Initial evaluation of a trauma patient using an ultrasound

Young-Rock Ha

doi:10.5124/jkma.2012.55.11.1097

J Korean Med Assoc > Volume 55(11); 2012 > Article

Ha: Initial evaluation of a trauma patient using an ultrasound

Continuing Education Column

Journal of the Korean Medical Association

Journal of the Korean Medical Association 2012; 55(11): 1097-1112.

Published online: November 16, 2012

DOI: http://dx.doi.org/10.5124/jkma.2012.55.11.1097

Initial evaluation of a trauma patient using an ultrasound

Young-Rock Ha, MD

Emergency Department, Bundang Jesang Hospital, Seongnam, Korea.

Corresponding author: Ha Young-Rock, rocky66@naver.com

Received September 13, 2012 Accepted September 27, 2012

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Bedside ultrasonographic examination is known to be a quick, noninvasive, cost-effective, repeatable, and harmless diagnostic modality. It can be a powerful tool for clinicians, especially in time-dependent situations including trauma. Focused assessment with sonography in trauma (FAST) has been established as a protocol especially specifically for hemodynamically unstable patients with blunt abdominal trauma. The physiologic priority of airway, breathing, circulation, and disability (ABCD) of injured patients should be assessed using a multi-systemic, multi-focused, problem-based, and point-of-care ultrasound as an extension of physical examination. This ultrasound-enhanced trauma life support, so called FAST-ABCD, can provide a great deal of important information for helping the primary physician in critical decision-making by systemically combining the airway, lung, cardiovascular, abdominopelvic, orbital, and transcranial ultrasound. Additionally, it can provide information on airway patency, guidance of endotracheal intubation and cricothyroidotomy, lung contusion, limited hemodynamics, differential diagnosis of shock, intracranial hypertension, and even more extensively on a secondary survey from head to toe. The indications for the utility of ultrasound in trauma continue to evolve beyond FAST. FAST-ABCD could be incorporated into advanced trauma life support by obtaining more evidence through more studies worldwide.

Trauma; Point-of-care ultrasound; Focused assessment with sonogrpahy in trauma; Extended focused assessment with sonography in trauma

Acknowledgement

I would like to express my gratitude to all those who gave me the opportunity to complete this review. I want to thank Luca Neri, the former president of World Interactive Network of Focused Critical Ultrasound (WINFOCUS), Gordon Lee, and Hanho Doh for providing me valuable clinical data.

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Figure 1

Focused assessment with sonography in trauma including airway, breathing, circulation, and disablity (FAST-ABCD). Numbers on a figure indicate positions where probe would be applied to get images about airway, breathing, circulation, and disability. 1. Airway (neck) ultrasound (A). 2. Lung ultrasound (B). 3. Cardiovascular ultrasound (C). 4. Focused assessment with sonography in trauma (C). 5. Orbital and transcranial ultrasound (D).

Figure 2

Thyroid cartilage (arrows), transverse scan.

Figure 3

Cricoid cartilage, transverse scan. Cricoid cartilage (arrows). Transverse scan. The tissue-air border is shown as white line (arrow head).

Figure 4

Cricothyroid membrane. (A) Upper airway scanned in the midsagittal plane. (B) From the right side, thyroid cartilage (T), cricoid cartilage (C), and tracheal rings (TR). Cricothyroid membrane (arrow). The tissue-air border (arrow head).

Figure 5

Esophageal intubation. Transverse scan just cranial to the suprasternal notch. Enlarged esophagus by tube is shown on the deep left side of trachea (arrow head) in real time (arrow).

Figure 6

Lung pulse. (A) Left lung sliding is abolished in this selectively intubated patient and vertical movement of pleural line is identified along to the cardiac pulsation on a real-time 2D image, but it cannot be objectified on this static image. (B) M-mode can record vibrations in rhythm with the cardiac activity (arrows).

Figure 7

Longitudinal scan on thorax of a normal subject. (A) Upper and lower ribs and their acoustic shadows (vertical arrows). Pleural line and it's reverberation artifacts, Alines (horizontal arrows). (B) The upper rib-pleural line-lower rib profile shapes a sort of bat flying toward you, bat sign which is the basic landmark in lung ultrasound.

Figure 8

Seashore sign on M-mode. (A) This static image can not show lung sliding, which can be identified in real time. A-lines (horizontal arrows) (B) This M-mode image shows a double component pattern separated by the pleural line (vertical arrows). The top looks waves, and the bottom looks sand. It recalls the beach, hence the seashore sign.

Figure 9

Multiple B-lines (lung rockets). Vertical lines arising from pleural line are shown. They are comet tails with well-defined, laser-like lines spreading up to the edge of the screen without fading. These artifacts are caused by thickened interlobular septum.

Figure 10

Pneumothorax: A-line sign and stratosphere sign. (A) The absence of lung sliding cannot be visualized in this static image, but horizontal artifacts arising from the pleural line can be seen, and no B line is visible. This pattern called the A-line sign. (B) M-mode can show a pattern of completely horizontal lines, which means no motion of the structures above and below the pleural line (vertical arrow). This M-mode pattern called the stratosphere sign.

Figure 11

Pneumothorax: lung point. In real time, a transient inspiratory movement is visible at the pleural line. Arrows indicate the border between lung and air (pneumothorax), which is moving. This is the lung point sign. + LS, presence of lung sliding; - LS, absence of lung sliding.

Figure 12

Hemothorax. Hemothorax (H) can have internal echo. Consolidated lung (C) caused by compressive atelectasis is visualized. Bright echogenic spots in the consolidated lung are the airbrochogram (arrows).

Figure 13

Pleural effusion: sinusoid sign. (A) Small pleural effusion is visible at a middle axillary line (arrow). (B) The thickness of effusion varies in rhythm with the respiratory cycle. Deep border, a visceral pleura (arrow) moves toward the chest wall, thus shaping sinusoid.

Figure 14

Lung contusion (LC): consolidation. Image scanned sagittally on the left side (probe was positioned on a little bit higher than usual region of focused assessment with sonography in trauma in left upper quadrant). Hypoechoic lesion for alveolar consolidation (socalled hepatization) whose dimensions remained unchanged during the inspiration phase (LC). Blood within the thorax (horizontal arrows). Diaphragm (vertical arrow). H, hematoma; S, spleen; St, stomach gas. Courtesy of Dr. Gordon Lee.

Figure 15

Lung contusion: B-lines. Lung contusion can be visualized as B-lines. Within 1 to 2 hours after primary injury, A progressive infiltrate into interstitial space cause thickened interlobular septum. Focal B-lines are shown in the upper intercostal space (arrows), but no B-line is visible in the lower intercostal space.

Figure 16

Flattened inferior vena cava (IVC). Subcostal longitudinal view in hemorrhagic shock. Flattened IVC is demonstrated (arrows). Additionally small and hyperkinetic ventricles can be identified on cardiac ultrasound.

Figure 17

Cardiac tamponade. Subcostal 4 chamber view in the hypotensive patient. Echogenic pericardial effusion (E) compressing the right ventricle is visible (arrow).

Figure 18

Focused assessment with sonography for trauma: hemoperitoneum. (A) Peritoneal effusion in Morison's pouch. (B) Peritoneal effusion in Douglas pouch. (C) Peritoneal effusion in subdiaphragmatic and splenorenal recess.

Figure 19

Measurement of optic nerve sheath diameter (ONSD). The optic nerve sheath is a linear hypoechoic structure posterior to the globe. Caliper 1 identifies the site of ONSD measurement 0.3 cm behind the retina. Caliper 2 measures the ONSD (0.3 cm in this case).