Focused Abdominal Sonography in Trauma BY:Dr.K.Azarkhish.

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




Evaluating Hepatorenal

interface Possibility of fluid

in Morison’s pouch - Right Supramesocolic space

Technical Problems Bowel gas Rib artifact

Evaluating Hepatorenal


in Morison’s pouch - Right Supramesocolic space

Technical Problems Bowel gas Rib artifact


Where exactly is Morrison’s Pouch? Where exactly is Morrison’s Pouch?


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


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


Towards patient’s head

Probe placed Perpendicular Mid - coronal plane Just superior to the


Towards patient’s head


Evaluating Spleno-renal


in splenorenal recess

Technical Problems Bowel gas,

splenic flexure gas

Rib artifact

Evaluating Spleno-renal


in splenorenal recess

Technical Problems Bowel gas,

splenic flexure gas

Rib artifact


Where exactly is Splenorenal Recess? Where exactly is Splenorenal Recess?


Where is splenorenal

recess?

Where is splenorenal

recess?


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


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


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


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


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


Pelvis: Long Axis Probe placed

longitudinally 2 cm superior to the

symphysis pubis Midline of the

abdomen “aimed” caudally into

the pelvis Probe facing



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)


anterior pelvis Free fluid in the

pelvic cul-de-sac (Pouch of Douglas)



landmarks)


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)



landmarks)


anterior pelvis Free fluid in the pelvic

cul-de-sac (Pouch of Douglas)



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

Focused Abdominal Sonography in Trauma BY:Dr.K.Azarkhish.

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