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83
Clinical Scenario Answers
Case 1
Question 1
RUQ is NORMAL ____ ABNORMAL __X__
LUQ is NORMAL ____ ABNORMAL __X__
Pelvic view is NORMAL ____ ABNORMAL __X__
Case 2
Question 1
Which critical questions and decisions you need a quick answer for ?
Below are some possible answers:
• Right PTX or hemothorax?
• Is there blood in the belly?
• Which is the priority for managing shock? Thorax, abdomen, or pelvis?
• Straight to OR or time for further investigations? (It depends on resources too.)
• If to OR, which problem is to fi x fi rst?
• Is she pregnant?
Question 2
Do you think EFAST could help you ?
• YES, of course!
Question 3
List the fi nding you could rule in / out with US :
• Hemoperitoneum (yes/no)
• Assessment of the amount of hemoperitoneum (Is it a shock from pelvis fracture
only and/or intra-abdominal injury?)
• Hemothorax (yes/no)
• Pneumothorax (yes/no)
• IVC diameter: is my patient completely “empty”?
Question 4
Interpret US images :
• All US EFAST views are normal.
• Your patient is empty.
• No pregnancy.
No fl uid detectable everywhere.
Your patient is probably bleeding only from the pelvic fracture!
Question 5
Interpret US images :
1. Right hemithorax NORMAL
2. Left hemithorax NORMAL
3. RUQ ABNORMAL_free fl uid ++__
4. LUQ ABNORMAL_free fl uid ++__
5. Pelvis ABNORMAL_free fl uid ++, fl oating loops
6. IVC view (insp.) EMPTY
6 The Role of EFAST in a Comprehensive US Trauma Management
84
Question 6
Now, you know that:
A. Your patient is in shock.
B. There is NO blood in the thorax.
C. There is blood in the belly.
D. Grossly, Huang score is > 3 (at least 5: Morison 2 + Douglas 2 + Perisplenic 1);
McKenney score is > 3 (8 [cm in Douglas pouch, at least] + Morison 1 + Perisplenic
1); Sirlin score is at least 3 (Douglas 1, Morison 1, Perisplenic 1).
E. The probability of surgical intraperitoneal bleeding is very HIGH .
Suggested Reading
1. Mayse ML (2005) Real-time ultrasonography. Should this be available to every critical care
physician? Crit Care Med 33:1231–1238
2. Melniker LA (2006) Randomized controlled clinical trial of p-o-c limited US for trauma in the
ED: the fi rst SOAP trial. Ann Emerg Med 48:227–235
3. Neri L, Storti E, Lichtenstein D (2007) Toward an ultrasound curriculum for critical care medi-
cine. Crit Care Med 35(Suppl):S290–S304
4. Zago M (2009) Time for a comprehensive US-enhanced trauma management. Eur J Trauma
Emerg Surgery 35:339-40
M. Zago and D. Mariani
85
M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons,
DOI 10.1007/978-88-470-5274-1_7, © Springer-Verlag Italia 2014
7.1 Introduction
Abdominal trauma in combination with pelvic injuries is a major cause of death in
patients with multiple injuries in the fi rst 24 h after trauma. In blunt abdominal
trauma (BAT), determining which patients should be triaged to laparotomy is impor-
tant, even more, when these patients are unstable. A rapid, accurate triage and initia-
tion of resuscitation and specifi c therapy are crucial as delayed treatment is
associated with increased morbidity and mortality.
The ultrasound examination (FAST) is the gold standard as early screening
method in the emergency department (ED) and provides a quick, standardized over-
view of the intraperitoneal cavity searching for the typical sites of free fl uid accu-
mulation as already described in detail in previous chapters. Meanwhile, it is part of
the Advanced Trauma Life Support
®
algorithm. The presence of free abdominal
fl uid in the ED in combination with hemodynamically unstable patients indicates
the necessity of urgent laparotomy without any further diagnostics [ 1 – 3 ].
At the trauma scene however, clinical parameters and physical examination are
the only prehospital measures to detect intra-abdominal bleeding in spite of its low
accuracy and reliability. In patients with undiagnosed intra-abdominal bleeding,
crucial time may be lost. The determination of a source of hemorrhage at the trauma
scene might expedite transport and disposition and may result in more timely and
effective defi nite therapy.
Through a joint civilian-military initiative, the fi rst portable handheld ultrasound
devices were developed suitable for the battlefi eld or a mass casualty situation. The
modern handheld devices are small and lightweight with adequate battery life and
have increasing technical features with relative simplicity to use and an excellent
quality of image scans. These handheld devices add one more dimension to FAST
M. Ruesseler , MD
Department of Trauma Surgery , University Hospital of the Goethe-University ,
Theodor-Stern-Kai 7 , Frankfurt 60590 , Germany
e-mail:
miriam.ruesseler@kgu.de
7
Prehospital Ultrasound in Trauma:
Role and Tips
Miriam Ruesseler
86
as they make prehospital FAST (p-FAST) a possibility to detect life-threatening
injuries within the “golden hour” and appropriately triage the patients as demon-
strated in several studies.
7.2 Feasibility of p-FAST
Several studies confi rmed the feasibility of p-FAST in prehospital trauma care
[
4 – 9 ]. These studies were able to demonstrate that p-FAST could be performed in
both ground-based and air rescue with a sensitivity, specifi city, and accuracy com-
parable to FAST under inhospital conditions (Table 7.1 ). In 95 % of the investigated
patients (219/239) by Walcher et al. [ 9 ], the time frame was suffi cient to integrate
and complete p-FAST into prehospital trauma care algorithm. The investigation
time of p-FAST is comparable to inhospital times in the ED (p-FAST with negative
fi ndings: 2.4 ± 0.8 min [ 9 ]; FAST with negative fi ndings: 2.3 to 2.6 + 0.25 to 1.2 min
[ 1 , 3 ]).
p-FAST can lead to relevant changes in prehospital trauma therapy and manage-
ment with the aim to shorten the time to surgical therapy (Table 7.2 ). The patients
receive p-FAST on average 35 ± 13 min prior to inhospital FAST or CT scan [ 9 ].
Early diagnosis is precious as it can contribute to accelerate and optimize patient
care and orientation.
Detection of hemoperitoneum at the trauma scene means that the receiving hos-
pital can be notifi ed in advance and the inhospital trauma team can modify their
preparations by expanding their team to include a surgeon and prepare theater for
urgent laparotomy for hemorrhage control. Based on the p-FAST results, the admit-
ting trauma center might be changed toward the closest appropriate hospital, espe-
cially in rural settings, where mean response times and mean transport times can be
much longer.
Table 7.1 Sensitivity, specifi city, and accuracy of ultrasound in blunt abdominal trauma
First author and
reference no.
Year Modality n Sensitivity Specifi city Accuracy
Diagnostic
reference
standard
Boulanger [
1 ] 1996 FAST 400 81 97 94 DPL, CT
Brown [
10 ] 2001 FAST 2,693 84 96 96 DPL, CT,
laparotomy,
autopsy
Kirkpatrick [
6 ] 2005 HHFAST 313 68.6 96.9 91.6 CT, laparotomy
Walcher [
9 ] 2006 p-FAST 202 93 99 99 CT, laparotomy
Busch [
11 ] 2006 PHASE 38 90 96 FAST, CT
Modifi ed from Ruesseler et al. [
12 ]
FAST focused abdominal sonography in trauma, HHFAST handheld FAST, p-FAST prehospital
FAST, CT computed tomography, DPL diagnostic peritoneal lavage, PHASE prehospital applica-
tion of sonography in emergencies
M. Ruesseler
87
7.3 Training
US is the fi rst and foremost an operator-dependant examination. Thus, experience
plays an important role, and sensitivity drops with little experience. A standardized
training with both theoretical and hands-on modules is mandatory to gain the
required skills to conduct FAST or p-FAST suffi ciently. This training should include
subjects with positive fi ndings.
Emergency physicians/paramedics treating patients at the scene of an accident face
several challenges such as time pressure. This has important implications for the train-
ing program. Thus, the training program should include real-time simulation training
and different patient positions (e.g., ventral position), where the learner has to fi nd
the appropriate time frame to integrate p-FAST into the prehospital trauma care algo-
rithm, adopt the transducers’ position, and furthermore face the time pressure. After
a 1-day course with hands-on training as described above, p-FAST can be performed
by both paramedics and physicians who were not familiar with the technique before
attending the course with a high sensitivity, specifi city, and accuracy [ 13 ]. However,
to maintain this skill at the required competence level, regular practice is necessary.
7.4 Tips and Pitfalls
p-FAST should be performed on all traumatized patients with suspected BAT. As
intra-abdominal bleeding is a dynamic situation, p-FAST should be repeated every
15 min during the prehospital period as well as in the emergency department if sus-
picious physical fi ndings with negative or slight positive initial p-FAST result occur
as hemorrhage may not yet have been apparent [ 2 ]. Thus, p-FAST can be used to
monitor the patient.
p-FAST can be performed within the fi rst several minutes, while other team
members are carrying out simultaneous diagnostic and therapeutic maneuvers.
However, the appropriate time frame has to be considered, as p-FAST should not
delay the trauma algorithm, constrain other necessary procedures, or even delay the
prehospital transport to the hospital and thus the defi nitive treatment.
Reasons for an incomplete p-FAST can be bright sunlight (technical failure),
gross obesity, thoracic skin emphysema due to lack of penetration of sonographic
Table 7.2 Consequences
of p-FAST results [
9 ]
Modifi cation in therapy (21 %) and management on scene (30 %)
Changes in selection of trauma center (22 %)
Information transfer about prehospital fi ndings to trauma team
(52 %)
Changes in trauma team preparation and management (92 %)
Ultrasound on scene 35 min prior to FAST in the emergency
department
7 Prehospital Ultrasound in Trauma: Role and Tips
88
waves or reverberation artifacts. Duration of examination has to be kept short; thus,
if the examination cannot be performed properly, it should be stopped and repeated
under optimized conditions (e.g. different patient position).
p-FAST should be used as screening method to identify patients at risk. It is not
indicated for a defi nitive diagnosis as the only question that can be answered with
high accuracy is the presence or absence of free fl uid. Thus, no time should be
wasted on trying to identify organ lesions, but the patient should be moved to CT or
operating room as quickly as possible. p-FAST must not be performed if its result
would not have any infl uence on further prehospital therapy, management, or choice
of hospital.
Tips and Tricks
US is a highly user-dependant examination; thus, an adequate training and
regular practice are obligatory
Tips and Tricks
FAST and p-FAST training should include mainly hands-on training, sub-
jects with positive fi ndings, real-time scenario training, and different subject
positions
Tips and Tricks
Repeat p-FAST every 15 min to monitor the patient
Tips and Tricks
Perform p-FAST while other team members simultaneously perform proce-
dures of the trauma algorithm
Pitfalls
Time is wasted on trying to identify organ lesions
→ p-FAST should only identify the presence or absence of free fl uid
M. Ruesseler
89
References
1. Boulanger BR, Mclellan BA, Brenneman FD et al (1996) Emergent abdominal sonography as
a screening test in a new diagnostic algorithm for blunt trauma. J Trauma 40:867–874
2. Rozycki GS, Ballard RB, Feliciano DV et al (1998) Surgeon-performed ultrasound for the
assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg 228:557–567
3. Wherrett LJ, Boulanger BR, Mclellan BA et al (1996) Hypotension after blunt abdominal
trauma: the role of emergent abdominal sonography in surgical triage. J Trauma 41:815–820
4. Brooks AJ, Price V, Simms M (2005) FAST on operational military deployment. Emerg Med
J 22:263–265
5. Heegaard W, Plummer D, Dries D et al (2004) Ultrasound for the air medical clinician. Air
Med J 23:20–23
6. Kirkpatrick AW, Sirois M, Laupland KB et al (2005) Prospective evaluation of hand-held
focused abdominal sonography for trauma (FAST) in blunt abdominal trauma. Can J Surg
48:453–460
7. Lapostolle F, Petrovic T, Lenoir G et al (2006) Usefulness of hand-held ultrasound devices in
out-of-hospital diagnosis performed by emergency physicians. Am J Emerg Med 24:237–242
8. Walcher F, Kortum S, Kirschning T et al (2002) Optimized management of polytraumatized
patients by prehospital ultrasound. Unfallchirurg 105:986–994
9. Walcher F, Weinlich M, Conrad G et al (2006) Prehospital ultrasound imaging improves man-
agement of abdominal trauma. Br J Surg 93:238–242
10. Brown MA, Casola G, Sirlin CB et al (2001) Blunt abdominal trauma: screening us in 2,693
patients. Radiology 218:352–358
11. Busch M (2006) Portable ultrasound in pre-hospital emergencies: a feasibility study. Acta
Anaesthesiol Scand 50:754–758
12. Ruesseler M, Kirschning T, Breitkreutz R et al (2009) Prehospital and emergency department
ultrasound in blunt abdominal trauma. Eur J Trauma Emerg Surg 35:341–346
13. Walcher F, Kirschning T, Muller MP et al (2010) Accuracy of prehospital focused abdominal
sonography for trauma after a 1-day hands-on training course. Emerg Med J 27:345–349
Remember
p-FAST can signifi cantly increase diagnostic performance and diagnostic
accuracy. However, it should never delay the prehospital trauma algorithm nor
patients transport to defi nitive therapy. US is highly user-dependant; thus,
training and regular practice are obligatory.
7 Prehospital Ultrasound in Trauma: Role and Tips
91
M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons,
DOI 10.1007/978-88-470-5274-1_8, © Springer-Verlag Italia 2014
8.1 Introduction
Contrast-enhanced ultrasound (CEUS) is a new tool for investigating blunt abdomi-
nal trauma. Ultrasound contrast agents (UCAs) are exogenous nontoxic substances
smaller than red blood cells. In combination with nonlinear imaging methods, they
offer the possibility of detecting abnormal parenchymal tissue, accurately recogniz-
ing or excluding abdominal solid organ injuries and assessing their size and compli-
cations. The technique is capable of showing the extent of the lesions to the capsule
and the presence of active bleeding, overcoming the limits of baseline sonography
in studying traumatic parenchymal injuries.
8.2 Scanning Technique
8.2.1 How to Scan
UCAs are microbubbles with a diameter from 2 to 6 μm composed of a shell of
biocompatible materials, including proteins, lipids, or biopolymers. These agents
M. Valentino (*)
Department of Diagnostic Imaging—Radiology Unit,
Hospital of Tolmezzo, Via Morgagni 18, Tolmezzo 33028, Italy
e-mail:
mvm.valentino@gmail.com
L. Barozzi
Department of Diagnostic Imaging—Radiology Unit,
Maggiore Hospital, Largo Bartolo Nigrisoli, 2, Bologna 40100, Italy
e-mail:
libero.barozzi@alice.it
C. Rossi
Department of Diagnostic Imaging—Emergency Radiology Unit ,
University Hospital of Parma, Via Gramsci 14, Parma 43100, Italy
e-mail:
crrossi@ao.pr.it
8
CEUS: What Is It?
Massimo Valentino , Libero Barozzi , and Cristina Rossi
92
are blood pool agents that remain in the intravascular compartment and do not leak
into the organ tissue. UCAs are injected IV as a bolus, increasing the signal of the
vascularized parenchyma: therefore, in the case of trauma , the areas of laceration
appear as defects of perfusion (“ black ”).
CEUS requires contrast-specifi c software, nowadays available in many portable
machines, with the suppression of the static signal of the tissues and highlighting
the signal from microbubbles circulating in the bloodstream.
The dose of UCA depends on the technical equipment, ranging from 1.2 to 2.4 mL
per dose. After IV injection, the microbubbles persist in the bloodstream for 8–10 min
and can cross the pulmonary and systemic capillary circulation without trapping. Their
long life allows the sonographer to investigate all the abdominal organs in real time.
UCAs differ from computed tomography contrast media because they lack inter-
stitial spread, consequently functioning as perfect traces of organ vascularization.
They are well tolerated, and serious reactions are rarely reported. Nevertheless,
adverse reaction toward UCA constituents must always be considered. Due to the absence
of renal excretion, UCAs can be safely employed also in patients with renal failure.
For trauma protocol, UCA is administered in two doses for visualization of the
right and the left upper quadrant organs, separately. This procedure is needed to
study the single organs during all the vascular phases (early and late phases). The
study is interpreted simultaneously during the investigation, and the record of the
investigation as a video clip allows reviewing for minor lesions, while the acquisi-
tion of static images is useful for measuring the lesions.
Trauma study begins with FAST protocol, and CEUS follows immediately after-
ward. During FAST, the optimal patient positions and the accessibility of the organs
are assessed for planning CEUS.
8.2.2 Normal Anatomy (Fig. 8.1a – d )
In CEUS, the normal parenchyma appears homogeneously hyperechoic with the
vessels having the maximum of echogenicity. The enhancement starts 10–15 s after
the UCA injection, the time of delay depending on the specifi c vascular physiology
of the investigated organ.
The kidneys show rapid, intense, and transient enhancement due to the absence
of glomerular fi ltration after IV UCA injection. The arterial phase of CEUS starts
10–15 s after intravenous injection and lasts up to about 40 s, when the venous
phase becomes prevalent. The venous and late phase lasts from 3 to 6 min. In the
arterial phase, the cortex shows the most intense enhancement, whereas in the late
phase the whole kidney appears homogeneously perfused.
In the liver, UCAs are fi rstly visualized in the hepatic artery, followed by those
in the portal vein. Hence, the CEUS process is always divided into the arterial phase
(<30 s from the injection of UCA), portal phase (31–121 s), and late phase (>120 s). In
the portal phase, the liver appears homogeneously perfused, with slightly hyperechoic
vessels and anechoic gallbladder. The delayed phase is particularly useful for char-
acterization of focal liver lesions since almost all malignant lesions are hypoechoic
in this phase. Also traumatic lesions are well visible in the portal and delayed phase.
M. Valentino et al.
93
Splenic parenchyma starts about 12–15 s after UCA injection. In this phase, we
can observe an inhomogeneous enhancement of the spleen, resembling the well-
known zebra-striped pattern seen on dynamic CT. The phase can give the false
impression of a scattered spleen, confusing the sonographer: we suggest studying
fi rst the left kidney and then moving to the spleen in the venous phase. Approximately
50 s after the injection, the venous phase starts, and the splenic parenchyma becomes
homogeneous, showing dense persistent enhancement for up to 5–7 min. In this
phase, the injured parenchyma is well detectable as a hypoenhanced area.
In the pancreas, uptake of contrast medium during CEUS is very rapid; at
approximately 25–40 s, it produces a transient, bright homogeneous enhancement
that is due to the high vascularization of the organ. Accumulation in the capil-
laries is negligible; thus, the washout also occurs rapidly after the arterial phase,
giving the pancreas a darkened appearance in contrast to the adjacent liver after
2 min. Consequently, CEUS may be diffi cult at delineating masses, but it allows an
excellent delineation of traumatic lesions.
ab
c
d
Fig. 8.1 ( a ) CEUS of normal kidney. In the arterial phase, the cortex shows the most intense
enhancement. Note the absence of enhancement in the renal pelvis. ( b ) CEUS of normal liver in
the venous phase. In this phase, the liver appears homogeneously perfused, with the vessels and
border clearly defi ned. ( c ) CEUS of normal spleen in venous phase. In this phase, the parenchyma
appears homogeneous with a persistent enhancement for up to 5–7 min. ( d ) CEUS of normal pan-
creas. In the venous phase, pancreas has a darkened appearance ( arrows ) in contrast to the adjacent
liver, but the vessels ( asterisk ) allow to identify it
8 CEUS: What Is It?