1. Abdominal trauma, penetrating trauma and ultrasound
ST3/DRE-EM Regional Training Day
Friday 13th October 2017
Richard Kendall
Consultant in emergency medicine

2. Patient 1 23 year old man Pedestrian hit by car
On arrival P110, BP 124/64, GCS 15
Left lower chest and LUQ

3. What imaging do you arrange first?
CXR and pelvis AP
Cervical spine
FAST
CT abdomen and CXR
Whole Body CT (WBCT)

4. What imaging do you arrange first?
CXR and pelvis AP
Cervical spine
FAST
CT abdomen and CXR
Whole Body CT (WBCT)

5. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study
The Lancet
Huber-Wagner et al (the working group on polytrauma of the German Trauma Society)
Volume 373, Issue 9673, Pages , 25 April 2009
trauma registrar review
n = 4621 patients, 1491 underwent WBCT
WBCT increased probability of survival

6. But
WBCT – up to 30 mSv
Addenbrooke’s data: 10% show no radiological abnormality

12. A 10 mSv CT in a 25 year old is associated with an estimated :-
Computed Tomography — An Increasing Source of Radiation Exposure Brenner DJ and Hall EJ NEJM Volume 357: November 29, 2007 Number 22
A 10 mSv CT in a 25 year old is associated with an estimated :-
Risk of induced cancer 1 in 900
Risk of induced fatal cancer 1 in 1800

13. Patient 2 28 year old woman Driver, frontal impact at 50 mph
On scene RSI (agitated, GCS 9 E2V2M5)
Seat belt bruising to chest and abdomen
In resus P136 BP 84/45

14. What imaging do you arrange first?
CXR, pelvis AP
CXR, pelvis AP, lateral Cervical spine
Pelvis AP
Pelvis AP and FAST
WBCT

15. What imaging do you arrange first?
CXR, pelvis AP
CXR, pelvis AP, lateral Cervical spine
Pelvis AP
Pelvis AP and FAST
WBCT

16. FAST Focussed Assessment with Sonography in Trauma Haemoperitoneum
Haemopericardium
eFAST (extended FAST)
Pneumothorax
Haemothorax

17. e-FAST basic views Cardiac RUQ LUQ Pelvic
Morison’s Pouch and Right Pleural Cavity
LUQ
Splenorenal / Perisplenic and Left Pleural Cavity
Pelvic
& 6. Anterior chest for pneumothorax

18. Pericardial
Transducer placed in sub-xiphoid region with beam projecting in coronal plane

19. Subcostal
Liver RV LV

20. l 20

21. Right Upper Quadrant
Transducer positioned in right posterior to mid-axillary line with beam in coronal plane (level with xiphi-sternum)

22. RUQ Window

23. Abnormal View 23

24. Left Upper Quadrant Window
Transducer positioned in left posterior axillary line with beam in coronal plane.

25. LUQ Window

26. LUQ

27. Thoracic (bases) Lung Bases
Increased sensitivity with increased number of views
Will identify pleural effusions

28. To Evaluate the Thorax
Liver
Diaphragm
Pleural space

29. Haemothorax 29

30. Pleural effusion - pitfall
Peritoneal fluid

31. Pelvic Window
Transducer placed transversely in midline above the symphysis pubis
Probe rotated 90o to move beam into sagittal plane

32. Patient 3 27 year old man Altercation multiple stabbings to chest
Attended to by enhanced pre-hospital care team – RSI
Arrives with P126 BP 63/42
FAST shows pericardial effusion

33. When do you perform a thoracotomy?
Immediately
If loses output
Under no circumstances

34. When do you perform a thoracotomy?
Immediately
If loses output
Under no circumstances

35. Within 10 minutes of cardiac arrest from penetrating trauma
Emergency Thoracotomy “how to do it” Wise et al Emerg Med J 2005;22:22-24
Within 10 minutes of cardiac arrest from penetrating trauma
Clam Shell thoracotomy
Bilateral 4cm thoracostomies midaxillary line
Skin incision
Scissors (Gigli saw) – open ‘clam’, retractor
Incise pericardium

37. Patient 4 46 year old man MVC – RSI on scene Brought be helicopter
Bilateral thoracostomies prior to transfer

38. Where do we put the chest drains
Through the thoracostomy
Through a distant site
Through the thoracostomy and give IV antibiotics
Through a distant site and give IV antibiotics

39. Where do we put the chest drains
Through the thoracostomy
Through a distant site
Through the thoracostomy and give IV antibiotics
Through a distant site and give IV antibiotics

40. Patient 5 35 year old man Shotgun wound to right groin
P134 BP 90/46 GCS14 (E3V5M6)
Bleeding profusely
IV access and aggressive fluid resuscitation

41. How do we try and stop the bleeding?
Firm pressure with gauze
Firm pressure with CELOX
Pack wound and firm pressure gauze
Pack wound and firm pressure CELOX

42. How do we try and stop the bleeding?
Firm pressure with gauze
Firm pressure with CELOX
Pack wound and firm pressure gauze
Pack wound and firm pressure CELOX

43. CELOX Haemostatic agent chitosan Extracted from shrimp shells
Forms gel like clot once in contact with blood

44. Patient 6 24 year old man Jumped off roof of hospital
Brought to ED within 15 minutes
P145 BP palpable carotid pulse
Unable to obtain peripheral vascular access

45. Do you..... Insert subclavian line Insert internal jugular line
Insert intraosseous needle
Insert femoral line

46. Do you..... Insert subclavian line Insert internal jugular line
Insert intraosseous needle
Insert femoral line

47. EZ-IO

48. Summary
WBCT
FAST
Resuscitative Thoracotomy
Thoracostomies
CELOX
EZ-IO