Abdominal trauma, penetrating trauma and ultrasound

1. Abdominal trauma, penetrating trauma and ultrasound ST3/DRE-EM Regional Training Day Friday 13th October 2017 Richard Kendall Consultant in emergency medicine

2. Patient 1 • 23 year old man • Pedestrian hit by car • On arrival P110, BP 124/64, GCS 15 • Left lower chest and LUQ

3. What imaging do you arrange first? • CXR and pelvis AP • Cervical spine • FAST • CT abdomen and CXR • Whole Body CT (WBCT)

4. What imaging do you arrange first? • CXR and pelvis AP • Cervical spine • FAST • CT abdomen and CXR • Whole Body CT (WBCT)

5. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study The Lancet Huber-Wagner et al (the working group on polytrauma of the German Trauma Society) Volume 373, Issue 9673, Pages 1455 - 1461, 25 April 2009 • trauma registrar review • n = 4621 patients, 1491 underwent WBCT • WBCT increased probability of survival

6. But....... • WBCT – up to 30 mSv • Addenbrooke’s data: 10% show no radiological abnormality

12. Computed Tomography — An Increasing Source of Radiation ExposureBrenner DJ and Hall EJNEJM Volume 357:2277-2284 November 29, 2007 Number 22 A 10 mSv CT in a 25 year old is associated with an estimated :- • Risk of induced cancer 1 in 900 • Risk of induced fatal cancer 1 in 1800

13. Patient 2 • 28 year old woman • Driver, frontal impact at 50 mph • On scene RSI (agitated, GCS 9 E2V2M5) • Seat belt bruising to chest and abdomen • In resus P136 BP 84/45

14. What imaging do you arrange first? • CXR, pelvis AP • CXR, pelvis AP, lateral Cervical spine • Pelvis AP • Pelvis AP and FAST • WBCT

15. What imaging do you arrange first? • CXR, pelvis AP • CXR, pelvis AP, lateral Cervical spine • Pelvis AP • Pelvis AP and FAST • WBCT

16. FAST • Focussed Assessment with Sonography in Trauma • Haemoperitoneum • Haemopericardium • eFAST (extended FAST) • Pneumothorax • Haemothorax

17. e-FAST basic views • Cardiac • RUQ • Morison’s Pouch and Right Pleural Cavity • LUQ • Splenorenal / Perisplenic and Left Pleural Cavity • Pelvic • & 6. Anterior chest for pneumothorax

18. Pericardial • Transducer placed in sub-xiphoid region with beam projecting in coronal plane

19. Subcostal Liver RV LV

20. l 20

21. Right Upper Quadrant • Transducer positioned in right posterior to mid-axillary line with beam in coronal plane (level with xiphi-sternum)

22. RUQ Window

23. Abnormal View www.emergencyultrasound.org.uk 23

24. Left Upper Quadrant Window • Transducer positioned in left posterior axillary line with beam in coronal plane.

25. LUQ Window

26. LUQ

27. Thoracic(bases) Lung Bases • Increased sensitivity with increased number of views • Will identify pleural effusions

28. To Evaluate the Thorax Liver Diaphragm Pleural space

29. Haemothorax 29

30. Pleural effusion - pitfall • Peritoneal fluid

31. Pelvic Window • Transducer placed transversely in midline above the symphysis pubis • Probe rotated 90o to move beam into sagittal plane

32. Patient 3 • 27 year old man • Altercation multiple stabbings to chest • Attended to by enhanced pre-hospital care team – RSI • Arrives with P126 BP 63/42 • FAST shows pericardial effusion

33. When do you perform a thoracotomy? • Immediately • If loses output • Under no circumstances

34. When do you perform a thoracotomy? • Immediately • If loses output • Under no circumstances

35. Emergency Thoracotomy “how to do it”Wise et alEmerg Med J 2005;22:22-24 • Within 10 minutes of cardiac arrest from penetrating trauma • Clam Shell thoracotomy • Bilateral 4cm thoracostomies midaxillary line • Skin incision • Scissors (Gigli saw) – open ‘clam’, retractor • Incise pericardium

37. Patient 4 • 46 year old man • MVC – RSI on scene • Brought be helicopter • Bilateral thoracostomies prior to transfer

38. Where do we put the chest drains • Through the thoracostomy • Through a distant site • Through the thoracostomy and give IV antibiotics • Through a distant site and give IV antibiotics

39. Where do we put the chest drains • Through the thoracostomy • Through a distant site • Through the thoracostomy and give IV antibiotics • Through a distant site and give IV antibiotics

40. Patient 5 • 35 year old man • Shotgun wound to right groin • P134 BP 90/46 GCS14 (E3V5M6) • Bleeding profusely • IV access and aggressive fluid resuscitation

41. How do we try and stop the bleeding? • Firm pressure with gauze • Firm pressure with CELOX • Pack wound and firm pressure gauze • Pack wound and firm pressure CELOX

42. How do we try and stop the bleeding? • Firm pressure with gauze • Firm pressure with CELOX • Pack wound and firm pressure gauze • Pack wound and firm pressure CELOX

43. CELOX • Haemostatic agent chitosan • Extracted from shrimp shells • Forms gel like clot once in contact with blood

44. Patient 6 • 24 year old man • Jumped off roof of hospital • Brought to ED within 15 minutes • P145 BP palpable carotid pulse • Unable to obtain peripheral vascular access

45. Do you..... • Insert subclavian line • Insert internal jugular line • Insert intraosseous needle • Insert femoral line

46. Do you..... • Insert subclavian line • Insert internal jugular line • Insert intraosseous needle • Insert femoral line

47. EZ-IO

48. Summary • WBCT • FAST • Resuscitative Thoracotomy • Thoracostomies • CELOX • EZ-IO