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Trauma sonography
- 1. 外傷超音波簡介外傷超音波簡介 陳昭文 醫師陳昭文 醫師 急診部 外傷科急診部 外傷科 高雄醫學大學附設中和紀念醫院高雄醫學大學附設中和紀念醫院
- 2. Trauma Service / KMUH • 及時而正確的診斷對嚴重外傷之病患是及時而正確的診斷對嚴重外傷之病患是 絕對重要的…絕對重要的… • 我們常用的工具我們常用的工具 :: • Physical ExaminationPhysical Examination • DPLDPL • FASTFAST • Abdominal CTAbdominal CT ？？ ？？？？
- 3. Trauma Service / KMUH Scenario XYScenario XY • 1919 歲男性因車禍受腹部鈍傷送入急診歲男性因車禍受腹部鈍傷送入急診 ,, 血壓為血壓為 80/40 mmHg,80/40 mmHg, 心搏心搏 115,115, 左上腹壓痛左上腹壓痛 ;; 輸液輸液 2000ml2000ml 給予後血壓未見起色給予後血壓未見起色 ,, 你接下來要安排你接下來要安排 的檢 是查的檢 是查 ??
- 4. Trauma Service / KMUH Scenario XXScenario XX • 3131 歲女性於衝突受上腹部刀傷送入急診歲女性於衝突受上腹部刀傷送入急診 ,, 血壓血壓 為為 130/60 mmHg,130/60 mmHg, 心搏心搏 95,95, 上腹稍微壓痛上腹稍微壓痛 ;; 初級檢傷後初級檢傷後 ,, 除上腹部五公分傷口外無其他外除上腹部五公分傷口外無其他外 傷傷 ;; 血壓仍然穩定血壓仍然穩定 ,, 你接下來要安排的檢 是查你接下來要安排的檢 是查 ??
- 5. Trauma Service / KMUH 常用診斷工具常用診斷工具 • DPLDPL • Sonographic survey (FAST)Sonographic survey (FAST) • CTCT
- 6. Trauma Service / KMUH DPLDPL • Diagnostic Peritoneal LavageDiagnostic Peritoneal Lavage • 腹膜腔內灌洗術腹膜腔內灌洗術 • 可近性高可近性高 ,, 易於床邊施行易於床邊施行 • 侵襲性檢查侵襲性檢查 • 易有偽陽性易有偽陽性
- 8. Trauma Service / KMUH • DPADPA ””A”A” ClosedClosed methodmethod
- 9. Trauma Service / KMUH 判讀方法判讀方法 • Open and closed techniquesOpen and closed techniques • Catheter inserted into the abdomen, aspirateCatheter inserted into the abdomen, aspirate • Positive if gross blood, bile, food, stoolPositive if gross blood, bile, food, stool • If aspirate negative, lavage with 1 liter NSIf aspirate negative, lavage with 1 liter NS • positivepositive • Lavage fluidLavage fluid >> 100,000 RBC/mm100,000 RBC/mm33 ,, • >>500 WBC/mm500 WBC/mm33 ,, • Bacteria on Gram stainBacteria on Gram stain
- 10. Trauma Service / KMUH Abdominal CTAbdominal CT • Computed tomography, CAT scanComputed tomography, CAT scan • 需影像部門配合需影像部門配合 ,, 檢 速度不一查檢 速度不一查 • 重裝備重裝備 ,, 可近性低可近性低 • 亂槍射鳥亂槍射鳥 ,, 一網打盡一網打盡 ,, 敏感度高敏感度高
- 11. Trauma Service / KMUH CAT scanCAT scan
- 12. Trauma Service / KMUH FASTFAST • FFocusedocused AAbdominalbdominal SSonography foronography for TTraumarauma • 輕裝備輕裝備 ,, 易於使用易於使用 • 檢 時間短查檢 時間短查 • 解析度不佳解析度不佳 • 受操作者個人經驗影響受操作者個人經驗影響
- 13. Trauma Service / KMUH FASTFAST • 主要搜尋腹腔內積液主要搜尋腹腔內積液 • 對生命徵象不穩之病患對生命徵象不穩之病患 ,, 先排除腹內出血與心先排除腹內出血與心 包填塞之可能包填塞之可能 • Basic 4 viewsBasic 4 views • 劍突下劍突下 Cardiac (subxyphoid) viewCardiac (subxyphoid) view • 右上腹右上腹 RUQ view (Morrison’s pouch)RUQ view (Morrison’s pouch) • 左上腹左上腹 LUQ view (splenorenal space)LUQ view (splenorenal space) • 骨盆腔骨盆腔 Suprapubic view (Cul-de-Sac)Suprapubic view (Cul-de-Sac)
- 14. Trauma Service / KMUH TypicalTypical 4 views4 views
- 16. Trauma Service / KMUH RUQ viewRUQ view • Longitudinal scanLongitudinal scan • Transverse scanTransverse scan • Intercostal scanIntercostal scan • Hypochondral scanHypochondral scan • Morison pouchMorison pouch • May observe pleuralMay observe pleural spacespace
- 17. Trauma Service / KMUH • 10% is identified with infusing 400ml10% is identified with infusing 400ml salinesaline • 97% is noted with infusing 1L saline97% is noted with infusing 1L saline Branney et al. J Trauma 1995Branney et al. J Trauma 1995
- 18. Trauma Service / KMUH LUQ viewLUQ view • Longitudinal scanLongitudinal scan • Transverse scanTransverse scan • Intercostal scanIntercostal scan • Hypochondral scanHypochondral scan • Spleen may be obscured during deepSpleen may be obscured during deep inspirationinspiration • May observe pleural space simultaneouslyMay observe pleural space simultaneously
- 19. Trauma Service / KMUH Same VictimSame Victim Subcapsular hematoma Pleural effusionSubcapsular hematoma Pleural effusion
- 20. Trauma Service / KMUH Subxyphoid viewSubxyphoid view • Pericardiac sacPericardiac sac • Echogenesity ofEchogenesity of bloodblood • Pericardial effusion?Pericardial effusion? • Heart movement?Heart movement? • DecompressiveDecompressive measuremeasure
- 22. Trauma Service / KMUH Echo guided pericardiocentesisEcho guided pericardiocentesis • EquipmentEquipment • 16-gauge short-bevel large-bore needle16-gauge short-bevel large-bore needle • 30- or 50-mL syringe30- or 50-mL syringe • Echo- guidedEcho- guided • Local anesthesiaLocal anesthesia • Sterile supplies and povidone-iodineSterile supplies and povidone-iodine solutionsolution
- 23. Trauma Service / KMUH Suprapubic viewSuprapubic view • Longitudinal scanLongitudinal scan • Transverse scanTransverse scan • Best viewed under full bladderBest viewed under full bladder • Physiologic fluidPhysiologic fluid
- 25. Trauma Service / KMUH Physiologic ascites massive pelvic fluidPhysiologic ascites massive pelvic fluid
- 26. Trauma Service / KMUH EFASTEFAST • ExtendedExtended FAST scanFAST scan • Detect thoracic lesionDetect thoracic lesion • Focus on occultFocus on occult pneumothorax (OPTX)pneumothorax (OPTX) • Gliding pleura signsGliding pleura signs
- 27. Trauma Service / KMUH Lung SlidingLung Sliding
- 28. Trauma Service / KMUH • Lung pointLung point
- 29. Trauma Service / KMUH HemothoraxHemothorax • Right or left Intercostal viewRight or left Intercostal view • Subcostal viewSubcostal view
- 30. Trauma Service / KMUH Blunt cardiac injuryBlunt cardiac injury • Pericardial effusionPericardial effusion andand Wall motionWall motion • Valve injuries ( regurgitateValve injuries ( regurgitate ))
- 31. Trauma Service / KMUH FAST or not?FAST or not? • 100 victims of penetrating torso trauma assessed by our trauma100 victims of penetrating torso trauma assessed by our trauma teams. 48 stab wounds, 51 gunshot wounds, and 1 punctureteams. 48 stab wounds, 51 gunshot wounds, and 1 puncture wound..wound.. • The overall accuracy of the US examination in penetrating torsoThe overall accuracy of the US examination in penetrating torso trauma was 87%, with a sensitivity of 64% and a specificity oftrauma was 87%, with a sensitivity of 64% and a specificity of 96%. The positive predictive value was 86% and negative96%. The positive predictive value was 86% and negative predictive value was 87%...predictive value was 87%... • The US examination lacks sensitivity to be used alone inThe US examination lacks sensitivity to be used alone in determining operative interventiondetermining operative intervention……Rarely does USRarely does US information contribute to the management ofinformation contribute to the management of patients with penetrating abdominal injuriespatients with penetrating abdominal injuries *A PROSPECTIVE EVALUATION OF ULTRASONOGRAPHY DIAGNOSIS OF PENETRATING*A PROSPECTIVE EVALUATION OF ULTRASONOGRAPHY DIAGNOSIS OF PENETRATING ABDOMINAL INJURYABDOMINAL INJURY Dror Soffer MD, Mark McKenney et al. Ann Emerg Med 2003Dror Soffer MD, Mark McKenney et al. Ann Emerg Med 2003
- 32. Trauma Service / KMUH FAST or not?FAST or not? • 149 patients with suspicion for abdominal trauma were149 patients with suspicion for abdominal trauma were evaluated…leaving 134 patients for analysis.evaluated…leaving 134 patients for analysis. • There were 111 true negative FAST exams, 5 true positives, 17There were 111 true negative FAST exams, 5 true positives, 17 false negatives, and 2 false positives.false negatives, and 2 false positives. • Chi-square analysis showed significant discordance betweenChi-square analysis showed significant discordance between FAST and CT (p<0.001).FAST and CT (p<0.001). • Utilization of FAST as a screening tool for BAI inUtilization of FAST as a screening tool for BAI in hemodynamically stable trauma patients results inhemodynamically stable trauma patients results in under-under- diagnosisdiagnosis of intraabdominal injury…of intraabdominal injury… • Patients with suspected abdominal traumaPatients with suspected abdominal trauma should undergo routine CT scanning.should undergo routine CT scanning. *Not So Fast!*Not So Fast! M.T. Miller, ND, M.D. Pasquale et al. J Trauma 2002M.T. Miller, ND, M.D. Pasquale et al. J Trauma 2002
- 33. Trauma Service / KMUH PitfallPitfall • Operator-dependent: skillOperator-dependent: skill • Reliable?Reliable? • SensitivitySensitivity • Missed injuriesMissed injuries • Pelvic fluidPelvic fluid • Full BladderFull Bladder • Serial examinationSerial examination • Delayed onsetDelayed onset • Subcutaneous emphysemaSubcutaneous emphysema • Gas blockGas block
- 34. Trauma Service / KMUH The new ABCsThe new ABCs • AAdmitdmit • BBeginegin • CCT scanT scan
- 35. Trauma Service / KMUH 如何運用工具如何運用工具 ?? • When?When? • Why?Why? • Why not?Why not?
- 36. Trauma Service / KMUH DPLDPL • WhenWhen • 需立即作需立即作 YESYES 或或 NONO 決定時決定時 • Hemodynamic instabilityHemodynamic instability • 需進行大手術但無需進行大手術但無 CTCT 檢 時查檢 時查 • Rare these daysRare these days • 意識不清但需排除腸道損傷時意識不清但需排除腸道損傷時
- 37. Trauma Service / KMUH DPLDPL • WhyWhy • Quick decisionsQuick decisions • Looking primarily for gross bloodLooking primarily for gross blood
- 38. Trauma Service / KMUH DPLDPL • Why notWhy not • 為侵襲性檢查為侵襲性檢查 • Possible complicationPossible complication • 非治療性開腹手術比率過高非治療性開腹手術比率過高 • Non-therapeutic lap rate app 30%!Non-therapeutic lap rate app 30%! • 對穩定血行之病患並不適合對穩定血行之病患並不適合
- 39. Trauma Service / KMUH FASTFAST • WhenWhen • 需立即作需立即作 YESYES 或或 NONO 決定時決定時 • Hemodynamic instabilityHemodynamic instability • 穿刺傷之心包膜腔檢視穿刺傷之心包膜腔檢視 • Detect for fluidDetect for fluid
- 40. Trauma Service / KMUH FASTFAST • WhenWhen • 69 patients with69 patients with initial BP< 90 mmHginitial BP< 90 mmHg • 22 with positive FAST22 with positive FAST • 19(86%)needed a laparotomy19(86%)needed a laparotomy • 47 with negative FAST47 with negative FAST • 0(0%) needed a laparotomy0(0%) needed a laparotomy Wherrett LJ. J Trauma 1996
- 41. Trauma Service / KMUH FASTFAST • WhyWhy • 檢 迅速耗時短查檢 迅速耗時短查 • 為非侵襲性檢查為非侵襲性檢查
- 42. Trauma Service / KMUH FASTFAST • WhyWhy • Can be done rapidly!Can be done rapidly! • Positive FASTPositive FAST • Time required 19+/-5 sec.Time required 19+/-5 sec. • Just for internal bleeding or cardiac tamponadeJust for internal bleeding or cardiac tamponade • Negative FASTNegative FAST • Time required 154+/-13 sec.Time required 154+/-13 sec. Wherrett LJ. J Trauma 1996
- 43. Trauma Service / KMUH FASTFAST • Why notWhy not • 對穿刺傷敏感度不佳對穿刺傷敏感度不佳 • 評估損傷不 全面夠評估損傷不 全面夠 • 操作者水平影響判讀操作者水平影響判讀 • 無法成為標準篩檢工具無法成為標準篩檢工具
- 44. Trauma Service / KMUH Abdominal CTAbdominal CT • WhyWhy • 廣泛檢視腹部器官廣泛檢視腹部器官 • Solid organ, retroperitoneum, fluidSolid organ, retroperitoneum, fluid • 敏感度高敏感度高 • 非侵襲性非侵襲性
- 45. Trauma Service / KMUH Accuracy Vs. SensitivityAccuracy Vs. Sensitivity 正確率正確率 AccuracyAccuracy 敏感度敏感度 SensitivitySensitivity DPLDPL 98%98% 99%99% FASTFAST 96%96% 75-93%75-93% ABD CTABD CT 99%99% 99%99%
- 46. Trauma Service / KMUH Portable CAT scanPortable CAT scan HMC SeattleHMC Seattle
- 47. Trauma Service / KMUH Abdominal CTAbdominal CT • WhenWhen • 不必考量時間因素不必考量時間因素 • 廣泛損害評估是我們的目標廣泛損害評估是我們的目標 • 病患需接受其他部位病患需接受其他部位 CTCT 檢查檢查 • 穿刺腹部彈道之評估穿刺腹部彈道之評估
- 48. Trauma Service / KMUH Abdominal CTAbdominal CT • Why notWhy not • 時間緊繃時間緊繃 • 病患生命徵象不穩病患生命徵象不穩作作 CTCT 耗時又冒險耗時又冒險 • 腹膜炎癥象已現腹膜炎癥象已現 作作 CTCT 不影響不影響開刀之決定開刀之決定
- 49. Trauma Service / KMUH Abdominal CTAbdominal CT • Why notWhy not • Multi-institutional study for small bowelMulti-institutional study for small bowel injuryinjury • 13% without CT findings13% without CT findings • 21% with solid organ injuries21% with solid organ injuries • 33% with peritoneal signs33% with peritoneal signs Fakhry J Trauma 2003
- 50. Trauma Service / KMUH Digest time…Digest time… • 了解各檢 工具的優缺點查了解各檢 工具的優缺點查 • 避免無謂的時間浪費避免無謂的時間浪費 • 正確的醫療處置正確的醫療處置
- 51. Trauma Service / KMUH 處理流程處理流程 AA 腹部穿刺傷 生命徵象不穩定 腹膜炎 (+) 生命徵象穩定 腹膜炎 (-) 開腹探查 可能合併 心臟外傷 穿刺傷或彈道 需進一步探查 FAST Pericardial view 其他 CT Your choice
- 52. Trauma Service / KMUH Resuscitation Other injury? 開腹探查 處理流程處理流程 BB 腹部鈍傷 生命徵象不穩定 腹膜炎 (+/-) FAST 優先 無超音波 DPL 檢 結果查 (+) 檢 結果查 (-)
- 53. Trauma Service / KMUH Solid organ injury Retroperitoneal injury Observation LOCDPL 處理流程處理流程 CC 腹部鈍傷 生命徵象穩定 腹膜炎 (-) CT Scan 檢 結果查 (-) 檢 結果查 (+) (-) OBS/Tx (+) Exp-lap?
- 54. Trauma Service / KMUH Can you make your decision now?Can you make your decision now?
- 55. Trauma Service / KMUH Scenario XXScenario XX • 5252 歲女性因車禍受腹部鈍傷送入急診歲女性因車禍受腹部鈍傷送入急診 ,, 血壓為血壓為 80/40 mmHg,80/40 mmHg, 心搏心搏 115,115, 左上腹壓痛左上腹壓痛 ;; 輸液輸液 2000ml2000ml 給予後血壓未見起色給予後血壓未見起色 ,, 你接下來要安你接下來要安 排的檢 是查排的檢 是查 ??
- 56. Trauma Service / KMUH Resuscitation Other injury? 開腹探查 處理流程處理流程 BB 腹部鈍傷 生命徵象不穩定 腹膜炎 (+/-) FAST 優先 無超音波 DPL 檢 結果查 (+) 檢 結果查 (-) Hemodynamic Instablity FAST Free fluid(+)
- 57. Trauma Service / KMUH Scenario XYScenario XY • 3131 歲男性於衝突受上腹部刀傷送入急診歲男性於衝突受上腹部刀傷送入急診 ,, 血壓血壓 為為 130/60 mmHg,130/60 mmHg, 心搏心搏 95,95, 上腹稍微壓痛上腹稍微壓痛 ;; 初級檢傷後初級檢傷後 ,, 除上腹部五公分傷口外無其他外除上腹部五公分傷口外無其他外 傷傷 ;; 血壓仍然穩定血壓仍然穩定 ,, 你接下來要安排的檢 是查你接下來要安排的檢 是查 ??
- 58. Trauma Service / KMUH 處理流程處理流程 AA 腹部穿刺傷 生命徵象不穩定 腹膜炎 (+) 生命徵象穩定 腹膜炎 (-) 開腹探查 可能合併 心臟外傷 穿刺傷或彈道 需進一步探查 FAST Pericardial view 其他 CT Your choice Stable Vital signs
- 59. Trauma Service / KMUH ConclusionConclusion • Don’t get “Don’t get “ABCABC” syndrome” syndrome • Good DecisionGood Decision Favorable outcomeFavorable outcome • Good PracticeGood Practice Favorable outcomeFavorable outcome • Time pressureTime pressureBedside surveyBedside survey