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Trauma sonography

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    Trauma sonography Trauma sonography Presentation Transcript

    • 外傷超音波簡介 陳昭文 醫師 急診部 外傷科高雄醫學大學附設中和紀念醫院
    • • 及時而正確的診斷對嚴重外傷之病患是 絕對重要的…• 我們常用的工具 : • Physical Examination • DPL • FAST • Abdominal CT ? ? ? Trauma Service / KMUH
    • Scenario XY• 19 歲男性因車禍受腹部鈍傷送入急診 , 血壓為 80/40 mmHg, 心搏 115, 左上腹壓痛 ; 輸液 2000ml 給予後血壓未見起色 , 你接下來要安排 的檢查是 ? Trauma Service / KMUH
    • Scenario XX• 31 歲女性於衝突受上腹部刀傷送入急診 , 血壓 為 130/60 mmHg, 心搏 95, 上腹稍微壓痛 ; 初級檢傷後 , 除上腹部五公分傷口外無其他外 傷 ; 血壓仍然穩定 , 你接下來要安排的檢查是 ? Trauma Service / KMUH
    • 常用診斷工具• DPL• Sonographic survey (FAST)• CT Trauma Service / KMUH
    • DPL• Diagnostic Peritoneal Lavage• 腹膜腔內灌洗術 • 可近性高 , 易於床邊施行 • 侵襲性檢查 • 易有偽陽性 Trauma Service / KMUH
    • Openmethod Trauma Service / KMUH
    • • DPA ”A” Closed method Trauma Service / KMUH
    • 判讀方法• Open and closed techniques• Catheter inserted into the abdomen, aspirate• Positive if gross blood, bile, food, stool• If aspirate negative, lavage with 1 liter NS• positive • Lavage fluid > 100,000 RBC/mm3, • >500 WBC/mm3, • Bacteria on Gram stain Trauma Service / KMUH
    • Abdominal CT• Computed tomography, CAT scan • 需影像部門配合 , 檢查速度不一 • 重裝備 , 可近性低 • 亂槍射鳥 , 一網打盡 , 敏感度高 Trauma Service / KMUH
    • CAT scanTrauma Service / KMUH
    • FAST• Focused Abdominal Sonography for Trauma • 輕裝備 , 易於使用 • 檢查時間短 • 解析度不佳 • 受操作者個人經驗影響 Trauma Service / KMUH
    • FAST• 主要搜尋腹腔內積液• 對生命徵象不穩之病患 , 先排除腹內出血與心 包填塞之可能• Basic 4 views • 劍突下 Cardiac (subxyphoid) view • 右上腹 RUQ view (Morrison’s pouch) • 左上腹 LUQ view (splenorenal space) • 骨盆腔 Suprapubic view (Cul-de-Sac) Trauma Service / KMUH
    • Typical4 views Trauma Service / KMUH
    • Trauma Service / KMUH
    • RUQ view• Longitudinal scan• Transverse scan• Intercostal scan• Hypochondral scan • Morison pouch • May observe pleural space Trauma Service / KMUH
    • • 10% is identified with infusing 400ml saline• 97% is noted with infusing 1L saline Branney et al. J Trauma 1995 Trauma Service / KMUH
    • LUQ view• Longitudinal scan• Transverse scan• Intercostal scan• Hypochondral scan • Spleen may be obscured during deep inspiration • May observe pleural space simultaneously Trauma Service / KMUH
    • Subcapsular hematoma Pleural effusion Same Victim Trauma Service / KMUH
    • Subxyphoid view• Pericardiac sac • Echogenesity of blood • Pericardial effusion? • Heart movement? • Decompressive measure Trauma Service / KMUH
    • Trauma Service / KMUH
    • Echo guided pericardiocentesis• Equipment • 16-gauge short-bevel large-bore needle • 30- or 50-mL syringe • Echo- guided • Local anesthesia • Sterile supplies and povidone-iodine solution Trauma Service / KMUH
    • Suprapubic view• Longitudinal scan• Transverse scan • Best viewed under full bladder • Physiologic fluid Trauma Service / KMUH
    • Trauma Service / KMUH
    • Physiologic ascites massive pelvic fluid Trauma Service / KMUH
    • EFAST• Extended FAST scan• Detect thoracic lesion • Focus on occult pneumothorax (OPTX)• Gliding pleura signs Trauma Service / KMUH
    • Lung Sliding Trauma Service / KMUH
    • • Lung pointTrauma Service / KMUH
    • Hemothorax• Right or left Intercostal view• Subcostal view Trauma Service / KMUH
    • Blunt cardiac injury• Pericardial effusion and Wall motion• Valve injuries ( regurgitate ) Trauma Service / KMUH
    • FAST or not?• 100 victims of penetrating torso trauma assessed by our trauma teams. 48 stab wounds, 51 gunshot wounds, and 1 puncture wound..• The overall accuracy of the US examination in penetrating torso trauma was 87%, with a sensitivity of 64% and a specificity of 96%. The positive predictive value was 86% and negative predictive value was 87%...• The US examination lacks sensitivity to be used alone in determining operative intervention…Rarely does US information contribute to the management of patients with penetrating abdominal injuries *A PROSPECTIVE EVALUATION OF ULTRASONOGRAPHY DIAGNOSIS OF PENETRATING ABDOMINAL INJURY Dror Soffer MD, Mark McKenney et al. Ann Emerg Med 2003 Trauma Service / KMUH
    • FAST or not?• 149 patients with suspicion for abdominal trauma were evaluated…leaving 134 patients for analysis.• There were 111 true negative FAST exams, 5 true positives, 17 false negatives, and 2 false positives.• Chi-square analysis showed significant discordance between FAST and CT (p<0.001).• Utilization of FAST as a screening tool for BAI in hemodynamically stable trauma patients results in under- diagnosis of intraabdominal injury…• Patients with suspected abdominal trauma should undergo routine CT scanning. *Not So Fast! M.T. Miller, ND, M.D. Pasquale et al. J Trauma 2002 Trauma Service / KMUH
    • Pitfall• Operator-dependent: skill • Reliable?• Sensitivity • Missed injuries• Pelvic fluid • Full Bladder• Serial examination • Delayed onset• Subcutaneous emphysema • Gas block Trauma Service / KMUH
    • The new ABCs• Admit• Begin• CT scan Trauma Service / KMUH
    • 如何運用工具 ?• When?• Why?• Why not? Trauma Service / KMUH
    • DPL• When • 需立即作 YES 或 NO 決定時 • Hemodynamic instability • 需進行大手術但無 CT 檢查時 • Rare these days • 意識不清但需排除腸道損傷時 Trauma Service / KMUH
    • DPL• Why • Quick decisions • Looking primarily for gross blood Trauma Service / KMUH
    • DPL• Why not • 為侵襲性檢查 • Possible complication • 非治療性開腹手術比率過高 • Non-therapeutic lap rate app 30%! • 對穩定血行之病患並不適合 Trauma Service / KMUH
    • FAST• When • 需立即作 YES 或 NO 決定時 • Hemodynamic instability • 穿刺傷之心包膜腔檢視 • Detect for fluid Trauma Service / KMUH
    • FAST• When • 69 patients with initial BP< 90 mmHg • 22 with positive FAST • 19(86%)needed a laparotomy • 47 with negative FAST • 0(0%) needed a laparotomy Wherrett LJ. J Trauma 1996 Trauma Service / KMUH
    • FAST• Why • 檢查迅速耗時短 • 為非侵襲性檢查 Trauma Service / KMUH
    • FAST• Why• Can be done rapidly! • Positive FAST • Time required 19+/-5 sec. • Just for internal bleeding or cardiac tamponade • Negative FAST • Time required 154+/-13 sec. Wherrett LJ. J Trauma 1996 Trauma Service / KMUH
    • FAST• Why not • 對穿刺傷敏感度不佳 • 評估損傷不夠全面 • 操作者水平影響判讀 • 無法成為標準篩檢工具 Trauma Service / KMUH
    • Abdominal CT• Why • 廣泛檢視腹部器官 • Solid organ, retroperitoneum, fluid • 敏感度高 • 非侵襲性 Trauma Service / KMUH
    • Accuracy Vs. Sensitivity 正確率 敏感度 Accuracy Sensitivity DPL 98% 99% FAST 96% 75-93% ABD CT 99% 99% Trauma Service / KMUH
    • Portable CAT scan HMC SeattleTrauma Service / KMUH
    • Abdominal CT• When • 不必考量時間因素 • 廣泛損害評估是我們的目標 • 病患需接受其他部位 CT 檢查 • 穿刺腹部彈道之評估 Trauma Service / KMUH
    • Abdominal CT• Why not • 時間緊繃 • 病患生命徵象不穩穩作 CT 耗時又冒險 • 腹膜炎癥象已現 現 作 CT 不影響開刀之決定 Trauma Service / KMUH
    • Abdominal CT• Why not • Multi-institutional study for small bowel injury • 13% without CT findings • 21% with solid organ injuries • 33% with peritoneal signs Fakhry J Trauma 2003 Trauma Service / KMUH
    • Digest time…• 了解各檢查工具的優缺點• 避免無謂的時間浪費• 正確的醫療處置 Trauma Service / KMUH
    • 處理流程 A 腹部穿刺傷生命徵象不穩定 生命徵象穩定 腹膜炎 (+ ) 腹膜炎 (- )開腹探查 可能合併 穿刺傷或彈道 其他 心臟外傷 需進一步探查 FAST Your CT Pericardial view choice Trauma Service / KMUH
    • 處理流程 B 腹部鈍傷 生命徵象不穩定 腹膜炎 (+ /- ) F AS T 優先 無超音波波 D PL 檢查結果 (+ ) 檢查結果 (- ) Resuscitation 開腹探查 Other injury? Trauma Service / KMUH
    • 腹部鈍傷處理流程 C 生命徵象穩定 腹膜炎 (- ) C T S c an 檢查結果 (- ) 檢查結果 (+ ) Observation Solid organ injury LOCDPL Retroperitoneal injury (-) OBS/Tx (+) Exp-lap? Trauma Service / KMUH
    • Can you make your decision now? Trauma Service / KMUH
    • Scenario XX• 52 歲女性因車禍受腹部鈍傷送入急診 , 血壓為 80/40 mmHg, 心搏 115, 左上腹壓痛 ; 輸液 2000ml 給予後血壓未見起色 , 你接下來要安 排的檢查是 ? Trauma Service / KMUH
    • 處理流程 B 腹部鈍傷 生命徵象不穩定 腹膜炎 (+ /- ) Hemodynamic Instablity FASTFree fluid(+) FAS T 優先 無超音波波 D PL 檢查結果 (+ ) 檢查結果 (- ) Resuscitation 開腹探查 Other injury? Trauma Service / KMUH
    • Scenario XY• 31 歲男性於衝突受上腹部刀傷送入急診 , 血壓 為 130/60 mmHg, 心搏 95, 上腹稍微壓痛 ; 初級檢傷後 , 除上腹部五公分傷口外無其他外 傷 ; 血壓仍然穩定 , 你接下來要安排的檢查是 ? Trauma Service / KMUH
    • 處理流程 A Stable Vital signs 腹部穿刺傷生命徵象不穩定 生命徵象穩定 腹膜炎 (+ ) 腹膜炎 (- )開腹探查 可能合併 穿刺傷或彈道 其他 心臟外傷 需進一步探查 FAST Your CT Pericardial view choice Trauma Service / KMUH
    • Conclusion• Don’t get “ABC” syndrome• Good Decision  Favorable outcome• Good Practice  Favorable outcome• Time pressureBedside survey Trauma Service / KMUH
    • Trauma Service / KMUH
    • Trauma Service / KMUH