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?