Trauma scan

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Trauma scan

  1. 1. Review Article The Focused Abdominal Sonography for Trauma Scan Pearls and Pitfalls John P. McGahan, MD, John Richards, MD, Marijo Gillen, MD, PhD Objective. To review the state-of-the-art use of sonography in evaluating the patient with trauma. Methods. We reviewed our experience in performing more than 5000 sonographic examinations in the patient with trauma. The recent experience of other publications advocating newer applications of sonography in the patient with trauma are discussed and presented in a pictorial fashion. Results. The main focus of sonography in the patient with trauma has been in performance of the focused abdominal sonography for trauma scan. The focused abdominal sonography for trauma scan is usu- ally performed in the patient with blunt abdominal trauma and is used to check for free fluid in the abdomen or pelvis. There are certain pitfalls that need to be avoided and certain limitations of the focused abdominal sonography for trauma scan that need to be recognized. These pitfalls and limita- tions are reviewed. More recently, sonography has been used to detect certain solid-organ injuries that have a variety of appearances. Thus, sonography may be used to localize the specific site of injury in these patients. More recently, sonography has been used to evaluate thoracic abnormalities in patients with trauma, including pleural effusions, pneumothoraces, and pericardial effusions. Conclusions. The use of sonography in evaluating the patient with trauma has rapidly expanded in the past decade. Those using sonography in this group of patients should be aware of its many uses but also its poten- tial pitfalls and limitations. Key words: abdominal parenchymal injury; abdominal sonography; focused abdominal sonography for trauma; Morison pouch; pitfalls. T Abbreviations he use of sonography in the detection of abdom- BAT, blunt abdominal trauma; CT, computed tomogra- inal parenchymal injuries is not new; sonogra- phy; FAST, focused abdominal sonography for trauma; IAI, intra-abdominal injury phy as a diagnostic tool for detection of traumatic hemorrhage of the spleen was described more than 30 years ago.1 In an early report by Asher et al2 in 1976, the sensitivity of sonography for detection of splenic injury from blunt abdominal trau- ma (BAT) was reported to be 80%. However, after these early reports, sonography was not routinely used for Received February 25, 2002, from the Department evaluation of injury from BAT, probably because of of Radiology (J.P.M., M.G.) and Division of widespread use of computed tomography (CT) for Emergency Medicine (J.R.), University of California BAT.3,4 It has only been in the 1990s that sonography has Davis Medical Center, Sacramento, California. Revision requested March 14, 2002. Revised been more widely advocated for the screening evalua- manuscript accepted for publication March 21, tion of patients with BAT.5 2002. Special thanks to Debra Odam for technical sup- port in manuscript preparation. Sonographic Examination Address correspondence and reprint requests to John P. McGahan, MD, Department of Radiology, The sonographic examination that is performed for eval- University of California Davis Medical Center, School of Medicine, 4860 Y St, Suite 3100, Sacramento, CA uation of the patient with BAT has changed considerably 95817. since first described in the early 1990s. There has been a © 2002 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 21:789–800, 2002 • 0278-4297/02/$3.50
  2. 2. The Focused Abdominal Sonography for Trauma Scan learning curve within the literature, and this Sensitivity of FAST examination has changed appropriately. The main focus of the examination has been on The sensitivity of the FAST scan has ranged detection of free fluid within the abdomen of from 63% to 100%.5,7,9–18 In almost all of the patients with acute trauma. One original studies, sonographic specificities remained description of the use of sonography in BAT high, in the range of 90% or greater. In a critical was to obtain a single view of the Morison review of a number of these studies5,9–18 report- pouch to detect free fluid.6 However, that ing high sensitivity for sonography, Pearl and examination has been abandoned in favor of a Todd19 found flaws in the study design. These more comprehensive examination, which has flaws included the following: no trial used a been well described in the literature.7 This completely blinded format; only 2 of the 11 examination has been named focused abdom- specified consecutive patient enrollment; inal sonography for trauma (FAST). This usual- training for those performing the examina- ly includes sonography of the right upper tions ranged from 2 hours to many years of quadrant, including the hepatorenal fossa experience; and, finally, there was no standard (Figs. 1 and 2); the left upper quadrant, includ- of reference with which sonographic results ing the perisplenic region; the right and left could be compared. For instance, Rothlin et paracolic gutters (Fig. 3); and the pelvis, per- al16 clearly stated that, “It has become accept- formed to detect free fluid. Free fluid will grav- able in Europe to calculate sensitivities and itate to the most dependent portion of the specificities for sonography concerning only pelvis (Figs. 4 and 5), and as such, free fluid in the patient’s course.” A number of studies have the pelvis may be missed if the patient has an not included clinical outcome, instead com- empty bladder.7 In some instances, an exami- paring sonography with CT, diagnostic peri- nation of the epigastrium to check for free toneal lavage, or laparotomy; these have had fluid, free air, or both is also performed.8 Other sensitivities in the range of 63% to 69%.7,18,20 In components of the examination include an analysis of these series with lower sensitivities, intercostal or subdiaphragmatic view of the there is no doubt of 2 facts: (1) we can improve heart. Examination of the chest is performed if, sensitivity by learning from our previous in fact, there has been chest as well as abdom- errors; and (2) the FAST scan will not detect all inal trauma; such an examination will be dis- hollow- or solid-organ injuries. cussed below. Figure 1. Image from a 56-year-old woman with a splenic laceration and Figure 2. Image from a 26-year-old patient with a splenic laceration. free fluid after a fall. Free fluid is shown in the right upper quadrant Longitudinal sonography of the right upper quadrant (RUQ) of the (RUQ) of the abdomen. This patient required splenectomy. C indicates abdomen shows a trace amount of free fluid in the hepatorenal fossa renal cyst; and L, liver. (arrow). No splenectomy was required. 790 J Ultrasound Med 21:789–800, 2002
  3. 3. McGahan et al A B Figure 3. Free fluid in the abdomen. A, Longitudinal scan through the right (RT) paracolic gutter shows free fluid surrounding a loop of bowel. B, Other free fluid is shown in the right lower quadrant (RTLQ) of the abdomen (open arrow). Sonographic Pitfalls therefore imperative that we use a full-bladder technique to detect free fluid in the pelvis. There are a few pitfalls that occur with the FAST Second, there have been a number of articles scan. First, without a full bladder, free fluid in that have pointed out that sonography can miss the pelvis will often be missed.7 In analyzing our important organ injury that will require surgery original work, we had 14 false-negative findings, in the patient with trauma.7,20,21–24 For instance, of which 6 were in cases in which free fluid was Dolich et al22 reported 43 patients with false- identified in the pelvis on CT but not shown on negative sonographic findings, of which 10 sonography. These patients were examined with (33%) required surgery. Shanmuganathan et al24 an empty bladder, because a Foley catheter was studied more than 11,000 patients with BAT by placed before the sonography was performed. using sonography and found that 467 had If, in fact, there were a full bladder, we would abdominal organ injuries with CT or laparotomy have theoretically identified free fluid in the correlation. In 310 (66%) of these, there was free pelvis, which would have decreased our false- fluid detected on sonography. However, 157 negative findings to a total of 8. This would have (34%) of the 467 patients had no sonographically increased our sensitivity from 63% to 79%. It is detected free fluid; 26 of these 157 patients Figure 4. Image from a 23-year-old woman with a splenic laceration and Figure 5. Image from a 25-year-old woman with physiologic free fluid pelvic fluid after a motor vehicle accident. Longitudinal scan of the pelvis after a motor vehicle accident. Longitudinal scan through the partially shows slightly echogenic free fluid (arrow) anterior and cephalad to the filled bladder (B) shows the uterus (U) and a trace of free fluid (open bladder (B). This patient required a splenectomy. arrow) in the cul-de-sac. This free fluid was thought to be physiologic. J Ultrasound Med 21:789–800, 2002 791
  4. 4. The Focused Abdominal Sonography for Trauma Scan without free fluid required further surgical or reported that when 400 mL of saline was infused angiographic intervention. Shanmuganathan et in the abdomen during diagnostic peritoneal al24 therefore thought that the FAST scan may lavage with the patient in the Trendelenburg frequently miss patients with surgically cor- position, only 10% of patients had fluid identified rectable injuries. Most of these studies’ authors in the Morison pouch. It took 1 L of saline to advocate the use of sonography as the initial identify fluid in the Morison pouch in 97% of screening examination but think that CT should cases. This illustrates the possible limitations of remain the definitive imaging modality, especial- a single-view scoring system of the upper ly for hemodynamically stable patients.21,24 We abdomen for detection of free fluid. It also have found sonography to be very useful for the emphasizes the importance of gravity in the triage of unstable patients with appreciable free distribution of fluid into the pelvis and the fluid in the abdomen but would agree that CT need for a good acoustic window (full bladder) still should be used for those stable patients who when examining the pelvis. have undergone sonography and in whom there To develop a scoring system, Huang et al13 is suggestion of an intra-abdominal injury (IAI). infused saline during diagnostic peritoneal Finally, there is little doubt that sonography lavage and then used sonography to detect free will be limited or unable to show certain types fluid. He based his criteria on locating pockets of injuries. These are not restricted to but of fluid with a thickness of 2 mm or greater. include spinal and pelvic fractures, diaphrag- Each region or pocket of fluid 2 mm or greater matic ruptures,25 vascular injuries,24 pancreatic received a score of 1. Patients with 3 pockets, injuries,26 adrenal injuries, and some bowel and or a score of 3 or greater, were taken to the mesenteric injuries (Fig. 6).27 operating room. Even with a score of less than 3, 14 of 24 patients were taken to surgery. Free Fluid Scoring Systems McKenney et al29 proposed a scoring system in which all vertical heights of fluid measured in An initial sonographic scoring system proposed centimeters in the abdomen were added. A by Jehle et al6 included a single view of the score of greater than 3 was associated with an Morison pouch to check for free fluid. This was a increased need for surgical intervention. The simple all-or-none system for identification of a subphrenic, subhepatic, and perisplenic areas hypoechoic “stripe” between the liver and and pelvis represented the 4 sites in which, if kidney. With this protocol, Jehle et al6 reported a fluid were isolated, would most often result in a sensitivity of 81.8%. However, Branney et al28 need for surgery. Figure 6. Images from a 4-year-old boy with a colonic tear, an ileal tear, and a mesenteric laceration after a motor vehicle accident. A, Sonography of the right upper quadrant (RUQ) shows large amounts of free fluid in the hepatorenal fossa (open arrow). B, Computed tomography of the abdomen shows thickening of the small bowel (curved arrow) with free fluid noted in the abdomen (arrow). This patient had surgical repair of the small-bowel laceration. A B 792 J Ultrasound Med 21:789–800, 2002
  5. 5. McGahan et al Sirlin et al30,31 published 2 articles describing a tion of 41% of solid-organ injuries. However, scoring system and location of fluid. For each most studies have not shown this high detec- anatomic region in which fluid was detected, 1 tion rate. This is not a new topic in sonography. point was given. With a score of 0, 1.4% of the In 1983, vanSonnenberg et al33 injected blood patients had an IAI; with a score of 1, 59% had an into cadaver organs and also noted the appear- IAI; with a score of 2, 85% had an IAI; and with a ance of blood in the liver after fine-needle aspi- score of 3, 83% had an IAI. With regard to surgi- ration biopsy. These hematomas appeared as cal intervention, for patients with a score of 0, linear echogenic foci within the parenchymal 0.4% required surgery; with a score of 1, 13% organs. required surgery; with a score of 2, 36% required The FAST literature has paid little attention surgery; and with a score of 3, 63% required to the appearance of solid organs. However, surgery. Therefore, the higher the score, the there is some limited work on this topic. higher the rate of IAI and need for surgery.31 This Stengel et al34 showed that with the use of a group also found that hepatic injuries were like- 7.5-MHz linear array probe, injuries were ly to have associated free fluid in the right upper much more easily detected than with a 3.5- quadrant or the lower recesses, whereas for MHz convex probe. Much of this work on clas- splenic injuries, free fluid was identified in either sification of solid-organ injury has been the right or left upper quadrant as well as the performed by Richards, McGahan, and col- recesses.30 These scoring systems have a com- leagues.28,35–38 Although solid-organ injury is mon denominator; that is, an increase in the infrequently identified, there are certain pat- amount of free fluid in the abdomen or pelvis terns that predominate when shown. A diffuse raises the likelihood of major IAI. When we per- heterogeneous pattern is a predominant pat- form the examination at our institution, we ana- tern shown in splenic lacerations (Figs. 7–9), lyze the amount of fluid subjectively. If large whereas a discrete hyperechoic pattern is pockets of fluid are noted throughout the shown most often in hepatic lacerations abdomen, we will often send these patients to (Figs. 10 and 11). 35,36 It is of interest that surgery without confirmatory CT, especially if this discrete hyperechoic pattern in the they are not hemodynamically stable.27 liver is very similar to the pattern origi- nally described by vanSonnenberg et al33 in Serial Sonography 1983. Also, in the spleen, subcapsular hematomas are shown as either hyperechoic A few studies20,32 have shown that serial or hypoechoic rims surrounding the splenic sonography performed as a part of the follow- parenchyma (Figs. 12 and 13). Siniluoto and up physical examination may be useful for detecting free fluid in patients with BAT. Certainly, an examination after stabilization of Figure 7. Image from a 62-year-old man with a splenic laceration after a motor the patient will allow the sonographer more vehicle accident. Sonography of the left upper quadrant (LLUQ) of the abdomen time for a comprehensive examination. If shows a very disorganized and heterogeneous appearance to the spleen. There was free fluid in the abdomen. This patient was sent directly to the operating room there is active bleeding in the abdomen, the for a splenectomy. amount of fluid should increase with time and would be more amenable to sonographic detection. The value of serial sonography has not been fully investigated. Solid-Organ Injuries Most FAST examinations have focused on detection of free fluid in the abdomen. Only a few have focused on the use of sonography to directly detect parenchymal organ injuries. Rothlin et al16 reported sensitivity of 41.4% for detection of organ injury by sonography. McGahan et al7 also showed sonographic detec- J Ultrasound Med 21:789–800, 2002 793
  6. 6. The Focused Abdominal Sonography for Trauma Scan A B Figure 8. Images from a 23-year-old man with a splenic laceration after a motor vehicle accident. A, Longitudinal sonography of the left upper quad- rant (LUQ) of the abdomen shows a hypoechoic rim surrounding the spleen (arrows) and a heterogeneous appearance to the spleen. B, Computed tomography of the upper abdomen shows active extravasation of contrast (arrow) within the splenic bed. There was free fluid in the abdomen. This patient underwent a splenectomy. associates39 showed that splenic lacerations The Chest not detected on initial sonography become hypoechoic over a few days. In kidneys, more Sonography has been shown to be useful for severe injuries show a completely disorganized diagnosing pleural effusions (Fig. 15),40 pericar- pattern (Fig. 14). There is only limited experi- dial effusions (Fig. 16),41,42 and pneumothoraces ence in identifying injuries to the pancreas, (Figs. 17 and 18).43,44 Pleural effusions are easily adrenal glands, and bowel on sonography. identified on sonography and can be seen as a hypoechoic or an anechoic stripe in the depen- dent portion of the thorax when the right or left upper quadrant of the abdomen is examined. It is possible to diagnose pneumothoraces on the basis of sonography by noting the absence of Figure 9. Image from a 35-year-old man with a splenic laceration after an assault. the normal “sliding lung” sign and instead not- Sonography showed multiple mixed echogenic regions (open arrow) throughout ing the “comet tail” that originates from the the spleen. This patient required a splenectomy. Reprinted with permission from pneumothorax. The parietal pleura is fixed to Radiographics.38 the ribs and muscles of the thorax, whereas the visceral pleura is adherent to the lung. Sliding lung refers to the observation of the bright echogenic line of the visceral pleura, which is adherent to the lung, moving or sliding during normal inspiration and expiration. The comet tail sign may be more correctly a reverberation artifact of closely spaced echoes that are identi- fied deep to a pneumothorax. Thus, in the region of the pneumothorax, sliding of the vis- ceral pleura of the lung adjacent to the parietal pleura is not observed. Very high sensitivities have been reported for identification of pneu- mothorax by sonography.43,44 Many examiners incorporate the subcostal view of the heart as a portion of the FAST scan. This is useful in diagnosing a pericardial effu- sion. However, Blaivas et al42 pointed out the 794 J Ultrasound Med 21:789–800, 2002
  7. 7. McGahan et al A B Figure 10. Images from a 20-year-old man with multiple abdominal injuries including a hepatic laceration after a motor vehicle accident. A, Sonography of the right upper quadrant (RUQ) of the abdomen shows a fairly well-demarcated echogenic region in the liver (arrow). B, Postoperative CT of the upper abdomen shows the corresponding hepatic laceration of the liver. Reprinted with permission from Radiographics.38 potential pitfalls of overdiagnosing pericar- Summary dial effusions. They set up a study in which emergency medicine residents and fellows It is apparent that the use of sonography in the trained in sonography had trouble discerning evaluation of patients with trauma has greatly epicardial fat from effusions, and sonography increased over the last few years, and undoubt- had sensitivity of 73% and specificity of edly there will be more widespread use of 44%.40 Finally, cardiac tears or ruptures of the sonography in the future. In the abdomen, heart may be noted on sonography.45 Thus, in sonography can show free fluid and, in some the future, sonography will probably prove to situations, can identify solid-organ injuries. If be a more useful tool in identifying abnor- appreciable free fluid is detected, this may, in malities in the chest with blunt and penetrat- fact, indicate that patients should be sent for ing trauma. immediate surgical intervention depending on Figure 11. Images from a 46-year-old male pedestrian with a hepatic laceration after being hit by an automobile. A, Sonography shows a well-demar- cated echogenic region in right lobe of the liver corresponding to the liver laceration (arrow). B, Computed tomography shows the liver laceration (arrow) extending into the periportal region. Reprinted with permission from Radiographics.38 A B J Ultrasound Med 21:789–800, 2002 795
  8. 8. The Focused Abdominal Sonography for Trauma Scan Figure 12. Image from a 43-year-old man with an initial splenic lacera- Figure 13. Image from a 26-year-old man with a splenic laceration after tion after an assault. Sonography of the left upper quadrant (LUQ) of the a motor vehicle accident. Sonography shows a well-demarcated, abdomen shows a well-demarcated, echogenic subcapsular hematoma echogenic subcapsular hematoma in the spleen (open arrow). There was of the spleen (open arrow). This patient required a splenorrhaphy fol- free fluid in the abdomen. This patient required a splenectomy. LUQ indi- lowed by a splenectomy. Reprinted with permission from Radio- cates left upper quadrant. graphics.38 LUQ indicates left upper quadrant. A Figure 14. Images from an 18-year-old woman with intra-abdominal injuries including a renal laceration after a motor vehicle accident. A, Sonography of the right upper quadrant (RUQ) of the abdomen shows a large hypoechoic region in the middle and lower pole of the right kidney (arrows). B, Computed tomography of the right kidney shows the renal laceration with surrounding hematoma. This patient required a nephrectomy. C, Sonography of the pelvis through the patient’s bladder (B) shows the uterus (U) but no free fluid in the abdomen or pelvis. B C 796 J Ultrasound Med 21:789–800, 2002
  9. 9. McGahan et al Figure 15. Pleural effusion. Sonography of the right upper quadrant Figure 16. Pericardial effusion. A subcostal view of the heart shows the (RUQ) shows right pleural effusion (PL EFF; arrow) in a patient with acute right (R) and left (L) ventricles surrounded by a well-demarcated, hypo- trauma to the chest and abdomen. echoic rim corresponding to a moderately sized pericardial effusion (arrow). A Figure 17. Sonography of normal lung. A linear array transducer (A) and a sector transducer (B) show echogenic lines of the pleura (arrows). With inspiration and expiration, the sliding lung can be identified on real-time sonography. B J Ultrasound Med 21:789–800, 2002 797
  10. 10. The Focused Abdominal Sonography for Trauma Scan B Figure 18. Sonography of a focal pneumothorax. A linear array trans- ducer (A) and a sector transducer (B) show the echogenic interface of a normal lung (open arrow). There is a focal pneumothorax and a corre- sponding comet tail artifact (arrows). RT CHT ANT indicates right chest, A anterior. their clinical status. However, for patients in 6. Jehle D, Guarino J, Karamanoukian H. Emergency whom no free fluid is identified, there remains department ultrasound in the evaluation of blunt the risk of an IAI. abdominal trauma. Am J Emerg Med 1993; 11:342– The examiner must realize that certain abnor- 346. malities may not be identified by sonography 7. McGahan JP, Rose J, Coates TL, Wisner DH, within the abdomen of a patient with acute Newberry P. Use of ultrasonography in the patient trauma. These limitations must be realized for with acute abdominal trauma. J Ultrasound Med effective use of sonography as a screening tool. 1997; 16:653–662. In the future, the use of sonography for patients with chest trauma will also increase identifica- 8. Grechenig W, Peicha G, Clement HG, Grechenig M. tion of pleural effusions and pneumothoraces. Detection of pneumoperitoneum in ultrasound Sonography can also be used to diagnose examination: an experimental and clinical study. abnormalities of the heart, including pericardial Injury 1999; 30:173–178. effusion and potential cardiac rupture. 9. Forster R, Pillasch J, Zielke A, Malewski U, Rothmund M. Ultrasonography in blunt abdominal trauma: References influence of the investigator’s experience. J Trauma 1992; 34:264–269. 1. Kristensen JK, Buemann B, Kuehl E. Ultrasonic scan- ning in the diagnosis of splenic haematomas. Acta 10. Goletti O, Ghiselli G, Lippons FV, et al. The role of Chir Scand 1971; 137:653–657. ultrasonography in blunt abdominal trauma: results in 250 consecutive cases. J Trauma 1994; 36:178– 2. Asher WM, Parvin S, Virgilio RW, Haber K. 181. Echographic evaluation of splenic injury after blunt trauma. Radiology 1976; 118:411–415. 11. Gruessner R, Mentges B, Duber C, Ruckert K, Rothmund M. Sonography versus peritoneal lavage 3. Federle MP, Griffiths B, Minagl H, Jeffrey RB Jr. in blunt abdominal trauma. J Trauma 1989; 29: Splenic trauma: evaluation with CT. Radiology 1987; 242–244. 162:69–71. 12. Hoffmann R, Nerlich M, Muggia-Sullam M, et al. 4. Foley WD, Cates JD, Kellman GM, et al. Treatment of Blunt abdominal trauma in cases of multiple trauma blunt hepatic injuries: role of CT. Radiology 1987; evaluated by ultrasonography: a prospective analysis 164:635–638. of 291 patients. J Trauma 1992; 32:452–458. 5. Kimura A, Otsuka T. Emergency center ultrasonog- 13. Huang MS, Liu M, Wu JK, Shih HC, Ko TJ, Lee CH. raphy in the evaluation of hemoperitoneum: a Ultrasonography for the evaluation of hemoperi- prospective study. J Trauma 1991; 31:20–23. 798 J Ultrasound Med 21:789–800, 2002
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