Gestione Del Trauma

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Clinician-performed focused sonography for the resuscitation

of trauma

Andrew W. Kirkpatrick, MD, FRCSC, FACS

As evidenced by the contents of this supplement, ultrasound(US) is being used as an all-purpose diagnostic and thera-

peutic tool in the critically ill. There aremany complementary medical imagingmodalities available today that allow pre-cise and detailed imaging of the human

body. Computed tomography (CT), mag-netic resonance, and angiography are op-tions, but none are as accessible, safe, andrepeatable as US. US can precisely delin-eate cardiac function, examine blood flowto the brain, direct percutaneous aspira-tion and cannulation, and detect venousthromboses, among a myriad of otherutilities, when used by experts. In theearly minutes to hours after severe in-

jury, however, US can particularly assistthe clinician by combining the physicalexamination with a focused goal-directed

test that can immediately confirm life-threatening diagnoses. Although focusedUS is typically interpreted in real-timeanalog format, it represents anatomy andphysiology captured in a digital format.US is also typically the first imaging thatcan be brought to the critically injured,often in remote or hostile settings (1, 2).

Traumatic Injury: A Continuing

Epidemic

Despite progress, trauma remains theleading cause of death among people15–44 yrs of age (3). Trauma is also aleading cause of death in low and middleincome countries, constituting 16% of the world’s burden of disease (4). Al-though the concept of the “golden hour”is now 20 yrs old, the majority of pre-

ventable trauma deaths still occur early

in hospitalization (5), constituting up to48% of trauma deaths even in the West-ern world (6). These fatalities are time-dependent (7) and involve managementof the airway (7), thoracic injuries (6, 7),and control of shock and hemorrhage (6,8). Deaths from traumatic brain injuries(TBI) are more frequent (42%) than hem-orrhage (39%) (9), but primary therapiesfor TBI remain limited at this time (10).Recognizing these areas are a critical fo-cus for clinicians, this article will specif-

ically examine the role of focused clinicalUS in the initial assessment and resusci-tation of the injured.

Origins of the Focused

Assessment with Sonography

for Trauma

US is a simple, portable, repeatabletest that involves no radiation and can becompleted at the bedside in seconds tominutes. Its rapid ability to detect freefluid as a marker of serious injury hassupported the dissemination of US intoresuscitative suites around the world andintroduced clinicians to the US-enhancedphysical examination (11–13). The pub-lished evidence reflects the fact that anydiscipline that, or individual who, under-takes a commitment to learn, practice,and review their results can attain profi-

ciency (14–22). A focused screen to iden-tify free intraperitoneal and intraperi-cardial fluid constitutes the Focused As-sessment with Sonography for Trauma(FAST) (23). The term itself emphasizesboth the “focused” nature and the factthat it is not limited to the abdominalcavity. European and Asian investigatorsinitially used US to examine injured pa-tients, quickly accepting it into theirpractices and surgical curriculums (24).

Although the first North American report

From the Departments of Critical Care Medicineand Surgery, Foothills Medicine Centre, Calgary, Al-berta, Canada.

The author has not disclosed any potential con-flicts of interest.

Supported, in part, by the Dr. Derrick ThompsonGrant of the Canadian Intensive Care Foundation.

For information regarding this article, E-mail:[email protected].

Copyright © 2007 by the Society of Critical CareMedicine and Lippincott Williams & Wilkins

DOI: 10.1097/01.CCM.0000260627.97284.5D

Traumatic death remains pandemic. The majority of prevent-

able deaths occur early and are due to injuries or physiologic

derangements in the airway, thoracoabdominal cavities, or brain.

Ultrasound is a noninvasive and portable imaging modality that

spans a spectrum between the physical examination and diag-

nostic imaging. It allows trained examiners to immediately con-

firm important syndromes and answer clinical questions. Newer

technologies greatly increase the fidelity, accessibility, ease of

use, and informatic manipulation of the results. The early bedside

use of focused ultrasound as the initial imaging modality used to

detect hemoperitoneum and hemopericardium in the resuscitationof the injured patient has become an accepted standard of care.

Widespread dissemination of basic ultrasound skills and technol-

ogy to facilitate this brings ultrasound to many resuscitative and

critical care areas. Although not as widely appreciated, the fo-

cused use of ultrasound may also have a role in detecting hemo-

thoraces and pneumothoraces, guiding airway management, and

detecting increased intracranial pressure. Intensivists generally

utilize a treating philosophy that requires the real-time integration

of many divergent sources of information regarding their patients’

anatomy and physiology. They are therefore positioned to take

advantage of focused resuscitative ultrasound, which offers im-

mediate diagnostic information in the early care of the critically

injured. (Crit Care Med 2007; 35[Suppl.]:S162–S172)K EY WORDS: ultrasound; injury; resuscitation; physical examina-

tion; thoracic injury

S162 Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)



was in 1992 (19), the FAST became widely accepted so that within 7 yrs, ithad replaced the diagnostic peritoneal la-

vage as the initial screening modality of choice for severe abdominal trauma in80% of North American centers sur-

veyed (25). The FAST is now taught in the Advanced Trauma Life Support course(26). Practice management guidelinesfrom the Eastern Association for the Sur-

gery of Trauma recommend it be consid-ered the initial diagnostic modality to ex-clude hemoperitoneum (27).

The FAST has been reported to guidecare, to save time and money, and toreduce radiation exposure (28–30). Aprospective nonrandomized trial of FASTuse recorded changes in managementplans in 33% of cases after FAST (12).The FAST was quickly accepted into clin-ical practice, predominantly based on thepremise that it could expedite triage of the seriously injured. Hemorrhagicdeaths have been identified as the leadingcause of potentially preventable injury-related death (31), causing 80% of earlyhospital deaths, being most frequentlyabdominal (32). Shock, synonymous withcellular hypoxia, is time critical. Unfortu-nately, the clinical abdominal examina-tion is often inaccurate due to distractinginjuries, altered consciousness, and non-specific signs and symptoms (13, 33, 34).

An autopsy study reported that abdomi-nal injuries were the most frequentlymissed conditions in traumatic emer-gency department deaths, including a

number of potentially salvageable pa-tients who had been transferred fromother hospitals (35). A patient who is ex-sanguinating and requires a splenectomymay have an identical physical examina-tion to one who is dying from retroperi-toneal bleeding, in whom laparotomymight be detrimental. Transporting suchpatients for CT scanning is contraindi-cated, and thus, the diagnostic peritoneallavage had been favored as the preferredmodality to confirm intraperitonealblood. The diagnostic peritoneal lavage is

generally safe, but it has complications, istime consuming, and forever changes theresults of physical examination and sub-sequent imaging (36).

Expediency

With experience, the FAST can givealmost instantaneous positive results

when used to localize the major source of hemorrhage in unstable patients (21). Insuch circumstances, the primary goal is

to detect large fluid collections, analo-gous to a grossly positive diagnostic peri-toneal lavage. A number of authors havereported that among hypotensive cohortsrequiring laparotomy, all had positiveFAST examinations (20, 21, 37), includ-ing children (38) and adults examined

with handheld machines (39). In hypo-tensive patients, a massive hemoperito-neum can quickly be detected with a

single view of the Morison pouch in 82–90% of cases (21, 40), requiring a deter-mination time of 19 secs on average (21).

A negative FAST takes longer to perform,as the examiner can conclude a positivedetermination with identification of asingle area, unless using a scoring systemrequires evaluation of all peritoneal sites.

Although negative or minimally positiveFAST examinations may still representsignificant pathology, they direct thesearch for the major site of bleedingaway from the peritoneal cavity (20, 41).

Wherrett et al. (21) reported that none of 47 hypotensive patients with a negativeFAST required acute laparotomy for hem-orrhage control. Further, the FAST wasnegative in all but one with a retroperi-toneal bleeding source, in whom it wasonly trace positive (21). Recognizing thatbedside US can address the detection of multiple life-threatening conditions, anumber of groups have recently formalizedresuscitative protocols for the patient withundifferentiated hypotension. These proto-cols emphasize the expedient detection of hemoperitoneum, pericardial effusion, and

ruptured aortic aneurysms (42, 43) and thefocused evaluation of cardiac function intrained hands (44).

When making such decisions, it is cru-cial that the sonographic windows havebeen well visualized—meaning determi-nate. In a small but significant number of trauma patients, the FAST is indetermi-

nate, as the examiner is unable to visu-alize the reference organs well enough tomake a determination (45, 46). The mostcommon causes are obesity and subcuta-neous emphysema (45). In such settings,

the clinician should not consider theFAST results in decision making.

Conduct of the Examination

The ultimate goal of the FAST is toquickly localize fluid contrasted againstrecognizable organs. For introductoryand training purposes, the basic FASTtechnique was defined as the real-timeexamination of four torso regions (fourPs): pericardial, perisplenic, perihepatic(Morison pouch), and pelvic (pouch of Douglas) (13, 23). To interrogate theseareas, the US probe is typically firstplaced in the subxiphoid area and di-rected toward the patient’s left shoulderto provide a four-chamber view of theheart. The Morison pouch is then identi-fied using a right intercostal view to iden-tify any anechoic fluid between the liverand right kidney (Fig. 1). The left inter-costal view interrogates the interface be-tween the spleen and left kidney, andpelvic views examine for fluid around afull bladder. Practically, the examinationis done before a bladder catheter is

placed, with the catheter placed andclamped, or with fluid instilled into thecatheter if the bladder has been drained.

Figure 1. Sonographic image of hepatorenal space (Morison pouch) demonstrating free fluid ( arrow)

contrasted between the liver and right kidney. The patient was found to have an intraperitoneal bladder

rupture at laparotomy.

S163Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)



Others have augmented these basicanatomic locations. Sisley et al. (47) andMa et al. (16) have recommended addingsupradiaphragmatic views for the detec-tion of pleural fluid. Others routinely ex-amine the pericolic gutters for fluid (28,48). Maneuvers that increase the accu-racy of scanning include repeated exam-inations intended to detect newly accu-mulated fluid from ongoing visceral leak

or bleeding. Blackbourne et al. (49) dem-onstrated an increase in FAST sensitivityfrom 31% to 72% in a select population

with few true positive scans by repeatingthe FAST within 24 hrs. This is supportedby consensus recommending follow-upFAST examinations and6 hrs of clinicalobservation before accepting a FAST asnegative (23). The Advanced Trauma LifeSupport course recommends a “control”scan be repeated after a 30-min interval(26). The patient may also be positionedin Trendelenburg position to facilitatefluid accumulation in the Morison pouch(50). In practice, however, the most crit-ically ill would typically be undergoingdefinitive interventions or able to un-dergo a CT scan within 30 mins of hos-pital arrival.

If the patient is stable, initial evalua-tion of the pericardial site allows gainsettings to be optimized for blood (47). If the patient is unstable, the Morisonpouch may provide the quickest clinicaldirection. A review of 10,000 patientsconfirmed that the right upper quadrantor the Morison pouch as the most likely

place to detect major hemoperitoneum.The Morison pouch was positive 86% of the time, whereas the left upper quadrantand pelvis were only positive 55% and43% of the times, respectively (47).

Pericardial Component

Cardiac tamponade is a form of ob-structive shock for which clinical presen-tation can vary from subtle to cata-strophic. Although penetrating woundsto the precordium are typically obvious, a

high index of suspicion is required inblunt trauma. Classic signs such astachycardia, muffled heart sounds, andincreased venous pressure are easilymissed (51). The FAST may quickly iden-tify pericardial fluid, allowing for imme-diate bedside interventions or expeditedtransport to an operating room (16, 20,52) (Fig. 2). Early FAST studies variablyincluded an examination of the pericar-dial sac. Subsequently, consensus hasbeen to consider this a standard region of

the FAST (23). Some clinical series havereported sensitivities of 100% and speci-ficities of 97–99% for identifying freepericardial fluid (16, 53).

Blunt cardiac injury refers to a spec-trum of injuries ranging from simpleelectrocardiographic changes to free wallrupture (54). Cardiogenic shock fromblunt cardiac injury is uncommon in sur-

vivors to hospital, although cardiac inju-ries are common in autopsy series (51).

When pump dysfunction occurs afterblunt injury, it presents an exceedinglydifficult diagnostic challenge that mayonly be resolved with formal echocardi-ography (51, 55) (Fig. 3). Although de-tecting intrapericardial fluid is well

within the capability of clinicians, evalu-ating cardiac function requires dedicatedtraining. Although this skill level is cur-rently largely unavailable during trauma

resuscitation, the continued adoptionand experience with echocardiographicskills in critical care provides an oppor-tunity for expedited diagnoses that mightimprove the care of this group.

FAST as the Definitive

Abdominal Imaging Test

In current practice, trauma US hastaken on two congruous yet distinctroles. One is the early identification of unstable trauma victims requiring urgentsurgical interventions (40), and the othermore controversial role, is that of exclud-ing stable patients from further abdomi-nal imaging (14, 15, 56–58). A number of centers have reported on the efficiency of using the FAST as the sole abdominalimaging modality in hemodynamicallystable patients without high clinical sus-

Figure 2. Sonographic image of pericardial fluid ( arrows) that was hemodynamically compromising.

Figure 3. Formal echocardiographic study that reveals an acute posttraumatic flail mitral valve leaflet( arrow).




picion of injury. A number of larger serieshave shown this to be safe (20), with nodeaths related to missed injuries beingreported (37, 46, 59). Much of this evi-dence accrues from larger series of pa-tients with low injury acuity or in whomthere were few positive results (20, 37).Clinicians need to be keenly aware of thelimitations of trauma sonography. It is a

very user-dependent examination. The

FAST may miss injuries that are not as-sociated with free intraperitoneal fluid,such as hollow viscus, mesenteric, intra-parenchymal solid, or retroperitoneal in-

juries (59–62). Some recent series havereported sensitivities as low as 31–42%(49, 62, 63). These injuries may also bemissed by CT, emphasizing that no im-aging test is foolproof. Although CTscanning will detect more pathology,injuries detected often have no clinicalinfluence (49).

Algorithms to Reduce the Riskof Missed Injuries

Identifying markers may direct pa-tients at higher risk of sono-occult inju-ries to undergo CT. These include severeor persistent abdominal pain, seat-beltsigns or other abdominal wall contu-sions, pulmonary contusion, hematuria,or fractures of the lower ribs, spine, orpelvis (20, 20, 37, 46, 64). Centers thatrely on sonography technicians have sug-gested bypassing FAST for a screening CTin these situations (37), although consid-

ering the FAST as a required componentof the physical examination is an alter-nate philosophy.

Organ-Specific Injuries and

Focused Sonography

Accurate depiction of organ injury instable patients has revolutionized thecare of hemodynamically stable patients,permitting successful nonoperative man-agement in many cases. If the FAST ex-amination is being used as a sole diagnos-

tic test, the ability to delineate specificorgan injuries is greatly diminished.Groups with greater skills, however, havedemonstrated that US can detect specificorgan injuries. Holm and Mortensen (65)set the stage for using US in the traumasetting in 1968, reporting the identifica-tion of a splenic rupture with associatedhematoma. In experienced hands, a sono-graphic examination can identify specificparenchymal injuries (57, 66– 69), gener-ally finding a greater sensitivity the

higher the severity of injury (63, 67, 68).Contrast-enhanced US may improve theaccuracy of solid organ imaging and re-

veal active contrast extravasation relatedto active bleeding (70, 71). These studiesoften rely on technicians or radiologists(57, 67, 68), potentially reducing theavailability. The emphasis of the FAST issimplicity, intended to be within the capa-bilities of an on-site clinician. Thus, US

delineation of organ detail may warrantfurther evaluation at patient follow-uprather than at initial resuscitation.

Scoring Systems

Although the standard FAST is binary, with any fluid constituting a positive re-sult, authors have explored whether freefluid can be quantified and whether thismight direct care. Huang et al. (72)scored hemoperitoneum from 0 to 8, cor-relating a score of 3 with 1000 mL of intraperitoneal fluid. This was corrobo-rated by Boulanger et al. (25), who notedall hypotensive patients with a score of 3 underwent therapeutic laparotomy.McKenney et al. (73) described anothersystem that added 1 point for each of upto four peritoneal regions to the depth incentimeters of a fifth potential region.

When the hemoperitoneum score was3, 87% required a laparotomy, includ-ing 89% of those who were initially nor-motensive but deteriorated in shock

within 4 hrs. In the subacute phase of care, hemoperitoneum scoring may have

utility in the nonoperative managementof solid organ injuries (63). Although nosingle system has been universally ac-cepted, future evaluation might considernewer technologies. Three-dimensionalUS seems to be a reliable and reproduc-ible method of measuring irregular fluidand blood collections (74, 75). Fully au-tomated volume calculations combined

with transducers that automatically per-form real-time sweeps of a predefined area(four-dimensional) (75, 76) offer the poten-tial for generating continuous real-time as-

sessment of visceral hemorrhage (77).

Evidence-Based Medicine

Despite the enthusiasm for the FAST, well-validated scientific proof of utilityremains sparse. This criticism is easilyapplied to the majority of care provided tothe critically ill, given the complexity of the patents and inherent difficultiesstudying them. Stengel et al. (78– 80)have performed a series of ongoing sys-

temic reviews, concluding that there isinsufficient evidence to justify the pro-motion of US-based clinical pathways insuspected blunt trauma (80). It is impor-tant to note that there were insufficientdata to discriminate between hemody-namically stable and unstable patients (acritical distinction), trivial and nontrivialinjuries, or initial and repeated examina-tions (79). An analysis of 62 publications

with 18,167 patients revealed an overallsensitivity of 79% and a specificity of 99.2% for detecting free fluid, organdamage, or both (79). Methodologic rigorhad a major effect on accuracy, with lessrigorous studies reporting higher accu-racy. Overall, they corroborate that theFAST has moderate sensitivity; when itdetects injuries or fluid it is decisive, buta negative FAST should not be trustedbecause the likelihood ratios of a negativetest were 0.2 to 0.35.

Inclusion in the Cochrane review re-quired comparisons between the FASTexamination and either diagnostic perito-neal lavage or CT scan (80). Althoughthese analyses are methodologically cor-rect if one considers the FAST a stand-alone diagnostic test, they may not reflectthe utility of using the FAST as a sub-component of an algorithm or as simplyan extension of the physical examination.

A dedicated effort to elucidate the true worth of the FAST would need to focus onspecific homogeneous patient groups,notably hemodynamically unstable pa-tients, and compare the physical exami-

nation with the FAST. All other aspects of care of these complicated patients wouldalso need to be rigidly standardized, pre-senting a monumental challenge. The ap-propriate studies to allow meta-analyticstudy may never be done. Clinicians havecome to depend on the FAST to the pointthat they would not accept a control groupof patients. For example, a randomized trialof the FAST examination was terminatedearly because the investigators thoughtthey could no longer justify as ethical the

withholding of the FAST examination from

eligible patients (28).

FAST Examination for

Penetrating Trauma

The ability to quickly delineate majorabdominal fluid collections after pene-trating thoracoabdominal trauma directsoperative planning. Asensio et al. (81) re-gretted a limited use of early FAST indirecting surgical sequencing andstrongly recommended its increased




use. A majority of surveyed US centersreported using FAST for penetratingtrauma (25), and meta-analysis showedno accuracy differences between studiesincluding and excluding penetratingtrauma (79). Studies have demonstratedexcellent specificities (94–100%) butonly modest sensitivities (46–71%) (52,82, 83). Thus, a positive FAST is a strongpredictor of injury and should immedi-

ately direct patients to laparotomy, whereas negative tests should prompt an-other diagnostic strategy (83).

Hand-Carried Ultrasound

A number of portable handheld USunits have recently become available toclinicians. The first such units were de-

veloped through a joint civilian–militaryinitiative to provide portable US capabil-ities suitable for battlefield or mass casu-alty situations (84). The primary benefitof these devices for trauma care providers

will be earlier diagnosis, potentially evenin the prehospital setting, to expeditetransport priorities and disposition. Al-though the fidelity and image quality of early hand-carried US units did notmatch that of the standard floor-basedmachines, their diagnostic performanceregarding the FAST examination seemscomparable (11, 39, 85). This class of UShas been tested in many adverse envi-ronments and found to be clinicallyuseful (2, 86–88).

Future of the FAST Examination

After an initial wave of enthusiasm,the limitations of the FAST have beenmore widely appreciated. These aremainly its inability to detect injuries notassociated with free fluid and its generalinability to quantify the degree of organinjury. In the decades since the North

American introduction of FAST, CT scan-ning has made remarkable progress incapabilities to become indispensable intrauma care. This had led to routine use

of nearly whole-body CT scanning (89). Although invaluable, CT scanning greatlyincreases radiation exposure (90, 91).

With liberal use, this imparts a small butfinite risk of later cancer, especially in

younger patients (91). In one study, CTcontributed 97.5% of the total effectiveradiation dose from all imaging in trau-matized children (91). Optimal CT scan-ning also requires nephrotoxic contrastagents. US and CT scanning should thusbe used as complementary tests, with CT

being of higher fidelity but with US beingreadily repeated during the initial en-counter and during routine reassess-ments. How much should the medicalsystem pay to detect all the injuries de-tected on CT that do not influencemedical care is a societal question that war-rants formal economic analysis. Balancingthe FAST’s limitations, however, is the rap-idly increasing scope of the examination to

encompass the entire primary AdvancedTrauma Life Support survey.

Extended FAST and Thoracic

Trauma

To save lives, the resuscitating clini-cian must efficiently address life-threat-ening thoracic injuries, which are re-sponsible for 25% of trauma deaths (92,93). Life-threatening thoracic injuriesthat should be detected during a primarysurvey include tension pneumothoraces(PTXs), massive hemothoraces, cardiactamponade, and flail chest injuries (93).Rib fractures are the most common seri-ous thoracic injury and pneumothoracesare the most common intrathoracic in-

jury after blunt trauma (92, 93). In allthese settings, focused US can providerapid diagnosis.

Hemothoraces

Sisley et al. (47) demonstrated thatthoracic sonography utilizing the sameprobe used for the FAST examination

could accurately detect acute traumaticeffusions. US was 97.5% sensitive and99.7% specific compared with chest radi-ography’s (CXR’s) 92.5% and 99.7%, re-spectively. Ma et al. (16) also demon-strated a 96% sensitivity and 100%specificity. Medical students can betrained in short periods of time to detectpleural fluid collections in critically illpatients (47). This experience has ledmany investigators to augment the stan-dard FAST examination with routine

views of the pleural space.

Pneumothoraces

The direct depiction of a pneumotho-rax by US is physically impossible becauseair has extremely high acoustic imped-ance, which causes almost complete re-flectance of sound waves. Thus, only ar-tifacts are seen deep to the pleura in thenormal lung (94). As both hemothoracesand pneumothoraces are pleural-baseddiseases, the underlying lung does not

need to be seen to detect them. The con-cept of using US to exclude or infer thepresence of a PTX relies on the premisethat if the pleural surfaces are in apposi-tion, then intrapleural air cannot bepresent. The focused goal of the sonogra-pher is simply to identify the contiguityof the visceral and parietal pleura usingsimple sonographic signs. We considerthis to be an extended FAST (EFAST)

(95).Unless there are pleural adhesionsfrom previous disease or injury (a condi-tion thus reducing the risk of PTX), nor-mal respiration is associated with a phys-iologic sliding or gliding of the twopleural surfaces on one another, knownas lung sliding (LS) (95–98). LS is least atthe apices and greatest at the lung bases(96). “Comet-tail” artifacts (CTAs) are re-

verberation artifacts that arise from dis-tended water-filled interlobular septa un-der the visceral pleura. They can beconsidered the US equivalent of “KerleyB-lines” (96, 99). Being related to the

visceral pleura, they can only be seen when the visceral pleura is in appositionto the parietal pleura (Fig. 4). Themarked difference in acoustic impedancebetween the parietal pleura and a PTXcreates a marked horizontal reverbera-tion artifact seen as the mirror image of the chest wall. Lichtenstein et al. (100)designate this the A-line, a brightly echo-genic line recurring at an interval thatexactly replicates the interval betweenthe skin and pleural line.

Examining the pleural interfaces withthe color power Doppler mode can en-hance the depiction of LS by emphasizingmotion, a finding designated the power

slide (101). Color power Doppler docu-ments a physiologic process as a singleimage, allowing for simpler archiving andteletransmission. Similarly, the use of M-mode documents the presence of LS (theseashore sign) (Fig. 5) or its absence withPTX (the stratosphere sign) (Fig. 6), asthe pleural movement will normally gen-erate a homogeneous granular pattern

(96, 100). Another sign well documentedin M-mode is the “lung point”; when thelung intermittently contacts the parietalpleura with inspiration, thus regularly al-ternating between the seashore andstratosphere signs (Fig. 7).

The first description of the use of USto investigate pneumothoraces was re-ported in a veterinary journal in 1986(102). Subsequent descriptions followedafter lung biopsy (94, 103, 104), in themedical intensive care unit (105–107),




and in a mixed group that included stabletrauma patients (108). Thereafter, the fo-cused use of US to assess PTXs receivedimpetus from a space medicine problem

(97, 109). The International Space Sta-tion supports US as the only diagnosticimaging modality in an environment

with increased PTX risk (110, 111). This

prompted further investigations to eval-uate the diagnostic potential both onearth (95, 112), and in weightlessness(110), suggesting that US is equal if notmore accurate than supine radiographyfor detecting PTXs (98, 110, 113).

Lichtenstein et al. (100, 105–107)have extensively studied the sonographicdiagnosis of PTXs. The “meaningful” CTA(B-line) has five mandatory features: aris-

ing from the pleural line, well-defined(laser-beam like), spreading to the screenedge, erasing the A-lines, and moving

with LS (Fig. 2) (100). These specific fea-tures distinguish it from the Z-line, aCTA that is ill-defined, vanishes after afew centimeters, does not move with LS,and that seems devoid of pathologicmeaning (100). Subcutaneous emphy-sema creates specific CTAs that rise abovethe pleural line, resulting in an indeter-minate examination. Subcutaneous em-physema itself carries a seven-fold in-creased risk and 98% specificity foroccult PTX, providing an indication forchest drainage in the unstable patient(114).

Occult Pneumothoraces

Several groups have reported on theutility of US as an adjunct to the CXR(112, 115). By using CXR as the goldstandard, however, these studies, by def-inition, ignore the issue of occult pneu-mothoraces, PTXs seen on CT but not onCXR (114, 116). Their prevalence may

range up to 64% in intubated multi-trauma patients (117). In centers usingfrequent CT scan, more than one half of all PTXs may be occult (95, 98, 113, 116,118). Considering only PTXs seen onCXRs considerably underestimates thepotential of the EFAST. Due to the effectof gravity, the supine lung hinges dor-sally, with air collecting anteromedially(119, 120). Supine PTXs are most com-monly anterior (84%), apical (57%), andbasal (41%), corresponding to the mostaccessible chest locations for US (121).

Lichtenstein et al. (100) retrospec-tively evaluated 200 consecutive intensivecare unit patients corroborated with CT.The absence of LS alone had 100% sen-sitivity but only 78% specificity for diag-nosing occult pneumothoraces. When an

A-line was seen with absent LS, however,there was a 95% sensitivity and 94%specificity for diagnosing occult pneumo-thoraces. The presence of a lung pointhad 100% specificity for occult pneumo-thoraces. A prospective study of hand-

Figure 4. Comet-tail artifacts ( arrows) demonstrated on sonographic image of left chest of a patient

with acute respiratory distress syndrome.

Figure 5. Beach sign of normal pleural sliding deep to stationary chest wall, depicted using M-mode

ultrasound function.

Figure 6. Stratospheric sign of pneumothorax with absence of any pleural movement.




carried US focused on the most difficultto diagnose subset, those patients re-maining after the obvious PTXs (CXR orclinical) were treated (95). In the remain-ing patients, EFAST had a 49% vs. a 21%sensitivity compared with CXR in the set-ting of very high specificities and positivelikelihood ratio, being corroborated byCT (95). A pitfall, as in other studies, was

bilateral PTXs, likely due to the loss of apatient-specific “normal” comparative ex-amination (95, 122). Another study of 176patients using similar methodology (US,followed by CXR and CT) used a protocolexamining four thoracic locations, allow-ing a determination of PTX size (122).The investigators systematically searchedfor LS, supplemented by color powerDoppler, assessing the relative size of thePTX through the relative topography of LS. There was a 98% sensitivity for US

compared with 76% for CXR, a specificityof 99% vs. 100% for CXR, and a positivelikelihood ratio of 121 for EFAST (122).

Magnitude of Pneumothoraces

Although PTXs are dynamic, manage-ment is often based on the perceived size.

Allowing for factors such as transport and

positive pressure ventilation, many smallpneumothoraces are managed expect-antly, whereas large ones are drained(116). The original description in horsesdescribed scanning from ventral to dorsaland noting the point where a static gasartifact met the respiratory motion of thelung (102). An early report by Sistrom etal. (94) concluded that US was of no usein determining the volume of PTX. Thismay have related both to the lack of real-time scanning and to using radiography

as a control (95, 100, 110). Subsequentstudies have suggested that sonographymay have utility in determining not onlythe presence but actual size of a PTX.Lichtenstein et al. (107) subsequently de-scribed this fleeting appearance of eitherLS or CTAs intermittently replacing aPTX pattern as the lung point sign (Fig.7). Sargsyan et al. (110) coincidentallydescribed this as partial sliding, imply-

ing that smaller or occult pneumotho-races might be detected. Blaivas et al.(122) noted good correlation betweenthe estimates of PTX size and CT findings(Spearman rank correlation, 0.82) usingthe relative thoracic topography of LS.

Probe Selection and Placement

Some groups favor high-frequencylinear array transducers that provide thebest resolution of the pleural interfaceand whose footprint fits well between the

ribs (94, 95, 98, 123). This necessitates alargely transverse scan in the upper ribspaces that is perpendicular to the mainaxis of LS (100). Conversely, other groupshave emphasized the practicality of usinga lower-frequency probe that can also beused for the abdominal portion of theEFAST, decreasing time spent exchang-ing probes (122). The transducer is firstplaced longitudinally on the chest, per-pendicular to the ribs, to identify thepleural interface in reference to the over-lying (and acoustically impervious) ribs.

Thereafter, the transducer is rotatedtransversely between the ribs to bring theechogenic pleural stripe into profile, gen-erating the “bat sign” as a basic landmark(96, 100). Thereafter, the EFAST assesses

whether LS or CTAs at the interface canbe detected. If there is no LS and nocomet tails are visible, the examinershould suspect the presence of a pneu-mothorax, a suspicion further heightenedby the presence of the horizontal rever-beration artifact (A-line). Color powerDoppler may accentuate LS and provide

documentation, as does M-mode. Detec-tion of an image where partial sliding ora lung point is present marks the lateralaspect of the pneumothorax (lung point).

Airway Management

As US is increasingly available at thebedside in critically ill patients, it may aidin airway management. Endotracheal tube(ETT) misplacement in those arriving atemergency departments already intubated

Figure 7. Lung point sign related to intermittent contact between visceral and parietal pleura,

resulting in the regular alteration between the stratospheric and beach signs.

Figure 8. Sonographic image of a 0.64-cm optic nerve sheath diameter of a victim of a motor vehicle

collision who developed brain death.




has been reported in up to 25% of cases(124, 125). Moreover, end-tidal CO2, thegold standard in ETT confirmation, may beoccasionally seen even with a mal-posi-tioned ETT (124, 125). Kirkpatrick et al.(95) noted two false-positive PTX diagnoses

when left-sided LS was absent after rightmain stem ETT placement. LS and movingCTAs returned after ETT repositioning.Subsequently, Chun et al. (126) described

the potential utility of using US to con-firm ETT placement. Weaver et al. (127)randomly inserted an ETT into the main-stem trachea, right main bronchi, oresophagus of cadavers. Using the pres-ence or absence of LS distinguishedesophageal from tracheal intubation witha 95–100% sensitivity and 100% specific-ity. Further, right main intubation wasdistinguished from mainstem with a 69–79% sensitivity and 93–100% specificity.Hsieh et al. (128) utilized a similar phi-losophy by bilaterally imaging the dia-phragmatic movements after intubationfrom a subxiphoid window, describing re-al-time correction of right main-stem in-tubations. Lichtenstein et al. (129) de-scribed CTAs oscillating with the cardiacpulsation, but not with respiratory effort,after selective right lung intubation asthe “lung pulse.” The lung pulse indi-cated complete atelectasis of the leftlung. In conclusion, it should be empha-sized that sonographic evaluation is bestutilized as either an adjunctive airwaymanagement technique or in austere sit-uations in which no other technologies

are available. These techniques may dem-onstrate ventilation but not the adequacyof such.

Posttraumatic Expanding

Intracranial Pathology

Management of serious closed headinjuries requires early identification of intracranial hemorrhage amenable tosurgical intervention. It is possible thatclinicians can quickly infer increased in-tracranial pressure from an early focused

examination of the optic nerve sheath, which is anatomically continuous withthe dura matter and through which cere-brospinal fluid percolates (130, 131) (Fig.8). Although there is not great experienceas yet, early reports are encouraging(132). A reference position 3 mm behindthe globe is chosen to give the greatestUS contrast, being the most distensiblepart of the sheath and giving the mostreproducible results (133). Normal refer-ence ranges are considered up to 5.0 mm

in adults, 4.5 mm in children aged 1–15 yrs, and 4.0 mm in infants (130, 131).

Pediatric Patients

The use of the FAST is less establishedin pediatric trauma care, although thegeneral principles remain unchanged.The FAST is clinically useful when it pro-

vides a positive result, especially among

hypotensive patients, but should be sus-pect when negative (38, 79, 134). Theo-retically, there may be specific advan-tages of US in children related to the thinbody wall and lack of intraperitoneal fatstripes (135). The EFAST and other ex-panded techniques are also applicable topediatric and even neonatal populations(128, 131, 136), who are both at risk of transportation to distant CT scanners andmore sensitive to ionizing radiation.

Future Directions

Critical care medicine, like our soci-ety, lives in the information age. The ma-

jority of the information acquired andanalyzed in the critical care unit is digitalin nature (137). Most decisions regardingpatient care in critical care medicine arenow made on the basis of numerical in-formation represented as bytes ratherthan atoms (39). Satava (138) hasstressed the information system’s inte-gration benefits of total body scans (ho-lomers). Although conceptualized as sep-arate tests, CT, US, and magnetic

resonance imaging are thus simply infor-mation systems with different eyes (139).In the future, it is probable that all infor-mation acquired about a patient from thefirst prehospital assessment onward willbe automatically compiled to build anincreasingly elegant holomer. This willallow decision support, digital transmis-sion, documentation, remote consulta-tion, manipulation, and data fusion, with-out delaying or distracting the clinicianfrom the clinical interaction. Despitethese powerful technologies, the essence

of the examination will remain the en-hancement of the clinician’s bedside di-agnostic capabilities.

ACKNOWLEDGMENTS

I thank Dr. Bernard R. Boulanger, De-partment of Surgery, University of Ken-tucky, Lexington, KY; and Dr. RosaleenChun, Department of Anesthesia, Foot-hills Medical Centre, Calgary, Alberta,Canada.

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