Sonographic Assessment of Blunt Abdominal Trauma in the Emergency Department: The FAST Exam
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The document discusses the Focused Assessment with Sonography for Trauma (FAST) exam used to diagnose blunt abdominal trauma. The FAST exam uses ultrasound to quickly check for fluid in four areas of the abdomen that could indicate internal bleeding. While fast and non-invasive, the FAST exam has limitations as it can miss some injuries and has variable accuracy depending on the operator. The document explores different trauma algorithms and how the FAST could be incorporated while accounting for its limitations.
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Hemorrhage is the leading cause of preventable death following trauma. Non-compressible hemorrhage is of particular concern as these patients require emergent intervention and many will die prior to anatomic hemostasis. For years, left anterior thoracotomy, the “ED thoracotomy”, was the standard of care for temporary proximal aortic occlusion, but survival remained dismal. Endoluminal aortic occlusion which was actually first described in the 1950s. With the increasing use of endovascular therapies for a wide variety of vascular disease, the “REBOA” (Resuscitative Endovascular Balloon Occlusion of the Aorta) began to be reported for use for ruptured abdominal aneurysms in the 2000s. Since that time, interest in its use in trauma has been increasing with a variety of basic science studies and early clinical series and case reports documenting potential benefits. Although no large randomized trials, or even large observational studies, are available, use of the REBOA is considered standard of care in many centers. Typically the REBOA is placed via the femoral artery either percutaneously or via a cut down and the aorta is occluded with a balloon placed over a wire by standard Seldinger-type technique. The balloon can be placed in “zone 1” just above the diaphragm to provide occlusion to the abdominal viscera and pelvic vasculature or in “zone 3” at the aortic bifurcation to provide inflow control to the pelvis and lower extremities. Injuries are then addressed and the balloon is carefully deflated taking care to avoid metabolic collapse from reperfusion. One main limitation of this technique is that the currently approved device in the United States requires a 12F sheath which requires an open femoral artery repair which obvious can be associated with significant complications. There are a huge number of unanswered questions about the use of REBOA in 2015:
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6. How do we best train providers to place the REBOA?
7. How to we assure competency of providers?
8. Will lower profile devices make the technique more accessible and be associated with fewer complications?
Chest Trauma
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1) The document provides an overview of the evaluation and management of abdominal trauma, including both blunt and penetrating mechanisms.
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3) In stable blunt trauma, physical exam, FAST, and CT scan are used to identify injuries before considering discharge.
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This document discusses isolated head injuries in pediatric trauma patients and the association with shock and hypotension. The key points are:
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Prevention vs Treatment MGB Leaks v2
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In short:
Management Post Op Leaks
1. First Prevent Leaks
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Simple Leak Management Protocol
Leak found 24-48hr
= No Diagnostic Tests
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Fear Leak: Suspect a Leak in Every Case
Leak found 24-48hr
= No Diagnostic Tests
No WBC
No CAT Scan
No Chest XRay
If patient does not feel well reexplore early
= Immediate Exploration
Expect many negative explorations when you begin
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Categorize:
1. Acute peritonitis, sepsis, leak NOT contained
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2. Stable patient, not septic, leak contained
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ABx, Drainage and Feeding
Complication Management; Better to Prevent a Leak than to be Expert in Man...
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Better to
Prevent a Leak than to be
Expert in
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