Ultrasound in upper abdominal trauma

Bildgebende Verfahren: Röntgen, Ultraschall, CT, Nuklearmedizin

In der Intensivmedizin findet die radiologische Diagnostik überwiegend am Krankenbett statt (»bedside radiology«). Etwa 90 % der radiologischen Untersuchungen in der Intensiv- und Notfallmedizin stellen projektionsradiographische Röntgenaufnahmen des Thorax, des Abdomens und des Skelettsystems dar. In zunehmendem Maße werden neben den klassischen Aufnahmen auch die Schnittbildverfahren eingesetzt. Hier kommt der Ultraschalldiagnostik eine führende Rolle zu, gefolgt von der Computertomographie (CT).

Ultrasonography for Interval Assessment in the Nonoperative Management of Hepatic Trauma

Abdominal ultrasonography (US) is gaining widespread acceptance as a valuable diagnostic tool in the initial evaluation of trauma victims. We investigated the utility of US as a follow-up radiologic study in nonoperative hepatic trauma. Patients with liver injury designated for non-operative management were prospectively studied over a 2-year period at our primary adult resource center for trauma. Computed tomography (CT) and radiologist-performed US were obtained at admission and at 1 week. The ability of US to detect lesions, fluid, and complications was evaluated by comparing with the corresponding CT. Twenty-five hepatic trauma patients in the study were successfully managed nonoperatively and had both initial and follow-up US and CT scans: 1 (4%) grade I, 5 (20%) grade II, 7 (28%) grade III, 7 (28%) grade IV, and 5 (20%) grade V. Four complications developed [biloma (3) and biliary fistula (1)] in 3 patients with grade IV injury and 1 with a grade II injury. Interval US appropriately detected a complication or confirmed the absence of complication in all (13/13, 100%) patients with low-grade (I–III) injury and only missed a small biloma in one patient with a grade IV injury. Interval US and CT agreement was 92 per cent for change in hemoperitoneum or parenchymal lesion. Ultrasonography is a convenient imaging modality in the evaluation of hepatic trauma. US is sufficient to detect or exclude complications in low-grade injuries. In high-grade injuries, US may be an adjunct to CT for definitive interval assessment.

The Natural History of Untreated Penetrating Diaphragm Injury: An Animal Model

BACKGROUND

Surgical repair of diaphragm injuries is rather straightforward, but diagnosis can be difficult. The natural history of diaphragm injury is quite controversial. Undoubtedly, many diaphragmatic injuries are missed at the initial evaluation. Some theories state that diaphragm injuries do not heal, and that all eventually lead to herniation. Current theories regarding uniform herniation of all diaphragm injuries are not supported by animal models. The authors developed a penetrating diaphragm injury model to study the natural history of this injury.

METHODS

This study used 48 male Sprague-Dawley rats weighing 300-425 g. During the study, 24 of the rats received a 16-gauge needle puncture of the left diaphragm mimicking a small penetrating wound, whereas 24 of the rats received an injury produced with a 2.7-mm aortic punch, which created a defect comparable to a much larger penetrating wound. Half of the animals in each group were euthanized at 1 month, and the other half at 10 months. This allowed short- and long-term follow-up of the injuries. Gross inspection of the left diaphragm was performed after the animals were sacrificed via a thoracoabdominal incision. All diaphragms then were removed for examination.

RESULTS

All the rats experienced perioperative recovery. None of the 24 rats with a 16-gauge needle injury had an injury at 1 month (n = 12) or 10 months (n = 12). No patent injury was noted in the aortic punch injury group (n = 12) sacrificed at 1 month. At 10 months, 1 of 12 animals had a small hepatic herniation through the aortic punch injury. All the injuries displayed adhesions to the underlying left hepatic lobe.

CONCLUSIONS

The authors developed a penetrating diaphragm injury model to understand better the natural history of this injury. Spontaneous healing occurred in 98% of the animals. In this animal model, because the left lobe of the liver is present beneath the left diaphragm, healing without herniation usually occurs. A role may exist for nonoperative treatment of human right diaphragm injuries in clinical practice. This animal model may prove useful in further defining future management for these injuries.

Diaphragmatic rupture and the association with occupant position in right-hand drive vehicles

Ruptured diaphragm following blunt trauma occurs with an incidence of 3 to 8% with right-sided rupture recognised with increasing frequency. This study aimed to investigate the influence of occupant position in right-hand drive (RHD) vehicles on the side of diaphragmatic injury. A retrospective analysis of the Scottish Trauma Audit Group database was performed to gather data on blunt diaphragmatic lacerations. Police records were also searched to ascertain the point of impact in the accidents studied. In total, 35 patients were studied, 25 drivers and 10 front-seat passengers. The incidence of right-sided rupture was 40% in drivers and 20% in FSPs. The incidence of associated pulmonary contusion, rib fracture and liver injury was also higher in drivers. Given the small sample size, these differences were not statistically significant, but they show an interesting trend. The right side of a driver's body is more exposed to injury in RHD vehicles, a fact that explains the significant association between driver's side impact and right-sided rupture. As right-sided injury is more difficult to detect, it is important that a high index of suspicion is maintained, especially when managing drivers from RHD vehicles.

New concepts in the management of patients with penetrating abdominal wounds

In the future, trauma research and care will have to become better, faster, and less expensive. Surgeons in the next millennium must be able to diagnose wounds, initiate correct procedures, and anticipate complications more accurately than before. Violent crime will not abate, nor will the proliferation of more powerful arms; these trends translate into graver traumatic wounds, giving the operating team less time to stabilize patients. Time management and team coordination are becoming key elements for patient survival, especially for patients with potentially fatal wounds, such as those to the heart. The authors have reduced the time from arrival to surgery to a few minutes. The keys to this feat are readiness, team coordination, and high morale. Financial resources will continue to be limited and allocated on a need-first basis. In the future, trauma centers will compete for dwindling funds. Technology is and always will be just a tool, whereas qualified trauma surgeons are irreplaceable, much more so than in any other surgical specialty. Observation, diagnosis, and surgery are, of course, greatly facilitated by ever-evolving technology, but since the time of Hippocrates, split-second decisions can ultimately be made only by the caregiver in the white smock. Trauma surgeons in the next millennium will have to exercise judgment based on knowledge, surgical skills, and contact with patients. To err is human, but in surgery, errors often cause death, and no machine will ever relieve surgeons of that burden.

Sonographic assessment of traumatic injury. Future developments

In all its forms and applications, sonography plays a significant role in the management of injured patients, from the emergency department to beyond hospital discharge. The use of new and existing sonographic technology will increase because sonographic imaging and measurements are generally less invasive; are inexpensive; use no ionizing radiation; and are portable, repeatable, and, in many instances, as accurate as the so-called "contemporary gold standards." The training and credentialing of physicians in sonography is in evolution and will be an increasingly important issue with more widespread use and broader applications. The future of sonography in trauma care in the next millennium is bright, and surgeons and surgical residents are encouraged to gain proficiency and learn about this new surgical frontier as it evolves.

An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. Focused Assessment for the Sonographic Examination of the Trauma patient

BACKGROUND

The Focused Assessment for the Sonographic Examination of the Trauma patient (FAST) sequentially surveys for the presence or absence of blood in dependent abdominal regions including the right upper quadrant, left upper quadrant, and the pelvis. But it does not readily identify intraparenchymal or retroperitoneal injuries, and a CT scan of the abdomen may be needed to reduce the incidence of missed injuries. We hypothesized that select patients who are considered high risk for occult injuries should undergo a CT scan of the abdomen when the FAST is negative so that occult injuries can be detected.

STUDY DESIGN

An algorithm was prospectively tested for the evaluation of select injured patients over a 3 1/2-year period. Entrance criteria included adult patients with a blunt mechanism of trauma, a negative FAST examination, and a spine fracture (with or without cord injury), or a pelvic fracture. Trauma team members performed the FAST on patients during the Advanced Trauma Life Support secondary survey. Data recorded included the patient's mechanism and type of injury, the results of the FAST and CT scan examinations, operative or postmortem findings or both, and patient outcomes. Patients with spine injuries were grouped according to spine level and the presence or absence of neurologic deficit. The patients with pelvic fractures were grouped according to the Young and Resnick classification.

RESULTS

One hundred two of 1,490 patients (6.8%) who had FAST examinations were entered into this study. Thirty-two patients (30.5%) had spine injuries, with only one false-negative ultrasound result. Seventy patients (68.6%) had pelvic fractures with 13 false-negative ultrasound results: 11 ring (9 from motor vehicle crashes, 2 from pedestrians struck), 1 acetabular, and 1 isolated pelvic fracture. Nine patients underwent nonoperative management for solid organ injuries, and 4 patients needed surgery.

CONCLUSIONS

Based on these preliminary data, we conclude that patients with pelvic ring-type fractures should have CT scans of the abdomen because of the higher yield for occult injuries.

Hyperechoic appearance of hepatic parenchyma on ultrasound examination of patients with blunt hepatic injury

OBJECTIVE

To study the significance of a geographic hyperechoic liver parenchyma pattern on ultrasound (US) examination of patients with blunt abdominal injury.

DESIGN

Prospective clinical study with double-blind evaluation of images and clinical data.

METHODS AND MAIN RESULTS

We performed US examinations in 831 consecutive patients admitted to our hospital for blunt abdominal trauma and identified 33 with a geographic hyperechoic pattern in the liver. We correlated the appearance with computed tomographic images and with clinical, angiographic, and scintigraphic data. All patients with a geographic hyperechoic pattern showed mild computed tomographic evidence of hepatic injury (Mirvis grade 2, 69%; Mirvis grade 3, 31%). Excluding patients who required urgent surgery for other reasons and patients in shock, patients with the geographic hyperechoic pattern were managed conservatively with no complications.

CONCLUSION

The geographic hyperechoic pattern of liver parenchyma on US examination of trauma patients is a mild injury that, of itself, does not require surgical therapy.

Diaphragmatic injuries

A 6-year series of 26 patients with diaphragmatic injury is presented, 15 with rupture from blunt injuries and 11 after penetrating injuries. All had associated injuries and seven died because of these. The diagnosis may be difficult and was consequently delayed in two patients. Eleven ruptured diaphragms were diagnosed before operation, 14 on the operating table and one at autopsy (dead on arrival). Herniation of abdominal organs was seen in nine of 15 patients after blunt injuries. In most patients repair was via laparotomy using absorbable sutures. It is still essential that the surgeon should be aware of the possibility of the diagnosis and the associated severe injuries.

Thoracic sonography for diagnosis and intervention

Many physicians believe that ultrasound has limited usefulness in chest disease. Our clinical experiences and a review of the literature in preparation for this monograph have convinced us that sonography can be a very useful and versatile tool for thoracic diagnosis and intervention. Although there are some limitations caused by interposed ribs and air-containing lung, almost all of the compartments of the chest can be evaluated with ultrasound, which gives unique and clinically useful information. Ultrasound guidance for biopsy and drainage does take some time to learn, but we feel that the effort is very worthwhile. The same advantages ultrasound enjoys for other body regions make it a modality that will see increased use in the chest as well. We hope that this monograph will stimulate our colleagues to explore and expand upon the techniques described.

Abdominal ultrasonography in trauma

The use of ultrasonography for the investigation of urgent diagnostic dilemmas is by no means new. Although it has been widely used for almost 40 years, during the past two decades ultrasonography has achieved a primary role in Europe and Asia in the investigation of emergent conditions such as trauma. The use of this bedside diagnostic modality is expanding rapidly and will continue to do so. Emergency physicians have developed a fellowship program in emergency ultrasonography, have set forth a model curriculum for physician training in emergency ultrasonography, and have begun to conduct hands-on courses for academic emergency physicians. Because diagnostic ultrasonography has proven to be of value in the diagnosis and management of a variety of emergent conditions, ultrasound examination, interpretation, and clinical correlation should be immediately available around the clock in resuscitation areas. It is hoped that (1) ultrasound training will be incorporated into general surgical residency programs, (2) ultrasound curriculum and credentialing processes will be established, and (3) more surgeons will have this modality available to them as part of their diagnostic armamentarium in the evaluation of injured patients.

Isolated blunt rupture of the infrarenal inferior vena cava: the role of ultrasound and computed tomography in an occult injury

A case of isolated blunt rupture to the infrarenal vena cava secondary to assault is reported. This case report is presented to heighten awareness of an unusual presentation of this potentially lethal injury and to emphasize that diagnostic modalities may offer subtle or indirect indications of an injury that, when coupled with clinical signs and symptoms, prompt surgical intervention necessary for patient salvage.

Spleen Injury in Sports

In brief Following injury, stabilized patients who might have suffered significant trauma to the spleen require ongoing clinical assessment coupled with radiographic imaging. CT is the initial method of choice, although radionuclide scintigraphy may be indicated for pregnant patients and for those who have an iodine allergy. The roles of ultrasound, angiography, and abdominal plain film radiography are limited. Abnormalities demonstrated on contrast-enhanced CT studies include spleen laceration, subcapsular hematoma, and hemoperitoneum. Radionuclide scintigraphy will help diagnose splenosis.

The role of early sonography in the management of the acute abdomen

A prospective study was set up in a busy teaching hospital to evaluate the role of a 24 h emergency ultrasonography service in patients presenting with acute abdominal pain. Seventy-five patients due for admission via the accident and emergency department with acute onset of upper or lower abdominal pain were imaged at the request of our surgical colleagues. In 14 patients (18.7%), a diagnosis was made up by sonographic examination which had not been clinically expected. Twelve of this group were female with gynaecological pathology and all 14 had their proposed emergency surgery deferred following the sonographic examination. In 26 patients (34.7%), sonography confirmed the first diagnosis suspected clinically and in nine cases (12%) confirmed the second or third differential diagnosis. Sonography made no contribution to the diagnosis in 24 patients (32%) and in two cases (2.6%) was considered misleading. The results of this study demonstrate that emergency ultrasonography is most useful in the diagnosis of female patients presenting with mid to lower abdominal pain.

Sonographic Spectrum of Focal Splenic Lesions

Sonograms of 50 patients with a clinical suspicion of splenic abnormality were reviewed. With the use of high-resolution static and real-time equipment, combined with variable patient positioning, focal splenic lesions were well imaged. A wide variety of pathologic entities was sonographically demonstrated, including traumatic hematomas, primary and metastatic neoplasms, cysts, infarcts, and inflammatory granulomas.