PowerPoint Presentation
Good morningIm a consultant in Oxford UK and a run our
department POCUS fellowships
I have no financial disclosures to make1
Qns How many have ready access to one of these?/How many already
utilise US when treating trauma casesHow many of you work in depts
where majority of medical colleagues are trained?
2
CONTENT
Im going to give a brief overview of what we do in OxfordThe
FAST and eFAST protocols which is almost synonimous with Trauma
USAreas of future development Beyond eFASTAnd Ill wrap up with a
summary3
This is where I work Oxford. A beautiful place. We had a well
established echo training programme but when it comes to POCUS,
weve been doing it for about a year.4
This is the view of the hospital. I always show this picture of
the new section of the hospital. Thats the neuro ICU. The adult ICU
is buried in the basement. 5
In the UK, trauma services have been centralised and Oxford is
one of the major trauma centres. We are number 3. What that means
is that if someone was involved in a major trauma incident, the
pre-hospital team would aim to bring these pts to these hospitals
either by land ambulance or air ambulance.6
We are busy, last month we saw an average of 2 major trauma
calls a day. The majority of our big trauma calls are vehicle
related. Fair few stabbings. We dont get shootings as a general
rule.7
The other source of trauma workload is this we have lots of
rural areas and these are dangerous things. Trauma involving horses
and cows are not unusual.8
The role of ultrasound in traumaFAST + (e)FASTProcedural
guidance Intubation confirmation and endotracheal tube placement
Nerve blocks for analgesiaIntercostal/paravertebral blocks for rib
fracturesLimbs blocks for limb trauma Central and peripheral venous
accessParacentesis/Intercostal drainage guidance
The ultrasound machine is a very diverse and useful tool. We
tend to think about it in the context of the acute setting
assessment FAST, eFAST. Acute procedural tools, vascular access,
drains. But it can also be used in the subacute setting peripheral
nerve blocks and others to aid analgesia.9
With a high degree of sensitivity for the detection of potential
survivors after traumatic arrest, FAST represents an effective
method of separating those that do not warrant the risk and
resource burden of RT from those who may survive. The likelihood of
survival if pericardial fluid and cardiac motion were both absent
was zero.
2015 paper from the Annals of Surgery. analysis over 4 years.
Nearly 200 patients who suffered a traumatic cardiac arrest. Their
conclusion..10
OK. The focused assessment by sonography in or for trauma. FAST.
I have to admit in our centre, we have become more selective in
when we use FAST and US. Its probably because we access to trauma
CT scans so readily.
What I want to do now is to go through the basics of FAST and
perhaps we can discuss things in greater detail later. 11
In the context of Its mostly about fluid. Fluid in the context
of trauma is usually blood.12
FAST(e)FAST
Scan areas there are 4 in the original FAST- R and LUQ,
suprapubic and subcostal. The extended FAST adds in areas to assess
for pleural fluids and pneumothorax13
RUQTransducer Coronal planeMarker towards patients headMid -
axillary line3 review areasHepato-renal recess (Morrisons
pouch)Inferior pole of kidney into right paracolic gutterBelow
diaphragm
LUQTransducerCoronal planeMarker cephaladMore superior than
RUQ6th 9th intercostal spacesMore posterior than RUQ3 review
areasBelow the diaphragm (peri-splenic space)Between spleen and
left kidneyInferior pole left kidney (left paracolic gutter)
LUQ scan area is usually more posterior. Knuckle into the
bed.18
Although fluid can collect between the spleen and kidney, more
commonly you get fluid collecting as a rim above the spleen. 21
SuprapubicTransducerMidlineCoronal and transverseJust superior
to pubic symphysisFan left to right, superior to inferiorReview
areasRectovesical spaceVesicouterine spaceRectouterine pouch (pouch
of Douglas)Posterior wall of bladder
22
Longitudinal 23
27
Sub-costalTransducerTransverseSubcostalLiver as acoustic
windowIncrease depth
We move on to the subcostal views familiar to those of you who
perform transthoracic echocardiography. 28
www.ultrasoundoftheweek.com
www.ultrasoundoftheweek.com
eFASTPleural effusionPneumothorax
34
PneumothoraxTransducerCurvilinearLinearLongitudinalMid-clavicular
lineReviewMarching antsComet tails A lines
The Seashore Sign
Normality vs Pneumothorax
The lung pointThe probe is facing the pneumothorax, in
expiration.During inspiration the lung volume has increased and now
the probe is facing the lung.The probe remains motionless
Is lung ultrasound really of any
use?SensitivitySpecificityPneumothorax98%99%Pleural
effusions97%~100%interstitial fluid~86%98%
TWOS
Optic nerve sheathOptic nerve sheath diameter (ONSD) and ICP
relatedMeasured 3 mm posterior to the globe ONSD greater than 5 mm
is considered abnormal and elevated intracranial pressure should be
suspected
From broomedocs
46
Ultrasound and airwaywww.philips.com/CCEMeducation
Primary SurveyPotential role of ultrasoundAirwayDetermine
tracheal positionConfirm ETT placement and positionBreathingAssess
for pneumothorax and haemothoraxCirculationAssess for
haemoperitoneumAssess for haemopericardiumAssess for haemothoraxTo
guide peripheral or central venous accessAssess intravascular
fillingDisabilityAssess optic nerve sheath diameter as a reflection
of intracranial pressureExposure
Benefits of (e)FASTRapid and BedsideNon-InvasiveRepeatable
serial examinationCan be integrated into the primary or secondary
survey and performed quickly, without removing patients from the
clinical arenaNo radiation
49
Operator dependentSensitivitySpecificityGovernance
ULTRASOUND LESS SENSITIVE THAN CT
THE CT IS GOLD STANDARD53
In summary.NOT PERFECTDoes not replace clinical examinationDoes
not replace CTRequires training Good clinical governance
Useful
linksUltrasoundoftheweek.com5minsono.comUltrasoundvillage.comUltrasoundpodcast.com#POCUS
I do however believe that US would eventually integrate into
everyday ICU management in the same way that echo has.55
Fellowships
Adrian [email protected]@avkwong
