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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5836_Библиотеки_им_академика_М_И_Перельмана.pdf
73
What do you think?
Question 1
RUQ is NORMAL ____ ABNORMAL ____
LUQ is NORMAL ____ ABNORMAL ____
Pelvic view is NORMAL ____ ABNORMAL ____
Do you change strategy?
CT scan again?
Or immediately OR?
If OR is your choice, you probably agree this could be the story:
• Laparotomy in 20 min after arrival
• Aspiration of 1.5 l of blood, splenectomy, and repair of minor laceration of the
mesentery
• No transfusions
• No ICU
• Discharge on day 7
6.7.2 Case 2a
This scenario should be managed with a comprehensive US protocol. Answer and
check step by step at the end of the chapter.
Primary Survey in ED
A: Maintained
B: Decreased breath sounds on the right lung
SaO
2
: 83 %
C: BP 75/50, HR 110/min, clinically unstable pelvic fracture
D: GCS 14, confused
E: Temp 35.7 °C
Infusion of crystalloids, 750 ml
A 32-year-old woman had been involved in a one-car collision. She was a
passenger in the front seat and restrained. Her car rolled over. She was trapped
for 15 min. The windshield was smashed.
She was conscious, and the vital signs are as follows: BP 120/70 dropped
to 90/75, HR 90/min, RR 32, and SaO
2
90 % with O
2
supplementation.
Torso and pelvis seem injured. Five hundred milliliters of crystalloids was
infused during transport to ED.
6 The Role of EFAST in a Comprehensive US Trauma Management
74
Question 1
Which critical questions and decisions you need a quick answer for? (Write
below with a pencil and then compare with suggestions at the end of the chapter)
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Question 2
Do you think EFAST could help you?
YES ____ NO ____
Question 3
If NO, If you have chosen NO, you prefer to follow a surgical path that is not US
driven and might miss some opportunities. Please read what would happen with US
for your information: may be you become surprised!
If YES, list the fi nding you could rule in/out in a few seconds with US, waiting
for pelvis x-ray:
( Write below with a pencil , solutions at the end of the chapter )
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
This was the pelvis x-ray of the female patient
Fig. 6.5 Clearly an open
book fracture!
M. Zago and D. Mariani
75
Fig. 6.6 Clearly an open
book fracture!
Fig. 6.7 Right hemithorax
view
And these are the US relevant fi ndings:
(No PTX on both sides)
6 The Role of EFAST in a Comprehensive US Trauma Management
76
Fig. 6.9 R U Q
Fig. 6.8 Left hemithorax
view
Fig. 6.10 LUQ
M. Zago and D. Mariani
77
Fig. 6.11 Pelvic view
ab
Fig. 6.12 IVC view. ( a ) Expiration. ( b ) Inspiration phase
Question 4
Interpret US images:
1. Right hemithorax NORMAL ____ ABNORMAL____
2. Left hemithorax NORMAL ____ ABNORMAL____
3. RUQ NORMAL ____ ABNORMAL____
4. LUQ NORMAL ____ ABNORMAL____
5. Pelvis NORMAL ____ ABNORMAL____
6. IVC view (insp.) FULL ____ EMPTY____
( Go at the end of the Chapter for solutions, and come back quickly )
6 The Role of EFAST in a Comprehensive US Trauma Management
78
Now, you know that:
A. Your patient is in shock.
B. There is blood in the thorax: YES_____ NO _____
C. There is blood in the belly: YES_____ NO _____
D. There is an open book fracture (type B1). You know these kinds of fractures are
generally associated with venous and only rarely arterial bleeding.
Now, you can decide :
• If not yet done, put a sling around the pelvic ring and intrarotate the legs.
• Look at hemodynamics evolution.
(It should rapidly improve …
Yes, it improves! BP 100/65, HR 90/min, GCS 15)
• Depending on your resources (your hospital, your team, your trauma system, etc.):
– CT scan (fi rst option, if possible) --> excluded other visceral lesions, further
decisions for pelvic fracture (angiography if arterial blush or indirect signs of
arterial injury, immediate ORIF, external fi xation and delayed ORIF)
– External fi xation and close resuscitation/observation
– Immediate transfer to a referral center
________________________________________________________
Different situations could be depicted for a similar case scenario, with identical
conditions on the scene and after primary survey in ED.
6.7.3 Case 2b
Same patient, same mechanism of trauma, and same clinical fi ndings.
You perform now the US on this unlucky female with the same pelvic fracture
shown on Fig. 6.5 . Look at the US fi ndings (No PTX on both sides):
Fig. 6.13 Right hemithorax
view
M. Zago and D. Mariani
79
Fig. 6.14 Left hemithorax
view
Fig. 6.15 R U Q
6 The Role of EFAST in a Comprehensive US Trauma Management
80
Fig. 6.17 Pelvic view
Fig. 6.16 LUQ
ab
Fig. 6.18 IVC view. ( a ) Expiration. ( b ) Inspiration phase
M. Zago and D. Mariani
81
Question 5
Interpret US images:
1. Right hemithorax NORMAL ____ ABNORMAL ____
2. Left hemithorax NORMAL ____ ABNORMAL ____
3. RUQ NORMAL ____ ABNORMAL ____
4. LUQ NORMAL ____ ABNORMAL ____
5. Pelvis NORMAL ____ ABNORMAL ____
6. IVC view (insp.) FULL ____ EMPTY ____
( Solutions at the end of the Chapter )
Question 6
Now, you know that:
A. Your patient is in shock.
B. There is blood in the thorax: YES_____ NO _____
C. There is blood in the belly: YES_____ NO _____
D. Grossly, Huang score is __; McKenney score is __; Sirlin score is __.
E. The probability of surgical intraperitoneal bleeding is
HIGH ____ LOW ____
F. There is an open book fracture (type B1). You know these kinds of fractures are
generally associated with venous and only rarely arterial bleeding.
( Look at right answer before turning the page .)
6 The Role of EFAST in a Comprehensive US Trauma Management
82
Now, you can decide . I don’t think you take the same decisions as in the previous
situation …
• If not yet done, put a sling around the pelvic ring and intrarotate the legs.
• CT? No, please!
• Massive transfusion protocol activation (if not yet done).
• Damage Control strategy and resuscitation, wherever you are and whatever are
the skills of your team:
– Straight to OR.
– Stop the bleeding (damage control surgery).
– Possible pelvic packing.
– External fi xation or pelvic binder.
ICU for stabilization.
Here is an already printed algorithm, with a slight modifi cation
Is my patient in a life-threatening condition?
Should I overcome EFAST?
If no,
EFAST
®
where is fluid?
ABCDE-US
®
other quick info on anatomy&physiology?
PHYSIOLOGY + ANATOMY
+ ABCDE-US
my decision is
life-saving maneuver or immediate DCS or further work-up
Ó
¯
Summary
• US can help you in assessing faster BOTH anatomy AND physiology
• A comprehensive US-driven trauma management allows you to explore the
potential of US probe in your hands
So :
• Different clinical decisions
• In similar settings
• Thanks to US fi ndings
• Obtained in a few seconds
• REMEMBER: ABCDE - US helps you to quickly “ see and assess ” the
anatomy and physiology for decision making
M. Zago and D. Mariani