Primary survey
Assessment and possible problems
Key questions
A
Definitive 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 fluid? 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 confirm 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 fluid 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? | |
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 difficult technical skills (for instance, assessment of tracheal tube positioning needs the same skills needed for PTX evaluation); what is amazing and difficult 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 flexible: the recent emphasis on “C-ABCDE” approach (find and stop the bleeding as soon as possible!) can be strongly supported by US. EFAST can rule in/out torso free fluid. US can confirm that the patient is “empty” (looking at the heart chambers and heartbeat from the subxiphoid 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 significant free fluid, but extraperitoneal packing/external fixation/angioembolization if it is not).
Comprehensive US-helped trauma management is flexible: its role can change according to your available resources. So, train yourself daily to be able to profit in emergency situations.
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 flexible tool: use whenever you need it
Some specific 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 fluid detectable with US. From the clinical and practical point of view, this is only relatively relevant. We know there are plenty of lesions without free peritoneal fluid, at least at the beginning. US cannot overcome suspicion index, based on trauma mechanism, 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 fluid itself is often not enough to impose a laparotomy. Consider physiology first 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 fluid (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).
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 |
Table 6.3
McKenney score (2001)
US view | Assessment | Scorea |
|---|---|---|
Morison | + | 1 |
Perisplenic | + | 1 |
Douglas | + | 1 |
Table 6.4
Sirlin score (2001)
US view | Assessment | Score |
|---|---|---|
Morison | + | 1 |
Perisplenic | + | 1 |
Douglasa | + | 1 |
Paracolic right | + | 1 |
Paracolic left | + | 1 |
Perirenal right (retroperitoneal) | + | 1 |
Perirenal left (retroperitoneal) | + | 1 |
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 deficit – 5 (Melniker).
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.
Scores for estimating the amount of hemoperitoneum are easily applicable in a few seconds.
High scores strongly suggest/indicate early definitive 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.
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 confirmed the increasing rate of detection of fluid for the secondary exam. This datum is often overcome by performing 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 significantly increased in an average of 20 % from primary to secondary exam in detecting the intraperitoneal fluid. Examining the space between small bowel loops with a linear probe (not properly a standard FAST view) significantly verificare bibliografia improved the sensitivity of ultrasonography 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 profit 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 difficult patients, you will discover some unexpected findings, and you will have the opportunity 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 confirming the right position of an endotracheal tube and for promptly reassessing the endotracheal tube after repositioning. Notwithstanding, unfortunately it is not a widespread standard.
Imagine you need:
To check in real time the transit of the endotracheal tube during a difficult 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
With an US probe, you can!
Related posts:
Full access? Get Clinical Tree
