The focused abdominal sonography for trauma scan: pearls and pitfalls

Accuracy of FAST in detecting intraabdominal bleeding in major trauma with pelvic and/or acetabular fractures: a retrospective cohort study

PURPOSE

The Focused Assessment with Sonography for Trauma (FAST) is a tool to rapidly detect intraabdominal and intrapericardial fluid with point-of-care ultrasound. Previous studies have questioned the role of FAST in patients with pelvic fractures. The aim of the present study was to assess the accuracy of FAST to detect clinically significant intraabdominal hemorrhage in patients with pelvic fractures.

METHODS

We included all consecutive patients with pelvic and/or acetabular fractures treated our Level 1 trauma center from 2009-2020. We registered patient and fracture characteristics, FAST investigations and CT descriptions, explorative laparotomy findings, and transfusion needs. We compared FAST to CT and laparotomy findings, and calculated true positive and negative findings, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

We included 389 patients. FAST had a sensitivity of 75%, a specificity of 98%, a PPV of 84%, and a NPV of 96% for clinically significant intraabdominal bleeding. Patients with retroperitoneal hematomas were at increased risk for laparotomy both because of True-negative FAST and False-positive FAST.

CONCLUSION

FAST is accurate to identify clinically significant intraabdominal blood in patients with severe pelvic fractures and should be a standard asset in these patients. Retroperitoneal hematomas challenge the FAST interpretation and thus the decision making when applying FAST in patients with pelvic fractures.

Neonatal and paediatric point-of-care ultrasound review

Purpose

Point-of-care ultrasound (POCUS) examinations for children and newborns are different from POCUS exams for adults due to dissimilarities in size and body composition, as well as distinct surgical procedures and pathologies in the paediatric patient. This review describes the major paediatric POCUS exams and how to perform them and summarizes the current evidence-based perioperative applications of POCUS in paediatric and neonatal patients.

Method

Literature searches using PubMed and Google Scholar databases for the period from January 2000 to November 2021 that included MeSH headings of [ultrasonography] and [point of care systems] and keywords including "ultrasound" for studies involving children aged 0 to 18 years.

Results

Paediatric and neonatal POCUS exams can evaluate airway, gastric, pulmonary, cardiac, abdominal, vascular, and cerebral systems.

Discussion

POCUS is rapidly expanding in its utility and presence in the perioperative care of paediatric and neonatal patients as their anatomy and pathophysiology are uniquely suited for ultrasound imaging applications that extend beyond the standard adult POCUS exams.

Conclusions

Paediatric POCUS is a powerful adjunct that complements and augments clinical diagnostic evaluation and treatment.

A Call for Development of Point-of-Care Ultrasound Training Recommendations in Obstetrics and Gynecology Residency

Point-of-care ultrasound (POCUS) skillsets are now taught throughout training levels from medical school through fellowship given the broad utility in assisting with bedside procedures and triaging clinical presentations for expedited workup. This is reflected in training curricula for emergency medicine, internal medicine, and general surgery residencies. However, these skillsets are not formally taught or required in obstetrics and gynecology residency. We present the opinion that these skillsets and curricula should be developed for obstetrics and gynecology trainees given their exposure to patients with similar clinical presentations in which the clinical management would be aided by POCUS.

Development of a Consensus-Based Definition of Focused Assessment With Sonography for Trauma in Children

Importance

The wide variation in the accuracy and reliability of the Focused Assessment With Sonography for Trauma (FAST) and the extended FAST (E-FAST) for children after blunt abdominal trauma reflects user expertise. FAST and E-FAST that are performed by experts tend to be more complete, better quality, and more often clinically valuable.

Objective

To develop definitions of a complete, high-quality, and accurate interpretation for the FAST and E-FAST in children with injury using an expert, consensus-based modified Delphi technique.

Design, Setting, and Participants

This consensus-based qualitative study was conducted between May 1 to June 30, 2021. It used a scoping review and iterative Delphi technique and involved 2 rounds of online surveys and a live webinar to achieve consensus among a 26-member panel. This panel consisted of international experts in pediatric emergency point-of-care ultrasonography.

Main Outcomes and Measures

Definitions of complete, high-quality, and accurate FAST and E-FAST studies for children after injury.

Results

Of the 29 invited pediatric FAST experts, 26 (15 men [58%]) agreed to participate in the panel. All 26 panelists completed the 2 rounds of surveys, and 24 (92%) participated in the live and asynchronous online discussions. Consensus was reached on FAST and E-FAST study definitions, and the panelists rated these 5 anatomic views as important and appropriate for a complete FAST: right upper-quadrant abdominal view, left upper-quadrant abdominal view, suprapubic views (transverse and sagittal), and subxiphoid cardiac view. For E-FAST, the same FAST anatomic views with the addition of the lung or pneumothorax view were deemed appropriate and important. In addition, the panelists rated a total of 32 landmarks as important for assessing completeness. Similarly, the panelists rated 14 statements on quality and 20 statements on accurate interpretation as appropriate.

Conclusions and Relevance

This qualitative study generated definitions for complete FAST and E-FAST studies with high image quality and accurate interpretation in children with injury. These definitions are similar to those in adults with injury and may be used for future education, quality assurance, and research. Future research may focus on interpretation of trace volumes of abdominal free fluid and the use of serial FAST.

eFAST exam errors at a level 1 trauma center: A retrospective cohort study

OBJECTIVES

Extended Focused Assessment with Sonography for Trauma (eFAST) ultrasound exams are central to the care of the unstable trauma patient. We examined six years of eFAST quality assurance data to identify the most common reasons for false positive and false negative eFAST exams.

METHODS

This was an observational, retrospective cohort study of trauma activation patients evaluated in an urban, academic Level 1 trauma center. All eFAST exams that were identified as false positive or false negative exams compared with computed tomography (CT) imaging were included.

RESULTS

4860 eFAST exams were performed on trauma patients. 1450 (29.8%) were undocumented, technically limited, or incomplete (missing images). Of the 3410 remaining exams, 180 (5.27%) were true positive and 3128 (91.7%) were true negative. 27 (0.79%) exams were identified as false positive and 75 (2.19%) were identified as false negative. Of the false positive scans, 7 had no CT scan and 8 had correct real-time trauma paper documentation of eFAST exam results when compared to CT and were excluded, leaving 12 false positive scans. Of the false negative scans, 11 were excluded for concordant documentation in real-time trauma room paper documentation, 20 were excluded for no CT scan, and 2 were excluded as incomplete, leaving 42 false negative scans. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam were the most common source of errors.

CONCLUSION

The eFAST exams in trauma activation patients are highly accurate. Unfortunately poor documentation and technically limited/incomplete studies represent 29.8% of our eFAST exams. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam are the most common source of errors.

Use of point-of-care ultrasound to diagnose spontaneous rupture of fibroid in pregnancy

Background: Complications of fibroids in pregnancy are well known, including postpartum hemorrhage, labor dystocia, and cesarean delivery. Outside of pregnancy and labor, the rare occurrence of spontaneous fibroid rupture has been documented. Case: The current case report involves a woman who presented with acute abdominal pain in the third trimester of pregnancy and was found to have spontaneous rupture of a fibroid before the onset of labor. Her initial presentation, diagnosis through use of point-of-care ultrasound, acute surgical management, and postoperative course are described. Conclusion: When assessing acute abdominal pain in a pregnant patient, fibroid rupture should be considered despite the absence of prior uterine surgery. Bedside point-of-care ultrasonography is a useful tool for assessment of abdominal pain in the third trimester of pregnancy.

Extension of the thoracic spine sign as a diagnostic marker for thoracic trauma

INTRODUCTION

The initial evaluation of patients with thoracic trauma remains a diagnostic challenge for surgery and emergency physicians. Chest sonography plays a key role in the approach for this group of patients, through extended and focused evaluation with trauma sonography (E-FAST).

OBJECTIVES

To establish the diagnostic performance of the extension of the thoracic spine sign using chest sonography in trauma to diagnose hemothorax and compare it with the gold standard test chest computed tomography (CT).

METHODS

This prospective observational study was conducted over 1 year. Patients who attended the emergency room with closed or penetrating thoracic or thoraco-abdominal trauma, an indication for a chest CT as part of a diagnostic evaluation according to institutional protocols, and who previously underwent a chest sonogram to determine the extent of the thoracic spine sign to diagnose hemothorax. Sonographic results were compared to a radiologist's interpretation of the chest CT. The radiologists were blinded to the initial sonogram interpretation.

RESULTS

Seventy-six patients were enrolled with an average age of 32 years. They mainly had closed trauma, which accounted for 77.6% of samples, and 222 chest images were taken. The sensitivity and specificity for this study were 78.7% and 92.6%, respectively, with a positive predictive value and negative predictive value of 65% and 97.8%, respectively.

CONCLUSIONS

Extension of the thoracic spine sign allows rapid identification of the presence, and more precisely, the absence of pleural effusion. This, therefore, allows an appropriate diagnosis and approach in the emergency room in patients with chest trauma.

Diagnostic options for blunt abdominal trauma

PURPOSE

Physical examination, laboratory tests, ultrasound, conventional radiography, multislice computed tomography (MSCT), and diagnostic laparoscopy are used for diagnosing blunt abdominal trauma. In this article, we investigate and evaluate the usefulness and limitations of various diagnostic modalities on the basis of a comprehensive review of the literature.

METHODS

We searched commonly used databases in order to obtain information about the aforementioned diagnostic modalities. Relevant articles were included in the literature review. On the basis of the results of our comprehensive analysis of the literature and a current case, we offer a diagnostic algorithm.

RESULTS

A total of 86 studies were included in the review. Ecchymosis of the abdominal wall (seat belt sign) is a clinical sign that has a high predictive value. Laboratory values such as those for haematocrit, haemoglobin, base excess or deficit, and international normalised ratio (INR) are prognostic parameters that are useful in guiding therapy. Extended focused assessment with sonography for trauma (eFAST) has become a well established component of the trauma room algorithm but is of limited usefulness in the diagnosis of blunt abdominal trauma. Compared with all other diagnostic modalities, MSCT has the highest sensitivity and specificity. Diagnostic laparoscopy is an invasive technique that may also serve as a therapeutic tool and is particularly suited for haemodynamically stable patients with suspected hollow viscus injuries.

CONCLUSIONS

MSCT is the gold standard diagnostic modality for blunt abdominal trauma because of its high sensitivity and specificity in detecting relevant intra-abdominal injuries. In many cases, however, clinical, laboratory and imaging findings must be interpreted jointly for an adequate evaluation of a patient's injuries and for treatment planning since these data supplement and complement one another. Patients with blunt abdominal trauma should be admitted for clinical observation over a minimum period of 24 h since there is no investigation that can reliably rule out intra-abdominal injuries.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BACKGROUND

Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.

METHODS

Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.

RESULTS

Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).

CONCLUSIONS

Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

U.S. Army Combat Medic eFAST Performance with a Novel Versus Conventional Transducers: A Randomized, Crossover Trial

BACKGROUND

Point-of-injury extended focused assessment with sonography in trauma (eFAST) may identify life-threatening torso hemorrhage and expedite casualty evacuation. The purpose of this study was to compare combat medic eFAST performance between the novel and conventional ultrasound (US) transducers.

METHODS

We conducted a randomized crossover trial. Medic participants, previously naïve to US, were randomized to the type of transducer first utilized. The primary outcome was eFAST completion time in seconds. Secondary outcomes included diagnostic accuracy, technical adequacy, and transducer ease-of-use rating.

RESULTS

Forty medics performed 160 eFASTs. We found a statistically significant difference in eFAST completion times in favor of conventional transducers (304 vs. 358 s; P = 0.03). There was no statistically significant difference between the conventional and novel transducers in terms of diagnostic accuracy (97.7% vs. 96.0%; P = 0.25) and technical adequacy (65% vs. 72.5%; P = 0.11). Median transducer ease-of-use rating (Likert 1-5 scale) was statistically significant in favor of the conventional transducers (5 vs. 4; P = < 0.001).

CONCLUSIONS

Extended focused assessment with sonography in trauma exam times was faster with the conventional transducers. Combat medics performed diagnostically accurate eFASTs with both transducer types in a simulated aid station setting after a brief training intervention. Conventional transducers were rated higher for ease-of-use.

Emergency Focused Assessment with Sonography in Blunt Trauma Abdomen

Background:

Focused assessment with sonography in trauma (FAST) being a rapid noninvasive examination is used primarily to evaluate for the evidence of traumatic free fluid suggestive of injury in the peritoneal, pericardial, and pleural cavities. It is widely recognized as a mainstream emergency skill in the management of trauma.

Aim:

The aim of the study is to evaluate the accuracy of FAST in patients presenting with blunt abdominal trauma.

Methods:

Data were collected prospectively from FAST scans conducted in blunt trauma abdomen (BTA) patients. Positive and negative FAST scans were confirmed either with contrast-enhanced computed tomography (CECT) abdomen or with exploratory laparotomy, thus dividing it further into four groups, i.e., true-positive, false-positive, true-negative, and false-negative scans. After collecting the data, accuracy of FAST was calculated.

Results:

In this study, a total of 104 patients were included. The mean age was 38.17 years. Most common cause of BTA was road traffic accident. The overall sensitivity, specificity, and accuracy of FAST were 69.8%, 92.1%, and 80.8%, respectively.

Conclusion:

This study showed that FAST is of paramount importance in patients who are hemodynamically unstable as it has a high positive predictive value. However, a FAST-negative result should always be confirmed by other modalities.

The Face, Content, and Construct Validity Assessment of a Focused Assessment in Sonography for Trauma Simulator

OBJECTIVE

Hemorrhage identification in trauma care is a major priority. Focused assessment in sonography for trauma (FAST) offers a rapid, reliable means of detecting torso bleeding. The aims of this study were to conduct a face, content, and construct validity assessment of a FAST simulator and establish a rigorous assessment tool.

DESIGN

Participants were requested to perform a FAST scan and state if any abnormality was found in each region. Metrics evaluated included time, errors, and missed targets. Accuracy of images obtained was assessed by 2 independent radiologists. Experts completed a face and content validity questionnaire at the end of the study.

SETTING

The study took place in the simulation suite within the Academic Surgical Unit of the Department of Surgery and Cancer.

PARTICIPANTS

Novices had no prior experience with ultrasound, intermediates had less than 6 months experience with fewer than 50 FAST scans performed, and experts had more than 1 year of experience with greater than 100 FAST scans performed. There were 31 participants: 11 experts, 10 intermediates, and 10 novices.

RESULTS

The face and content validity questionnaire scored high marks across all categories and achieved an overall median realism score of 8 ± 1.5 on a Likert scale. Experts performed the FAST scan faster with more accuracy and fewer errors than other cohorts (p < 0.001). Both the novices and intermediates were the slowest, least accurate, and either missed or made the most errors when scanning the lung bases and spleen.

CONCLUSIONS

This study has established the face, content, and construct validities of a FAST simulator, which could be used to accelerate training for novices. Additionally, it has demonstrated a rigorous method for FAST assessment, which has proven to be effective and in doing so addressed some of the criticisms leveled against it.

Do we really rely on fast for decision-making in the management of blunt abdominal trauma?

INTRODUCTION

The Focused Assessment with Sonography in Trauma examination (FAST) is currently taught and recommended in the ATLS(®), often as an addendum to the primary survey for patients with blunt abdominal trauma. Although it is non-invasive and rapidly performed at bedside, the utility of FAST in blunt abdominal trauma has been questioned. We designed this study to examine our hypothesis that FAST is not an efficacious screening tool for identifying intra-abdominal injuries.

METHODS

We performed a retrospective chart review of all patients with confirmatory diagnosis of blunt abdominal injuries with CT and/or laparotomy for a period of 1.5 years (from 7/2009 to 11/2010). FAST was performed by ED residents and considered positive when free intra-abdominal fluid was visualized. Abdominal CT, or exploratory laparotomy findings were used as confirmation of intra-abdominal injury.

RESULTS

A total of 1671 blunt trauma patients were admitted to and evaluated in the Emergency Department during a 1½ year period and 146 patients were confirmed intra-abdominal injuries by CT and/or laparotomy. Intraoperative findings include injuries to the liver, spleen, kidneys, and bowels. In 114 hemodynamically stable patients, FAST was positive in 25 patients, with a sensitivity of 22%. In 32 hemodynamically unstable patients, FAST was positive in 9 patients, with a sensitivity of 28%. A free peritoneal fluid and splenic injury are associated with a positive FAST on univariate analysis, and are the independent predictors for a positive FAST on multiple logistic regression.

CONCLUSION

FAST has a very low sensitivity in detecting blunt intraabdominal injury. In hemodynamically stable patients, a negative FAST without a CT may result in missed intra-abdominal injuries. In hemodynamically unstable blunt trauma patients, with clear physical findings on examination, the decision for exploratory laparotomy should not be distracted by a negative FAST.

From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment

Ultrasound is a ubiquitous and versatile diagnostic tool. In the setting of acute injury, ultrasound enhances the basic trauma evaluation, influences bedside decision-making, and helps determine whether or not an unstable patient requires emergent procedural intervention. Consequently, continued education of surgeons and other acute care practitioners in performing focused emergency ultrasound is of great importance. This article provides a synopsis of focused assessment with sonography for trauma (FAST) and the extended FAST (E-FAST) that incorporates basic thoracic injury assessment. The authors also review key pitfalls, limitations, controversies, and advances related to FAST, E-FAST, and ultrasound education.

The use of FAST scan by paramedics in mass-casualty incidents: a simulation study

INTRODUCTION

The Focused Abdominal Sonography in Trauma (FAST) scan is used to detect free fluid in the peritoneal cavity, or pericardium, to quickly assess for injuries needing immediate surgical intervention. Mass-casualty incidents (MCIs) are settings where paramedics must make triage decisions in minutes. The Simple Triage and Rapid Transport (START) system is used to prioritize transport. The FAST scan can be added to the triage of critical patients, and may aid in triage.

METHODS

This was a single-blinded, randomized control trial. Ten paramedics with field experience were trained with an ultrasound machine in the performance of the FAST scan. Two weeks were allowed to pass before testing to simulate the time between training of standard procedures and their implementation. On test day, five peritoneal dialysis patients with instilled dialysis fluid and five matched control patients were placed in a room in a random order where the paramedics performed FAST scans on each patient. The paramedics were assessed by declaring positive or negative for each evaluation, as well as being timed for the total exercise.

RESULTS

Of the ninety tests (one paramedic dropped out due to family emergency), the paramedics had a mean accuracy of 60% and median of 62% (range 40%-80%). There was a statistically significant higher false-positive rate of 59% than false-negative rate of 41% (P < .01). Sensitivity was 67% with a specificity of 56%. Average time taken was 1,218 seconds (121.8 seconds per patient) with a range of 735-1,701 seconds and a median of 1,108 seconds.

CONCLUSION

In this simulation study, paramedics had difficulty performing FAST scans with a high degree of accuracy. However, they were more apt to call a patient positive, limiting the likelihood for false-negative triage.

The emergency radiology of pelvic trauma

The imaging of pelvic trauma is complex and may involve different radiological techniques depending on the severity and type of injury. Following high-energy blunt trauma, computed tomography (CT) is the investigation of choice as it can identify life-threatening findings such as arterial extravasation as well as bony and soft tissue injuries, in particular that of the urological system. In this overview of pelvic imaging in trauma, the role of CT, plain radiography and focussed assessment with sonography in trauma (FAST) are considered, as well as the role of interventional radiology for pelvic haemorrhage.

Emergency sonography AIDS diagnostic accuracy of torso injuries: a study in a resource limited setting

Introduction. Clinical evaluation of patients with torso trauma is often a diagnostic challenge. Extended focused assessment with sonography for trauma (EFAST) is an emergency ultrasound scan that adds to the evaluation of intrathoracic abdominal and pericardial cavities done in FAST (focused assessment with sonography for trauma). Objective. This study compares EFAST (the index test) with the routine standard of care (SoC) investigations (the standard reference test) for torso trauma injuries. Methods. A cross-sectional descriptive study was conducted over a 3-month period. Eligible patients underwent EFAST scanning and the SoC assessment. The diagnostic accuracy of EFAST was calculated using sensitivity and specificity scores. Results. We recruited 197 patients; the M : F ratio was 5 : 1, with mean age of 27 years (SD 11). The sensitivity of EFAST was 100%, the specificity was 97%, the PPV was 87%, and the NPV was 100%. It took 5 minutes on average to complete an EFAST scan. 168 (85%) patients were EFAST-scanned. Most patients (82) (48%) were discharged on the same day of hospitalization, while 7 (4%) were still at the hospital after two weeks. The mortality rate was 18 (9%). Conclusion. EFAST is a reliable method of diagnosing torso injuries in a resource limited context.

Ultrasonography for clinical decision-making and intervention in airway management: from the mouth to the lungs and pleurae

OBJECTIVES

To create a state-of-the-art overview of the new and expanding role of ultrasonography in clinical decision-making, intervention and management of the upper and lower airways, that is clinically relevant, up-to-date and practically useful for clinicians.

METHODS

This is a narrative review combined with a structured Medline literature search.

RESULTS

Ultrasonography can be utilised to predict airway difficulty during induction of anaesthesia, evaluate if the stomach is empty or possesses gastric content that poses an aspiration risk, localise the essential cricothyroid membrane prior to difficult airway management, perform nerve blocks for awake intubation, confirm tracheal or oesophageal intubation and facilitate localisation of tracheal rings for tracheostomy. Ultrasonography is an excellent diagnostic tool in intraoperative and emergency diagnosis of pneumothorax. It also enables diagnosis and treatment of interstitial syndrome, lung consolidation, atelectasis, pleural effusion and differentiates causes of acute breathlessness during pregnancy. Patient safety can be enhanced by performing procedures under ultrasound guidance, e.g. thoracocentesis, vascular line access and help guide timing of removal of chest tubes by quantification of residual pneumothorax size.

CONCLUSIONS

Ultrasonography used in conjunction with hands-on management of the upper and lower airways has multiple advantages. There is a rapidly growing body of evidence showing its benefits.

TEACHING POINTS

• Ultrasonography is becoming essential in management of the upper and lower airways. • The tracheal structures can be identified by ultrasonography, even when unidentifiable by palpation. • Ultrasonography is the primary diagnostic approach in suspicion of intraoperative pneumothorax. • Point-of-care ultrasonography of the airways has a steep learning curve. • Lung ultrasonography allows treatment of interstitial syndrome, consolidation, atelectasis and effusion.

Intra-arrest formation of right-heart thrombi -- a case illustrated by real-time ultrasonography

The presence of free-floating right-heart thrombus has been reported in a cardiac arrest patient in the periarrest period. Free-floating right atrial thrombus is a rare phenomenon seen in patients developing severe pulmonary embolism, and is associated with increased mortality. However, there have been no previously reported cases of right-heart thrombus formation during a resuscitated cardiac arrest. We present the pre-hospital case of a woman in the clinical setting of cardiogenic shock due to acute myocardial infarction who developed asystolic cardiac arrest on the scene. Recent implementation of ultrasonography into the regional pre-hospital care protocol enabled sonographic investigation before and during cardiac arrest. This allowed detection of right atrial septal thrombus formation in the course of advanced life support and its migration through the tricuspid valve. The pathophysiological consequences, clinical significance and potential therapeutic options are discussed.

Non-operative management of liver trauma

The liver is one of the commonest intra-abdominal organs injured worldwide in blunt and penetrating trauma and its management has evolved significantly in the last 30 years. Mandatory laparotomy has been replaced by an acceptance that for most blunt hepatic trauma, a selective non-operative approach is safe and effective with a failure rate ie the need to proceed to delayed laparotomy of approximately 10%. There is a markedly lower rate of complications in those that are managed non-operatively. Adjuncts to this conservative regimen such as angioembolisation and delayed laparoscopy to treat biliary peritonitis increase the chances of avoiding laparotomy. This belief in non-operative management has also been transferred to some degree to penetrating liver trauma, where there is a gradual accumulation of evidence to support this non-operative approach in a carefully selected group of patients. This article examines the evidence supporting the selective non-operative management of both blunt and penetrating liver trauma and describes the outcomes and complications.

The role of early multislice computed tomography in major trauma

Whole-body multislice spiral computed tomography (MSCT) has become a very important dignostic tool in the management of patients with multiple injuries. Many reports exist which demonstrate the feasibility and the benefit when using whole-body MSCT in the early phase of in-hospital management of trauma patients. Even in hemodynamically instable patients (except cardiac arrest), whole-body MSCT can be used and is a safe diagnostic procedure. While the diagnostic superiority of multislice computed tomography is proven for different organ regions (e.g. head/brain, chest, abdomen, pelvis and spine), its use as a single whole-body scan is still part of an ongoing discussion. Especially concerns about radiation exposure are the reason for uncertainty about when using whole-body trauma scan. Predefined scan protocols and individual positioning of patients may help to keep radiation dose as minimal as possible. To justify higher radiation dose, the indication must be chosen appropriately. Therefore, the use of a sensitive and specific triage scheme seems to be reasonable. Overscanning patients with minor trauma needs to be avoided, while the benefit for patients with severe multiple injuries is obvious.

Evaluation of gastrointestinal injury in blunt abdominal trauma "FAST is not reliable": the role of repeated ultrasonography

Background

To determine the diagnostic Accuracy of Focused Assessment Sonography for Trauma (FAST) and repeated FAST in the patients with blunt abdominal trauma.

Methods

In this retrospective study we collected the data of all patients from September 2007 to July 2011 with gastrointestinal injury. The intraoperative outcome was compared with FAST technique and the repeated or delayed sonography.

Results

A total number of 1550 patients with blunt abdominal trauma underwent FAST in a period of 4 years in our hospital. Eighty-eight (5.67%) patients were found to have gastrointestinal injury after exploratory laparotomy. Fifty-five (62.5%) patients had isolated gastrointestinal injury and 33 (37.5%) patients had concomitant injury to the other solid organs. In those with isolated gastrointestinal injury, the sensitivity of FAST was 38.5%. Repeated ultrsonography was performed in 34 patients with false negative initial FAST after 12-24 hours. The sensitivity of repeated ultrasonography in negative initial FAST patients in detection of gastrointestinal injury was 85.2% (95% CI, 68.1%, and 94.4%).

Conclusion

Repeated sonography after 12 to 24 hours in patients with negative initial FAST but sustain abdominal symptom can facilitated a diagnosis of GI tract injury and can be as effective method instead of Computed tomography in developing country.

The technical errors of physicians learning to perform focused assessment with sonography in trauma

OBJECTIVES

The objective was to assess the incidence of various technical errors committed by emergency physicians (EPs) learning to perform focused assessment with sonography in trauma (FAST).

METHODS

This was a retrospective review of the first 75 consecutive FAST exams for each EP from April 2000 to June 2005. Exams were assessed for noninterpretable views, misinterpretation of images, poor gain, suboptimal depth, an incomplete exam, or backward image orientation.

RESULTS

A total of 2,223 FAST exams done by 85 EPs were reviewed. Multiple noninterpretable views or misinterpreted images occurred in 24% of exams for those performing their first 10 exams, 3.6% for those performing their 41st to 50th exams, and 0% for those performing their 71st to 75th exams (Cochran-Armitage trend test = 10.5, p < 0.0001). A single noninterpretable view, poor gain, suboptimal depth, incomplete exam, or backward image orientation occurred in 48% of exams for those performing their first 10 exams, 17% for those performing their 41st to 50th exams, and 5% for those performing their 71st to 75th exams (Cochran-Armitage trend test = 11.6, p < 0.0001).

CONCLUSIONS

The incidence of specific technical errors of EPs learning to perform FAST at our institution improved with hands-on experience. Interpretive skills improved more rapidly than image acquisition skills.

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.

FAST scan: is it worth doing in hemodynamically stable blunt trauma patients?

BACKGROUND

During the last decade, focused assessment with sonography for trauma increasingly has become the initial diagnostic modality of choice in trauma patients. It is still questionable, however, whether its use results in the underdiagnosis of intra-abdominal injury. It also remains doubtful whether a positive focused assessment with sonography for trauma affects clinical decision making in hemodynamically stable blunt trauma patients as evidenced through abdominal computerized tomography use. The aim of this study was to evaluate the results of focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients and to determine its role in the diagnostic evaluation of these patients.

METHODS

We reviewed our prospectively maintained trauma database. In trauma patients at our institute, focused assessment with sonography for trauma examinations are performed by surgery residents and are considered positive when free intra-abdominal fluid is visualized. Abdominal computerized tomography, diagnostic peritoneal lavage, or exploratory laparotomy findings were used as confirmation of intra-abdominal injury.

RESULTS

In our 7-year study period, 2,980 trauma patients were evaluated at our institute, of which 2,130 patients underwent a focused assessment with sonography for trauma. In all, 18 patients had an inconclusive focused assessment with sonography for trauma, whereas 7 patients died on arrival, leaving 2,105 patients for our analysis. A total 88 true positive focused assessment with sonography for trauma were conducted. All hemodynamically stable blunt trauma patients who had a positive focused assessment with sonography for trauma (70/88) were confirmed by computerized tomography. Patients who underwent exploratory laparotomy directly (17/88) or diagnostic peritoneal lavage (1/88) as confirmation either had penetrating trauma or became hemodynamically unstable. A total of 1,894 true negative focused assessments with sonography for trauma scans were conducted, with 1,201 confirmed by computerized tomography and the rest by observation. In all, 118 false negative focused assessment with sonography for trauma were performed, of which 44 (37.3%) subsequently required exploratory laparotomy. Five patients had false positive focused assessment with sonography for trauma scans. Focused assessment with sonography for trauma scan had an overall sensitivity of 43%, a specificity of 99%, and positive and negative predictive values of 95% and 94%, respectively. Accuracy was 94.1%. In the hemodynamically stable blunt trauma group, there were 60 patients with true positive focused assessment with sonography for trauma examinations and 87 patients with false negative focused assessment with sonography for trauma examinations. In this group of patients, focused assessment with sonography for trauma had a sensitivity of 41%, specificity of 99%, and positive and negative predictive values of 94% and 95%, respectively. The overall accuracy was 95%.

CONCLUSION

Given the low sensitivity, a negative focused assessment with sonography for trauma without confirmation by computerized tomography may result in missed intra-abdominal injuries. It is also observed in all focused assessment with sonography for trauma positive hemodynamically stable blunt trauma patients, confirmation is preferred through the use of a computerized tomography for better understanding of the intra-abdominal injuries and to decide on operative versus no-operative management. Thus, the use of focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients seems not worthwhile. It should be reserved for hemodynamically unstable patients with blunt trauma.

Ultrasound studies

This article focuses on the clinical use of ultrasound with the obstetric, gynecologic, and trauma patient by reviewing recent case studies of the use of ultrasound for diagnostic purposes. The article also summarizes the American Institute of Ultrasound in Medicine (AIUM) guidelines for use in several types of patients. The AIUM is a multidisciplinary association whose purpose is to "advance the art and science of ultrasound in medicine and research through educational, scientific, literary, and professional activities." The organization provides guidelines in conjunction with many professional organizations, such as the American College of Cardiology and the American College of Obstetrics and Gynecology. AIUM also serves as an accrediting body for ultrasound practices.

Abdominal trauma: from operative to nonoperative management

The nonoperative care of intraabdominal trauma in the polytraumatised patient greatly depends on imaging techniques. The haemodynamically unstable patient should undergo expedient sonography to rule out abdominal haemorrhage. The use of computer tomography (CT) in this difficult patient group is also currently evaluated, however it takes specific amendments to the protocol and institution. In the hemodynamically stable patient however, computer tomography is the modality of choice to evaluate the injured abdomen. Nonoperative treatment can be successful in up to 80% of selected cases. Adjuncts to nonoperative care include embolisation of the spleen and liver in cases of arterial bleeding, and endoscopic retrograde cholangio pancreaticography (ERCP) and stenting for injuries to the biliary tree.

Findings and limitations of focused ultrasound as a possible screening test in stable adult patients with blunt abdominal trauma: a Greek study

Our objective is to underline the place of FAST (focus assessment by sonography for trauma) ultrasonography (US) in the investigation of blunt abdominal trauma. We retrospectively examined the ultrasound findings in 1,999 haemodynamically stable adult patients. These people were admitted to the emergency room (ER) for possible blunt abdominal trauma. All were stable at admission and a FAST ultrasound examination was made. Initial findings were compared with the clinical course after at least 24 h of observation time and CT results. Among the 1,999 US examinations, abnormalities were found in 109 (5.5%) cases. Among them, 102 had free peritoneal fluid, and in 58 examinations, ruptures, lacerations or haematomas were demonstrated. Despite its limitations, such as in cases involving uncooperative patients, excessive bowel gas, obesity and empty bladder, the FAST technique seems to be an accurate method to evaluate the possibility of abdominal blunt trauma in stable patients. Because of the high negative predictive value of the FAST technique in stable patients with blunt abdominal trauma, we recommend that a stable patient with negative ultrasound results at admission remain under close observation for at least 12 or preferably 24 h before being discharged.

Focused assessment with sonography for trauma: the FAST scan

Focused assessment with sonography for trauma or focused abdominal sonography for trauma — the FAST scan, has become a useful modality for the initial evaluation of patients with blunt abdominal trauma. The technique is used to identify free fluid in the abdomen and pelvis and to detect the presence of a pericardial effusion. FAST can be performed by any trained individual, not necessarily a sonographer or radiologist, aiding in the immediate availability of this technique in the emergency situation. We will discuss the applications and sensitivity of this technique in trauma and review the potential pitfalls and limitations which need to be understood if this technique is to be safely applied. The use of FAST for the detection of pneumothoraces in trauma and other advances in FAST scanning, such as scoring systems and paediatric FAST are also reviewed.

Abdominal ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture

BACKGROUND

Detection of hemoperitoneum in patients with pelvic fracture and hemodynamic instability is important to determine the need for laparotomy versus pelvic angiography. The use of ultrasound (FAST [Focused Assessment with Sonography for Trauma]) for the evaluation of hemoperitoneum after blunt abdominal trauma has become widespread. However, its sensitivity and specificity in patients with pelvic fracture remain poorly defined. The purpose of this study was to determine the sensitivity and specificity of FAST for the detection of hemoperitoneum in patients with pelvic fracture and an increased risk for hemorrhage.

METHODS

The medical records for all admissions to our Level I trauma center from November 2003 to February 2005 were retrospectively reviewed. Inclusion criteria were presence of pelvic fracture with at least one of the following risk factors for hemorrhage: age > or =55, hemorrhagic shock (systolic blood pressure <100 mm Hg), or unstable fracture pattern. Emergency department FAST results were recorded. Surgery residents trained and certified in ultrasonography in the acute setting performed all FAST examinations and an in house attending surgeon reviewed them. Presence of hemoperitoneum was confirmed by laparotomy or abdominopelvic computed tomography (CT) scan.

RESULTS

There were 146 patients who met entry criteria, 126 of who had a FAST examination performed. A total of 104 patients underwent a confirmatory evaluation of their abdomen with either operative exploration (n = 20) or CT scan (n = 84). Eight patients underwent diagnostic peritoneal lavage before CT confirmation and were excluded. Ninety-six patients constituted the study group. Nineteen patients presented in hemorrhagic shock. There were 11 true-positive, 52 true-negative, 2 false-positive, and 31 false-negative results. Sensitivity and specificity were 26% and 96%, respectively. Positive and negative predictive values were 85% and 63%, respectively.

CONCLUSIONS

A FAST examination with negative result does not aid in determining the need for laparotomy versus pelvic angiography in patients with pelvic fracture at risk for hemorrhage. These patients should undergo additional confirmatory evaluation to exclude intraperitoneal hemorrhage.

The Utility of Sonography for the Triage of Blunt Abdominal Trauma Patients to Exploratory Laparotomy

OBJECTIVE

The purpose of this study was to assess the utility of focused abdominal sonography for trauma (FAST) in the triage of hypotensive and normotensive blunt abdominal trauma patients to exploratory laparotomy.

MATERIALS AND METHODS

Data entered in a trauma registry database were retrospectively reviewed and were correlated with medical records, radiology reports, and surgical laparotomy reports. In the setting of blunt abdominal trauma, hypotensive patients were compared with normotensive patients who underwent FAST.

RESULTS

During the 6-year study period, 4,029 patients with blunt abdominal trauma underwent sonography, 122 of whom were hypotensive on arrival and underwent FAST. Of 87 hypotensive patients with positive findings on FAST, 69 (79%) were taken directly to exploratory laparotomy without the need for CT. In predicting the need for therapeutic laparotomy in hypotensive patients, the sensitivity of FAST was 85%, specificity was 60%, and accuracy was 77%. Of the 3,907 normotensive patients, 3,584 had negative FAST findings, whereas 323 had positive FAST findings. In normotensive patients, the sensitivity of FAST was 85%, specificity was 96%, and accuracy was 96%. In the combined patient population (all hypotensive and normotensive patients), 4,029 patients with blunt abdominal trauma underwent sonography: 3,619 had negative and 410 had positive FAST findings. In all patients regardless of blood pressure, the sensitivity of FAST was 85%, specificity was 96%, and accuracy was 95%.

CONCLUSION

Hypotensive patients screened in the emergency department with positive FAST findings may be triaged directly to therapeutic laparotomy, depending on the results of the sonography examination, without the need for CT.

Appearance of Solid Organ Injury with Contrast-Enhanced Sonography in Blunt Abdominal Trauma: Preliminary Experience

OBJECTIVE

The purpose of this study was to compare the detection rate of injury and characterize imaging findings of contrast-enhanced sonography and non-contrast-enhanced sonography in the setting of confirmed solid organ injury.

SUBJECTS AND METHODS

This prospective study involved identifying hepatic, splenic, and renal injuries on contrast-enhanced CT. After injury identification, both non-contrast-enhanced sonography and contrast-enhanced sonography were performed to identify the possible injury and to analyze the appearance of the injury. The sonographic appearance of hepatic, splenic, and renal injuries was then analyzed, and the conspicuity of the injuries was graded on a scale from 0 (nonvisualization) to 3 (high visualization).

RESULTS

Non-contrast-enhanced sonography revealed 11 (50%) of 22 injuries, whereas contrast-enhanced sonography depicted 20 (91%) of 22 injuries. The average grade for conspicuity of injuries was increased from 0.67 to 2.33 for spleen injuries and from 1.0 to 2.2 for liver injuries comparing non-contrast-enhanced with contrast-enhanced sonography, respectively, on a scale from 0, being nonvisualization, to 3, being high visualization. The splenic injuries appeared hypoechoic with occasional areas of normal enhancing splenic tissue within the laceration with contrast-enhanced sonography. Different patterns were observed in liver injuries including a central hypoechoic region. In some liver injuries there was a surrounding hyperechoic region.

CONCLUSION

Contrast-enhanced sonography greatly enhances visualization of liver and spleen injuries compared with non-contrast-enhanced sonography. Solid organ injuries usually appeared hypoechoic on contrast-enhanced sonography, but often a hyperechoic region surrounding the injury also was identified with liver injuries.

Ultrasonic interrogation of tissue vibrations in arterial and organ injuries: preliminary in vivo results

Soft tissues surrounding vascular injuries are known to vibrate at audible and palpable frequencies, producing bruits and thrills. We report the results of a feasibility study where Doppler ultrasound (US) was used to quantitatively estimate the tissue vibrations after induced trauma in an animal model. A software-programmable US system was used to acquire quadrature-demodulated ensembles of received US echoes bypassing clutter filtering and other conventional Doppler processing stages. The waveforms of tissue velocity surrounding the injury site were then estimated from the clutter data using autocorrelation and analyzed to determine vibration characteristics. Six New Zealand white rabbits and two juvenile pigs were used for the study. The femoral artery of the anesthetized animal was punctured with an 18-gauge needle to model a peripheral arterial trauma, and the liver was surgically exposed and incised to model organ trauma. Two types of oscillatory tissue motion were observed: "vibrations" with high frequency (>50 Hz) and low peak-peak amplitude (<1 microm) and "flutter" with low frequency (<50 Hz) and high peak-peak amplitude (>1 microm). Active bleeding in femoral artery punctures produced tissue vibrations at the frequency of 323 +/- 214 Hz (mean +/- standard deviation, pooled for both rabbits and pigs) and the amplitude of 0.24 +/- 0.15 microm. Active bleeding in liver incisions produced vibrations at the frequency of 120 +/- 47 Hz and the amplitude of 0.33 +/- 0.25 microm. Flutter was observed in punctured arteries at the frequency of 28 +/- 13 Hz the amplitude of 2.92 +/- 1.75 microm, and in incised livers at the frequency of 26 +/- 6 Hz and the amplitude of 1.53 +/- 0.76 microm. In a punctured artery, the vibration frequency and phase of tissue surrounding the artery were highly correlated between neighboring locations in tissue (correlation coefficient = 0.98), and with the flow oscillations in the lumen (correlation coefficient = 0.96). This preliminary study indicates that tissue vibrations could provide additional physiologic information for detecting, localizing and monitoring internal bleeding using US.

Prospective Study to Evaluate the Influence of FAST on Trauma Patient Management

BACKGROUND

Previous studies have concentrated on the accuracy of Focused Assessment with Sonography in Trauma (FAST), but evaluation of whether FAST changes subsequent management has not been fully assessed.

METHODS

This prospective study compared 419 trauma admissions in two groups, FAST and no-FAST, for demographics, time of resuscitation, and action after resuscitation. The 194 patients undergoing FAST had their management plan specified before, and confirmed after, FAST was performed to assess for change in management. To ensure scan consistency and to minimize bias, criteria were established to define an adequate FAST.

RESULTS

FAST was performed in 194 patients (46%), assessing for free fluid. Management was changed in 59 cases (32.8%) after FAST. Laparotomy was prevented in 1 patient, computed tomography was prevented in 23 patients, and diagnostic peritoneal lavage was prevented in 15 patients. Computed tomography rates were reduced from 47% to 34% and diagnostic peritoneal lavage rates were reduced from 9% to 1%.

CONCLUSIONS

FAST plays a key role in trauma, changing subsequent management in an appreciable number of patients.

Moderne Diagnostik des Bauchtraumas

In case of suspected intra-abdominal injury, fast transport of the patient to a suitable hospital is of high priority. The initial clinical examination aims at identifying patients with potentially life-threatening bleeding that require emergency surgery. In patients with penetrating trauma, laparoscopy is favoured to exclude suspected perforation of the peritoneum. If a peritoneal perforation is identified, exploratory laparotomy is recommended to exclude or treat lacerations of the hollow viscus. Although clinical examination should be performed its sensitivity and specificity of up to 82% and 45%, respectively, are not sufficient as the sole screening method. For the further diagnostic workup, diagnostic peritoneal lavage has been completely replaced by abdominal ultrasound examination in Germany and many other countries. Focussing not only on the detection of free abdominal fluid but also searching for parenchymal organ lesions and performing repeated examinations increases accuracy up to 96%, with specificity of 99.8% and sensitivity of 72.1%. Computed abdominal tomography with a helical scanner with and without intravenous contrast media is currently the gold standard of imaging techniques to identify traumatic abdominal injuries. A sensitivity of 97.2% and specificity of 94.7% can be achieved. False negative findings must be expected with hollow organ injuries. Serial clinical and ultrasound examinations as well as lab testing in conjunction with repeated CT may help to identify such lesions. Increased intra-abdominal pressure (IAP) with consecutive abdominal compartment syndrome and multiple organ dysfunction is a delayed complication from conditions such as severe intra-abdominal bleeding, major bleeding from pelvic ring fractures, and profuse fluid resuscitation. The IAP should be measured routinely in patients at risk, and decompression laparotomy may be indicated with pressures of higher than 20 mmHg.

Pelvic free fluid: clinical importance for reproductive age women with blunt abdominal trauma

OBJECTIVE

To evaluate the importance of isolated pelvic free fluid (FF) detected by ultrasound examination in pregnant patients and in non-pregnant reproductive age women with blunt abdominal trauma (BAT).

METHODS

Reproductive age women aged 10-50 years who presented with BAT and underwent focused abdominal sonography for trauma (FAST) from January 1995 to June 2002 at a Level 1 trauma center were included. Patients were assigned to four groups according to the location of FF detected by ultrasound (Group 1, no FF; Group 2, FF in pelvis; Group 3, FF in abdomen; Group 4, FF in abdomen and pelvis). Ultrasound findings were compared with intra-abdominal and pelvic injuries detected by computed tomography and/or laparotomy. Pair-wise comparison was performed using a Fisher's exact test.

RESULTS

Ultrasound detection of FF in the abdomen alone or FF in the abdomen and pelvis was significantly associated with intra-abdominal injury (IAI) compared to those without FF (P < 0.001) for both pregnant and non-pregnant reproductive age women. FF isolated to the pelvis was also associated with a higher injury rate compared to no FF in pregnant women (30% vs. 3%, P = 0.005) and in non-pregnant reproductive age women (39.5% vs. 3.7%, P < 0.001).

CONCLUSIONS

In reproductive age women with BAT, ultrasound detection of FF in the abdomen alone, in both the abdomen and pelvis, or isolated to the pelvis is associated with a higher IAI rate. Therefore, isolated FF in the pelvis should not necessarily be considered physiological in pregnant and non-pregnant patients with BAT.

Ultrasound detection of blunt urological trauma: a 6-year study

The objective of this study was to assess the utility of emergency ultrasonography in the detection of blunt urological injury. A retrospective review was conducted of all consecutive emergency blunt trauma ultrasonograms (US) obtained at a level I trauma centre from January 1995 to January 2001. Among the 4320 emergency ultrasonograms performed, 596 patients (14%) had intraabdominal injury and, of these, 99 patients (17%) had urological injuries. The sensitivity of ultrasound for all urological injuries was 67%, and specificity was 99.8%. For isolated urological injuries, sensitivity and specificity were 55.6 and 99.8%, respectively. Ultrasound was most accurate in the detection of grade III renal injuries, identifying 14/15 (93%), and 13 underwent laparotomy. For isolated urological injuries, 15 of 25 (60%) patients with a true-positive US underwent laparotomy compared to 3 of 20 (15%) with a false-negative US. Isolated urological injury was significantly associated with an ultrasonographic pattern of free fluid in the left upper quadrant and the left pericolic gutter (odds ratio=55.1; P<0.001), followed by isolated fluid in the left pericolic gutter (odds ratio=8.6; P=0.04). Although emergency ultrasonography is useful in the triage of patients with blunt urological trauma, it may miss significant urological injury requiring further intervention. As most renal injuries may be managed non-operatively, further studies such as contrast-enhanced CT or angiography should be obtained in the stable patient with suspected blunt urological injury.

Technology Insight: hand-carried ultrasound cardiac assessment—evolution, not revolution

Hand-carried ultrasound devices can enhance the art of bedside physical examination by increasing diagnostic accuracy, detecting disease at an earlier stage, and improving triage and referral of patients. Although limitations of device cost and portability can be overcome with technologic advances, the shortage of standardized imaging and training opportunities now needs to be addressed to move the technique forward. Cardiologists are the best-qualified subspecialists to design and teach a simplified training program for bedside use of hand-carried ultrasound devices to assess the cardiovascular system.

Sonographic measurement of the inferior vena cava as a marker of blood loss

Detecting and monitoring blood loss in trauma patients can often be challenging when an obvious source of hemorrhage is not readily seen.

OBJECTIVE

To provide a noninvasive measurement of circulating blood volume and of drop therein by measuring the change in the inferior vena cava diameter (IVCd) in relationship to blood loss.

METHODS

This was a prospective observational study on blood donors at a donation center. The IVCd, both during inspiration (IVCi) and during expiration (IVCe), was measured in volunteers both before and after blood donation of 450 mL. All actual blood donors aged 18 years and older were eligible for enrollment. Persons who were younger than 18 years, who declined to participate in the study, or who did not meet blood center criteria for blood donation were excluded. All examinations were performed in the supine position with the ultrasound transducer placed in a subxyphoid location. Sagittal sections of the IVC behind the liver were imaged and the maximal diameter of the IVCe and the minimal diameter of the IVCi were measured. Statistical analysis included test for normality, paired t test, and correlation analysis.

RESULTS

A total of 31 volunteers (18 male) with a mean age of 49.5 years (range, 18-73) were studied. The mean IVCe before blood donation was 17.4 mm (95% CI, 15.2-19.7 mm) and after blood donation was 11.9 mm (95% CI, 10.3-13.6 mm). The mean IVCi before blood donation was 13.3 mm (95% CI, 11.3-15.3 mm), but after blood donation was 8.13 mm (95% CI, 6.7-9.6 mm). The difference between IVCe before and after blood donation (dIVCe) was 5.5 mm (95% CI, 4.3-6.3 mm) yielding a P < .0001. The difference between IVCi before and after donation (dIVCi) was 5.16 mm (95% CI, 4.2-5.9 mm) yielding a P < .0001. The dIVCe and the dIVCi were closely correlated ( r = 0.83). Similarly, the pre-IVCe correlated well to the post-IVCe ( r = 0.74) and the pre-IVCi correlated well to the post-IVCi ( r = 0.75).

CONCLUSIONS

Our data indicates that the measurement of the IVC diameter is a reliable indicator of blood loss, even in small amounts of 450 mL. On average, there was about a 5-mm decrease in both the IVCe and IVCi after donation of 450 mL of blood. The measurement of the IVCe may be an important addition to the ultrasonographic evaluation of trauma and other potentially volume-depleted patients.

Rare right ventricular myxoma detected incidentally on a FAST examination

A young man underwent Focused Assessment with Sonography in Trauma (FAST) scan for blunt abdominal trauma. An incidental finding on the pericardial view was the presence of a tumor in the right ventricle. Detailed cardiac imaging and subsequent excision revealed the presence of a myxoma. The patient had no obvious cardiac symptoms, but the awareness and experience of the examiner during the FAST examination detected this rare heart tumor at a latent stage, preventing serious, irreversible complications. This case demonstrates the potential importance of looking above the diaphragm during routine abdominal sonography, especially in patients who are critically ill.

[Shock trauma room diagnosis: initial diagnosis after blunt abdominal trauma. A review of the literature]

OBJECTIVE

Blunt abdominal trauma is most common in the polytraumatized patient and beside neurocranial trauma one major determinant of early death in these patients. Therefore, immediate recognition of an abdominal injury is of life-saving importance.

METHODS

Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system).

RESULTS

Clinical examination is not reliable for evaluation of abdominal injury. Abdominal ultrasound, especially if only focusing on free fluid (FAST) is not sensitive enough. Today, CT-scan of the abdomen is the gold-standard in diagnosing abdominal injury. Diagnostic Peritoneal Lavage (DPL) has a high sensitivity but in our region only is used in exceptional cases. The patient with continuing hemodynamical instability after abdominal trauma and evidence of free intraperitonial fluid has to undergo laparotomy.

CONCLUSION

After blunt abdominal trauma, initially ultrasound investigation should be performed in the emergency room. This should not only focus on free intraabdominal fluid but also on organ lesions. Regardless of the findings from ultrasound or clinical examination, the hemodynamically stable patient should undergo a CT-scan of the abdomen in order to proof or exclude an abdominal injury.

Blunt Abdominal Injury in the Pregnant Patient: Detection with US

PURPOSE

To determine the accuracy of ultrasonography (US) for the detection of blunt intraabdominal injury in pregnant patients and to compare differences between pregnant and nonpregnant patients of childbearing age.

MATERIALS AND METHODS

A retrospective review of results of all consecutive emergency blunt trauma US examinations performed at a level I trauma center from January 1995 to June 2002 was conducted. Data on demographics, free fluid location, and patient outcome were collected. Injuries were determined on the basis of results of computed tomography and/or laparotomy. The Student t test was used to detect differences between continuous variables, and chi(2) analysis was used to evaluate differences between proportions.

RESULTS

A total of 2319 US examinations for blunt trauma were performed in girls and women between the ages of 10 and 50 years. There were 328 pregnant patients, 23 of whom had intraabdominal injury. The mean age of the pregnant patients was 24.7 years +/- 6.1 (standard deviation) (age range, 14-42 years). In pregnant patients, the sensitivity of US was 61% (14 of 23 patients), the specificity was 94.4% (288 of 305 patients), and the accuracy was 92.1% (302 of 328 patients). Pregnant patients were significantly more likely to have sustained injuries from assault (odds ratio: 2.6, P < .001). The most common pattern of free fluid accumulation detected at US in pregnant patients was that of fluid in the left and right upper quadrants and pelvis (n = 4, 29%); the second most common pattern was one of isolated pelvic fluid (n = 3, 21%).

CONCLUSION

For detection of intraabdominal injury, US was less sensitive in pregnant patients than in nonpregnant patients but was highly specific in both subgroups. The sensitivity of US was highest in pregnant patients during the first trimester.

Common laboratory and diagnostic testing in patients with gastrointestinal disease

Evaluating patients with gastrointestinal (GI) illness involves the use of many different diagnostic modalities, including laboratory studies, diagnostic imaging, and endoscopy. Rapid advances in all three areas have provided clinicians with a wide array of testing at their fingertips. The frequent challenge in evaluating a patient is deciding which testing will lead to a diagnosis in the most direct and efficient manner. This article reviews many of the tests that are considered in the evaluation of individuals with complaints referable to the GI tract.