was negative. 21 patients out of 50, were managed
conservatively. 4 patients out of 21 deteriorated and had
to be operative. Remaining 17 patients managed
conservatively successfully. In three out of these four
false negative patients, intra-peritoneal fluid was not even
picked up by ultrasonography. When we compared the
results of both ultrasonography and Four quadrant tap in
the initial assessment of a patient presented with blunt
abdominal trauma we found that these results were
comparable with each other.
Ultrasonography is rapid, economical, safe, non-invasive
and accurate test for the detection of intra-peritoneal fluid
in the blunt abdominal trauma victims and the need for
laparotomy in the patients with a negative
ultrasonography is rare. So abdominal ultrasonography
should be the first step in the radiological assessment of
all patients presented with blunt abdominal trauma.
Four quadrant tap can be performed in the initial
evaluation of a patient presented with blunt abdominal
trauma, especially when ultrasonographic facility could
not be available in the multi trauma patients to rule out
abdominal injuries quickly before performing surgery.
Four quadrant tap is as effective as ultrasonography, to
pick up the intra-peritoneal fluid in the assessment of
blunt trauma patient but with slightly less sensitivity,
specificity and accuracy and a little bit invasive.
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