Trauma sonography

外傷超音波簡介外傷超音波簡介

陳昭文醫師陳昭文醫師急診部外傷科急診部外傷科

高雄醫學大學附設中和紀念醫院高雄醫學大學附設中和紀念醫院

Trauma Service / KMUHTrauma Service / KMUH

• 及時而正確的診斷對嚴重外傷之病患是及時而正確的診斷對嚴重外傷之病患是絕對重要的絕對重要的……

• 我們常用的工具我們常用的工具 ::• Physical ExaminationPhysical Examination• DPLDPL• FASTFAST• Abdominal CTAbdominal CT

？？？？？？


Scenario XYScenario XY• 1919 歲男性因車禍受腹部鈍傷送入急診歲男性因車禍受腹部鈍傷送入急診 , , 血壓為血壓為

80/40 80/40 mmHg, mmHg, 心搏心搏 115, 115, 左上腹壓痛左上腹壓痛 ; ; 輸液輸液 20200000mlml 給予後血壓未見起色給予後血壓未見起色 , , 你接下來要安排的你接下來要安排的檢查是檢查是 ??


Scenario XXScenario XX

• 3131 歲女性於衝突受上腹部刀傷送入急診歲女性於衝突受上腹部刀傷送入急診 , , 血壓血壓為為 130/60 130/60 mmHg, mmHg, 心搏心搏 95, 95, 上腹稍微壓痛上腹稍微壓痛 ; ; 初級檢傷後初級檢傷後 , , 除上腹部五公分傷口外無其他外除上腹部五公分傷口外無其他外傷傷 ; ; 血壓仍然穩定血壓仍然穩定 , , 你接下來要安排的檢查是你接下來要安排的檢查是 ??


常用診斷工具常用診斷工具• DPLDPL• Sonographic survey (FAST)Sonographic survey (FAST)• CTCT


DPL DPL

• Diagnostic Peritoneal LavageDiagnostic Peritoneal Lavage• 腹膜腔內灌洗術腹膜腔內灌洗術

• 可近性高可近性高 , , 易於床邊施行易於床邊施行• 侵襲性檢查侵襲性檢查• 易有偽陽性易有偽陽性


Open method


• DPADPA

””A”A”

ClosedClosed

methodmethod


判讀方法判讀方法• Open and closed techniques Open and closed techniques • Catheter inserted into the abdomen, aspirate Catheter inserted into the abdomen, aspirate • Positive if gross blood, bile, food, stool Positive if gross blood, bile, food, stool • If aspirate negative, lavage with 1 liter NS If aspirate negative, lavage with 1 liter NS • positivepositive

• Lavage fluid Lavage fluid >> 100,000 RBC/mm 100,000 RBC/mm33, , • >>500 WBC/mm500 WBC/mm33, , • Bacteria on Gram stain Bacteria on Gram stain


Abdominal CTAbdominal CT

• Computed tomography, CAT scanComputed tomography, CAT scan• 需影像部門配合需影像部門配合 , , 檢查速度不一檢查速度不一• 重裝備重裝備 , , 可近性低可近性低• 亂槍射鳥亂槍射鳥 , , 一網打盡一網打盡 , , 敏感度高敏感度高


CAT scanCAT scan


FASTFAST

• FFocused ocused AAbdominal bdominal SSonography for onography for TTraumarauma• 輕裝備輕裝備 , , 易於使用易於使用• 檢查時間短檢查時間短• 解析度不佳解析度不佳• 受操作者個人經驗影響受操作者個人經驗影響


FASTFAST

• 主要搜尋腹腔內積液主要搜尋腹腔內積液• 對生命徵象不穩之病患對生命徵象不穩之病患 , , 先排除腹內出血與心先排除腹內出血與心

包填塞之可能包填塞之可能• Basic 4 viewsBasic 4 views

• 劍突下劍突下 Cardiac (subxyphoid) view Cardiac (subxyphoid) view • 右上腹右上腹 RUQ view (Morrison’s pouch) RUQ view (Morrison’s pouch) • 左上腹左上腹 LUQ view (splenorenal space) LUQ view (splenorenal space) • 骨盆腔骨盆腔 Suprapubic view (Cul-de-Sac)Suprapubic view (Cul-de-Sac)


TypicaTypical l 4 4

viewsviews



RUQ viewRUQ view

• Longitudinal scanLongitudinal scan• Transverse scanTransverse scan• Intercostal scanIntercostal scan• Hypochondral scanHypochondral scan

• Morison pouchMorison pouch• May observe pleural May observe pleural

spacespace


• 10% is identified with infusing 400ml 10% is identified with infusing 400ml salinesaline

• 97% is noted with infusing 1L saline 97% is noted with infusing 1L saline

Branney et al. J Trauma Branney et al. J Trauma 19951995


LUQ viewLUQ view

• Longitudinal scanLongitudinal scan• Transverse scanTransverse scan• Intercostal scanIntercostal scan• Hypochondral scanHypochondral scan

• Spleen may be obscured during deep Spleen may be obscured during deep inspirationinspiration

• May observe pleural space simultaneously May observe pleural space simultaneously


Same VictimSame Victim

Subcapsular hematoma Pleural Subcapsular hematoma Pleural effusioneffusion


Subxyphoid viewSubxyphoid view

• Pericardiac sacPericardiac sac• Echogenesity of Echogenesity of

bloodblood• Pericardial effusion?Pericardial effusion?• Heart movement?Heart movement?• Decompressive Decompressive

measuremeasure



Echo guided Echo guided pericardiocentesispericardiocentesis

• EquipmentEquipment• 16-gauge short-bevel large-bore needle16-gauge short-bevel large-bore needle• 30- or 50-mL syringe30- or 50-mL syringe• Echo- guidedEcho- guided• Local anesthesiaLocal anesthesia• Sterile supplies and povidone-iodine Sterile supplies and povidone-iodine

solutionsolution


Suprapubic viewSuprapubic view• Longitudinal scanLongitudinal scan• Transverse scanTransverse scan

• Best viewed under full bladderBest viewed under full bladder• Physiologic fluidPhysiologic fluid



Physiologic ascites massive pelvic Physiologic ascites massive pelvic fluidfluid


EFASTEFAST

• ExtendedExtended FAST scan FAST scan• Detect thoracic lesionDetect thoracic lesion

• Focus on occult Focus on occult pneumothorax (OPTX)pneumothorax (OPTX)

• Gliding pleura signsGliding pleura signs


Lung SlidingLung Sliding


• Lung pointLung point


HemothoraxHemothorax

• Right or left Intercostal viewRight or left Intercostal view• Subcostal viewSubcostal view


Blunt cardiac injuryBlunt cardiac injury

• Pericardial effusionPericardial effusion and and Wall motionWall motion• Valve injuries ( regurgitateValve injuries ( regurgitate ) )


FAST or not?FAST or not?• 100 victims of penetrating torso trauma assessed by our trauma 100 victims of penetrating torso trauma assessed by our trauma

teams. 48 stab wounds, 51 gunshot wounds, and 1 puncture teams. 48 stab wounds, 51 gunshot wounds, and 1 puncture wound..wound..

• The overall accuracy of the US examination in penetrating torso The overall accuracy of the US examination in penetrating torso trauma was 87%, with a sensitivity of 64% and a specificity of trauma was 87%, with a sensitivity of 64% and a specificity of 96%. The positive predictive value was 86% and negative 96%. The positive predictive value was 86% and negative predictive value was 87%... predictive value was 87%...

• The US examination lacks sensitivity to be used alone in The US examination lacks sensitivity to be used alone in determining operative interventiondetermining operative intervention……Rarely does US Rarely does US information contribute to the management of information contribute to the management of patients with penetrating abdominal injuriespatients with penetrating abdominal injuries

*A PROSPECTIVE EVALUATION OF ULTRASONOGRAPHY DIAGNOSIS OF PENETRATING *A PROSPECTIVE EVALUATION OF ULTRASONOGRAPHY DIAGNOSIS OF PENETRATING ABDOMINAL INJURY ABDOMINAL INJURY Dror Soffer MD, Mark McKenney et al. Ann Emerg Med 2003Dror Soffer MD, Mark McKenney et al. Ann Emerg Med 2003


FAST or not?FAST or not?• 149 patients with suspicion for abdominal trauma were 149 patients with suspicion for abdominal trauma were

evaluated…leaving 134 patients for analysis. evaluated…leaving 134 patients for analysis. • There were 111 true negative FAST exams, 5 true positives, 17 There were 111 true negative FAST exams, 5 true positives, 17

false negatives, and 2 false positives. false negatives, and 2 false positives. • Chi-square analysis showed significant discordance between Chi-square analysis showed significant discordance between

FAST and CT (p<0.001).FAST and CT (p<0.001).• Utilization of FAST as a screening tool for BAI in Utilization of FAST as a screening tool for BAI in

hemodynamically stable trauma patients results in hemodynamically stable trauma patients results in under-under-diagnosisdiagnosis of intraabdominal injury… of intraabdominal injury…

• Patients with suspected abdominal trauma Patients with suspected abdominal trauma should undergo routine CT scanning.should undergo routine CT scanning.

*Not So Fast! *Not So Fast! M.T. Miller, ND, M.D. Pasquale et al. J Trauma 2002M.T. Miller, ND, M.D. Pasquale et al. J Trauma 2002


PitfallPitfall• Operator-dependent: skillOperator-dependent: skill

• Reliable?Reliable?

• SensitivitySensitivity• Missed injuriesMissed injuries

• Pelvic fluid Pelvic fluid • Full BladderFull Bladder

• Serial examinationSerial examination• Delayed onsetDelayed onset

• Subcutaneous emphysema Subcutaneous emphysema • Gas blockGas block


The new ABCsThe new ABCs

• AAdmitdmit• BBeginegin• CCT scanT scan


如何運用工具如何運用工具 ??

• When?When?• Why?Why?• Why not?Why not?


DPLDPL

• WhenWhen• 需立即作需立即作 YESYES 或或 NONO 決定時決定時

• Hemodynamic instabilityHemodynamic instability

• 需進行大手術但無需進行大手術但無 CT CT 檢查時檢查時• Rare these daysRare these days

• 意識不清但需排除腸道損傷時意識不清但需排除腸道損傷時


DPLDPL

• WhyWhy• Quick decisionsQuick decisions• Looking primarily for gross bloodLooking primarily for gross blood


DPLDPL

• Why notWhy not• 為侵襲性檢查為侵襲性檢查

• Possible complicationPossible complication

• 非治療性開腹手術比率過高非治療性開腹手術比率過高• Non-therapeutic lap rate app 30%!Non-therapeutic lap rate app 30%!

• 對穩定血行之病患並不適合對穩定血行之病患並不適合


FASTFAST

• WhenWhen• 需立即作需立即作 YESYES 或或 NONO 決定時決定時

• Hemodynamic instabilityHemodynamic instability

• 穿刺傷之心包膜腔檢視穿刺傷之心包膜腔檢視• Detect for fluidDetect for fluid


FASTFAST

• WhenWhen• 69 69 patients with patients with initial BP< 90 mmHginitial BP< 90 mmHg• 22 with positive FAST22 with positive FAST

• 19(86%)needed a laparotomy19(86%)needed a laparotomy

• 47 with negative FAST47 with negative FAST• 0(0%) needed a laparotomy0(0%) needed a laparotomy

Wherrett LJ. J Trauma 1996


FASTFAST

• WhyWhy• 檢查迅速耗時短檢查迅速耗時短• 為非侵襲性檢查為非侵襲性檢查


FASTFAST

• WhyWhy• Can be done rapidly!Can be done rapidly!

• Positive FASTPositive FAST• Time required 19+/-5 sec.Time required 19+/-5 sec.• Just for internal bleeding or cardiac tamponadeJust for internal bleeding or cardiac tamponade

• Negative FASTNegative FAST • Time required 154+/-13 sec.Time required 154+/-13 sec.

Wherrett LJ. J Trauma 1996


FASTFAST

• Why notWhy not• 對穿刺傷敏感度不佳對穿刺傷敏感度不佳• 評估損傷不夠全面評估損傷不夠全面• 操作者水平影響判讀操作者水平影響判讀• 無法成為標準篩檢工具無法成為標準篩檢工具



• WhyWhy• 廣泛檢視腹部器官廣泛檢視腹部器官

• Solid organ, retroperitoneum, fluidSolid organ, retroperitoneum, fluid

• 敏感度高敏感度高• 非侵襲性非侵襲性


Accuracy Vs. SensitivityAccuracy Vs. Sensitivity

正確率正確率Accuracy Accuracy

敏感度敏感度SensitivitySensitivity

DPLDPL 98%98% 99%99%

FASTFAST 96%96% 75-93%75-93%

ABD CTABD CT 99%99% 99%99%


Portable CAT scanPortable CAT scan

HMC SeattleHMC Seattle



• WhenWhen• 不必考量時間因素不必考量時間因素• 廣泛損害評估是我們的目標廣泛損害評估是我們的目標• 病患需接受其他部位病患需接受其他部位 CTCT 檢查檢查• 穿刺腹部彈道之評估穿刺腹部彈道之評估



• Why notWhy not• 時間緊繃時間緊繃

• 病患生命徵象不穩病患生命徵象不穩作作 CTCT 耗時又冒險耗時又冒險• 腹膜炎癥象已現腹膜炎癥象已現

作作 CTCT 不影響不影響開刀之決定開刀之決定



• Why notWhy not• Multi-institutional study for small bowel Multi-institutional study for small bowel

injuryinjury• 13% without CT findings13% without CT findings• 21% with solid organ injuries21% with solid organ injuries• 33% with peritoneal signs33% with peritoneal signs

Fakhry J Trauma 2003


Digest time…Digest time…

• 了解各檢查工具的優缺點了解各檢查工具的優缺點• 避免無謂的時間浪費避免無謂的時間浪費• 正確的醫療處置正確的醫療處置


處理流程處理流程 AA

腹部穿刺傷

生命徵象不穩定腹膜炎 (+)

生命徵象穩定腹膜炎 (-)

開腹探查可能合併心臟外傷

穿刺傷或彈道需進一步探查

FAST Pericardial view

其他

CTYour

choice


ResuscitationOther injury?

開腹探查

處理流程處理流程 BB 腹部鈍傷生命徵象不穩定腹膜炎 (+/-)

FAST 優先無超音波 DPL

檢查結果 (+) 檢查結果 (-)


Solid organ injuryRetroperitoneal injury

ObservationLOCDPL

處理流程處理流程 CC腹部鈍傷


CT Scan

檢查結果 (-) 檢查結果 (+)

(-) OBS/Tx (+) Exp-lap?


Can you make your decision now?Can you make your decision now?Can you make your decision now?Can you make your decision now?


Scenario XXScenario XX

• 5252 歲女性因車禍受腹部鈍傷送入急診歲女性因車禍受腹部鈍傷送入急診 , , 血壓為血壓為80/40 80/40 mmHg, mmHg, 心搏心搏 115, 115, 左上腹壓痛左上腹壓痛 ; ; 輸液輸液 22000000mlml 給予後血壓未見起色給予後血壓未見起色 , , 你接下來要安排你接下來要安排的檢查是的檢查是 ??


ResuscitationOther injury?

開腹探查

處理流程處理流程 BB

腹部鈍傷生命徵象不穩定腹膜炎 (+/-)

FAST 優先無超音波 DPL

檢查結果 (+) 檢查結果 (-)

HemodynamicInstablity FAST

Free fluid(+)


Scenario XYScenario XY

• 3131 歲男性於衝突受上腹部刀傷送入急診歲男性於衝突受上腹部刀傷送入急診 , , 血壓血壓為為 130/60 130/60 mmHg, mmHg, 心搏心搏 95, 95, 上腹稍微壓痛上腹稍微壓痛 ; ; 初級檢傷後初級檢傷後 , , 除上腹部五公分傷口外無其他外除上腹部五公分傷口外無其他外傷傷 ; ; 血壓仍然穩定血壓仍然穩定 , , 你接下來要安排的檢查是你接下來要安排的檢查是 ??


處理流程處理流程 AA

腹部穿刺傷

生命徵象不穩定腹膜炎 (+)


開腹探查可能合併心臟外傷

穿刺傷或彈道需進一步探查

FAST Pericardial view

其他

CTYour

choice

Stable Vital signs


ConclusionConclusion

• Don’t get “Don’t get “ABCABC” syndrome” syndrome• Good Decision Good Decision Favorable outcome Favorable outcome• Good Practice Good Practice Favorable outcome Favorable outcome• Time pressureTime pressureBedside surveyBedside survey



Health & Medicine

Trauma sonography