Emergency us FAST procedure
what is the initial survey of the FAST scan ?
initial survey is directed in the subxiphoid plane with the transducer angled in a cephalic direction toward the 4 chambers of the heart in order to image the pericardial sac The pericardial cavity can also be seen by a parasternal view
describe the steps of DPL
1.Patient is placed in the supine position and the bladder is emptied by catheterization 2.stomach is emptied by a NG tube because a distended stomach may extend to the anterior abdominal wall 3.skin is anesthetized and a 3-cm vertical incision is made 4.incision is made either in the midline or at the paraumbilical site with multiple layers of tissue penetrated before the parietal peritoneum is located
what is m mode used to detect?
M-mode is used to detect pneumothorax (air in the pleural cavity)
what does DPL carrie complication risks of?
invasive procedures carries a complication risk of bowel perforation, bladder penetration, vascular laceration, and wound complications
contained parenchymal injuries of the liver and spleen as well as bowel injuries may not be accompanied by hemoperitoneum; therefore they may be missed if screening US alone is use to evaluate for blunt trauma T or F
true
what is the stratosphere sign?
Pneumothorax When you apply M-mode US, the absence of lung sliding is shown as parallel horizontal lines above and below the pleural line, resemble a 'barcode.' This is called the stratosphere sign This sign indicates a pneumothorax at this intercoastal space
what parts of the RUQ are evaluated?
RUQ is then evaluated, including the diaphragm, dome of the liver, subhepatic space, Rt kid, and Rt flank liver is quickly scanned to look for texture abnormalities
when you apply M-Mode intercostally what happens to the pleural line?
When you apply M-mode intercostally, the pleural line divides the image in half
how does a extensive splenic injury present?
an extensive splenic injury presents as a diffusely heterogeneous parenchymal pattern with both hyperechoic and hypoechoic regions
During the Fast exam what areas do you scan?
goal is to scan the 4 quadrants, pericardial sac and cul-de-sac for the presence of free fluid or hemoperitoneum FAST scan area of evaluation is widespread, extending from the pericardial sac to the bladder and includes the perihepatic area, perisplenic region, paracolic gutters, and cul-de-sac visceral organs are assessed for heterogeneity and evaluated with color Doppler if necessary
how do hematoma appear ?
hematomas and localized lacerations will appear echogenic or hypoechoic that over time will become anechoic with the onset of hemolysis
where does hemorrhage in the peritoneal cavity collect?
hemorrhage in the peritoneal cavity collects in the most dependent area of the abdomen
if there is a massive hemoperitoneum, what happens to the intraperitoneal organs ?
if there is massive hemoperitoneum, the intraperitoneal organs will float in the surrounding fluid fluid is usually hypoechoic or hyperechoic with a few internal echoes and conforms to the anatomic site it occupies
for the Fast scan what is the protocol for filling the bladder?
if there is no contraindication to catheterization, the empty Bl is filled with 200-300 ml of sterile saline through a Foley catheter to insure Bl distention to allow adequate visualization of the pelvic cavity
what does FAST stand for?
Focused Assessment with Sonography for Trauma: FAST
what is a diagnostic peritoneal lavage?
An invasive procedure that's used to sample the intraperitoneal space for evidence of damage to the viscera and blood vessels 95% sensitivity
besides hemoperitoneum, what can free fluid represent ?
FF usually represents hemoperitoneum, although it may represent urine, bile or ascitic fluid
why is CT not used in emergency situations?
CT remains the radiology standard for investigating the injured abdomen, but requires Pt transfer and inevitable delay (bowel preparation)
what areas of the body are DPL limited to ?
DPL is limited to injuries of the retroperitoneum, pancreas or contained injuries to solid intraperitoneal organs
what is Efast?
E-FAST: Extended FAST evaluates the thorax besides the areas evaluated by FAST
E fast what does it evaluate?
E-FAST: Extended FAST evaluates the thorax for pleural effusion and pneumothorax besides the areas evaluated by FAST
what is fast? what does it focus on?
FAST is a limited examination of the abdomen/pelvis to evaluate free fluid or pericardial fluid examination is focused to look for the presence of free fluid, texture of the visceral organs, and pericardial sac around the heart in the context of traumatic injury, free fluid is usually caused by hemorrhage and contributes to the assessment of the circulation
Free Pelvic Fluid in Women IMAGE
Free Pelvic Fluid in Women in female Pts of reproductive age with trauma, free fluid isolated to the cul-de-sac is likely physiologic and clinical follow-up should suffice female Pts with fluid elsewhere usually have clinically important injury and require further evaluation
what is the sonographic appearance of free fluid?
Sonographic Appearance of Free Fluid FF usually represents hemoperitoneum, although it may represent urine, bile or ascitic fluid hemorrhage in the peritoneal cavity collects in the most dependent area of the abdomen most common site of fluid accumulation is the subhepatic space regardless of the site of the injury next most common space is the pelvis blood in the pelvis may collect centrally in the pouch of Douglas or laterally in the paravesical space if there is massive hemoperitoneum, the intraperitoneal organs will float in the surrounding fluid fluid is usually hypoechoic or hyperechoic with a few internal echoes and conforms to the anatomic site it occupies
what is the seashore sign?
The motionless portion above the pleural line creates horizontal 'waves,' and the sliding line below it creates granular pattern, the 'sand'
if the Pt is hemodynamically stable, the value of US is limited by the large % of organ injuries that are not associated with free fluid. T or F
True
is US highly sensitive to organ injuries?
US has been found not to be highly sensitive for the identification of organ injuries
the FAST exam is simultaneously performed with what other examinations?
US of the abdomen/pelvis is performed simultaneously with the physical assessment, resuscitation, and stabilization of the trauma Pt
what does a brisk intraparenchymal hemorrhage look like? global parenchymal injury ?
a brisk intraparenchymal hemorrhage may be identified as an anechoic region within the abnormal parenchyma, whereas a global parenchymal injury may project in the liver as a widespread architectural disruption with absence of the normal vascular pattern
what type of patients is DPL appropriate for?
appropriate for alert Pts in stable condition
where else can blood collect in the pelvis ?
blood in the pelvis may collect centrally in the pouch of Douglas or laterally in the paravesical space
what does DPL stand for?
diagnostic peritoneal lavage
why is the epigastrium briefly examined for?
epigastrium is briefly examined to look for fluid around the stomach
how long does the FASt exam take?
length of time of the exam is usually 5 min.
what is the most easily detected parenchymal injury on us?
liver lacerations or contusions were more easily detected with US than any other visceral abdominal injury
what is the most common site for fluid accumulation?
most common site of fluid accumulation is the subhepatic space regardless of the site of the injury next most common space is the pelvis
Pitfalls and Limitations of FAST
obesity may prevent adequate visualization of the anatomic structures in some cases the presence of subcutaneous emphysema precludes adequate US visualization presence of subcutaneous air from a pneumothorax that dissects into the abdominal cavity may collect over the spleen or liver
assessment of the abdomen for possible sustained intraabdominal injury owing to blunt abdominal trauma is common clinical challenge for surgeons and emergency medicine physicians why may physical findings be unreliable?
physical findings may be unreliable because of the state of Pt consciousness, neurologic deficit, medication, or other associated injuries
what are the pitfalls of ABD us?
pitfalls of ABD US include failure to show contained solid-organ injuries; injuries to diaphragm, pancreas, and adrenal gland; and some bowel injuries
can an us exclude an intraperitoneal injury?
therefore, a negative US does not exclude an intraperitoneal injury, and close clinical observation or CT is warranted
what does the LUQ examine for ? why is the pelvic cavity evaluated for?
transducer is then moved to the LUQ to observe the diaphragm, spleen, Lt kid, and Lt flank to search for the presence of fluid pelvic cavity is evaluated for the presence of free fluid in the cul-de-sac