Trauma Ultrasound: What you need to know
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Ultrasound plays an important role in the assessment and management of trauma patients. The Focused Assessment with Sonography for Trauma (FAST) exam is used to rapidly detect fluid in the pericardial sac, pleural space, or abdomen which could indicate life-threatening injuries. An extended FAST (eFAST) adds assessment of the lungs for pneumothorax. Ultrasound can also guide procedures like vascular access, nerve blocks, and tube placement. While ultrasound has good sensitivity and specificity for many applications, it is operator dependent and does not replace clinical examination or CT imaging. Proper training and governance are required for its effective use in trauma.
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Trauma Ultrasound: What you need to know
- 3. CONTENT Overview of ultrasound in trauma 01 FAST + (e)FAST 02 Beyond (e)FAST 03 Summary 04
- 9. The role of ultrasound in trauma • FAST + (e)FAST • Procedural guidance • Intubation confirmation and endotracheal tube placement • Nerve blocks for analgesia • Intercostal/paravertebral blocks for rib fractures • Limbs blocks for limb trauma • Central and peripheral venous access • Paracentesis/Intercostal drainage guidance
- 10. With a high degree of sensitivity for the detection of potential survivors after traumatic arrest, FAST represents an effective method of separating those that do not warrant the risk and resource burden of RT from those who may survive. The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.
- 13. FAST (e)FAST
- 14. RUQ • Transducer • Coronal plane • Marker towards patients head • Mid - axillary line • 3 review areas • Hepato-renal recess (Morrisons pouch) • Inferior pole of kidney into right paracolic gutter • Below diaphragm
- 18. LUQ • Transducer • Coronal plane • Marker cephalad • More superior than RUQ • 6th – 9th intercostal spaces • More posterior than RUQ • 3 review areas • Below the diaphragm (peri-splenic space) • Between spleen and left kidney • Inferior pole left kidney (left paracolic gutter)
- 22. Suprapubic • Transducer • Midline • Coronal and transverse • Just superior to pubic symphysis • Fan left to right, superior to inferior • Review areas • Rectovesical space • Vesicouterine space • Rectouterine pouch (pouch of Douglas) • Posterior wall of bladder
- 28. Sub-costal • Transducer • Transverse • Subcostal • Liver as acoustic window • Increase depth
- 33. eFAST • Pleural effusion • Pneumothorax
- 37. Pneumothorax • Transducer • Curvilinear • Linear • Longitudinal • Mid-clavicular line • Review • Marching ants • Comet tails • A lines
- 40. The ‘lung point’ • The probe is facing the pneumothorax, in expiration. • During inspiration the lung volume has increased and now the probe is facing the lung. • The probe remains motionless
- 42. IS LUNG ULTRASOUND REALLY OF ANY USE? Sensitivity Specificity PNEUMOTHORAX 98% 99% PLEURAL EFFUSIONS 97% ~100% INTERSTITIAL FLUID ~86% 98%
- 44. TWO S
- 45. Optic nerve sheath • Optic nerve sheath diameter (ONSD) and ICP related • Measured 3 mm posterior to the globe • ONSD greater than 5 mm is considered abnormal and elevated intracranial pressure should be suspected
- 46. From broomedocs
- 48. Primary Survey Potential role of ultrasound Airway Determine tracheal position Confirm ETT placement and position Breathing Assess for pneumothorax and haemothorax Circulation Assess for haemoperitoneum Assess for haemopericardium Assess for haemothorax To guide peripheral or central venous access Assess intravascular filling Disability Assess optic nerve sheath diameter as a reflection of intracranial pressure Exposure
- 49. Benefits of (e)FAST •Rapid and Bedside •Non-Invasive •Repeatable – serial examination •Can be integrated into the primary or secondary survey and performed quickly, without removing patients from the clinical arena •No radiation
- 50. • Operator dependent • Sensitivity • Specificity • Governance
- 54. In summary…. • NOT PERFECT • Does not replace clinical examination • Does not replace CT • Requires training • Good clinical governance
- 55. Useful links • Ultrasoundoftheweek.com • 5minsono.com • Ultrasoundvillage.com • Ultrasoundpodcast.com • #POCUS
Editor's Notes
- Good morning I’m a consultant in Oxford UK and a run our department POCUS fellowships I have no financial disclosures to make
- Qns How many have ready access to one of these?/ How many already utilise US when treating trauma cases How many of you work in dept’s where majority of medical colleagues are trained?
- I’m going to give a brief overview of what we do in Oxford The FAST and eFAST protocols which is almost synonimous with Trauma US Areas of future development – Beyond eFAST And I’ll wrap up with a summary
- This is where I work – Oxford. A beautiful place. We had a well established echo training programme but when it comes to POCUS, we’ve been doing it for about a year.
- This is the view of the hospital. I always show this picture of the new section of the hospital. That’s the neuro ICU. The adult ICU is buried in the basement.
- In the UK, trauma services have been centralised and Oxford is one of the major trauma centres. We are number 3. What that means is that if someone was involved in a major trauma incident, the pre-hospital team would aim to bring these pts to these hospitals either by land ambulance or air ambulance.
- We are busy, last month we saw an average of 2 major trauma calls a day. The majority of our big trauma calls are vehicle related. Fair few stabbings. We don’t get shootings as a general rule.
- The other source of trauma workload is this – we have lots of rural areas and these are dangerous things. Trauma involving horses and cows are not unusual.
- The ultrasound machine is a very diverse and useful tool. We tend to think about it in the context of the acute setting – assessment – FAST, eFAST. Acute procedural tools, vascular access, drains. But it can also be used in the subacute setting – peripheral nerve blocks and others to aid analgesia.
- 2015 paper from the Annals of Surgery. analysis over 4 years. Nearly 200 patients who suffered a traumatic cardiac arrest. Their conclusion…..
- OK. The focused assessment by sonography in or for trauma. FAST. I have to admit in our centre, we have become more selective in when we use FAST and US. Its probably because we access to trauma CT scans so readily. What I want to do now is to go through the basics of FAST and perhaps we can discuss things in greater detail later.
- In the context of Its mostly about fluid. Fluid in the context of trauma is usually blood.
- Scan areas – there are 4 in the original FAST- R and LUQ, suprapubic and subcostal. The extended FAST adds in areas to assess for pleural fluids and pneumothorax
- LUQ – scan area is usually more posterior. Knuckle into the bed.
- Although fluid can collect between the spleen and kidney, more commonly you get fluid collecting as a rim above the spleen.
- Longitudinal
- We move on to the subcostal views – familiar to those of you who perform transthoracic echocardiography.
- THE CT IS GOLD STANDARD
- I do however believe that US would eventually integrate into everyday ICU management in the same way that echo has.