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Emergency Ultrasound in Trauma

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Page 1: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Emergency Ultrasound in

Trauma

Page 2: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Introduction

• Whose done a formal course?• Who learnt at the bedside?• Who thinks they know what they are doing?• What is the role of FAST in (signifcant) blunt

trauma?

Page 3: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Introduction

• Brief history• Over view view of FAST• E-FAST• Pearls and pitfalls • The role of FAST in patient management

Page 4: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

History

Page 5: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

History of The FAST EXAM

• Bedside ED US in trauma became routine in Japan and Germany in the 1970’s

• ED physicians in the USA began using US in the 1980’s

• Now an integral part of ATLS• Since 2001, all ED residents in the USA do

formal US training

Page 6: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

FAST is Focussed

• ED ultrasound asks focussed (yes or no questions)

- does this patient have a AAA - does this patient have a gallstone - does this patient have an abscess• The FAST exam only asks “does this patient

have free fluid?” - yes / no / indeterminate

Page 7: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

FAST is Focussed

• We don’t care where the fluid comes from - and we can’t tell• We are not looking for organ injuries - some ED US “experts” are now talking about diagnosing specific injuries - sens is too low

Page 8: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

“ The most important preoperative objective in the management of the patient with trauma is to ascertain whether or not laparotomy is needed, and not the diagnosis of a specific organ injury”

Page 9: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Why Look For Fluid?

• In trauma, free fluid is assumed to be blood• Bleeding into the abdomen is the leading

cause of preventable death in trauma• In the standard FAST we look for fluid in the

abdomen, pleural space and pericardium• In the E-FAST we add looking for a

pneumothorax

Page 10: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Aims of FAST

• Main aim is to identify who needs to go to the operating theatre “stat”

- the unstable patient with a positive FAST• Some advocate using the FAST in stable

patients to determine - who needs a CT scan - who can be discharged This is controversial (FAST does not rule out injuries)

Page 11: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Aims of FAST

• Also used for triage in mass casualty situations - Iraq and other illegal wars - Haiti - Armenian Earthquake in 1988 performed 400 FAST’ sin 48 hours (1 every 10 minutes)

Page 12: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Free Fluid

• In trauma, we assume that free fluid is blood.• It may not be - urine - bowel contents - still need a laparotomy• Ascites (use clinical judgement)• Pysiological fluid in a pre-menopausal woman

Page 13: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 14: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

When Do We Perform the FAST

• Looking for bleeding - part of “C” in the primary survey• Need to be a bit flexible - priority in penetrating chest injuries?• Needs to be done before - insertion of IDC - the log roll

Page 15: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

When Do We Perform The FAST?

• With small modern machines you can do the FAST without getting in the way

• Can do it whilst other procedures are being performed

• Can repeat as often as needed - patient condition changes - as a routine to improve sensitivity

Page 16: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Serial FAST’s

• Backbourne 2004 et al - sens of initial FAST vrs CT: 32% (spec = 98) - sens of repeat FAST vrs CT: 72% - 26 patients has a negative initial scan and a positive repeat scan (n = 108) - of these 10 went to laparotomy - no patient with a negative FAST at 4 hours developed “significant” intraperitoneal bleeding - but does this mean that they are safe to discharge?

Page 17: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 18: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Where Do we Look

• We know where to look• We know why we are looking in that location• We need to go over it because we forget it

when we put the probe on the patient - can result in false-negative scans when the amount of free fluid is small

Page 19: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 20: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 21: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 22: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Where Do We Look

• Trauma patients arrive in a supine position• Fluid accumulates in anatomically dependent

areas

Page 23: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Dependent Areas in The Supine Patient

Page 24: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

The Pelvis

Page 25: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

The Pelvis

Page 26: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 27: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Where Do We Look

• Sisley et al 1998 - reviewed 10000 patients with positive FAST - RUQ was positive in 86% - LUQ: positive in 55% - Pelvis: positive in 43%

Know how to scan the RUQ.

Page 28: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Dogs Love CPAP

Page 29: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

How Much Fluid Can We Detect

Page 30: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Branney, S.W. et al: Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid J Trauma:1995: 39

• Peritoneal lavage fluid infused in 100 patients• Simultaneous scan of Morison’s pouch

– By physicians ( Surgery,EM, Radiology)– Blinded to volume and rate of infusion– Mean volume of detection: 619cc– Sensitivity at 1 liter: 97%– 10% physicians detected less than 400cc

Page 31: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

How Much Fluid Can We Detect

• Lots of studies• Location dependent• Position dependent• Pleural space: < 50 to 100 ml• Pelvis: 150 ml• RUQ: 200 to 600 if supine < 100 if right lateral decubitus ? 5 degrees head down

Page 32: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

How Much Fluid Can We Dectect?

• Not that important• What is important - unstable and free fluid = laparotomy - negative / indeerminate scan = repeat latter

Page 33: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Where Do We Look: The Order

• Doesn’t matter• Most people start in the URQ - money shot - stop if positive• Exception is if there is penetrating trauma to

the chest - look for pericardial fluid first - clinically silent and can crash

Page 34: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Trauma Study

The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study.

Rozycki GS: J Trauma. 1999

• Pericardial scans performed in 261 patients• Sensitivity 100%, specificity 96.9%• PPV: 81% NPV:100%• Time interval BUS to OR: 12.1 +/- 5.9 min

Page 35: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Where Do We Look: The Order

• More important is to scan each area thoroughly

• Don’t get sucked in to trying to complete the FAST quickly

- systematic look for occult haemorrhage (SLOH)

Don’t get distracted by storing images.

Page 36: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 37: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

FAST: Sensitivity & Specificity

Page 38: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

A Quick Rant

Page 39: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Imaging Sensitivity

• Values quoted in the literature for sensitivity / specificity don’t help my practice

- too many variables• “Modern CT scanners have a sensitivity of 98%

for SAH” - what generation scanner - how many detectors - who read the scan - timing of the scan - what was the gold standard

Page 40: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Study n sensitivity(%) specificity(%) npv(%)

Ballard et al, 1999 102 28 99 85

Boulanger et al, 1996 400 81 97 96

Chiu et al, 1997 772 71 100 98

Coley et al, 2000 107 38 97 78

Hoffmann et al, 1992 291 89 97 93

Ingeman et al, 1996 97 75 96 92

Kern et al, 1997 518 73 98 98

Liu et al, 1993 55 92 95 84

McElveen et al, 1997 82 88 98 96

McKenney et al, 1996 996 88 99 98

Rozycki et al, 1993 470 79 96 95

Rozycki et al, 1995 365 90 100 98

Rozycki et al, 1998 1227 78 100 99

Shackford et al, 1999 234 69 98 92

Thomas et al, 1997 300 81 99 98

Tso et al, 1992 163 69 99 96

Wherret et al, 1996 69 85 90 93

Yeo et al, 1999 38 67 97 93

Total 6324 75 98 94

Page 41: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Ultrasound

• Well known to be user dependent• For FAST, so few are positive it’s hard to get a

feel for how skilled you are - unless you know a friendly peritoneal dialysis patient

Page 42: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Sensitivity & Specificity

• In general - sensitivity 80 to 90% - specificity over 95%• In the unstable patient, free fluid is 100%

sensitive for an injury requiring a laparotomy - 3 papers - total n = 133

Page 43: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 44: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls & Pitfalls: General

• Free fluid can be subtle - can track into small places - can slip between loops of bowel and viscera• Some put head down for 5 minutes• Look carefully between - the diaphragm and liver - diaphragm and spleen

Page 45: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls & Pitfalls: General

• Free fluid has straight edges and may be pointy

• False positives are often round and appear contained

- gallbladder - ICC - fluid in the bowel

Page 46: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: General

• Fresh blood is black• Blood can clot within minutes - takes on the same density as soft tissue - can be missed - need to consider how long since the accident

Page 47: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: General

• Beware of perinephric fat - can be mistaken for free fluid or clotted blood• Usually a speckled appearance (internal

echos) - look at the other kidney - usually overweight patient - roll them and see if it moves

Page 48: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: General

• Predictors of false negative FAST - Subcutaneous emphysma - Pelvic Fracture - Spinal fracture

• Consider CT.

Page 49: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: URQ

• Consider 5 degrees head down• There 4 areas to examine - Morison’s Pouch - inferior pole of kidney (right paracolic gutter) - under the diaphragm - lung base • Rare to see all 4 in one view - scan all 4 areas

Page 50: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: RUQ

• Lung base - look for mirror artefact - loss of mirror aretact 96% sens & 100% spec for haemothorax (Ma 1997)

Page 51: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Normal URQ

Page 52: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

URQ: Haemothorax

Page 53: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 54: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 55: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls:

• False positives - gallbladder - IVC - perinephric fat - fluid in duodenum - renal cyst - adrenal gland (bright white margins)

Page 56: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 57: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

URQ: Free Fluid

Page 58: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 59: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 60: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

URQ: Free Fluid

Page 61: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Perinephric Fat

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Page 63: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: ULQ

• ULQ is not a mirror image of the RUQ• It is a hard view - kidney is more posterior (deep) - kidney is more cranial - (full) stomach gets in the way• Hand may be touching the bed

Page 64: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: ULQ

• You look in 4 areas - pleural space - sub-diaphragmatic - spleno-renal recess - inferior pole of kidney

Page 65: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: ULQ

• Fluid may only be seen between the diaphragm and spleen

- look carefully - ask them to breath in and out deeply which may move the diaphragm away from the spleen and reveal free fluid

Page 66: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

ULQ

Page 67: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: ULQ

• False positives - renal and splenic cysts - fluid in stomach - adrenal gland - blood vessels at the splenic hilum

Page 68: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

ULQ: Free Fluid

Page 69: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

ULQ: Free Fluid

Page 70: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Sub-diaphragmatic Fluid

Page 71: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 72: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 73: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 74: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 75: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

LUQ: Pleural Effusion

Page 76: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: Suprapubic

• Need a full bladder - do before the IDC - try a bag of NS as a window if bladder empty• Can put head up for a few minutes• You get posterior acoustic enhancement - if image too bright it will mask fluid - turn down the gain and TGC

Page 77: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: Suprapubic

• In general - longitudinal view: fluid to left of screen - transverse view: fluid beneath bladder

• Bladder may be hard to locate on obese patients

- usually lower than you think

Page 78: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls:

• False positives - seminal vesicles - impacted rectum - physiological fluid in a young female - iliopsoas muscles

Page 79: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 80: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Longitudinal Pelvic Female: Normal

Page 81: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Female Pelvis: Free Fluid

Page 82: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Female Pelvis: Lots of Fluid

Page 83: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Transverse Female Pelvis: Normal

Page 84: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Transverse Female Pelvis: Free fluid

Page 85: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 86: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 87: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
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Pearls and Pitfalls: Subcostal

• Important view in penetrating chest trauma• Can be difficult to obtain good views - fat - pain - uncooperative - probe should be almost flat on the abdomen - increase depth?• If you can’t get a good view, try PLAX

Page 90: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls: Subcostal

• False positive: pericardial fat pad - usually has speckled appearance - often just anterior - an effusion usually lies in a dependent position

Page 91: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls and Pitfalls:

• False positive: pleural effusion - in the PLAX view - find the aorta - fluid anterior to the aorta is pericardial - fluid deep to the aorta is pleural

Page 92: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Sub-costal View

Page 93: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pericardial Effusion

Page 94: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pericardial Effusion

Page 95: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 96: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

E-FAST

Page 97: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Erect Pneumothorax

Page 98: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Supine Pneumothorax

• Lung falls posteriorly• Air rises to the highest point• Air seen near the

diaphragm first

Page 99: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is
Page 100: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Etching of the Diaphragm

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Deep Sulcus Sign

Page 104: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

HOW ELSE CAN WE DIAGNOSE A PNEUMOTHORAX?

• Supine CXR has a low sensitivity • CT has a high is sensitivity but…….

Page 105: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

CT is a Cold & Lonely Place to Die

Page 106: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

THE E-FAST• Perform FAST as usual• Then scan the chest for a

pneumothorax - sens US = > 90% - sens supine x-ray = 28 – 65%

Only excludes a pneumothoraxunder the probe.

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Normal Pneumothorax

Sea-shore Sign Barcode Sign

Page 116: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls & Pitfalls

• Slung sliding excludes a pneumothorax (under the probe)

- the reverse is not true• Comet tails exclude a pneumothorax - the reverse is not true• Look at the highest point of the chest - additional views will increase the sensitivity of the scan (slide more at bases)

Page 117: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pearls & Pitfalls

• Absence of lung sliding may be - a pneumothorax - adhesions - pleurodesis - right mainstem intubation - hyper-inflated asthma! (lung pulse present)• Consider the clinical context

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Role of FAST

• No debate about - role in penetrating chest injury - unstable patient• Practices vary for the stable patient

Page 120: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Pericardial Effusion

• May be stable on arrival with a normal physical exam

• Can then rapidly decompensate• We can diagnose an effusion before they

decompensate• Rozycki et al 1996 - from US to OT in a mean time of 12 minutes

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Unstable Patient & Negative FAST

• Look for non-abdominal blood loss - long bone - retroperitoneum - pelvic injury - external - cardiac event - spinal shock

Page 123: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

Unstable Patient & Negative FAST

• DPL?• Serial FAST exams?• CT is patient stabilises• OT anyway?

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The Stable Patient

• Jeremy our beloved trauma leader does not believe that a stable patient should not get a FAST

- clinically suspicious: get a CT• Others argue that a positive FAST - gives an early warning of potential decompensation - guide to who gets a CT

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Penetrating Trauma

• No concensus opinion• As per blunt trauma?

• Stable and no peritonism: CT• Unstable or peritonism: OT

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Conclusions

• It’s not a race; Slowly and systematically assess all areas

• The FAST asks only “Is there free fluid?”• The E-FAST adds “Is there a pneumothorax?”• A negative FAST does not exclude intra-

abdominal injury• A positive FAST in an unstable patient wins a

trip to the OT

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Page 128: Emergency Ultrasound in Trauma. Introduction Whose done a formal course? Who learnt at the bedside? Who thinks they know what they are doing? What is

POL3193a Report 1 - Safety Leaders Who are they What do they do · 2018-09-26 · Safety Leaders: Who are they? What do they do? [Page 1] Cranfield University, School of Management

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