Focused Abdominal Sonography for Trauma

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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
    Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
    History
    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner.
    There are a number of sources of stem cells, namely, adult cells generally extracted from bone marrow, cord cells, extracted during pregnancy and cryogenically stored, and embryonic cells, extracted from an embryo before the cells start to differentiate. As to source and method of acquiring stem cells, harvesting autologous adult cells entails the least risk and controversy.
    Autologous stem cells are obtained from the patient’s own body; and since they are the patient’s own, autologous cells are better than both cord and embryonic sources as they perfectly match the patient’s own DNA, meaning that they will never be rejected by the patient’s immune system. Autologous transplantation is now happening therapeutically at several major sites world-wide and more studies on both safety and efficacy are finally being announced. With so many unrealized expectations of stem cell therapy, results to date have been both significant and hopeful, if taking longer than anticipated.
    What’s been the Holdup?
    Up until recently, there have been intense ethical debates about stem cells and even the studies that researchers have been allowed to do. This is because research methodology was primarily concerned with embryonic stem cells, which until recently required an aborted fetus as a source of stem cells. The topic became very much a moral dilemma and research was held up for many years in the US and Canada while political debates turned into restrictive legislation. Other countries were not as inflexible and many important research studies have been taking place elsewhere. Thankfully embryonic stem cells no longer have to be used as much more advanced and preferred methods have superseded the older technologies. While the length of time that promising research has been on hold has led many to wonder if stem cell therapy will ever be a reality for many disease types, the disputes have led to a number of important improvements in the medical technology that in the end, have satisfied both sides of the ethical issue.
    CCSVI Clinic
    CCSVI Clinic has been on the leading edge of MS treatment for the past several years. We are the only group facilitating the treatment of MS patients requiring a 10-day patient aftercare protocol following neck venous angioplasty that includes daily ultrasonography and other significant therapeutic features for the period including follow-up surgeries if indicated. There is a strict safety protocol, the results of which are the subject of an approved IRB study. The goal is to derive best practice standards from the data. With the addition of ASC transplantation, our research group has now preparing application for member status in International Cellular Medicine Society (ICMS), the globally-active non-profit organization dedicated to the improvement of cell-based medical therapies through education of physicians and researchers, patient safety, and creating universal standards. For more information please visit http://www.neurosurgeonindia.org/
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Focused Abdominal Sonography for Trauma

  1. 1. Focused Abdominal Sonography for Trauma FAST
  2. 2. FAST Portable Rapid Non-invasive Repeatable Cost-effective
  3. 3. FAST Minimal amount of fluid in abdomen detectable by USG ~ 200 - 650ml High sensitivity in detecting haemoperitoneum (63 - 100%) High specificity in detecting haemoperitoneum (96 - 99%) Low sensitivity in detecting specific organ lesions (<50%) Sensitivity may improve with contrast
  4. 4. FAST 4 views – RUQ – Pelvis – LUQ – Subcostal cardiac - for haemoperitoneum
  5. 5. FAST Posterior peritoneum and reflections, indicating potential sites of intra-abdominal fluid localization and spread.
  6. 6. FAST 4. Cardiac 2. LUQ 1. RUQ 3. Pelvis Location of probe placement for the trauma examination.
  7. 7. FAST 1. RUQ Normal RUQ scan
  8. 8. FAST Abdominal CT with fluid in Morison’s pouch, demonstrating the ultrasound beam planes for different body placement sites.
  9. 9. FAST 2. LUQ Normal LUQ scan
  10. 10. FAST 3. Pelvis Normal male pelvis, transverse view
  11. 11. FAST 3. Pelvis Normal male pelvis, longitudinal view
  12. 12. Haemoperitoneum - RUQ Small wedge of hypoechoic blood between liver and kidney.
  13. 13. Haemoperitoneum - LUQ Free fluid (blood) in spleno-renal recess
  14. 14. Haemoperitoneum - Pelvis Transverse pelvic view demonstrating a small amount of blood in the Pelvis
  15. 15. Sonographic Pitfalls Free fluid in pelvis will often be missed without a full bladder – Sensitivity improved from 63% to 79% with full-bladder technique (McGahan et al)
  16. 16. Sonographic Pitfalls Sonography can miss important organ injury that will require surgery – Dolich et al reported 43 patients with false-negative sonographic findings, of which 10 (33%) required surgery – Shanmuganathan et al: 467 patients with organ injuries; 157 (34%) had no free fluid on USG; 26 of these 157 required surgery – USG: triage for unstable patient – CT still needed if intra-abdominal injury (IAI) is suspected
  17. 17. Sonographic Pitfalls Sonography is limited or unable to show certain types of injuries – Spinal and pelvic fractures – Diaphragmatic ruptures – Vascular injuries – Pancreatic injuries – Adrenal injuries – Some bowel and mesenteric injuries
  18. 18. Free Fluid Scoring Systems Huang at al: – each ‘>2mm fluid pocket’ score 1; – score > 3 = surgery McKenney et al: – vertical height of fluid in cm added – score > 3 = ↑ need of surgery
  19. 19. Free Fluid Scoring Systems Sirlin et al: fluid in each anatomic region = 1 point Score IAI (%) Surgery (%) 0 1.4 0.4 1 59 13 2 85 36 3 83 63 Conclusion: an increase in the amount of free fluid raises the likelihood of major IAI
  20. 20. Solid-Organ Injuries Rothlin et al reported sensitivity of 41.4% McGahan et al reported sensitivity of 41% Stengel et al showed that injuries were more easily detected with a 7.5 MHz linear probe than with a 3.5 MHz convex probe
  21. 21. Solid-Organ Injuries A diffuse heterogeneous pattern predominant in splenic lacerations A discrete hyperechoic pattern most often in hepatic lacerations Subcapsular splenic haematomas are shown as either hyperechoic of hypoechoic rims Severe kidneys injuries show a completely disorganized pattern
  22. 22. Splenic Laceration Sonography of LUQ shows splenic lacerations confirmed by CT
  23. 23. Renal Laceration A renal laceration at the mid-pole of Right Kidney with huge anterior perinephric haematoma
  24. 24. Clinical PEARLS Trendelenberg’s position Scan the liver tip for small volume haemoperitoneum Repeat the scan if suspicious Fill the bladder by foley Lower the gain for pelvic scan Clot can be echogenic Look for acute angles = free fluid
  25. 25. Paracolic Gutters Views Time consuming Skill & experience demanding Minimal increase in sensitivity
  26. 26. Paracolic Gutters Views Transverse right paracolic gutter scan demonstrating free fluid
  27. 27. Paracolic Gutters Views Transverse right paracolic gutter scan demonstrating free fluid
  28. 28. What if USG -ve? Is CT needed? Sirlin 2002 – 4000 patients – 3680 USG -ve – if Fracture or Haematuria → CT • 11% to OR – if no Fracture and no Haematuria → no CT • only 0.1% to OR
  29. 29. FAST 4. Cardiac Normal Subcostal scan
  30. 30. Pericardial Effusion Subcostal short axis with pericardial effusion
  31. 31. Additional Utilization Haemothorax – anechoic areas above diaphragm – high sensitivity & specificity – reverse Trendelenberg or sitting improve sensitivity – as little as 20 ml may be detected
  32. 32. Haemothorax Small right pleural collection
  33. 33. Haemothorax Diaphragm Large left haemothorax
  34. 34. Additional Utilization Pneumothorax – lost of ‘sliding’ sign – lost of reverberation artifact – other artifacts: ring-down artifact; ?comet tail artifact – M-mode and Power Doppler may help Rib fracture – disruption of cortex
  35. 35. The End

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