You want to put that contrast where?

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Indications for Triple Contrast in Trauma Patients

What is triple contrast?

It is short for triple contrast CT scanning (3-CT) where oral, intravenous, and rectal contrast are administered.

When is it indicated?

  • Penetrating torso trauma
  • Retroperitoneal injury

Don’t want to wait for oral contrast to go all the way? Add the rectal contrast.

WHY?

You will be able to identify peritoneal violation/injury or vascular injury. The rectal contrast helps to illuminate retroperitoneal injuries since the rectum and descending colon are retroperitoneal (so is the ascending colon). Some of the current alternatives include possible unnecessary exploratory laparotomy or admission for serial exams.

Most common use:

Selective contrast administration, IV + rectal, IV + oral, or all 3 depending on suspicion of injury (proximal vs distal bowel).

How do you give it?

  • You can administer the contrast via enema of a foley catheter.
  • Most clinicians use foley catheters which should be advanced just past the anal verge.
  • Inflate the balloon so that contrast does not immediately come out.
  • Avoid advancing the foley too deep because you could miss low rectal injuries.
  • Dilute 400-750cc water with 50cc water-soluble contrast.
  • Push just before imaging (while on the CT table). Once images have been attained, deflate the balloon and remove the foley (anticipate fluid return).

Capstone study:

Prospective study, 104 pts with penetrating trauma (54 GSW, 50 Stab)
Triple contrast (oral/rectal/IV) helical CT
Positive CT = peritoneal violation, injury to retroperitoneal colon, major vessel, urinary tract

CT 100% sensitive, 96% specific, 100% NPV, 97% accuracy in predicting need for laparotomy (PPV)

Shanmuganathan K, Mirvis SE, Chiu WC, et al. Triple contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and need for laparotomy 2001;177(6):1247-125

References

  1. Shanmuganathan K, Mirvis SE, Chiu WC, et al. Triple contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and need for laparotomy 2001;177(6):1247-125
  2. Shanmuganathan K, et al. Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury- a prospective study in 200 patients. Radiology. 2004 Jun;231(3):775-84.
  3. Pham TN, Heinberg E, Cuschieri J, Bulger EM, O’Keefe GE, Gross JA,Jurkovich GJ. The evolution of the diagnostic work-up for stab wounds to the back and flank. Injury. 2009;40(1):48–53.
  4. Albrecht RM, Vigil A, Schermer CR, Demarest GB 3rd, Davis VH, Fry DE. Stab wounds to the back/flank in hemodynamically stable patients: evaluation using triple-contrast computed tomography. Am Surg. 1999;65(7):683–687; discussion 7–8.
  5. Hauser CJ, Huprich JE, Bosco P, Gibbons L, Mansour AY, Weiss AR. Triple-contrast computed tomography in the evaluation of penetrating posterior abdominal injuries. Arch Surg. 1987;122(10):1112–1115.

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