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62
5.3.3 Penetrating Abdominal and Thoracoabdominal Trauma
The main recognized role of EFAST in penetrating abdominal trauma is to ruling in/
out intraperitoneal injuries in physiologically normal patients.
It has a high positive predictive value.
Comments to Penetrating Abdominal Trauma Flow Chart
1. Blood or enteric fl uid? A US-guided DPA is sometimes crucial and can change
your decision.
If the patient is hemodynamically normal, with a few amount of fl uid in the
abdomen, but you retrieve blood with DPA, you can probably observe this patient.
If the patient is hemodynamically normal, with a few amount of fl uid in the
abdomen, but you retrieve bile/enteric with DPA, go straight to OR (laparoscopy
or laparotomy).
2. US can help you in prioritizing the surgical approach (chest fi rst vs. abdomen
fi rst) in thoracoabdominal penetrating trauma.
a
b
Fig. 5.3 EFAST driven
protocol in penetrating
thoraco-abdominal injury
D. Mariani and M. Zago
63
5.3.4 Penetrating Thoracic Trauma (“Cardiac Box”)
Comments to Penetrating Thoracic Trauma Flow Chart
1. Pericardial window is a diagnostic procedure. A reliable US makes it unuseful.
2. Pericardial windows require to be ready for an immediate thoracotomy, if
positive.
3. Pericardiocentesis in trauma setting is nowadays only a bridge emergency
procedure on the way for OR. If you need this, US is a marvelous tool for guiding
the maneuver (not explained in this book).
Fig. 5.4 Flow chart for
Penetrating Thoracic Injury
in the “cardiac box”
5 Including EFAST in Trauma Algorithms: When? What Now?
65
M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons,
DOI 10.1007/978-88-470-5274-1_6, © Springer-Verlag Italia 2014
Before reading this chapter, be aware of the objectives:
6.1 Beyond EFAST
EFAST protocol remains the cornerstone for quickly answering a lot of key ques-
tions arising during the assessment of a trauma patient. Its value in speeding the
decisions for defi nitive treatment is demonstrated (Melniker). But from airway man-
agement to the detection of fractures, from venous cannulation to pulmonary contu-
sion assessment, and from monitoring volume replacement to NOM follow- up, US
revealed extremely useful in many steps of trauma patient evaluation and treatment.
An US probe could be ideally put everywhere on the body for answering focused
clinical questions.
The awareness about that is at the basis of the so-called ABCDE - US concept
(Neri), for which the US probe can help in the decision process in every step of the
primary, secondary, and tertiary survey in trauma patient. This does not mean you
should mandatorily use US for each A-B-C-D-E step, but you have to know you can
M. Zago , MD (*)
General Surgery Department , Minimally Invasive Surgery Unit,
Policlinico San Pietro , Bergamo , Italy
e-mail:
maurozago.md@gmail.com
D. Mariani , MD
General Surgery Department , AO Ospedale Civile di Legnano ,
Via Papa Giovanni Paolo II , Legnano , Milano 20025 , Italy
6
The Role of EFAST in a Comprehensive
US Trauma Management (ABCDE-US):
Facing with Clinical Scenarios
Mauro Zago and Diego Mariani
• An overview of extended applications of US in trauma.
• The ABCDE-US concept (clinically integrated US).
• Try to manage simulated cases with and without US.
66
rely on US every time you need it, according to the ATLS protocol, provided you
know the focused clinical question you have to solve (your clinical mind!) and how
to get the proper image (your skills!).
Table 6.1 shows a sample of questions you might answer in a critically ill trauma
patient.
ABCDE-US is a fully clinically integrated US!
The power and usefulness of real-time sonographic information for the critical
clinical decision-making process remains largely operator dependent, but several
experiences have shown that when appropriate training is provided, results are
highly accurate and reliable.
Surprisingly, you will realize that some applications for this innovative way to use
US are not diffi cult technical skills (for instance, assessment of tracheal tube position-
ing needs the same skills needed for PTX evaluation); what is amazing and diffi cult is
to “change” our mind, leaving considered gold standards beside, good as second tools.
Coming back to the example above, the quickest way to assess the proper positioning
of the endotracheal tube is not by chest x-ray but by US: you check, you move if
needed, you check again, and you secure, for only a few seconds.
Comprehensive US-helped trauma management is fl exible: the recent emphasis on
“C-ABCDE” approach (fi nd and stop the bleeding as soon as possible!) can be
Table 6.1 Questions possibly answered by US in trauma patient
Primary survey
Assessment and possible problems Key questions
A Defi nitive airway control Is tracheal tube in the right position?
B ptx – hemothorax – lung contusion Why the pt is dyspnoeic? Should I drain the thorax
now? Is there an occult ptx requiring drainage in
my intubated patient? Why does he desaturate if
there is no ptx or hemothorax?
C Hemothorax – hemoperitoneum
– hemopericardium – cardiac motility
– venous and artery cannulation
-volume replacement – IVC
assessment
Is there free fl uid? How much? Does it justify
hemodynamic instability? Where is the major
hemorrhage? Is there a PEA? Or cardiac
tamponade? Should I resuscitate this pt? Should I
take the pt to OR before any other diagnostic test?
How about preload? How is IVC? How can obtain
a quicker and safer vascular access?
D
Optical nerve caliper ( to be validated )
Can I confi rm intracranial hypertension?
E Long bone fractures Is there a femur fracture under this enlarged thigh?
Should this explain hemodynamics?
Secondary survey
Key questions
A
B ptx – hemothorax – lung contusion
C Hemothorax – hemoperitoneum –
hemopericardium – venous and artery cannulation
– volume replacement – bile ( DPA ) –
pneumoperitoneum – solid organ injuries (CEUS?)
Is abdominal fl uid really blood? Is
there a hollow viscus perforation? Is
there a solid organ injury? Should I
perform abdominal CT even in this
low energy trauma? Why the physical
exam is worsing after observation?
E Long bone fractures, sternal fractures, rib fractures Why does the pt complain pain if
x-rays are negatives?
M. Zago and D. Mariani
67
strongly supported by US. EFAST can rule in/out torso free fl uid. US can confi rm that
the patient is “empty” (looking at the heart chambers and heartbeat from the subxi-
phoid view and using IVC calipers), and if a pelvic fracture is present, FAST can give
you criteria to decide a strategy (such as laparotomy if there is signifi cant free fl uid,
but extraperitoneal packing/external fi xation/angioembolization if it is not).
Comprehensive US-helped trauma management is fl exible: its role can change
according to your available resources. So, train yourself daily to be able to profi t in
emergency situations.
Some specifi c aspects of US applications in trauma are depicted before going
through clinical scenarios.
6.2 Assessment of Free Abdominal Fluid: The Scores
Many experimental and clinical studies explored the minimal amount of fl uid
detectable with US. From the clinical and practical point of view, this is only rela-
tively relevant. We know there are plenty of lesions without free peritoneal fl uid, at
least at the beginning. US cannot overcome suspicion index, based on trauma mech-
anism, physiology, clinical evaluation, and associated lesions. A negative FAST
gives us more time to reasoning or observe, but is not enough.
On the other side, we know the amount of fl uid itself is often not enough to
impose a laparotomy. Consider physiology fi rst for decision in a hemodynamically
unstable patient, assess with other imaging techniques before NOM.
So, is there any sense to estimate the amount of free abdominal fl uid
( hemoperitoneum)? How can we do that? Is it reliable?
Three similar score systems are available; none is largely validated (Tables 6.2 , 6.3 ,
and 6.4 ).
Whatever score systems you use, it is really easy to get a score (the simplest are
Huang and McKenney).
Is there a utility? What is the meaning of the scores?
In Huang series, score ≥3 was associated with more than 1,000 ml of blood in
84 % of operated patients; Huang scores <3 corresponded to less than 1,000 ml and
only 38 % of therapeutic laparotomies.
Similarly, McKenney score ≥3 correlated with 87 % of therapeutic laparotomies,
a score <3 with only 15 %.
A positive FAST revealed a more effective prognostic factor for the need for
laparotomy than a base defi cit – 5 (Melniker).
• Brain leads hands: your brain asks for; your hands + US answer
• No answers? No skills? Go ahead without US
• US can help you many times until the patient is discharged (not only FAST!)
• US is a fl exible tool: use whenever you need it
6 The Role of EFAST in a Comprehensive US Trauma Management
68
For Sirlin and coworkers, scores >3 (three spaces or more) were related to
therapeutic laparotomy in 63 % of cases and ≥4 in 81 % of patients.
Table 6.3 McKenney score
(2001)
US view
Assessment
Score
a
Morison + 1
Perisplenic + 1
Douglas + 1
a
Measure the thickness of fl uid (in cm) where is the high-
est one. Add 1 point for each other positive view
Example : positive (4 cm) in Douglas, positive in
Morison, negative in perisplenic. Score: 4 + 1 + 0 = 5
Table 6.4 Sirlin score
(2001)
US view
Assessment
Score
Morison + 1
Perisplenic + 1
Douglas
a
+ 1
Paracolic right + 1
Paracolic left + 1
Perirenal right ( retroperitoneal )
+ 1
Perirenal left ( retroperitoneal )
+ 1
a
Not considered positive if small amount of fl uid in this
space only in young female
• Scores for estimating the amount of hemoperitoneum are easily applicable
in a few seconds.
• High scores strongly suggest/indicate early defi nitive hemostasis.
• Scoring hemoperitoneum immediately gives you an additional warning
and helps you to plan further actions.
• REMEMBER : the amount of hemoperitoneum is not the unique criterium
for choosing the right treatment.
Table 6.2 Huang score
(1994)
US view
Assessment
Score
Morison Minimal (<2 mm) 1
Moderate (>2 mm) 2
Douglas Minimal (<2 mm) 1
Moderate (>2 mm) 2
Perisplenic + 1
Floating bowel loops + 2
Paracolic gutters + 1
It is easy at a glance to recognize more or less than 2 mm
of fl uid
M. Zago and D. Mariani
69
6.3 Repeated US
The concept to repeat US exam a few hours (1–6) after trauma in stable patients is
not new.
Early studies in hemodynamically normal patients confi rmed the increasing rate
of detection of fl uid for the secondary exam. This datum is often overcome by per-
forming a CT.
Notwithstanding, in low-resource situations this option could be kept in mind.
“Low resources” refer not only to scarce resource hospitals but also to a hospital
without immediate CT availability during the night, facing with a presumed minor
trauma. For those patients, observation in the ED with repetition of EFAST could be
very effective, from both clinical and medicolegal issues.
The sensitivity of ultrasound exam signifi cantly increased in an average of 20 %
from primary to secondary exam in detecting the intraperitoneal fl uid. Examining
the space between small bowel loops with a linear probe (not properly a standard
FAST view) signifi cantly verifi care bibliografi a improved the sensitivity of ultraso-
nography in both primary and secondary FAST.
So, performing a secondary ultrasound exam in stable blunt abdominal trauma
patients and adding the interloop space scan to the routine FAST exam are good
tricks, which should not be forgotten, to use in special settings.
6.4 Minor Trauma and US
Would you like to be able to profi t from using US probe in polytrauma patients? Be
paranoid over-careful and apply US protocols in minor/stable trauma patients too.
You will standardize your technique, you will have time to improve your skills in dif-
fi cult patients, you will discover some unexpected fi ndings, and you will have the oppor-
tunity to check yourself with a CT or another colleague more skilled in US than you.
It is beyond the purpose of this book, but US can also help you in minor doubtful
skeletal trauma, like for detection of sternal and rib fractures.
6.5 US and Airway Management
US probe is a very effective and quick tool for confi rming the right position of an
endotracheal tube and for promptly reassessing the endotracheal tube after reposi-
tioning. Notwithstanding, unfortunately it is not a widespread standard.
Imagine you need:
• To check in real time the transit of the endotracheal tube during a diffi cult
intubation
• To perform a tracheostomy in a neck with a large lateral hematoma (Fig. 6.1 )
• To decide for a cricothyroidotomy in an obese patient with a large neck, where
tactile landmarks are missing
6 The Role of EFAST in a Comprehensive US Trauma Management
70
With an US probe, you can!
Follow us in the next volume, after having improved your skills in basic trauma US.
6.6 US and Hemodynamics Assessment and Monitoring
There is a so-called “quartet” singing different and very sensitive hemodynamic
ultrasound songs: heart, lung, IVC, and abdomen.
In a critically ill traumatized patient, your (expert) probe can help you explore
and get many important fi ndings you are asking for:
• HEART: beating rate, right and left chambers fi lling, pericardial fl uid, and myo-
cardial contraction (all at glance!)
• LUNG: wet or dry, pulmonary contusion (new or evolving), pleural effusion,
PTX evolution, and ARDS monitoring
• IVC: empty or full, how is changing after volume replacement
• ABDOMEN: the FAST fi ndings!
US fi ndings combined with the clinical status can offer you the right solution for
deciding the best for your patient, both in ED and in ICU or in the ward.
In order to not shaking your current knowledges now, we don’t put normal and
pathological US pictures of these topics.
It is another step of your performance, coming soon in another book....
6.7 Clinical Scenarios
Read, try to solve, and test yourself.
You have to manage the fi rst case with (or without) the EFAST protocol. Others
are presented to push you in a more extended use of US.
Fig. 6.1 Tracheal axis
detected by the linear probe
( arrow ) is displaced to the
right by a large neck
hematoma. Right incision for
tracheostomy is far away
from the midline ( dotted line )
M. Zago and D. Mariani
71
For didactical purposes, US is not included in pre-hospital phase, but you can
imagine it being applied and reasoning about management impact.
6.7.1 Case 1
The same case, with and without US
Chest x-ray and pelvis x-ray are negative.
The patient is immediately transferred to CT suite. US is considered unuseful,
time- consuming, and irrelevant.
Immediately after the head scan, patient shows sudden hypotension and signs of
shock: BP 80/40, HR 125 bpm, and SatHbO
2
90 %.
!! “Third class” shock !!
What do you do?
Which action will you take?
Probably, something like this:
• Exclude tension PTX --> excluded.
• Ask for blood and frozen plasma.
• Go quickly ahead with CT completion for ruling in/out hemoperitoneum.
• Alert OR.
OK. There is a huge hemoperitoneum with splenic injury OIS 4.
Next step is emergency laparotomy.
It is good if you are in OR 50 min after arrival.
Crash laparotomy, aspiration of 4 l of blood, and splenectomy were performed.
Blood is oozing from a lacerated mesentery and from any other rough surface.
You ask the anesthesiologist , “ how is the pH and core temperature ?”
pH 7.12; core T 34.2 °C
Need to bail out.
The following were performed: temporary abdominal closure, ICU rewarming
and resuscitation, and transfusion of 7 FFP, 10 RBC, and 1 PLT units.
Thirty-six hours later, a planned relaparotomy is performed. You find a seg-
mental small bowel ischemia due to mesenteric laceration. Bowel resection is
required, definitive abdominal closure performed.
The patient is discharged on day 10.
In summary: good choices, Damage Control Surgery correctly applied.
A 25-year-old athletic male injured after a vehicle crash, unrestrained and
with blunt thoracic and abdominal trauma. On scene and at admission in ED,
vital signs are as follows: BP 90/60, HR 115 bpm, and GSC 14.
After the primary survey and infusion of 500 ml of crystalloids, hemo-
dynamics is normal (BP 105/85, HR 95 bpm, SatHbO
2
96 %)
6 The Role of EFAST in a Comprehensive US Trauma Management
72
______________________
BUT imagine having decided to perform EFAST during the primary survey.
Look at the relevant US fi ndings:
Fig. 6.3 LUQ view
Fig. 6.2 R U Q v i e w
Fig. 6.4 Pelvic view, sagittal
M. Zago and D. Mariani