外傷超音波簡介
？ ？ ？ 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
Open method 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 scan Trauma 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
Typical 4 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
Same Victim Subcapsular hematoma Pleural effusion 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 Gliding pleura signs Focus on occult pneumothorax (OPTX) Gliding pleura signs Trauma Service / KMUH
Lung Sliding Trauma Service / KMUH
Lung point Trauma 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 Sensitivity Pelvic fluid 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 需進行大手術但無CT 檢查時 意識不清但需排除腸道損傷時 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 非治療性開腹手術比率過高 對穩定血行之病患並不適合 Possible complication 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 穿刺傷之心包膜腔檢視 Hemodynamic instability 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 Negative 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 敏感度高 非侵襲性 Solid organ, retroperitoneum, fluid 敏感度高 非侵襲性 Trauma Service / KMUH
Accuracy Vs. Sensitivity DPL 98% 99% FAST 96% 75-93% ABD CT Trauma Service / KMUH
Portable CAT scan HMC Seattle Trauma 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 腹膜炎癥象已現 病患生命徵象不穩作CT耗時又冒險 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 腹膜炎(+) 生命徵象穩定 腹膜炎(-) 開腹探查 可能合併 心臟外傷 穿刺傷或彈道 需進一步探查 其他 FAST Pericardial view CT Your choice Trauma Service / KMUH
處理流程 B 腹部鈍傷 生命徵象不穩定 腹膜炎(+/-) FAST 優先 無超音波DPL 檢查結果(+) 檢查結果(-) 開腹探查 Resuscitation Other injury? Trauma Service / KMUH
Retroperitoneal injury 處理流程 C 腹部鈍傷 生命徵象穩定 腹膜炎(-) CT Scan 檢查結果(-) 檢查結果(+) Observation LOCDPL Solid organ injury 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 FAST Free fluid(+) 無超音波DPL 檢查結果(+) 檢查結果(-) 開腹探查 Resuscitation 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 腹膜炎(+) 生命徵象穩定 腹膜炎(-) 開腹探查 可能合併 心臟外傷 穿刺傷或彈道 需進一步探查 其他 FAST Pericardial view CT Your choice Trauma Service / KMUH
Conclusion Don’t get “ABC” syndrome Good Decision Favorable outcome Good Practice Favorable outcome Time pressureBedside survey Trauma Service / KMUH
? Trauma Service / KMUH
THANK YOU! Trauma Service / KMUH