ULTRASOUND IN TRAUMAPetra Duran-Gehring, M.D.

University of Florida- Jacksonville

Objectives

Describe the indications and limitations of bedside ultrasound in trauma

Define the relevant local anatomy Understand the ultrasound protocol used

in the setting of trauma Recognize the relevant findings and

pitfalls in the detection of hemoperitoneum, hemopericardium and hemothorax

History

1970s: US first used to evaluate trauma patients in Europe

1980s: FAST replaces DPL in most trauma centers

1988: German Surgery Board requires US certification

1997: FAST included in ATLS course 2001: US training required in EM

residencies

Radiologic Evaluation in Trauma CT: non-invasive, gives detail about

organs DPL: most sensitive, invasive US: non-invasive, can detect 250cc of

free fluid in Morrison’s Pouch

What is FAST?

Focused

Assessment with

Sonography in

Trauma

Objective: Detection of

intra-abdominal free fluid

Detection of pericardial fluid

E-FAST: detection of hemothorax and pneumothorax

FAST

Benefits Performed rapidly Noninvasive Inexpensive Easily repeatable Highly specific for

therapeutic laparotomy

Limitations Obesity Subcutaneous

emphysema Non-specific

Indications

Rapid detection of: Hemoperitoneum Pericardial Effusions Pleural Effusions

Abdominal Trauma Chest Trauma

Abdominal Trauma

Blunt trauma Most widely studied Intraperitoneal bleeding due to splenic or

liver injury Penetrating trauma

50% sensitivity for determining the need for laparotomy

Doesn’t detect bowel injury Can still determine hemoperitoneum

Chest Trauma

Penetrating trauma Pericardial Effusion

Pericardium seals self creating effusion leading to tamponade

US identifies prior to Beck’s triad Screening exam for effusion

Hemothorax US more sensitive than CXR (20ml vs. 200ml for

detection) Extended FAST for pneumothorax, sensitive for

supine pts Blunt trauma

May determine cardiac rupture

Why FAST works

Fluid pools in predicable locations Subhepatic Perinephric Perisplenic Pelvic Subpleural

Position patient to best locate fluid Trendelenburg for upper quadrants Reverse trendelenburg for pelvis

FAST Anatomy

Phrenicolic

Ligament

Transverse Colon Mesentery

Morrison’s Pouch

Pelvis

Equipment

Probe 2-5 MHz Curved array Small footprint

Machine Maneuverable Color flow Doppler

FAST Components

Right Upper Quadrant

Left Upper Quadrant

Cardiac Subxiphoid Parasternal long

axis Suprapubic Extended FAST

Lung fields

Right Upper Quadrant

Position Probe placed with

indicator to pt’s head Probe placed around 8-

11th rib space, mid axillary line

May need to slide probe around rib shadow

Do not forget to interrogate inferior pole of kidney

RUQ

Liver

KidneyDiaphragm

Morrison’s Pouch

RUQ

Includes Liver Kidney Morrison’s pouch Diaphragm (E-FAST)

Look for: Fluid in Morrison’s pouch Lack of mirror artifact

Normally diaphragm acts as mirror, liver appears to be on either side

Indicates pleural fluid

RUQ Free Fluid

Intraperitoneal fluid Morrison’s Pouch Along the lower edge of

the liver Superior to liver

Pleural fluid Lack of mirror artifact Lung appears to float

with inhalation

RUQ Free Fluid

RUQ Free Fluid

Left Upper Quadrant

Position Probe placed with

indicator to pt’s head Probe placed around 6-

9th rib space, mid axillary line

May be difficult to achieve due to rib shadow

Ask pt to inhale deeply to displace anatomy inferiorly

LUQ

Kidney

Spleen

Diaphragm

LUQ

Includes Spleen Kidney Diaphragm (E-FAST)

Look for:

Fluid in spleenorenal fossa

Fluid inferior to spleen Lack of mirror artifact

LUQ Free Fluid

Intraperitoneal Fluid Splenorenal fossa Inferior to inferior pole of

spleen Superior to spleen

Pleural Fluid Lack of mirror artifact Lung floating with

inspiration

Cardiac View

May use either: Subxiphoid Parasternal long axis

Look for Cardiac activity Pericardial effusion RV collapse

Cardiac Limitations

View dependant on patient habitus and condition

Subxiphoid better COPD

Parasternal better Pregnancy Obesity Abdominal pain

Subxiphoid View

Position Probe placed in

epigastrium Probe indicator to

patient’s right Probe tip pointing

to pt’s left shoulder

Increase depth

Subxiphoid View

Four chamber view

Apex to right of screen

Left side at bottom of screen

Liver

RA

LA

LV

RV

Mitral Valve

Bicuspid Valve

Subxiphoid View

LV

LA

RA

RV

ApexLiver

Subxiphoid View

Parasternal View

Probe placed to the left of the sternum at 2-4th intercostal space

Long Axis Probe indicator to

patient’s right shoulder

Sagital plane

Parasternal Long Axis View

Three chambers in view LV LA RV

Aortic Root Valves

Mitral Aortic

LALV

RV

Mitral Valve

Aortic Outflow Tract

Aortic Valve

Parasternal Long Axis View

LV

RV

LA

Aortic root

Parasternal Long Axis View

Pericardial Effusion

Pericardial Effusion

Pericardial Tamponade

RV collapse

Pericardial Tamponade

RV collapse

Suprapubic

Position Transverse

Probe in the midline just cephalad to the pubic bone

Probe indicator pointed to pt’s right

Longitudinal Probe in the midline

just cephalad to the pubic bone

Probe indicator pointed to pt’s head

Suprapubic

Identify Bladder Uterus in women Pouch of Douglas

Look for Fluid: Men: posterior to bladder Women

Vesicouterine space Posterior to uterus

(Pouch of Douglas) Sharp edges indicate

fluid outside of bladder

Suprapubic

Bladder

Uterus

Bladder

Pouch of Douglas

Pouch of

Douglas

Pelvic Free Fluid

Posterior to bladder

Pelvic Free Fluid

Pouch of Douglas

Extended FAST

Addition to 4 view FAST exam Includes evaluation for hemothorax and

pneumothorax Two additional components

Expand UQ views to visualize diaphragm Lack of mirror artifact indicates

fluid/hemothorax Scan anterior chest

Lack of lung slide indicates pneumothorax

Hemothorax

Includes Liver or spleen Kidney Diaphragm

Look for: Lack of mirror

artifact Normally

diaphragm acts as mirror, liver appears to be on either side

Indicates pleural effusion

Hemothorax

Hemothorax

diaphragm

lung

Pneumothorax (ptx)

Occurs in 15-50% of pts with chest trauma Supine CXR

Misses up to 1/3 of all pneumothoraces Only 50-70% sensitive at detection ptx Inaccurate for anterior ptx due to air layering

Ultrasound Detects small or anterior ptx Sensitivity 92-100% (equal to CT scan) Negative predictive value 99-100%

Pneumothorax

Use high frequency linear probe (5-10 MHz)

Place probe on anterior chest wall, indicator to pt’s head

Slide down chest wall to interrogate each rib interspace

Lung Fields

Includes Rib with shadow Subcutaneous tissue

and muscle Pleura

Look for: Slide of the pleura Lack of sliding indicates

pneumothorax

Lung Anatomy

ribrib

pleura

Pneumothorax

Watch for slide of the pleura

Lack of sliding indicates pneumothorax B-Mode: direct

visualization M-Mode: “sandy

beach” May see the

leading edge of pneumothorax

Normal Lung Slide

Pneumothorax: no slide

Lung Slide

Normal Lung Pneumothorax

M-Mode

Normal Pneumothorax

“sandy beach” “bar code”

Other US Uses in Trauma

Diaphragmatic injury Evaluated using M-Mode Watch for motion

Fractures Can be used for closed reduction

Ocular

Fracture

Look for the hyperechoic bone with distal shadowing

Look for a disruption in the bony cortex

Subtle fractures on X-ray, more obvious on US

Fracture

Bone

Fracture

Ocular

Increased ICP Measure optic

nerve diameter Papilledema Retinal

Detachment Foreign Body

Ocular

Retina

Lens

Anterior Chamber

Optic Nerve

Increased ICP

Measure the optic nerve Measure 3mm

down from retina Measure diameter

of nerve at that point

Measurements greater than 5mm indicate increased ICP (>20mmHg)

Papilledema

Retinal Detachment

CASES

Case 1

18 y/o male unrestrained driver in high speed MVC

Arrived in c-collar and backboard with NRBM in place

Vitals: BP 84/41, P 121, R 30 & shallow, Pox 99% on NRBM

Case 1

PE: Moaning incoherantly, GCS 14 HEENT: PEERL 4mm, multiple facial lacs,

midface stable CHEST: decreased BS on R, no crepitus ABD: multiple abrasions, diffuse TTP EXT: pelvis stable, multiple abrasions, no

obvious deformity 2 large bore IVs placed Bedside US performed

Case 1 FASTRUQ LUQ

PELVISSUBX

Case 1 Chest US

Case 1

Chest tube was placed on R with a rush of air

Pt remained hypotensive and went to OR Found to have splenic lac and spleen

removed Admitted to trauma ICU

Case 2

84 y/o female restained driver in side impact MVC at 50mph

C/o pain in abd and L hip Arrives in full spine immobilization and

traction splint to L leg VS: BP 90/50, P 60, R 20, Pox 100% RA

Case 2

PE: GCS 15 HEENT: PEERL 4mm, NCAT CHEST: equal BS B, non labored ABD: Linear abrasion with ecchymosis

across abd, diffuse TTP EXT: pelvis stable, L femur TTP with

shortening and internal rotation 2 large bore IVs placed Bedside US performed

Case 2 FAST

RUQ LUQ

PELVIS SUBX

Case 2 L Femur US

Case 2

BP improved after IV fluids Ortho was consulted and placed a

traction pin for the proximal femur fracture

CT scan of the abdomen revealed a grade 1 liver laceration

Pt was admitted and the laceration was monitored but did not require surgery

Questions?????