1. Focused Abdominal Sonography in Trauma BY:Dr.K.Azarkhish

2. Goals of this lecture Where do I put the probe? How do I hold the probe? What am I looking at? - Normal anatomy What am I looking at? - Abnormal anatomy What can I tell from the abnormal anatomy? Pathologic fluid in the abdomen Pathologic fluid in the pericardium Does it make a difference? Review of the literature Where do I put the probe? How do I hold the probe? What am I looking at? - Normal anatomy What am I looking at? - Abnormal anatomy What can I tell from the abnormal anatomy? Pathologic fluid in the abdomen Pathologic fluid in the pericardium Does it make a difference? Review of the literature

3. Trauma Ultrasonography Intro Applications Anatomy Comparison Exam: Technical Considerations RUQ LUQ Subxiphoid/Subcostal Pelvis Ultrasonagraphic evaluation of pathologic states Intro Applications Anatomy Comparison Exam: Technical Considerations RUQ LUQ Subxiphoid/Subcostal Pelvis Ultrasonagraphic evaluation of pathologic states

4. FAST: Intro and Applications FAST exam: Focused Abdominal Sonography in Trauma Peritoneal Pericardial Pleural Indications Acute blunt or penetrating trauma Trauma in pregnancy Pediatric trauma Subacute trauma Goal: to identify fluid in a location where it does not normally belong FAST exam: Focused Abdominal Sonography in Trauma Peritoneal Pericardial Pleural Indications Acute blunt or penetrating trauma Trauma in pregnancy Pediatric trauma Subacute trauma Goal: to identify fluid in a location where it does not normally belong

5. FAST: Anatomy 7 dependent sites 1. Right Supramesocolic (Morison’s pouch) 2. Left Supramesocolic (Splenorenal rescess) 3. Right Pericolic gutter 4. Right Inframesocolic 5. Left Inframesocolic 6. Left Pericolic gutter 7. Pelvic cul-de-sac

6. FAST: Technical Considerations Probe placement? 1. RUQ: Morrison’s Pouch 2. LUQ: Splenorenal 3. Pelvis: Pelvic cul-de-sac 1. Transverse 2. Longitudinal 4. Subxiphoid/Subcostal: Pericardium righthead  Remember: Probe almost ALWAYS facing either patient’s right or patient’s head

7. FAST: RUQ exam Probe placed Perpendicular Mid-coronal plane Just superior to the iliac crest Probe facing Toward patient’s head

8. FAST: RUQ exam Evaluating Hepatorenal interface Possibility of fluid in Morison’s pouch - Right Supramesocolic space Technical Problems Bowel gas Rib artifact

9. FAST: RUQ exam Where exactly is Morrison’s Pouch?

10. FAST: RUQ exam Where exactly is Morrison’s Pouch?

11. FAST: RUQ exam Normal Anatomy In the supine patient, the hepatorenal space is the most dependent area Also is the least obstructed for fluid flow Morison’s Pouch Potential space between the liver and the right kidney in the hepatorenal recess Morison’s Pouch

12. FAST: RUQ exam Abnormal Anatomy Pathologic Fluid - mild L = liver D = diaphragm K = kidney RS = rib shadow FF1 = free fluid FF2 = free fluid

13. FAST: RUQ exam Abnormal Anatomy Pathologic Fluid - moderate L = liver K = Kidney FF = free fluid RS = rib shadow D = diaphragm L K FF RS D

14. Abnormal RUQ

15. FAST: RUQ exam Abnormal Anatomy Pathologic Fluid - massive L = liver K = kidney FF = free fluid L K FF

19. FAST: LUQ exam Probe placed Perpendicular Mid - coronal plane Just superior to the iliac crest Probe facing Towards patient’s head

20. FAST: LUQ exam Evaluating Spleno-renal interface Possibility of fluid in splenorenal recess Technical Problems Bowel gas, splenic flexure gas Rib artifact

21. FAST: LUQ exam Where exactly is Splenorenal Recess?

22. FAST: LUQ exam Where is splenorenal recess?

23. FAST: LUQ exam Normal Anatomy More difficult to evaluate than RUQ Left kidney more superior than right Do not have liver as acoustic window Splenorenal Recess Potential space between kidney and spleen Splenorenal Recess

24. Normal LUQ

25. Abnormal LUQ

29. FAST: LUQ exam Pathologic Fluid K = kidney S = spleen RS = rib shadow FF = free fluid

30. FAST: Subxiphoid exam Probe placed Patient’s epigastrium Just below xiphoid process of the sternum “entire” probe aimed at patients left shoulder Probe facing “notch” of probe placed toward patient’s right side

31. FAST: Subxiphoid exam Evaluating Fluid in the pericardium Wall dysfunction R heart strain Septal “bowing” Technical Problems Inability to get probe under xiphoid

32. FAST: Subxiphoid exam Normal Anatomy Liver at very top of screen Right ventricle on top of screen Right atrium and left ventricle line up below right ventricle Left ventricle on bottom of screen

33. FAST: Subxiphoid exam Review Normal Subcostal view RV = right ventricle RA = right atrium LV = left ventricle LA = left atrium IVS = interventricular septum IVS

34. FAST: Subxiphoid exam Subcostal view Large pericardial effusion Where to you measure amount of blood or fluid? Answer: anteriorly between the heart and liver Measure here!

35. FAST: Pelvis LA exam Pelvis: Long Axis Probe placed longitudinally 2 cm superior to the symphysis pubis Midline of the abdomen “aimed” caudally into the pelvis Probe facing Toward patient’s head

36. FAST: Pelvis LA exam Evaluating Free fluid in the anterior pelvis Free fluid in the pelvic cul- de-sac (Pouch of Douglas) Technical Problems Body habitus Empty bladder (no landmarks) Bladder trauma (no landmarks)

37. FAST: Pelvis LA exam Pelvis: Long Axis Normal Anatomy Evaluating Bladder Uterus in female: usually superior to bladder Prostate in male: usually posterior to bladder

40. FAST: TV Pelvis exam Pelvis: Transverse Probe placed 2 cm superior to the symphysis pubis Midline of the abdomen Probe facing Toward patient’s right Probe rotated 90 degrees counterclockwise from longitudinal

41. FAST: TV Pelvis exam Evaluating Free fluid in the anterior pelvis Free fluid in the pelvic cul- de-sac (Pouch of Douglas) Technical Problems Body habitus Empty bladder (no landmarks) Bladder trauma (no landmarks)

42. FAST: TV Pelvis exam Pelvis: Transverse Axis Normal Anatomy Evaluating Bladder Well cirucumscribed Contains fluid that appears anechoic

44. FAST: Pelvis exam - Pathology Transverse scans with free fluid in pelvis Female (top): uterus posterior to bladder Male (bottom) B = bladder UT = uterus FF = free fluid S = spine

45. Lacerations

50. Thank you all for listening to this presentation