1. Emergency Ultrasound in Trauma
Anthony J Weekes MD, RDMS
Janet G. Alteveer, MD
Sarah Stahmer, MD

2. Clinical Case
GR is a 62 y male who hit his right torso when he slipped on an icy sidewalk. He denies head trauma, and can walk without a limp. Two hours later the pain in his lower chest has increased he comes to the ED.

3. Clinical Case PE: BP116/72, pulse109, RR 24.
There is a minor abrasion to right lateral chest, which is tender to palpation. Diffuse mild abdominal tenderness.
Meds: Coumadin for irregular heartbeat

4. Clinical Case 2 large IV’s placed, CXR done. Blood tests sent.
Bedside ultrasound done.
CXR revealed lower rib fractures, no HTX or PTX

5. Clinical Case FFP ordered and OR notified.
He is found to have a liver laceration and 500 cc of blood in the peritoneal cavity.

6. Diagnostic Modalities in Blunt Abdominal Trauma
Diagnostic Peritoneal Lavage (DPL)
CAT Scan
Ultrasound (FAST exam)

7. Diagnostic Peritoneal Lavage
Advantages
Very sensitive for identifying intra-peritoneal blood
106 RBC/mm3 approx. 20 ml blood in 1L lavage fluid
Can be done at the bedside
Can be done in minutes
Disadvantages
Overly sensitive, may result in too high a laparotomy rate
Invasive
Difficult in pregnancy, or with many prior surgeries
Can not be repeated

8. CT Scan Advantages Disadvantages Identifies specific injuries
Good for hollow viscus and retroperitoneal injury
High sensitivity and specificity
Disadvantages
Expensive equipment
30-60 minutes to complete study
Only for stable patients
Not for pregnant patients

9. Focused Abdominal Sonography in Trauma
FAST

10. FAST Advantages Disadvantages
Can be performed in 5 minutes at the bedside
Non-invasive
Repeat exams
Sensitivity and specificity for free fluid equal to DPL and CT
Disadvantages
Operator dependent
May not identify specific injury
Poor for hollow viscus or retroperitoneal injury
Obesity, subcutaneous air may interfere with exam

11. FAST Principles Detects free intraperitoneal fluid
Blood/fluid pools in dependent areas
Pelvis
Most dependent
Hepatorenal fossa
Most dependent area in supramesocolic region

12. FAST Principles Pelvis and Supra-mesocolic areas communicate
Phrenicolic ligament prevents flow
Liver/spleen injury
Represents 2/3 of cases of blunt abdominal trauma

13. FAST- principles Intraperitoneal fluid may be Blood
Preexisting ascites
Urine
Intestinal contents

14. FAST – limitations
US relatively insensitive for detecting traumatic abdominal organ injury
Fluid may pool at variable rates
Minimum volume for US detection
Multiple views at multiple sites
Serial exams: repeat exam if there is a change in clinical picture
Operator dependent

15. Evidence supporting use of FAST
Multiple studies in USA by EM and trauma surgeons
Studies from Europe and Japan
Policy statements by specialty organizations

16. Jehle, D., et al, Am J Emerg Med, 1993
Emergency department ultrasound in the evaluation of blunt abdominal trauma.
Jehle, D., et al, Am J Emerg Med, 1993
Single view of Morison’s pouch in 44 patients
Performed by physicians after 2 weeks training
US compared to DPL and laparotomy
Sensitivity 81.8%
Specificity 93.9%

17. Trauma surgical study
A prospective study of surgeon-performed ultrasound as the primary adjuvant modality of injured patient assessment Rozycki et al.
N=358 patients
Outcomes used: US detection of hemoperitoneum/pericardial effusion

18. Results 53/358 (15%) patients w/ free fluid on “gold standard”
All patients: Sens 81.5%, spec 99.7%
Blunt trauma: Sens 78.6%, spec 100%
PPV 98.1%, NPV 96.2%
Overall accuracy was 96.5% for detection of hemoperitoneum or pericardium

19. Trauma Study
Rozycki G, et al 1998 Surgeon-performed ultrasound for the assessment of truncal injuries. Lessons learned from 1540 patients
FAST exam on patients with precordial or transthoracic wounds or blunt abdominal trauma

20. Precordial/Transthor : Sens 100%, Spec 99.3%
Protocol:
+ Pericardial fluid OR
Stable CT
+IP fluid
Unstable OR
Results
N= 1540 pts, 80/1540 (5%) with FF
Overall: Sens 83.3%, Spec 99.7%
PPV 95%, NPV 99%
Precordial/Transthor : Sens 100%, Spec 99.3%
Hypotensive BAT: Sens 100%, Spec 100%

21. FAST – Specialty Societies
Established clinical role in Europe, Australia, Japan, Israel
German Surgical Society requires candidates’ proficiency in ultrasound
United States
US in ATLS
US policies by frontline specialties
American College of Surgeons
ACEP,SAEM & AAEM

22. FAST
Perform during
Resuscitation
Physical exam
Stabilization

23. Equipment Curved array Various “footprints” Variable frequencies
Small footprint for thorax
Large for abdomen
Variable frequencies
5.0 MHz: thin, child
3.5 MHz: versatile
2.0 MHz: cardiac, large pts

24. Time to Complete Scan Each view: 30-60 seconds
Number of views dependent on clinical question and findings on initial views
Total exam time usually < 3-5 minutes
1988 Armenian earthquake
400 trauma US scans in 72 hrs

25. Focused Abdominal Sonography for Trauma (FAST)
Consists of 4 views
Subxiphoid
Right Upper Quadrant
Left Upper Quadrant
Pouch of Douglas

26. FAST Increased sensitivity with increased number of views
Will identify pleural effusions
Reliably detects as little as cc in the thorax
Sensitivity >96%, specificity %

27. Clinical experience with FAST
Intraperitoneal fluid
Sensitivity 82-98%, specificity %
Morison’s pouch alone 36-82% sensitivity
Increased sensitivity with
Increasing number of views
Trendelenberg
Serial examinations
Can detect as little as 250cc of free fluid

28. Clinical Experience Solid organ disruption Hollow viscus injury
40% sensitivity for all organs
33-94% for splenic injury
Hollow viscus injury
Sensitivity 57%
Retroperitoneal injury
Sensitivity for identification of hemorrhage <60%

29. RUQ Probe at right thoraco-abdominal junction
Liver : large acoustic window
Probe marker cephalad
Rib interference?
Rotate 30° counterclockwise

30. Scan Plane Same image if probe positioned Anterior Mid axillary
Posterior

31. RUQ Image on screen: Liver cephalad Kidney inferiorly
Morison’s Pouch*: space between Glisson’s capsule and Gerota’s fascia * * * *

32. Normal RUQ Image kidney Two toned structure Longitudinally
Transversely
Two toned structure
Cortex/medulla
Renal sinus

33. Appearance of blood Fresh blood Coagulating blood Anechoic (black)
First hypoechoic
Later hyperechoic

34. Normal Morison’s Pouch
Free fluid in Morison’s Pouch

41. Peritoneal lavage fluid infused in 100 patients
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

42. Volume Assessment by US
Caveat to Branney study:
Artificial condition: infused fluid
Fluid in Morison’s after pelvis overflow
Tiling et al :
ml detected by US
Collection >0.5cm suggests over 500ml
Transvaginal/rectal
15ml of free intraperitoneal fluid

43. Detection of Fluid by Ultrasound
Affected by positioning
Location of bleed
Rate of bleeding
Operator Experience
Value of sensitivity of Ultrasound:
Detects clinically injuries
Non-detection of fluid
May indicate self- limited bleeding

44. All Fluid is not Blood Ascites Ruptured Ovarian Cyst Lavage fluid
Urine from ruptured bladder

45. Mimics of Fluid in RUQ Perinephric fat Abdominal inflammation
May be hypoechoic like blood
Usually evenly layered along kidney
If in doubt, compare to left kidney
Abdominal inflammation
Widened extra-renal space
Echogenicity of kidney becomes more like the liver parenchyma

46. Pitfalls RUQ Scanning too soon before enough blood has accumulated
Not attempting multiple probe placements
Not placing the probe cephalad enough to use the acoustic window of the liver
Scanning too soon before enough blood has accumulated
Not repeating the scan

47. LUQ Probe at left posterior axillary line Near ribs 9 and 10
Angle probe obliquely (avoid ribs)

48. LUQ Scan Plane More difficult
Acoustic window (spleen) is smaller than liver
Mild inspiration will optimize image
Bowel interference is common

49. LUQ Scan *
spleen * *
kidney *
*Splenorenal fossa – a potential space

50. Normal Spleno-renal view
Free fluid around spleen

56. To Evaluate the Thorax Move probe Image cephalad longitudinal Liver
Diaphragm
Pleural space

57. Hemothorax
liver
diaphragm
fluid

58. Small Pleural Effusion
Large Pleural Effusion

59. 240 trauma US study patients 26 had hemothorax ( CT or chest tube)
Ma O John, Mateer J, Trauma Ultrasound Examination Versus Chest Radiography in the Detection of Hemothorax
Ann Emerg Med: March 1997
240 trauma US study patients
26 had hemothorax ( CT or chest tube)
CXR and US
0 false positive
1 false negative
25 true positive
214 true negative

60. Pelvic View Probe should be placed in the suprapubic position
Either can be transverse or longitudinal
Helpful to image before placement of a Foley catheter

61. Pelvis (Long View)

62. Pelvis: Transverse

63. Normal Transverse pelvic
Fluid in pelvis

64. Pelvic View – Sagittal Fluid in front of the bladder
clot
bladder
Fluid in front of the bladder
If bladder is empty or Foley already placed:
Trick of trade
IV bag on abdomen
Scan through bag

65. Blood in the Pelvis

68. Free fluid in the pelvis

69. FAST Algorithm

70. Ultrasound in the Detection of Injury
From Blunt or Penetrating Thoracic
Trauma

71. Penetrating Thoracic Injury
Clinical challenge
Where is the penetration?
What was the weapon?
What was the trajectory?
What organ(s) have been injured?
Improved outcomes in patients with normal or near-normal vital signs

72. Penetrating Cardiac Trauma
Pericardial effusion
May develop suddenly or surreptitiously
May exist before clinical signs develop
Salvage rates better if detected before hypotension develops

73. Clinical Case
QD is 37 year old male brought in by EMS for ingesting entire bottle of unidentified red and white pills. In the ambulance bay he pulls out a knife and stabs himself in the left nipple.

74. Clinical Case Initial BP 116/72, pulse 109 RR 24. IV’s placed.
No JVD, Clear breath sounds, non tender abdomen
As CXR is about to be done, pulse increases to 134.
Bedside ultrasound is done while cartridge is developed.

75. Clinical Case

76. Clinical Case Patient is taken to the OR
Penetrating cardiac wound is repaired

77. Subcostal View Most practical in trauma setting
Away from airway and neck/chest procedures
Also called Sub-Xyphoid view

78. Subcostal View

79. Subcostal View

80. Pericardial Fluid
fluid

86. Occult Penetrating Cardiac Trauma
Observation unreliable
Subxiphoid window
Invasive
100% sensitive, 92% specific
Negative exploration rates (as high as 80%)
Ultrasound reliable indicator of even small pericardial effusion

87. 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: /- 5.9 min

88. Avoid Pitfalls
Normal echo does not definitively rule out major pericardial injury
Repeat echo with  clinical picture
Epicardial fat pad may easily be misinterpreted as “clot”
Hemothorax may be confused with pericardial effusion

89. Blunt Cardiac Trauma Basic Assessments Advanced Assessments
Pericardial effusion
Assess for wall motion abnormality
RV:
closest to anterior chest wall
Most likely to be injured
Advanced Assessments
Assess thoracic aorta – may need TEE to see all of thoracic aorta
Hematoma
Intimal flap
Abnormal contour
Valvular dysfunction or septal rupture

90. Blunt cardiac trauma Injuries difficult to assess by FAST
Valvular incompetence
Myocardial rupture
Intracardiac thrombosis
Ventricular aneurysm
Coronary Thrombosis
Intra-cardiac Thrombosis

91. “ 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”