Abdominal Trauma and FAST scan (Dr. Derhim Afaqeeh , Yemen )
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Transcript of Abdominal Trauma and FAST scan (Dr. Derhim Afaqeeh , Yemen )
الرحمن الله بسم الرحيم
الرحمن الله بسم الرحيم
ABDOMINAL TRAUMA AND FAST SCAN
.
Dr. Derhim Alfaqeeh Radiologist Consultant
HO The Radiology Dept University Of Science And Technology Hospital -
Sana’a Decimber 17, 2013
ABDOMINAL TRAUMA AND FAST SCAN
.
Dr. Derhim Alfaqeeh Radiologist Consultant
HO The Radiology Dept University Of Science And Technology Hospital -
Sana’a Decimber 17, 2013
What does it Mean?What does it Mean?
FASTFocused Abdominal (Assessment with)Sonography in Trauma
INTRODUCTION INTRODUCTION
1980s- US for trauma in Japan, Germany 1990s- US for trauma in North America The term FAST introduced in 1996
1980s- US for trauma in Japan, Germany 1990s- US for trauma in North America The term FAST introduced in 1996
Goals 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 , pleura Visceral injuries
Does it make a difference in management?
PhysicsPhysics Ultrasound is a mechanical longitudinal wave
with a frequency exceeding the upper limit of human hearing (20 KHZ )
Medical ultrasound usually 2MHZ to 16 MHZ Ultrasound transducers send out ultrasound
waves and then “listen” for returning echoes Most transducers at this time send out waves
only approximately 1% of the time Hperechoic (greatest intensity, white) stone, gas Anechoic (no echoes , black ) fluid Hypoechoic (intermediate, shades of gray)
tissues, lesions
Ultrasound is a mechanical longitudinal wave with a frequency exceeding the upper limit of human hearing (20 KHZ )
Medical ultrasound usually 2MHZ to 16 MHZ Ultrasound transducers send out ultrasound
waves and then “listen” for returning echoes Most transducers at this time send out waves
only approximately 1% of the time Hperechoic (greatest intensity, white) stone, gas Anechoic (no echoes , black ) fluid Hypoechoic (intermediate, shades of gray)
tissues, lesions
transducer
TechniqueTechnique Low frequency probe 2.5 – 5.0
MHz Tissue penetration For deep structures High frequency probe 5 - 10
MHz Tissue penetration For superficial structures
Remember: Probe marker almost ALWAYS facing either patient’s right or patient’s head
FAST: ApplicationsFAST: Applications Indications
Acute blunt or penetrating torso trauma (stable or unstable patient )
Trauma in pregnancy Pediatric trauma Subacute torso trauma(unexplained hypotension)
Goal: To identify fluid in a location where it does not normally belong and detect visceral injury.
Indications Acute blunt or penetrating torso trauma (stable or
unstable patient ) Trauma in pregnancy Pediatric trauma Subacute torso trauma(unexplained hypotension)
Goal: To identify fluid in a location where it does not normally belong and detect visceral injury.
Where can I see FF?Where can I see FF?
Free fluid usually appears anechoic by US (black ) Accumulation in area of injury Overflows into dependent areas (pouch of Douglas,
Morrison’s pouch) via rivers (paracolic gutters)
Free fluid usually appears anechoic by US (black ) Accumulation in area of injury Overflows into dependent areas (pouch of Douglas,
Morrison’s pouch) via rivers (paracolic gutters)
FAST: AnatomyFAST: Anatomy
7 Dependent Sites
1. Right Supramesocolic (Morison’s pouch)
2. Left Supramesocolic (Splenorenal rescess)
3. Right Pericolic gutter
4. Right Inframesocolic
5. Left Inframesocolic
6. Left Pericolic gutter
7. Pelvic cul-de-sac
7 Dependent Sites
1. Right Supramesocolic (Morison’s pouch)
2. Left Supramesocolic (Splenorenal rescess)
3. Right Pericolic gutter
4. Right Inframesocolic
5. Left Inframesocolic
6. Left Pericolic gutter
7. Pelvic cul-de-sac
FAST: Technical ConsiderationsFAST: Technical Considerations• Standerded views (standerded
FAST ): 1 -Subxiphoid/Subcostal:
Pericardium 2 -RUQ: Morrison’s Pouch
3-Pelvis: Pelvic Cul-de-sac (Douglas )
Transverse Longitudinal
4- LUQ: Splenorenal & perisplenic spaces
• Extended views (E-FAST) :For pleural effusion
Remember: Probe marker almost ALWAYS facing either patient’s right or patient’s head
Supine patient
1
42
3
1) Subxiphoid exam1) Subxiphoid exam Probe placed
Transversally Midline plane Just below subxiphoid
region
Probe facing towards patient’s right
FAST: Subxiphoid examFAST: Subxiphoid exam Normal Anatomy Liver at very top of screen Epicardial fat vs. effusion
Thin layer anterior to RV
Not present posterior to LV
Normal Anatomy Liver at very top of screen Epicardial fat vs. effusion
Thin layer anterior to RV
Not present posterior to LV
Anterior
Posterior
Left Right
Normal Subxiphoid examNormal Subxiphoid exam
FAST: Subxiphoid examFAST: Subxiphoid exam
Pericardial Effusion
Pericardial EffusionPericardial Effusion
Types of pericardial effusions, subxiphoid cardiac view.Left image: typical effusion, middle image: clotted effusion , right image : with cardiac tamponade .
2)FAST: RUQ exam2)FAST: 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 Evaluating
Hepatorenal interface Possibility of fluid in
Morison’s pouch ( Right Supramesocolic space)
Evaluating Hepatorenal interface Possibility of fluid in
Morison’s pouch ( Right Supramesocolic space)
FAST: RUQ examFAST: RUQ exam Normal Anatomy In the supine
patient, the hepatorenal space (Morison’s Pouch) is the most dependent space
Normal Anatomy In the supine
patient, the hepatorenal space (Morison’s Pouch) is the most dependent space
Anterior
Posterior
Inferior Superior
Morison’sPouch
FAST: RUQ examFAST: RUQ exam
FAST: RUQ examFAST: RUQ exam
L
K
FF
RS
D
FAST: RUQ examFAST: RUQ exam
L
K
FF
3)FAST: Pelvis exam3)FAST: Pelvis exam Pelvis: Longitudinally and Transvers Axis. Probe placed
Transeversally than Longitudinally Midline 2 cm superior to the symphysis pubis “aimed” caudally into the pelvis (prostate )
Probe facing Toward patient’s head and right side.
Best with some urine in bladder(acoustic window) Evaluating
Bladder ,Uterus in female ,and Prostate in male
The potential spaces are Pouch of Douglas (Cul de sac ) in female and retrovesicle space in male
‘
Pelvis: Longitudinally and Transvers Axis. Probe placed
Transeversally than Longitudinally Midline 2 cm superior to the symphysis pubis “aimed” caudally into the pelvis (prostate )
Probe facing Toward patient’s head and right side.
Best with some urine in bladder(acoustic window) Evaluating
Bladder ,Uterus in female ,and Prostate in male
The potential spaces are Pouch of Douglas (Cul de sac ) in female and retrovesicle space in male
‘
FAST: Pelvis examFAST: Pelvis exam
Pelvis: Longitudinal Axis Normal Anatomy In the erect patient, the pouch of Douglas
(retrovesicle space ) is the most dependent space
Pelvis: Longitudinal Axis Normal Anatomy In the erect patient, the pouch of Douglas
(retrovesicle space ) is the most dependent space
Longitudinal
Superior
Posterior
Inferior
Anterior
retrovesicle space
Pouch of Douglas (Cul de sac )
Mild fluid in pouch of Douglas
Longitudinal
FAST: Pelvis examFAST: 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
Transverse
Anterior
Right Left
Posterior
Transverse
Pouch of Douglas Retrovesicle space
Transverse
FAST: Pelvis exam - Pathology
FAST: Pelvis exam - Pathology
Transverse
Bladder
FF
Transverse
4)FAST: LUQ exam4)FAST: LUQ exam Probe placed
Perpendicular Mid - coronal plane Just superior to the iliac crest
Probe facing Towards patient’s head
Evaluating Spleno-renal interface Possibility of fluid in
splenorenal recess and presplenic /subphrenic space( most common space for fluid collection in LUQ)
Probe placed Perpendicular Mid - coronal plane Just superior to the iliac crest
Probe facing Towards patient’s head
Evaluating Spleno-renal interface Possibility of fluid in
splenorenal recess and presplenic /subphrenic space( most common space for fluid collection in LUQ)
FAST: LUQ examFAST: LUQ exam Normal Anatomy More difficult to evaluate than
RUQ (do not have liver as acoustic window)
Left kidney more superior than right
Splenorenal Recess , Potential space between kidney and spleen
Presplenic /subphrenic space between spleen and diaphragm ( most common space for fluid collection in LUQ)
Normal Anatomy More difficult to evaluate than
RUQ (do not have liver as acoustic window)
Left kidney more superior than right
Splenorenal Recess , Potential space between kidney and spleen
Presplenic /subphrenic space between spleen and diaphragm ( most common space for fluid collection in LUQ)
Anterior
Inferior Superior
Posterior
Splenorenal Recess
Presplenic space
FAST: LUQ examFAST: LUQ exam
FF
Kidney
Spleen
FF
Diaphragm
Don’t mistake Don’t mistake
Don’t mistake
Don’t mistake Don’t mistake
FAST DemoFAST Demo
FAST Focused Abdominal Sonography In Trauma
FAST Focused Abdominal Sonography In Trauma
Reliability accuracy 86 - 97 % sensitivity 88 - 91.7 % specificity 94.7 - 99 %
Can detect 70 ml fluid (by linear probe can detect as little as 10 ml or less)
Reliability accuracy 86 - 97 % sensitivity 88 - 91.7 % specificity 94.7 - 99 %
Can detect 70 ml fluid (by linear probe can detect as little as 10 ml or less)
How To Interpret FASTHow To Interpret FAST
Positive: Fluid in pericardium or any 1 of 4 abdominal windows
Negative: No fluid in any windows
Indeterminate: If any one of the 4 windows is inadequately visualized
Positive: Fluid in pericardium or any 1 of 4 abdominal windows
Negative: No fluid in any windows
Indeterminate: If any one of the 4 windows is inadequately visualized
Does FAST Make a Difference In Trauma Management?Does FAST Make a Difference In Trauma Management?
During primary or secondary survey During primary or secondary survey
FAST
Positive Negative
Indeterminate
unstable stable
OR CT
unstable stable
ORDPL
CTDPL
Serial exam Repeat US/ CT
Adapted from: Rozycki GS, et al. J Trauma, 1996
Pearls Pearls
Lack of FF ≠ no injury Not enough to see (?too early) You missed it Hard-to-see places
FF may not be blood Urine, lavage fluid, ascites,
amniotic fluid, bowel contents, ruptured cyst
Lack of FF ≠ no injury Not enough to see (?too early) You missed it Hard-to-see places
FF may not be blood Urine, lavage fluid, ascites,
amniotic fluid, bowel contents, ruptured cyst
Advantages
Easy & Early to Diagnose in Resuscitation/Emergency room
Rapid(1 – 2.5 min) Repeatable Non-invasi Low cost.
Difficult to distinguish Type of fluid Site of bleeding , Solid organ injury
Cannot evaluate retroperitoneum Difficult in the obese patient , subcutaneous emphysema Examiner Dependent. Bowel gas interposition False –Negative : retroperitoneal & Hollow viscus injury
Disadvantages
Pitfalls and limits
• -Pre-exsiting fluid collection ( Ascites , dialysis )• -Pelvic fluid collection (female ) .• -Fluid filled bowel loops .• -Contained injury (hollow viscus, bowel wall
contusion, pancreatic trauma and renal pedicle injury)• -Echogenic clot.
The scan should be repeated during the secondary survey and also if the patient demonstrates clinical deterioration, since free fluid may have accumulated in the intervening time .The quality of images obtained may also be a limiting factor with patient obesity , gas in the bowel leading to degradation in image quality , subcutaneous emphysema , non-mobile patient and pnetrating injury.
Does FAST replace CT?Does FAST replace CT? Unstable patient, (+) FAST OR Stable patient, low force injury, (-) FAST consider observing patient.
CT is far more sensitive than FAST for detecting and characterizing abdominal injury in trauma. The gold standard for characterizing intraparenchymal injury.
“Death begins with a CT.” Never send an unstable patient to CT. FAST, however, can be performed during resuscitation.
Unstable patient, (+) FAST OR Stable patient, low force injury, (-) FAST consider observing patient.
CT is far more sensitive than FAST for detecting and characterizing abdominal injury in trauma. The gold standard for characterizing intraparenchymal injury.
“Death begins with a CT.” Never send an unstable patient to CT. FAST, however, can be performed during resuscitation.
FAST
Positive NegativeIndeterminate
unstable stable
OR CT
unstable stable
OR
DPL
CT
DPL
Serial exam Repeat US/ CT
??Is Pneumoperitoneum Can Be Detected By US?
YES
Is Pneumoperitoneum Can Be Detected By US?
YES
Pneumoperitoneum Pneumoperitoneum
Extended FAST (E-FAST)Extended FAST (E-FAST)RUQ, LUQ views: Check above diaphragm for hemothorax
CXR = US in detection of hemothoraxMa and Mateer. Ann Emerg Med, 1997
50-175cc vs. 20cc or less US does not replace CXR
Suprapubic view: Check uterus for pregnancy
RUQ, LUQ views: Check above diaphragm for hemothorax
CXR = US in detection of hemothoraxMa and Mateer. Ann Emerg Med, 1997
50-175cc vs. 20cc or less US does not replace CXR
Suprapubic view: Check uterus for pregnancy
HemothoraxHemothorax
KD
SPFF
D
Pleural Fluid
Right pleural effusion, transverse subxiphoid view
Don’t mistake Don’t mistake
Lung Scanning for PneumothoraxLung Scanning for Pneumothorax
Comet tails sign and sliding lung
Loss of comet tail and lung sliding movement
Loss of comet tail and lung sliding movement
Hollow Organs
StomachGall bladder
IntestinesUreters, Bladder
Solid Organs
LiverSpleenKidney
Pancreas
Vascular Injury
AortaVena Cava
Major Branches
Abdominal Organ Injury
Blunt InjuryAbdominal TraumaBlunt InjuryAbdominal Trauma
Spleen 25% Liver 15% Hollow viscus 15%
Ileum Sigmoid
Kidney 12% Retroperitoneal 13% Mesentery 5%
Spleen 25% Liver 15% Hollow viscus 15%
Ileum Sigmoid
Kidney 12% Retroperitoneal 13% Mesentery 5%
Compression / deceleration Crushing Shearing Avulsion
Compression / deceleration Crushing Shearing Avulsion
Solid-Organ Injuries (sonographic patterns)
I. Contusion : patchy ill defined non-linear echogenic area .
II. Subcapsular hematoma : under capsule.
III. Intra-parenchymal hematoma : well defined rounded hyperechoic area .
IV. Laceration : linear well defined hper / hypoechoic area.
V. Multiple lacerations/vascular injury (organic fracture ,disorganization )
Liver laceration and hematoma Liver laceration and hematoma
Subcapsular Liver hematoma
Liver laceration and hematoma
Splenic laceration
Spleen hematoma Subcapsular spleen hematoma
Splenic laceration
Preinephric and renal hematoma
Renal laceration
Subcapsular renal hematoma
ReferencesReferences
Vicki E Nobil , Manual of emergency and critical care ultrasound , Cabridge university 2007
Rosen, C. Ultrasound in Emergency Medicine. Emergency Medicine Clinics of North America. August 2004. Volume 22. Number 3.
O. John Ma and James R. Mateer. Emergency Ultrasound. McGraw-Hill. Medical Publishing Division. 2003.
Simon, B. Ultrasound in Emergency and Ambulatory Medicine. Mosby. 1997
Temkin, BB. Ultrasound Scanning: Principles and Protocols. WB Saunders. 1993.
Vicki E Nobil , Manual of emergency and critical care ultrasound , Cabridge university 2007
Rosen, C. Ultrasound in Emergency Medicine. Emergency Medicine Clinics of North America. August 2004. Volume 22. Number 3.
O. John Ma and James R. Mateer. Emergency Ultrasound. McGraw-Hill. Medical Publishing Division. 2003.
Simon, B. Ultrasound in Emergency and Ambulatory Medicine. Mosby. 1997
Temkin, BB. Ultrasound Scanning: Principles and Protocols. WB Saunders. 1993.
Questions?Questions?