Ultrasound in Trauma: Past, Present and · PDF file9/22/2014 1 Ultrasound in Trauma: Past,...

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    Ultrasound in Trauma:Past, Present and

    FutureAdeyinka A. Adedipe MD

    Division of Emergency MedicineUniversity of Washington

    Objectives

    How is bedside US is used to evaluate trauma patients?

    What are the advantages and limitations of bedside US in trauma care?

    What is new in US for trauma care?

    The Past . . .

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    Case 1: Big City, USA

    26 year old male Restrained driver HRMVA

    Obtunded at scene w/prolonged extrication

    HR: 118 BP:88/67 RR:6

    EMS: 2 large IVs and intubation

    Case 1: Big City, USA

    Primary Survey

    HR: 121 BP:85/53 RR:12 (bagged) 8.0 ETT Bilateral BS Weak femoral pulses/stable pelvis Pupils 32 bilaterally, MAE

    Case 1: Big City, USA

    Secondary Survey

    Abdominal tenderness diffusely

    Ecchymosis on the chest, abdomen and pelvis

    Gross deformity of left leg

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    . . . the FAST

    Primary Indications

    Identify intraperitoneal hemorrhage

    Identify pericardial effusion

    Identify hemothroax

    Main Views

    Hepatorenal

    Splenorenal

    Suprapubic

    Subxiphoid

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    Hepatorenal Space

    Hepatorenal

    Identify: Diaphragm Liver Kidney

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    Splenorenal Space

    Splenorenal

    Identify: Diaphragm Spleen Kidney

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    Suprapubic

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    Suprapubic

    Identify: Bladder Uterus (+/-)

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    Advantages

    Sensitive Rapid Bedside Test Noninvasive Non-ionizing Repeatable

    Limitations

    Retroperitoneum Solid Organs Hollow viscous

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    The Present . . .

    Case 2: Small Town, USA

    26 year old male Stab wound to the anterior chest

    Awake and alert at scene HR: 118 BP:88/67 RR: 20

    EMS: 2 large bore IVs

    Case 2: Small Town, USA

    Primary Survey: HR: 118 BP:88/67 RR: 20 Patent airway Bilateral BS Weak radial pulse MAE to command

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    Case 2: Small Town, USA 2cm laceration to chest

    Faint heart sounds

    Radial pulse diminishes with inspiration

    Prominent neck veins and upper torso plethora

    . . . the E-FAST

    The Extended FAST

    Emphasis on identifying pericardial hemorrhage

    Identify pneumothroax

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    Subxiphoid

    Subxiphoid

    Below costal margin

    Scan through the liver

    Subxiphoid

    Identify: Pericardium Right ventricle Left ventricle

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    Thoracic Views

    Hemothorax

    Begin at mid-axillary line, below rib margin

    Slide superiorly above level of

    diaphragm

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    Pneumothorax

    Midclavicular line, 2nd or 3rd intercostal space

    FIN

    Normal Lung: pleural slide and comet tail artifacts

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    Pneumothorax: loss of pleural slide

    The Future . . .

    Case 3: Remote Village, Far Away Nation

    26 year old male Kicked in the abdomen by a horse

    Family arranged for a cart to transport the patient

    Its taken them 5 days to get over the mountain range

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    Case 3: Remote Village

    Primary Survey

    HR: 118 BP: 88/67 RR: 24 Patent airway Bilateral BS Weak radial pulse/stable pelvis Lethargic, but neuro intact

    Case 3: Remote Village

    Secondary Survey

    Abdominal tenderness diffusely

    Rebound and guarding

    Ecchymosis around the umbilicus

    . . . the iFAST?

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    TeleSonography

    J Trauma, 2010

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    Resuscitative US

    J Trauma, 2009

    J Trauma Acute Care Surg, 2014

    Summary

    FAST

    E-FAST

    i-FAST

    ReferencesWilliams SR, et al The FAST and E-FAST in 2013: trauma ultrasonography:

    overview, practical techniques, controversies and new frontiers. Crit Care Clin. 2014

    Patel NY, et al Focused assessment with sonography for trauma: methods, accuracy, and indications Surg Clin North Am. 2011

    Daniel K. Does This Adult Patient Have a Blunt Intra-abdominal Injury? JAMA. 2012

    Kirkpatrick AW, et al. Cost-effective remote iPhone-teathered telementored trauma telesonography. J Trauma. 2010

    Nunez, et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009

    Ferrada, P et al. Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay. J Trauma Acute Care Surg. 2014

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    FIN