Ultrasound as used in thoracoabdominal trauma

Ultrasonography in trauma: a nation-wide cross-sectional investigation

BACKGROUND

The Focused Assessment with Sonography in Trauma (FAST) protocol is considered beneficial in emergent evaluation of trauma patients with blunt or penetrating injury and has become integrated into the Advanced Trauma Life Support (ATLS) protocol. No guidelines exist as to the use of ultrasonography in trauma in Denmark. We aimed to determine the current use of ultrasonography for assessing trauma patients in Denmark.

METHODS

We conducted a nation-wide cross-sectional investigation of ultrasonography usage in trauma care. The first phase consisted of an Internet-based investigation of existing guidelines, and the second phase was a series of structured interviews of orthopedic surgeons, anesthesiologists, and radiologists on call in all hospitals receiving traumatized patients in Denmark.

RESULTS

Guidelines were obtained from all 22 hospitals receiving traumatized patients in Denmark. Twenty-one (95.5%) of the guidelines included and recommended FAST as part of trauma assessment. The recommended person to perform the examination was the radiologist in n = 11 (50.0%), the surgeon in n = 6 (27.3%), the anesthesiologist in n = 1 (4.5%), and unspecified in n = 3 (13.6%) facilities. FAST indications varied between circulatory instability n = 8 (36.4%), team leader's discretion n = 6 (27.3%), abdominal trauma n = 3 (13.6%), and not specified n = 6 (27.3%). Telephone interviews revealed that exams were always n = 8 (36.4%) or often n = 4 (18.2%) registered in the patients' charts. The remaining n = 10 (45.5%) facilities either never registered n = 2 (9.1%), it was not possible to register n = 1 (4.5%), or unknown by the trauma leaders n = 7 (31.8%). Images were often stored in n = 1 (4.5%), never stored in n = 10 (45.5%), not possible to store in n = 2 (9.1%), and unknown in n = 9 (40.9%) facilities.

CONCLUSION

Ultrasonography was used in a non-uniform fashion by multiple specialties in Danish trauma facilities. Very few images from FAST examinations were stored and documentation was scanty. National guidelines on application and documentation of ultrasonography in trauma are called for.

Double jeopardy revisited: clinical decision making in unstable patients with, thoraco-abdominal stab wounds and, potential injuries in multiple body cavities

INTRODUCTION

In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult.Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy.

METHODS

All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death.

RESULTS

Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18–40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80–90 mm Hg). Median base excess was 6.5 (quartile range 12 to 2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group.

CONCLUSION

Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.

Sonographic optic nerve sheath diameter as an estimate of intracranial pressure in adult trauma

BACKGROUND

Intracranial pressure (ICP) is currently measured with invasive monitoring. Sonographic optic nerve sheath diameter (ONSD) may provide a noninvasive estimate of ICP. Our hypothesis was that bedside ONSD accurately estimates ICP in acutely injured patients. The specific aims were (1) to determine the accuracy of ONSD in estimating elevated ICP, (2) to correlate ONSD and ICP in unilateral and bilateral head injuries, and (3) to determine the effect of ICP monitor placement on ONSD measurements.

MATERIALS AND METHODS

A blinded prospective study of adult trauma patients requiring ICP monitoring was performed at a University-based urban trauma center. The ONSD was measured by ultrasound pre- and post-placement of an ICP monitor (Camino Bolt or Ventriculostomy).

RESULTS

One-hundred fourteen measurements were obtained in 10 trauma patients requiring ICP monitoring. Pre- and post-ONSD were compared with side of injury in the presence of an ICP monitor. ROC analysis demonstrated ONSD poorly estimates elevated ICP (AUC = 0.36). Overall sensitivity, specificity, PPV, NPV, and accuracy for estimating ICP with ONSD were 36%, 38%, 40%, 16%, and 37%. Poor correlation of ONSD to ICP was observed with unilateral (R(2) = 0.45, P < 0.01) and bilateral (R(2) = 0.21, P = 0.01) injuries. ICP monitor placement did not affect ONSD measurements on the right (P = 0.5), left (P = 0.4), or right and left sides combined (P = 0.3).

CONCLUSIONS

Sonographic ONSD as a surrogate for elevated ICP in lieu of invasive monitoring is not reliable due to poor accuracy and correlation.

Ultrasonographic applications after mass casualty incident caused by Wenchuan earthquake

BACKGROUND

Ultrasonography has been widely applied in clinical settings, and its role in the assessment of trauma has been approved. However, there are very few reports about its role in the management of mass casualties.

METHODS

In our hospital, we retrospectively analyzed the application, the methods, and the role of ultrasonography in rescuing the Wenchuan earthquake victims.

RESULTS

On a total of 3,307 wounded patients, 1,207 were examined by ultrasonography, and on a part of them, a follow-up was also performed. A total number of 1,386 ultrasound examinations were performed. Among them, 115 patients received ultrasound-guided interventional diagnosis and treatments. Ultrasound screening detected 23 cases of hemoperitoneum, 45 cases of pleural effusion (blood), 1 case of traumatic intimal tear of femoral artery, 3 cases of deep veins phlebothrombosis of lower limbs, 12 cases of deep-part hematoma of soft tissues. In five cases of negative results by ultrasonography, visceral injury was confirmed later by surgery or computed tomography or contrast-enhanced ultrasonography. All the ultrasound-guided interventional treatments were performed successfully, without any serious complication. The detection rate of trauma-related diseases was 6.96% (84 of 1,207) without false positive; however, the false negative rate was 5.6% (5 of 89). The bedside ultrasound became the preferred examination for the majority of injuries in middle and later stage after earthquake (72 hours to 6 weeks), accounting for 73.9% (458 of 620) of examinations. Ultrasonography-based FAST method was the primary examination tool of trauma in the early stage after earthquake.

CONCLUSION

In our hospital, ultrasonography was widely used in the triage of earthquake victims, bedside examination of severe cases, and interventional treatments. The advantages of ultrasonography such as convenience, noninvasiveness, high accuracy, and repeatability have been sufficiently demonstrated in this mass casualty, where ultrasonography played a great role in the rescue of victims of Wenchuan earthquake.

Bedside Ultrasonography in the ICU

This is the second of a two-part review on the application of bedside ultrasonography in the ICU. In this part, the following procedures will be covered: (1) echocardiography and cardiovascular diagnostics (second part); (2) the use of bedside ultrasound to facilitate central-line placement and to aid in the care of patients with pleural effusions and intra-abdominal fluid collections; (3) the role of hand-carried ultrasound in the ICU; and (4) the performance of bedside ultrasound by the intensivist. The safety and utility of bedside ultrasonography performed by adequately trained intensivists has now been well demonstrated. This technology, as a powerful adjunct to the physical examination, will become an indispensable tool in the management of critically ill patients.

Early evaluation and resuscitation of the pediatric trauma patient

Trauma is the leading case of death for children in the United States. Effective initial resuscitation of pediatric trauma patients can reduce mortality. Guidelines have been developed to facilitate patient care in a systematic and productive manner. Advances have been made in both diagnostic and therapeutic methods. The evaluation and treatment of trauma patients will continue to engage pediatric surgeons as efforts in trauma prevention become more successful.

Current use and perceived utility of ultrasound for evaluation of pediatric compared with adult trauma patients

OBJECTIVE

The objective of this study was to evaluate the current use and perceived utility of ultrasound in the assessment of pediatric compared with adult trauma patients.

METHODS

A questionnaire was developed and mailed to 72 pediatric emergency physicians, 120 general emergency physicians, and 117 trauma attendings at 240 institutions.

RESULTS

Of 309 surveys, 234 (75%) were completed. Ultrasound was available to 169 of 234 (72%) of the physicians, and 122 of 169 (72%) were performing the Focused Assessment by Sonography for Trauma examination to evaluate trauma patients. Seventy-three percent (110/150) of general emergency and trauma surgeons reported that ultrasound was available equally with or more readily than computed tomography (CT) scan. Only 26% (5/19) of pediatric emergency attendings considered ultrasound equally available with CT scan, and none considered it more readily available than CT scan. Ninety-two percent (137/149) of general emergency and trauma attendings responding to the question about utility considered ultrasound somewhat useful to extremely useful for assessing adult trauma patients, and 77% considered it useful for pediatric patients. Only 57% (12/21) of pediatric emergency attendings responding to the same question perceived ultrasound as useful for pediatric trauma evaluations.

CONCLUSIONS

We conclude that ultrasound for the assessment of trauma patients is widely used by general emergency physicians and trauma surgeons, whereas pediatric emergency physicians report less use and perceived utility.

Aeromedical trauma sonography by flight crews with a miniature ultrasound unit

BACKGROUND

While ultrasound has become an established diagnostic modality in trauma care, no study has evaluated its use in the prehospital setting.

OBJECTIVE

To examine the use of the focused abdominal sonography for trauma (FAST) exam in the prehospital setting.

METHODS

After a three-hour training session in the FAST exam, the nonphysician flight team of an emergency medical services (EMS) helicopter program attempted a FAST exam on trauma patients to determine the feasibility of such an intervention.

RESULTS

The majority (83%) of the 71 patients entered suffered blunt trauma. FAST exams could not be performed in 34 patients (48%) due to insufficient time (67%), inadequate patient access, or combativeness. Technical difficulties (difficult screen visualization due to ambient lighting, battery failure, and machine malfunction) prevented scanning in seven (19%) of the 37 in whom it was attempted. In those in whom scanning was successful, the pelvic view was most commonly obtained followed by the right upper quadrant (RUQ) and left upper quadrant (LUQ).

CONCLUSION

Significant advances in training, technology, and/or patient access will be necessary for aeromedical FAST to be feasible.

The routine use of sonography in penetrating torso injury is beneficial

BACKGROUND

Torso sonography (focused assessment with sonography for trauma [FAST]) has been added to our protocols for the evaluation of penetrating torso injury. The purpose of this study was to evaluate our recent experience and determine whether the use of FAST is beneficial.

METHODS

From January 1999 to January 2000, patients with penetrating torso injury and no clinical indication for surgery were evaluated by sonography with a selective use of other investigations. FAST consisted of sonographic views of the peritoneum and/or pericardium to determine the presence or absence of fluid.

RESULTS

During the study period, there were 238 victims of penetrating injury assessed by our trauma service, and sonography was performed in 72 (30%) patients as per our protocols. There were 31 stab, 37 gunshot/shotgun and, and 4 puncture wounds. Thirty-eight patients had peritoneal views, 6 patients had pericardial views, and 28 patients had both pericardial and peritoneal views obtained. Thirteen of 66 patients had free fluid in the peritoneal cavity and 12 of the 13 patients had a therapeutic laparotomy. No peritoneal fluid was seen in 53 of 66 patients, of whom 6 had abdominal injuries, 5 requiring surgery for diaphragm or bowel injuries. The sensitivity of FAST alone for abdominal injury was 67%, specificity was 98%, positive predictive value was 92%, and negative predictive value was 89%. Pericardial fluid was seen in 3 of 34 patients; one had a heart wound and two had negative pericardial windows. All 31 patients without pericardial fluid recovered without surgery.

CONCLUSION

The routine use of sonography in penetrating torso injury is beneficial. The detection of pericardial or peritoneal fluid is clinically useful. However, a negative FAST examination does not exclude abdominal injury, such as a diaphragm or hollow viscus wound, and further investigation or close follow-up is required.

Penetrating stab wounds to the abdomen: use of serial US and contrast-enhanced CT in stable patients

PURPOSE

To evaluate the usefulness of computed tomography (CT) and ultrasonography (US) for the initial assessment of penetrating abdominal stab wounds in patients who presented to the emergency department without indication for immediate laparotomy.

MATERIALS AND METHODS

During 36 months, 32 patients with a penetrating stab wound to the abdomen were examined with serial US (at admission and 12 hours later) and helical CT, with contrast material administered orally, intravenously, and rectally. Presence of hemoperitoneum and integrity of solid and hollow viscera were evaluated with both methods. Sonograms were interpreted by the radiologist who performed the examination, and CT images were independently evaluated by two radiologists. Findings of both techniques were compared with clinical outcome and/or surgical findings.

RESULTS

One (3.1%) of 32 patients required surgery: Surgical findings were massive hemoperitoneum and an extensive hepatic laceration. Both US and CT depicted these abnormalities. Thirty-one (96.9%) patients were treated conservatively, without surgery, and remained asymptomatic during 28 days of clinical follow-up after discharge from the hospital. US and/or CT showed intraperitoneal abnormalities in 21 of these patients. In 11 patients, both methods showed no evidence of visceral injury or hemoperitoneum, and none of these patients required surgery.

CONCLUSION

Serial US and CT help guide treatment for stable patients with penetrating stab injuries to the abdomen.

Non-operative management of solid organ trauma in children

Trauma is the commonest cause of mortality in infancy and childhood. Injuries from blunt trauma predominate, with multisystem injury, the rule. Blunt abdominal injury represents the third commonest cause of death from injury in this age group.

Initial management of the child combines assessment and resuscitation. If the child’s condition is stable then the injured organ should be definitively identified, usually by computerized tomography. Over 90% of children who are stable at this point can be managed conservatively, with a period of observation on an intensive care unit, followed by bed rest on a general ward. Instability at any point requires further resuscitation, reassessment and if necessary laparotomy. Repeated clinical assessment and radiological investigation are used to guide further management, mobilization and the return to normal activities.

Evolution in the treatment of complex blunt liver injuries

Over the last decade, major changes in the treatment of patients with blunt liver injuries have occurred, specifically with the nonoperative treatment of more complex injuries. These major changes can be summarized as follows: 1. Patients with blunt liver injuries are screened expeditiously by surgeon-performed ultrasonography. Depending on the initial findings and response to resuscitation, further decisions are made regarding the further evaluation. 2. Computed tomographic scanning is the mainstay of diagnosis for hepatic injuries after blunt trauma; the initial CT findings will help the trauma surgeon to determine the nonoperative treatment. 3. Liver injuries of grades I through III can be observed safely in a monitored unit and not necessarily in an ICU setting. Patients with injuries of grades IV and V are best initially observed in an ICU. 4. More than two thirds of patients with injuries of grades IV and V can be treated nonoperatively. However, 50% of these patients will require some type of interventional treatment, but not necessarily a laparotomy. 5. Initial findings on the CT scan can help to identify those patients who will need some type of interventional treatment and to identify associated injuries. 6. Elderly patients or patients with associated medical comorbidities can also be treated nonoperatively if strict guidelines are followed. 7. Complications in patients with complex blunt liver injuries are not uncommon. However, most of the complications can be safely treated by less invasive procedures.

Conservative management of penetrating torso trauma

Trauma has evolved as a specialty of its own over the past two decades, and has been the subject of much research and a huge number of trials, many of which are ongoing. As a result, it is now possible to apply an evidence-based practice to many trauma scenarios. The management of penetrating injuries to the chest or abdomen has traditionally followed a policy of emergency surgery as the first course of action. This has now shown to be unnecessary in many cases, particularly with the advances in diagnostic tests and imaging modalities. A large number of cases of penetrating torso trauma may require an operation at some stage, but obtaining the clearest diagnostic picture and optimizing the clinical condition of the patient before this undertaking will result in improved outcome. A selective approach to emergency surgery, with its attendant difficulties, is now recommended

Ultrasound and other imaging technologies in the intensive care unit

As technology advances, more imaging and procedures are performed at the bedside on critically ill patients in ICUs, thereby eliminating the risks of transporting patients. These imaging techniques can serve as diagnostic and therapeutic tools in treating the acute and chronic consequences of injured, critically ill patients. One area of growth is ultrasonography. Critical care applications of ultrasonography are expanding, and the learning curve of surgeons and intensivists performing some of these studies is improving. Ultrasonography can supplement physical examination and provide useful "real-time" information on nearly every body cavity. Other imaging technology is also available in a portable form, enabling imaging directly at the bedside. Images are now becoming readily and easily available with the advancement of teleradiology. Some of the imaging modalities are still in development, and their clinical effectiveness is being studied. In the future, more uses of these various imaging technologies may become evident and cost-effective.

Childhood trauma. Now and in the new millennium

Given the magnitude of childhood injuries that occur yearly in the United States, physicians need integrated echelons of care that include regional pediatric trauma centers, trauma centers with pediatric commitment, and EDs appropriate for children. Head injury is the most significant cause of morbidity and mortality among children, but physicians are far from effectively evaluating the dynamics of cerebral metabolism and oxygen delivery in the acute resuscitation of injured children. Critically injured children must be kept normothermic, and attention to the signs of hypovolemic shock must be monitored. Secondary brain ischemia frequently occurs because the details of resuscitation are not carefully monitored. A "leader" must be designated, and this should be someone experienced in childhood trauma. The younger the child and the more severe the injury, the more important is the notion of "experience." The ultimate goal, now and in the new millennium, should not be who, where, or when to administer care to critically ill or injured children but rather the quality of the treatment of these children.

Clinical evaluation of the child: injury to the chest and abdomen

In the paediatric age group (under 18 years) injury continues to be the dominant cause of mortality, being more common than all other causes combined. Disability resulting from injury represents a major expenditure in financial and emotional terms. The child’s anatomy and physiology are such that directly applying the principles of adult trauma care to the child can result in a less than optimal outcome and can add to long-term and/or permanent disability. Chest and abdominal injuries are the second and third most common causes of death, respectively, in childhood and when combined represent the second leading cause of death in this age group due to injury. There are six life-threatening injuries seen in paediatric injuries: airway obstruction, tension pneumothorax, massive haemothorax, open pneumothorax, flail chest and cardiac tamponade. There are six other potentially life-threatening injuries: simple pneumothorax, pulmonary contusion, tracheobronchial disruption, blunt cardiac injury, aortic disruption and haemothorax. These entities are discussed in terms of identification and treatment.

Abdominal injuries are generally well recognized by trauma surgeons. The difference in the paediatric age group involves the diagnosis of intra-abdominal injuries. The principle of diagnosis is that the injured organ should be specifically identified, not just left at the impression that something is bleeding, perforated or otherwise disrupted. The main diagnostic modality is the spiral or helical computerized tomography scan. This is an appropriate diagnostic method in all but the most severely injured and haemodynamically abnormal children. Care in initial assessment and management and in specific diagnosis has great potential to decrease the mortality in a country’s youngest citizens.

Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference

OBJECTIVE

To assemble an international panel of experts to develop consensus recommendations on selected important issues on the use of ultrasonography (US) in trauma care.

SETTING

R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md. The conference was held on December 4, 1997.

PARTICIPANTS

A committee of two co-directors and eight faculty members, in the disciplines of surgery and emergency medicine, representing four nations. Each faculty member had made significant contributions to the current understanding of US in trauma.

RESULTS

Six broad topics felt to be controversial or to have wide variation in practice were discussed using the ad hoc process: (1) US nomenclature and technique; (2) US for organ-specific injury; (3) US scoring systems; (4) the meaning of positive and negative US studies; (5) US credentialing issues; and (6) future applications of US. Consensus recommendations were made when unanimous agreement was reached. Majority viewpoints and minority opinions are presented for unresolved issues.

CONCLUSION

The consensus conference process fostered an international sharing of ideas. Continued communication is needed to advance the science and technology of US in trauma care.

The efficacy of focused abdominal sonography for trauma (FAST) as a screening tool in the assessment of injured children

PURPOSE

Focused abdominal sonography for trauma (FAST) is rapidly gaining acceptance as an effective and accurate way to determine significant abdominal injury. The authors analyzed their experience in 94 children with blunt torso trauma (BTT) to assess FAST accuracy in identifying operative lesions and utility in avoiding additional diagnostic studies.

METHODS

The authors' pediatric trauma registry was queried to identify all children with BTT who underwent FAST as part of their initial trauma assessment. Accuracy was determined by calculating sensitivity and specificity using as true positives those children with lesions requiring operative intervention. Utility was analyzed by reviewing the need for additional diagnostic or therapeutic intervention in those patients with negative FAST findings and negative clinical examination findings.

RESULTS

Three of these 94 children had lesions that required laparotomy. One was FAST positive (sensitivity, 33.3%). One of two FAST-negative patients was a child in extremis from a suspected thoracic aortic disruption, and the other was a child with an intestinal disruption in whom peritoneal signs developed 24 hours after injury. Of 89 FAST-negative children, 20 underwent abdominal computed tomography (CT) at the surgeon's request. Eight of these patients were found to have minor visceral injury that required no further treatment. The remaining 69 included the child with the aortic disruption and 68 patients whose hospital course was uneventful and required no additional intervention.

CONCLUSIONS

From the practical perspective of indicating need for operative intervention in BTT, FAST has a high specificity (95%); however, it is not particularly sensitive (33%). This excellent specificity in combination with clinical examination underscores FAST utility by avoiding unnecessary diagnostic intervention in 72% of the patients in this study.