Post on 17-Dec-2015
Focused Abdominal Sonography in Trauma
BY:Dr.K.Azarkhish
Focused Abdominal Sonography in Trauma
BY:Dr.K.Azarkhish
Goals of this lectureGoals of this lectureGoals of this lectureGoals of this lecture Where do I put the probe? How do I hold the probe? What am I looking at? - Normal anatomy What am I looking at? - Abnormal
anatomy What can I tell from the abnormal
anatomy? Pathologic fluid in the abdomen Pathologic fluid in the pericardium
Does it make a difference? Review of the literature
Where do I put the probe? How do I hold the probe? What am I looking at? - Normal anatomy What am I looking at? - Abnormal
anatomy What can I tell from the abnormal
anatomy? Pathologic fluid in the abdomen Pathologic fluid in the pericardium
Does it make a difference? Review of the literature
Trauma UltrasonographyTrauma UltrasonographyTrauma UltrasonographyTrauma Ultrasonography Intro Applications Anatomy Comparison Exam: Technical Considerations
RUQ LUQ Subxiphoid/Subcostal Pelvis
Ultrasonagraphic evaluation of pathologic states
Intro Applications Anatomy Comparison Exam: Technical Considerations
RUQ LUQ Subxiphoid/Subcostal Pelvis
Ultrasonagraphic evaluation of pathologic states
FAST: Intro and FAST: Intro and ApplicationsApplications
FAST: Intro and FAST: Intro and ApplicationsApplications
FAST exam: Focused Abdominal Sonography in Trauma Peritoneal Pericardial Pleural
Indications Acute blunt or penetrating trauma Trauma in pregnancy Pediatric trauma Subacute trauma
Goal: to identify fluid in a location where it does not normally belong
FAST exam: Focused Abdominal Sonography in Trauma Peritoneal Pericardial Pleural
Indications Acute blunt or penetrating trauma Trauma in pregnancy Pediatric trauma Subacute trauma
Goal: to identify fluid in a location where it does not normally belong
FAST: AnatomyFAST: AnatomyFAST: AnatomyFAST: Anatomy7 dependent sites7 dependent sites
1. Right Supramesocolic (Morison’s pouch)
2. Left Supramesocolic (Splenorenal rescess)
3. Right Pericolic gutter4. Right Inframesocolic5. Left Inframesocolic6. Left Pericolic gutter7. Pelvic cul-de-sac
7 dependent sites7 dependent sites1. Right Supramesocolic
(Morison’s pouch)2. Left Supramesocolic
(Splenorenal rescess)3. Right Pericolic gutter4. Right Inframesocolic5. Left Inframesocolic6. Left Pericolic gutter7. Pelvic cul-de-sac
FAST: Technical FAST: Technical ConsiderationsConsiderations
FAST: Technical FAST: Technical ConsiderationsConsiderations
Probe placement?Probe placement?1. RUQ: Morrison’s Pouch2. LUQ: Splenorenal 3. Pelvis: Pelvic cul-de-sac
1. Transverse2. Longitudinal
4. Subxiphoid/Subcostal: Pericardium
Remember: Probe almost ALWAYS facing either patient’s rightright or patient’s headhead
Probe placement?Probe placement?1. RUQ: Morrison’s Pouch2. LUQ: Splenorenal 3. Pelvis: Pelvic cul-de-sac
1. Transverse2. Longitudinal
4. Subxiphoid/Subcostal: Pericardium
Remember: Probe almost ALWAYS facing either patient’s rightright or patient’s headhead
FAST: RUQ examFAST: RUQ examFAST: RUQ examFAST: RUQ exam
Probe placed Perpendicular Mid-coronal plane Just superior to the
iliac crest Probe facing
Toward patient’s head
Probe placed Perpendicular Mid-coronal plane Just superior to the
iliac crest Probe facing
Toward patient’s head
FAST: RUQ examFAST: RUQ examFAST: RUQ examFAST: RUQ exam
Evaluating Hepatorenal
interface Possibility of fluid
in Morison’s pouch - Right Supramesocolic space
Technical Problems Bowel gas Rib artifact
Evaluating Hepatorenal
interface Possibility of fluid
in Morison’s pouch - Right Supramesocolic space
Technical Problems Bowel gas Rib artifact
FAST: RUQ examFAST: RUQ examFAST: RUQ examFAST: RUQ exam
Where exactly is Morrison’s Pouch? Where exactly is Morrison’s Pouch?
FAST: RUQ examFAST: RUQ examFAST: RUQ examFAST: RUQ exam
Where exactly is Morrison’s Pouch?
Where exactly is Morrison’s Pouch?
FAST: RUQ examFAST: RUQ examFAST: RUQ examFAST: RUQ exam Normal Anatomy In the supine patient,
the hepatorenal space is the most dependent area
Also is the least obstructed for fluid flow
Morison’s Pouch Potential space
between the liver and the right kidney in the hepatorenal recess
Normal Anatomy In the supine patient,
the hepatorenal space is the most dependent area
Also is the least obstructed for fluid flow
Morison’s Pouch Potential space
between the liver and the right kidney in the hepatorenal recess
Morison’sPouch
FAST: RUQ examFAST: RUQ examFAST: RUQ examFAST: RUQ exam Abnormal
Anatomy Pathologic Fluid
- mild
L = liver D = diaphragm K = kidney RS = rib shadow FF1 = free fluid FF2 = free fluid
Abnormal Anatomy
Pathologic Fluid - mild
L = liver D = diaphragm K = kidney RS = rib shadow FF1 = free fluid FF2 = free fluid
FAST: RUQ examFAST: RUQ examFAST: RUQ examFAST: RUQ exam Abnormal
Anatomy Pathologic Fluid
- moderate
L = liver K = Kidney FF = free fluid RS = rib shadow D = diaphragm
Abnormal Anatomy
Pathologic Fluid - moderate
L = liver K = Kidney FF = free fluid RS = rib shadow D = diaphragm
L
K
FF
RS
D
Abnormal RUQAbnormal RUQ
FAST: RUQ examFAST: RUQ examFAST: RUQ examFAST: RUQ exam
Abnormal Anatomy
Pathologic Fluid - massive
L = liver K = kidney FF = free fluid
Abnormal Anatomy
Pathologic Fluid - massive
L = liver K = kidney FF = free fluid
L
K
FF
FAST: LUQ examFAST: LUQ examFAST: LUQ examFAST: LUQ exam
Probe placed Perpendicular Mid - coronal plane Just superior to the
iliac crest Probe facing
Towards patient’s head
Probe placed Perpendicular Mid - coronal plane Just superior to the
iliac crest Probe facing
Towards patient’s head
FAST: LUQ examFAST: LUQ examFAST: LUQ examFAST: LUQ exam
Evaluating Spleno-renal
interface Possibility of fluid
in splenorenal recess
Technical Problems Bowel gas,
splenic flexure gas
Rib artifact
Evaluating Spleno-renal
interface Possibility of fluid
in splenorenal recess
Technical Problems Bowel gas,
splenic flexure gas
Rib artifact
FAST: LUQ examFAST: LUQ examFAST: LUQ examFAST: LUQ exam
Where exactly is Splenorenal Recess? Where exactly is Splenorenal Recess?
FAST: LUQ examFAST: LUQ examFAST: LUQ examFAST: LUQ exam
Where is splenorenal
recess?
Where is splenorenal
recess?
FAST: LUQ examFAST: LUQ examFAST: LUQ examFAST: LUQ exam
Normal Anatomy More difficult to
evaluate than RUQ Left kidney more
superior than right Do not have liver as
acoustic window Splenorenal Recess
Potential space between kidney and spleen
Normal Anatomy More difficult to
evaluate than RUQ Left kidney more
superior than right Do not have liver as
acoustic window Splenorenal Recess
Potential space between kidney and spleen
SplenorenalRecess
Normal LUQNormal LUQ
Abnormal LUQAbnormal LUQ
FAST: LUQ examFAST: LUQ examFAST: LUQ examFAST: LUQ exam
Pathologic Fluid
K = kidney S = spleen RS = rib
shadow FF = free fluid
Pathologic Fluid
K = kidney S = spleen RS = rib
shadow FF = free fluid
FAST: Subxiphoid examFAST: Subxiphoid examFAST: Subxiphoid examFAST: Subxiphoid exam
Probe placed Patient’s epigastrium Just below xiphoid
process of the sternum “entire” probe aimed
at patients left shoulder
Probe facing “notch” of probe
placed toward patient’s right side
Probe placed Patient’s epigastrium Just below xiphoid
process of the sternum “entire” probe aimed
at patients left shoulder
Probe facing “notch” of probe
placed toward patient’s right side
FAST: Subxiphoid examFAST: Subxiphoid examFAST: Subxiphoid examFAST: Subxiphoid exam
Evaluating Fluid in the
pericardium Wall dysfunction
R heart strain Septal “bowing”
Technical Problems Inability to get
probe under xiphoid
Evaluating Fluid in the
pericardium Wall dysfunction
R heart strain Septal “bowing”
Technical Problems Inability to get
probe under xiphoid
FAST: Subxiphoid examFAST: Subxiphoid examFAST: Subxiphoid examFAST: Subxiphoid exam Normal Anatomy Liver at very top of
screen Right ventricle on
top of screen Right atrium and
left ventricle line up below right ventricle
Left ventricle on bottom of screen
Normal Anatomy Liver at very top of
screen Right ventricle on
top of screen Right atrium and
left ventricle line up below right ventricle
Left ventricle on bottom of screen
FAST: Subxiphoid examFAST: Subxiphoid examFAST: Subxiphoid examFAST: Subxiphoid exam
Review Normal Subcostal
view
RV = right ventricle RA = right atrium LV = left ventricle LA = left atrium IVS =
interventricular septum
Review Normal Subcostal
view
RV = right ventricle RA = right atrium LV = left ventricle LA = left atrium IVS =
interventricular septum
IVS
FAST: Subxiphoid examFAST: Subxiphoid examFAST: Subxiphoid examFAST: Subxiphoid exam
Subcostal view Large pericardial
effusion
Where to you measure amount of blood or fluid?
Answer: anteriorly between the heart and liver
Subcostal view Large pericardial
effusion
Where to you measure amount of blood or fluid?
Answer: anteriorly between the heart and liver
Measure here!
FAST: Pelvis LA examFAST: Pelvis LA examFAST: Pelvis LA examFAST: Pelvis LA exam
Pelvis: Long Axis Probe placed
longitudinally 2 cm superior to the
symphysis pubis Midline of the
abdomen “aimed” caudally into
the pelvis Probe facing
Toward patient’s head
Pelvis: Long Axis Probe placed
longitudinally 2 cm superior to the
symphysis pubis Midline of the
abdomen “aimed” caudally into
the pelvis Probe facing
Toward patient’s head
FAST: Pelvis LA examFAST: Pelvis LA examFAST: Pelvis LA examFAST: Pelvis LA exam
Evaluating Free fluid in the
anterior pelvis Free fluid in the
pelvic cul-de-sac (Pouch of Douglas)
Technical Problems Body habitus Empty bladder (no
landmarks) Bladder trauma (no
landmarks)
Evaluating Free fluid in the
anterior pelvis Free fluid in the
pelvic cul-de-sac (Pouch of Douglas)
Technical Problems Body habitus Empty bladder (no
landmarks) Bladder trauma (no
landmarks)
FAST: Pelvis LA examFAST: Pelvis LA examFAST: Pelvis LA examFAST: Pelvis LA exam
Pelvis: Long Axis Normal Anatomy
Evaluating Bladder Uterus in female:
usually superior to bladder
Prostate in male: usually posterior to bladder
Pelvis: Long Axis Normal Anatomy
Evaluating Bladder Uterus in female:
usually superior to bladder
Prostate in male: usually posterior to bladder
FAST: TV Pelvis examFAST: TV Pelvis examFAST: TV Pelvis examFAST: TV Pelvis exam
Pelvis: Transverse Probe placed
2 cm superior to the symphysis pubis
Midline of the abdomen
Probe facing Toward patient’s right Probe rotated 90
degrees counterclockwise from longitudinal
Pelvis: Transverse Probe placed
2 cm superior to the symphysis pubis
Midline of the abdomen
Probe facing Toward patient’s right Probe rotated 90
degrees counterclockwise from longitudinal
FAST: TV Pelvis examFAST: TV Pelvis examFAST: TV Pelvis examFAST: TV Pelvis exam Evaluating
Free fluid in the anterior pelvis
Free fluid in the pelvic cul-de-sac (Pouch of Douglas)
Technical Problems Body habitus Empty bladder (no
landmarks) Bladder trauma (no
landmarks)
Evaluating Free fluid in the
anterior pelvis Free fluid in the pelvic
cul-de-sac (Pouch of Douglas)
Technical Problems Body habitus Empty bladder (no
landmarks) Bladder trauma (no
landmarks)
FAST: TV Pelvis examFAST: TV Pelvis examFAST: TV Pelvis examFAST: TV Pelvis exam
Pelvis: Transverse Axis Normal Anatomy
Evaluating Bladder Well
cirucumscribed Contains fluid that
appears anechoic
Pelvis: Transverse Axis Normal Anatomy
Evaluating Bladder Well
cirucumscribed Contains fluid that
appears anechoic
FAST: Pelvis exam - FAST: Pelvis exam - PathologyPathology
FAST: Pelvis exam - FAST: Pelvis exam - PathologyPathology
Transverse scans with free fluid in pelvis Female (top): uterus
posterior to bladder Male (bottom)
B = bladder UT = uterus FF = free fluid S = spine
Transverse scans with free fluid in pelvis Female (top): uterus
posterior to bladder Male (bottom)
B = bladder UT = uterus FF = free fluid S = spine
LacerationsLacerations
Thank you all for listening to this presentation
Thank you all for listening to this presentation