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Robert Reardon, MD

I. Introduction and IndicationsI. Pendahuluan dan IndikasiMany trauma patients have injuries that are not apparent on the initial physical exam. Banyak

pasien trauma cedera yang tidak terlihat pada ujian fisik awal. Patients can present with

distracting injuries or altered mental status. Pasien dapat hadir dengan cedera mengganggu ataustatus mental berubah. Significant bleeding into the peritoneal, pleural, or pericardial spaces may

occur without obvious warning signs. perdarahan yang signifikan ke dalam ruang peritoneal,

pleural, atau perikardial mungkin terjadi tanpa tanda-tanda peringatan yang jelas. The purpose ofbedside ultrasound in trauma is to rapidly identify free fluid (usually blood) in the peritoneal,

pericardial, or pleural spaces. Tujuan dari USG samping tempat tidur dalam trauma adalah untuk

dengan cepat mengidentifikasi cairan bebas (biasanya darah) di ruang peritoneal, perikardial,

atau pleura.Physicians in Germany and Japan began using routine bedside ultrasound for trauma patients in

the 1970's. (1) In the United States emergency physicians started using this tool in the 1980's (2

,3) and it has now become the initial imaging test of choice for trauma care in the United States

and is part of the Advanced Trauma Life Support (ATLS) protocol developed by the AmericanCollege of Surgeons. Dokter di Jerman dan Jepang mulai menggunakan ultrasound tempat tidur

rutin untuk pasien trauma pada tahun 1970-(.1) Dalam dokter darurat Amerika Serikat mulaimenggunakan alat ini di tahun 1980-(2,3) dan kini telah menjadi uji pencitraan awal pilihantrauma perawatan di Amerika Serikat dan merupakan bagian dari Advanced Trauma Life

Support (ATLS) protokol yang dikembangkan oleh American College of Surgeons.

FAST is an acronym for Focused Assessment with Sonography in Trauma and has become

synonymous with beside ultrasound in trauma. (14,15) The FAST exam, per ATLS protocoll,

is performed immediately after the primary survey of the ATLS protocol. "FAST" adalahsingkatan untuk Terfokus Penilaian dengan Sonografi di Trauma dan telah menjadi identik

dengan samping USG pada trauma (.14,15) Ujian CEPAT, per protocoll ATLS, dilakukansegera setelah survei primer dari protokol ATLS. Ultrasound is the ideal initial imaging modality

because it can be performed simultaneously with other resuscitative cares, providing vitalinformation without the time delay caused by radiographs or computed tomography (CT).

Ultrasound merupakan modalitas pencitraan yang ideal awal karena dapat dilakukan bersamaan

dengan pernafasan lain peduli, memberikan informasi penting tanpa waktu tunda yangdisebabkan oleh radiografi atau computed tomography (CT). The concept behind the FAST

exam is that many life-threatening injuries cause bleeding. Konsep di balik ujian FAST adalah

bahwa cedera yang mengancam jiwa banyak menyebabkan perdarahan. Although ultrasound isnot 100% sensitive for identifying all bleeding, it is nearly perfect for recognizing intraperitoneal

bleeding in hypotensive patients who need an emergent laparotomy and for diagnosing cardiac

injuries from penetrating trauma. (6-9) Recently, research studies have shown that bedside

ultrasound is equivalent to, or better than, chest radiography for identifying a hemothorax orpneumothorax in trauma patients. (10-13) For this reason some trauma centers have begun

performing an extended FAST exam (EFAST), evaluating for pneumo- and hemothorax in

addition to intraperitoneal injuries. (10,11,16) Meskipun USG tidak 100% sensitif untuk

mengidentifikasi pendarahan semua, hampir sempurna untuk mengenali perdarahanintraperitoneal pada pasien hipotensi yang memerlukan laparotomi muncul dan untuk

mendiagnosis cedera jantung dari penetrasi trauma (.6-9) Baru-baru ini, studi penelitian telah
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menunjukkan bahwa di samping tempat tidur USG adalah setara dengan, atau lebih baik dari,

radiografi dada untuk mengidentifikasi hemothorax atau pneumotoraks pada pasien trauma (.10-

13) Untuk alasan ini beberapa pusat trauma telah mulai melakukan ujian FAST diperluas(EFAST), untuk mengevaluasi dan hemothorax pneumo di Selain luka intraperitoneal. (10,11,

16)

Emergency physicians are trained to practice in a variety of different settings. dokter darurat

dilatih untuk praktek dalam berbagai pengaturan yang berbeda. Depending on the skill of the

operator and the practice setting, the FAST exam can be used in a variety of different ways toguide clinical decision-making. (16,17) Physicians should understand the potential

applications of trauma ultrasound as well as the common pitfalls and their own technical

limitations. Tergantung pada keterampilan operator dan pengaturan praktek, ujian FAST dapat

digunakan dalam berbagai cara yang berbeda untuk memandu pengambilan keputusan klinis (.16,17) Dokter harus memahami potensi aplikasi USG trauma serta umum perangkap dan

keterbatasan mereka sendiri teknis. It is important to recognize the imperfect nature of such

exams, but sonographers who master this challenge, will find it an invaluable tool in the care of

trauma patients. (16-18) Adalah penting untuk mengenali sifat yang tidak sempurna ujiantersebut, tetapi sonographers yang menguasai tantangan ini, akan menemukan alat yang sangat

berharga dalam perawatan pasien trauma. (16-18)

Specific Indications:Indikasi khusus:

Penetrating Cardiac TraumaPenetrating Cardiac TraumaBedside ultrasound performed by emergency physicians significantly decreases mortality in

patients with penetrating cardiac injuries. (9) Many patients with stab wounds to the heart don't

suffer significant blood loss because the wound in the pericardium seals, creating a pericardialeffusion. Tempat Tidur USG dilakukan oleh dokter darurat secara signifikan menurunkan angka

kematian pada pasien dengan luka menembus jantung (.9) Banyak pasien dengan luka tusukanke jantung tidak menderita kehilangan darah yang signifikan karena luka di segel perikardium,menciptakan efusi perikardial. Cardiac tamponade will usually develop, but may be delayed by

several minutes or even hours. Tamponade jantung biasanya akan mengembangkan, tetapi

mungkin tertunda beberapa menit atau bahkan jam. Prior to the development of tamponadepatients will be relatively asymptomatic. Sebelum perkembangan pasien tamponade akan relatif

tanpa gejala. When symptoms eventually develop, clinical decompensation occurs rapidly

resulting in shock and then cardiac arrest. Ketika gejala akhirnya mengembangkan,

dekompensasi klinis terjadi dengan cepat mengakibatkan shock dan kemudian serangan jantung.The classic signs of Beck's triad are not commonly present and are difficult to appreciate by

physical exam alone. "Klasik" tanda-tanda Beck's triad tidak umum hadir dan sulit untuk

menghargai dengan pemeriksaan fisik saja. The key to managing penetrating chest trauma is to

identify a developing pericardial effusion as early as possible, before tamponade and cardiacarrest occurs. Kunci untuk mengelola trauma dada tembus adalah untuk mengidentifikasi efusi

perikardial berkembang sedini mungkin, sebelum tamponade dan jantung penangkapan terjadi.

All patients with penetrating chest injury should be screened for a potential pericardialeffusion. Semua pasien dengan cedera menembus dada harus "diputar" untuk efusi perikardial

potensial. If an effusion is present cardiac injury is assumed until proven otherwise and the

patient should go directly to the operating room for a pericardial window or sternotomy. Jika
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4,23-25) Di samping dapat digunakan untuk membantu memprioritaskan manajemen awal

pasien dengan luka menembus beberapa atau lintasan rudal yang tidak diketahui (.26) Dalam

beberapa menit itu memungkinkan dokter untuk mengetahui untuk memusatkan upaya-upayaawal pada dada, jantung dan atau cedera intraperitoneal.

The sensitivity of the FAST exam for determining the need for laparotomy is only about 50%. (

27) Bowel injuries are very common in penetrating trauma and the FAST exam does not detectmost of these injuries. Sensitivitas dari ujian FAST untuk menentukan kebutuhan laparotomihanya sekitar 50%. (27) luka usus sangat umum dalam menembus trauma dan ujian FAST tidak

mendeteksi sebagian besar cedera. Some clinicians think that this low sensitivity makes the

FAST exam less useful in penetrating trauma, but others advocate it as a valuable tool to helpassess for significant hemoperitoneum and to help prioritize management when multiple

penetrating injuries are present. (4,5,17,24,26) Beberapa dokter berpikir bahwa ini

sensitivitas rendah membuat ujian FAST kurang berguna dalam menembus trauma, tetapi yang

lain advokat sebagai alat berharga untuk membantu menilai untuk hemoperitoneum signifikandan untuk membantu memprioritaskan manajemen ketika cedera penetrasi beberapa yang hadir. (

4,5,17,24,26)

Chest TraumaTrauma Dada

HemothoraxHemothoraxBleeding into the pleural space, called a hemothorax, is common in both blunt and penetratingtrauma. Pendarahan ke ruang pleura, yang disebut hemothorax, adalah umum pada trauma

tumpul dan penetrasi. It can usually be managed with placement of a simple chest tube. Hal ini

biasanya dapat dikelola dengan penempatan tabung dada sederhana.About 200 mL of pleural fluid is required before it can be detected with a plain CXR. (29)

Sekitar 200 mL cairan pleura diperlukan sebelum dapat dideteksi dengan CXR polos. (29)

Ultrasound is much more sensitive for detecting pleural fluid and can identify as little as 20mL in

the pleural space. (30) It was found to be equivalent to CXR in detecting hemothoraces intrauma and also showed to be a much quicker procedure, taking about 1 minute versus 15

minutes for chest radiography. (12,13) USG jauh lebih sensitif untuk mendeteksi cairan

pleural dan dapat mengidentifikasi sebagai sebagai sedikit 20ml di ruang pleura (.30)

Ditemukan setara dengan CXR dalam mendeteksi hemothoraces dalam trauma dan jugamenunjukkan menjadi lebih cepat prosedur banyak, mengambil sekitar 1 versus menit 15 menit

untuk radiografi dada. (12,13)

Chest radiographs are still necessary in trauma patients to evaluate the mediastinum, lungparenchyma and several other anatomic features. radiografi Dada masih diperlukan pada pasien

trauma untuk mengevaluasi mediastinum, parenkim paru dan beberapa fitur anatomis lainnya.

Ultrasound can be used during the initial minutes of the trauma evaluation to determine if urgent

chest tube placement is necassary. USG dapat digunakan selama menit awal evaluasi traumauntuk menentukan apakah dada penempatan tabung mendesak adalah necassary. A chest

radiograph can then be obtained after chest tube placement. Sebuah rontgen dada kemudian

dapat diperoleh setelah penempatan dada tabung. This approach saves valuable time whenmanaging an unstable multiple-trauma patient. (13,17,28) Pendekatan ini menghemat waktu

berharga ketika mengelola beberapa pasien-trauma tidak stabil. (13,17,28)

PneumothoraxPneumothoraxUsing ultrasound to evaluate for a pneumothorax is a relatively new concept but it is easy to
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learn. Menggunakan ultrasound untuk mengevaluasi pneumotoraks adalah sebuah konsep yang

relatif baru, tetapi mudah untuk belajar. Pneumothoraces are common in trauma and more than

half are missed on a supine chest radiograph. (31) Bedside ultrasound has been shown to beequal or more sensitive than CXR for detecting this lung injury. (10,11,31-34)

Pneumothoraces yang umum di trauma dan lebih dari separuhnya tidak terjawab pada radiografi

dada telentang (.31) Tempat Tidur USG telah terbukti sama atau lebih sensitif dibandingkanCXR untuk mendeteksi ini cedera paru (.10,11,31-34)Using ultrasound to look for occult pneumothoraces is most important in situations where

missing one could result in significant deterioration, especially patients requiring positive

pressure ventilation or helicopter transport. Menggunakan ultrasound untuk mencaripneumothoraces gaib yang paling penting dalam situasi di mana kehilangan satu bisa

mengakibatkan kerusakan yang signifikan, terutama pasien yang memerlukan ventilasi tekanan

positif atau transportasi helikopter.

Computed Tomography (CT) has many advantages over the FAST exam. Computed

Tomography (CT) memiliki banyak keuntungan dibandingkan ujian FAST.

CT of the abdomen is better than ultrasound for showing parenchymal injury and the source ofintraperitoneal bleeding. CT perut lebih baik daripada USG untuk menunjukkan cedera parenkim

dan sumber perdarahan intraperitoneal. CT is useful to differentiate solid organ injury frombowel injury or other causes of hemoperitoneum and it is far superior demonstratingretroperitoneal bleeding. CT berguna untuk membedakan cedera organ padat dari cedera usus

atau penyebab lain dari hemoperitoneum dan jauh lebih unggul menunjukkan pendarahan

retroperitoneal. Modern CT scanners can also use abdominal/pelvic images to reconstruct bonewindows and rule-out fractures of the spine and pelvis. Modern CT scanner juga dapat

menggunakan perut / gambar panggul untuk merekonstruksi jendela patah tulang dan aturan-

keluar dari tulang belakang dan panggul. Unfortunately, CT is very expensive, exposes patients

to radiation and usually requires a bolus of IV contrast material. Sayangnya, CT sangat mahal,paparan pasien terhadap radiasi dan biasanya membutuhkan bahan kontras bolus IV. Because of

these problems ultrasound will always have certain advantages over CT. Karena USG ini

masalah akan selalu memiliki kelebihan tertentu atas CT.

When is Trauma Ultrasound Most Useful?Kapan USG Trauma Paling Berguna?Since CT has better accuracy for diagnosing torso injuries, the FAST exam is most useful insituations where CT is not practical due to time constraints or when CT scan can be reasonably

avoided. Sejak CT memiliki akurasi yang lebih baik untuk mendiagnosis cedera batang tubuh,

ujian FAST yang paling berguna dalam situasi di mana CT adalah tidak praktis karena kendalawaktu atau bila CT scan dapat cukup dihindari.

Clinical scenarios where the FAST is most useful: Klinis skenario dimana FAST adalah yang

paling bermanfaat:

1. Hemodynamically unstable patients, when the cause of hypotension is unclear.Hemodinamik pasien tidak stabil, saat penyebab hipotensi tidak jelas.

2. Patients who need an emergent bedside procedure. Pasien yang membutuhkan prosedursamping tempat tidur muncul.
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Illustration 2aIlustrasi 2a Illustration 2bIlustrasi 2b

Illustration 2a& Illustration 2bIlustrasi 2a& 2b Ilustrasi

This shows an overview of potential intraabdominal and thoracic spaces. Hal ini menunjukkangambaran ruang intraabdominal dan toraks potensial.

These spaces are examined during the FAST exam to detect blood from organ or vascularinjuries. Ruang ini diperiksa selama ujian FAST untuk mendeteksi darah dari cedera organ atau

pembuluh darah.

IV.IV.Scanning Technique and Normal FindingsTeknik Scanning dan Temuan NormalThe FAST exam is often the first ultrasound exam that a novice clinician-sonographer will learn.Ujian FAST sering ujian USG pertama yang dokter yang pemula-sonogram akan belajar. Of

course it is important to know relevant anatomy and have a good understanding of the standard

scanning planes. Tentu saja penting untuk mengetahui anatomi yang relevan dan memilikipemahaman yang baik tentang pesawat pemindaian standar. Modern grayscale (B-mode)

ultrasound images are 2 dimensional representations. Modern grayscale (B-mode) gambar USG

2 dimensi representasi. Comprehensive ultrasound studies require scanning of every organ in 2different planes, each plane at a 90-degree angle to the other. Studi Komprehensif ultrasoundscanning memerlukan setiap organ dalam 2 bidang yang berbeda, masing-masing pesawat pada

sudut 90 derajat dengan yang lain. Fortunately, the FAST exam can be effectively performed

with limited scanning planes, since we are only trying to find free fluid and not do acomprehensive survey of the involved organs. Untungnya, ujian FAST dapat efektif dilakukan

dengan pesawat pemindaian terbatas, karena kami hanya mencoba untuk menemukan cairan

bebas dan tidak melakukan survei komprehensif dari organ-organ yang terlibat. This approachmakes the FAST exam easier to learn and less time consuming. Pendekatan ini membuat ujian

FAST lebih mudah untuk belajar dan memakan waktu kurang. The exam is performed in the

supine position, normal findings show regular anatomy and no intraperitoneal or intrathoracic

fluid. Ujian dilakukan dalam posisi terlentang, temuan normal menunjukkan anatomi teratur dantidak ada cairan intraperitoneal atau intrathoracic.

V. Abnormal FindingsV. Temuan AbnormalThe purpose of the FAST exam is to find free fluid (usually blood) in the pericardial, pleural, or

intraperitoneal spaces. Tujuan dari ujian FAST adalah untuk menemukan cairan bebas (biasanya

darah) di ruang perikardial, pleura, atau intraperitoneal. Free fluid is jet black and tends to collectin the most dependant areas and surround the organs Learning to perform the FAST exam simply

involves learning how to visualize the heart, diaphragms, liver, spleen and bladder. Free cairan

hitam pekat dan cenderung untuk mengumpulkan di daerah yang paling tergantung dan

mengelilingi organ Belajar untuk melakukan ujian FAST hanya melibatkan belajar bagaimana

untuk memvisualisasikan jantung, diafragma, hati, limpa dan kandung kemih. Interpretation ofthe FAST exam involves learning where free fluid commonly collects adjacent to these organs.

Interpretasi ujian FAST melibatkan belajar tempat fluida bebas biasanya mengumpulkanberdekatan dengan organ-organ ini.

The volume of intraperitoneal blood that can be detected using the FAST exam depends on theskill of the operator and which views are obtained. Volume darah intraperitoneal yang dapat

dideteksi dengan menggunakan ujian FAST tergantung pada keterampilan operator dan yang


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pandangan diperoleh. To optimize sensitivity to detect the smallest amount of free fluid possible,

it is important to obtain good images of multiple intraperitoneal sites. (20) A good quality

FAST can probably reliably detect about 200 mL of free intraperitoneal fluid. (1) If goodimages of the pelvis are obtained, requiring more technical skill, even smaller volumes may be

detected. (20,21) Placing a patient in the Trendelenburg position improves the sensitivity for

detecting free fluid in the Morison's pouch view. (22) Trendelenburg positioning is reasonablewhen the pelvic view is indeterminate or difficult to visualize. Untuk mengoptimalkansensitivitas untuk mendeteksi jumlah terkecil dari fluida bebas mungkin, adalah penting untuk

mendapatkan gambar yang baik dari beberapa situs intraperitoneal (.20) CEPAT berkualitas

baik mungkin dapat dipercaya mendeteksi sekitar 200 ml cairan bebas intraperitoneal. (1) baikgambar Jika dari pelvis diperoleh, membutuhkan lebih banyak keterampilan teknis, kecil volume

bahkan dapat dideteksi. (20,21) Menempatkan pasien dalam posisi Trendelenburg

meningkatkan sensitivitas untuk mendeteksi cairan gratis di Teman kantong tampilan Morison

tersebut. (22) positioning Trendelenburg adalah wajar ketika tampilan panggul adalah tdk atausulit untuk memvisualisasikan. Overall, the FAST exam is about 90% sensitive for detecting any

amount of intraperitoneal free fluid. (4) As noted previously, and most importantly, the FAST

exam is nearly perfect for detecting intraperitoneal bleeding that causes shock and requires anemergent laparotomy. (6,7) Secara keseluruhan, ujian FAST adalah sekitar 90% sensitif untuk

mendeteksi jumlah cairan bebas intraperitoneal (.4) Sebagaimana yang telah dijelaskan

sebelumnya, dan yang paling penting, ujian FAST hampir sempurna untuk mendeteksi

perdarahan intraperitoneal yang menyebabkan shock dan memerlukan laparotomi muncul. (6,7)

Cardiac ViewsCardiac TampilanThere are two different cardiac views that can be performed with the FAST exam. Ada dua

pandangan yang berbeda jantung yang dapat dilakukan dengan ujian FAST. One of the two is

usually sufficient to evaluate for a pericardial effusion. Salah satu dari dua biasanya cukup untukmengevaluasi untuk efusi perikardial. It is important to learn both views, because one of the

views may be easily obtained and the other impossible in any given patient. Adalah penting

untuk belajar baik pandangan, karena salah satu pandangan dapat dengan mudah diperoleh, dan

mungkin lainnya dalam setiap pasien diberikan.

Subxiphoid Four-Chamber View: Place the probe in the subxiphoid region with the marker-dot

toward the patients' right side or right shoulder. Subxiphoid Empat-Kamar Lihat: Tempatkanprobe di wilayah subxiphoid dengan penanda-dot ke 'sisi kanan pasien atau bahu kanan. Angle

the probe toward the left shoulder (Figure 1). Sudut probe ke bahu kiri (Gambar 1). This view

shows the right ventricle immediately adjacent to the left lobe of the liver (Figures 2, video clip

1). Pandangan ini menunjukkan ventrikel kanan berdekatan dengan lobus kiri hati (Gambar 2,video klip 1). A pericardial effusion will be easily recognized between the liver and the heart

(Video clip 2). Sebuah efusi perikardial akan mudah dikenali antara hati dan hati (video klip 2).

Increasing the depth of the image and having the patient take a deep breath will improve chancesof obtaining a good image. Peningkatan kedalaman gambar dan memiliki pasien menarik napas

dalam-dalam akan meningkatkan kemungkinan mendapatkan citra yang baik.
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Figure 1 Gambar 1 Figure 2 Gambar 2 Video clip 1 Video clip 1

Figure 1:Position of the ultrasound probe for the subxiphoid view. Gambar 1:Posisi probeUSG untuk tampilan subxiphoid.

Figure 2:Subxiphoid view. Video clip 1: Subxiphoid view. Gambar 2:.Melihat Subxiphoid

Video klip 1:tampilan Subxiphoid.

Video clip 2: Pericardial effusion (black stripe between liver and right ventricle). Video klip 2:

efusi perikardial (hitam strip antara hati dan ventrikel kanan).

Parasternal L

copy of fast

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