Radiol Clin N Am 42 (2004) 417 – 425

Emergency ultrasound in trauma patients
John P. McGahan, MDa,*, John Richards, MDb, Maria Luisa C. Fogata, MDa

Division of Diagnostic Radiology, University of California, Davis, School of Medicine, 4860 Y Street, Suite 3100, Sacramento, CA 95817, USA b Division of Emergency Medicine, University of California, Davis, School of Medicine, 2315 Stockton Boulevard, PSSB 2100, Sacramento, CA 95817, USA

Although ultrasound (US) was first described in the detection of blunt traumatic splenic injuries more than 30 years ago [1], it was never widely advocated until approximately 10 years ago [2 – 4]. There are probably two reasons for the initial limited use of sonography in blunt traumatized patients. The first is that the use of CT evolved at approximately the same time and was shown to be highly sensitive for evaluation of blunt abdominal trauma [5]. CT not only detected free fluid but also directly demonstrated the organ injury. Sonography also was used initially to detect specific organ injury rather than the free fluid associated with the injury. There were limitations in the ability and sensitivity of sonography in directly demonstrating the injured organ. It was not until the 1990s that the focused abdominal sonography for trauma (FAST) was developed for the main objective of detecting free fluid in patients with blunt abdominal trauma [2 – 4].

Sonographic examination The initial focus of sonographic examination was a single view of the hepatorenal fossa (Morison’s pouch) [2]. It was soon realized that a more comprehensive examination of the abdomen improved detection of free fluid, however [4]. This included examinations of both upper quadrants, the paracolic gutters, and pelvis. In 1997, McGahan et al [4]

documented that sonographic sensitivity for the detection of free fluid could be improved by having a full bladder. Often in traumatized patients a Foley catheter is placed and the bladder is decompressed, which eliminates the acoustic window in the pelvis needed to detect small or moderate amounts of free fluid. More recently, in an article by Hahn et al [6], patients with proven intra-abdominal injuries after blunt abdominal trauma were evaluated and it was demonstrated that the finding of free fluid with sonography was important. Seventy-eight percent of patients with free fluid on sonography required laparotomy, whereas only 27% without free fluid needed laparotomy. They also showed that examination of Morison’s pouch had the highest detection rate of free fluid in these patients (66%), whereas free fluid was detected 56% of the time in the upper quadrants, 48% of the time in the paracolic gutters, and 36% of the time in the pelvis. Examination of all areas was important, however, because 3 of the 604 patients with intra-abdominal injuries had free fluid only in paracolic gutters [6]. At our institution we always include an examination of the heart for pericardial fluid as a part of the FAST scan. US is also useful in examinations of the chest for pneumothorax or pleural effusion, which are discussed later in this article.

Sonographic findings Free fluid

* Corresponding author. E-mail address: (J.P. McGahan).

Free fluid typically appears as a hypoechoic region within the peritoneal cavity or pelvis and is usually linear or triangular in shape (Fig. 1). The

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with acute angles (arrow). (C) In the same patient as B. (A) Real-time US examination of the right upper quadrant demonstrates small triangular-shaped hypoechoic region (arrow) that corresponds to free fluid. This should cause little confusion.P. For instance. free fluid in the dependant portion of the pelvis can be missed. With the bladder decompressed after placement of a Foley catheter. It is important to recognize that although this free fluid is most likely pre-existing and probably physiologic. Pitfalls Patients with pre-existing ascites or iatrogenic free fluid (eg. Loops of fluid-filled bowel should not be confused with free intraperitoneal fluid. At the site of injury. 1). noted just inferior to the liver and the right kidney that corresponds to free fluid. In this situation. Bowel loops can be distinguished from free fluid because they are round and have peristalsis. It is impossible in these patients to know if the free fluid is caused by preexisting ascites. the blood may appear echogenic as it forms a clot adjacent to the injured organ (Figs. Fluid that surrounds bowel often appears triangular.418 J. traumatic injury. clotted blood at the . With severe injury. the fluid between the kidney and liver usually has a linear shape (see Fig. the specificity of sonography is high [4]. Fluid often accumulates at the site of injury but then flows throughout the abdomen and into the pelvis. a small amount of ‘‘physiologic’’ free fluid may be noted in the pelvis. it may be secondary to an injury. In some cases sonography may detect small amounts of free fluid that are not visualized with CT [4]. 2. In almost all recent studies of the use of sonography for detection of free fluid in patients with blunt abdominal trauma. The sensitivity of sonography for detection of free fluid in the pelvis may be decreased if a full bladder is not used. in Morison’s pouch. 3). dialysis patients) may have falsepositive sonogram results. Patterns of free fluid. shape of the fluid depends on its compression by the surrounding structures. Another potential pitfall of US detection of free fluid is that hematomas may appear echogenic. McGahan et al / Radiol Clin N Am 42 (2004) 417–425 Fig. 1. There maybe several pitfalls in recognition of free fluid within the abdomen (Box 1). searching for free fluid in other sites is important. (B) Real-time US of the right upper quadrant demonstrates larger hypoechoic region. Sonographic sensitivity in detecting injuries in patients with blunt abdominal trauma may be decreased for several reasons. In women of childbearing age. or a combination of the two. linear hypoechoic region in the hepatorenal fossa (Morison’s pouch) corresponds to free fluid (arrow).

slightly hyperechoic region along the anterior aspect of the spleen (arrow) that corresponds to subcapsular hematoma.21(Spec No):S191 – 9.4% and 0. Longitudinal real-time US of the spleen demonstrates well-demarcated. spleen.4%. McGahan et al / Radiol Clin N Am 42 (2004) 417–425 419 Fig. Wang L. For a score of 3. Free fluid scoring systems Scoring systems have been developed to help stratify patients into groups who may or may not require laparotomy. and the rate of surgical intervention was 13%.)      direct peritoneal lavage Pelvic fluid (female) Loops of fluid filled bowel Incomplete or empty bladder Echogenic clot Contained injury . For instance. in several patients no free fluid was detected. Pitfalls in examination of the abdomen for free fluid  Pre-existing fluid (ascites)  Iatrogenic free fluid as in dialysis or Fig.P. bowel and mesentery injuries. site of the injury may be echogenic and should not be overlooked (see Figs. and adrenal injuries [4]. Finally. Echogenic clot/liver laceration. diaphragmatic ruptures. The rate of intra-abdominal injury increased to 85% and rate of surgical intervention was 36%. such as the liver. (From McGahan JP. there is often no free fluid associated with contained injuries of solid organs. for a score of 2. (B) Real-time examination of the liver demonstrates fairly well marginated echogenic region in the liver (arrows) that corresponds to liver laceration. the rate of intra-abdominal injury was 59%. Others have stratified patients based on either the amount of free fluid in one location or the number of locations in which free fluid was detected. the percentage of pa- Box 1.8] described a scoring system based on the location of the fluid. 2. sonography is limited and unable to show some types of injuries. vascular injuries. respectively. For the score of 1. In the article by Hahn et al [6]. 3). yet 27% of these patients required laparotomy. Subcapsular hematoma of the spleen. From the RSNA refresher courses: focused abdominal US for trauma. 2. Radiographics 2001. This may be the greatest pitfall of the FAST scan and is discussed later in this article. pancreatic injuries. one point was given. with permission. Finally. Sirlin et al [7. or kidney. Richards JR.J. 3. including spinal and pelvic fractures. For each anatomic region in which fluid was detected. (A) Real-time US examination of the right upper quadrant of the abdomen shows right kidney (RTK) and echogenic clot anterior to the liver (RT LOBE). The percentage of patients with a score of 0 who had intra-abdominal injury or required surgical intervention (based on this scoring system) was 1.

and all improved clinically. A common theme would be the more the amount of free fluid. Others have advocated scoring systems based on the number of free fluid sites or the vertical height of free fluid [9. Numerous other studies have been published on the topic of the sensitivity of FAST. Polletti et al [17] demonstrated a sensitivity rate of 93% for sonography. however. Sonographic appearance of solid organ injuries Much of the work on sonographic classification and appearance of solid organ injuries has been performed by McGahan et al [23.26]. Rothhin et al [12] reported a sensitivity rate of 41. McGahan et al [4] calculated a sensitivity rate of only 63% when sonography was compared with CT or laparotomy and not using clinical observation as a gold standard. This detection rate is similar to past studies. usually more than 95% [11 – 13]. Sonography can be used to triage patients. Other results from recent literature vary. these patients would have been deemed as having true negative results. 310 (66%) of whom had free fluid detected by sonography. 157 patients (34%) with intra-abdominal injury had no free fluid. and 26 of these patients required surgery or further intervention. A diffuse heterogeneous echogenic pattern is the predominant Fig.420 J. in 744 pediatric patients with blunt abdominal trauma. Dolich et al [18] reported on 43 patients with false-negative sonography results. which corresponds to severe splenic laceration. this same study group showed that sonography had a sensitivity rate of 67% in detection of intra-abdominal injury [15]. In a large review of 3264 patients.4% for the direct detection of solid organ injuries by sonography. they were deemed as having false-negative results. More recently. the greater the likelihood of injury or the need for surgical intervention. Other studies have shown that sonography may miss injuries that may require surgery. When sonographic results are compared with clinical outcome. Solid organ injury After the initial studies on the use of sonography in detecting organ injuries in the 1970s [1]. McGahan et al / Radiol Clin N Am 42 (2004) 417–425 tients with intra-abdominal injury remained static at 83%. Sensitivity of sonography The sensitivity of sonography depends on what is used as the ‘‘gold’’ standard to which US is compared.000 patients with blunt abdominal trauma: 467 patients had intraabdominal injury. CT should be used for patients with a negative sonography result in whom there is a suggestion of intra-abdominal injury [20.24] and Richards et al [25. The higher the score. If clinical improvement had been used as the ‘‘gold’’ standard. the higher the injury rate and the greater the need for laparotomy. These patients did not require surgical intervention. US examination of the left upper quadrant demonstrates poorly marginated spleen with mixed echo pattern (arrows).10]. When using CT as the ‘‘gold’’ standard.5-MHz convex probe. Shanmuganathan et al [19] studied the use of sonography in more than 11.P. For instance. McGahan et al [4] also reported a sensitivity rate of 41% detection in solid organ injuries. however. more recent studies focused on the detection of free fluid [11 – 13]. acute solid organ injuries are often echogenic on sonography. Stengel et al [22] showed that a 7. A few recent studies have demonstrated the ability of sonography to detect parenchymal organ abnormalities directly. Richards et al [14] demonstrated a sonographic sensitivity rate of 68% for detecting free fluid or solid organ injuries. 4. the sensitivity rates of sonography are high. Miller et al [16] reported a sensitivity rate of 42% for the FAST scan when compared with CT. but rate of surgical intervention was 63%.21]. In this larger study by Shanmuga- nathan et al. This is the main reason for discrepancies in the sensitivities of FAST scan. When identified.5-MHz linear ray probe detected solid organ injuries much more readily than a 3. The probable reason for this discrepancy in sensitivities is that McGahan et al [4] showed that several minor lacerations of the liver or spleen were detected on CT but not detected by FAST. but one must remember that it may miss significant injuries that require further intervention. 10 of whom (33%) required surgery. . Splenic laceration. Polletti et al [17] showed a sensitivity rate of 41% for direct demonstration of organ injury.

to 5-minute interval. sonography also has been shown to be helpful in diagnosing pericardial effusions [29. Excellent enhancement of the parenchymal organs was obtained in all cases using contrast-enhanced sonography. With more experienced examiners. no lesions were confidently visualized. Germany). In 7 patients there was confirmation with CT. They evaluated 14 patients with abdominal trauma who were scanned with unenhanced US and contrast-enhanced sonography. may be observed on real-time sonography and is a normal finding (Fig. Renal injuries are echogenic. The authors believed that the contrast-enhanced sonography might expedite management of trauma patients [27]. More recently. In traumatized patients. which appeared hypoechoic on US. and kidneys were studied over a 3. 7). whereas the visceral pleura adheres to the lung. spleen. and there was good correlation between contrastenhanced sonography and contrast-enhanced CT in terms of the position and size of the abnormality. McGahan et al / Radiol Clin N Am 42 (2004) 417–425 421 pattern identified with splenic injuries (Fig. 5). however. Renal laceration. and the kidney in 4 patients. (A) Longitudinal scan of the right upper quadrant of the abdomen demonstrates ill-defined region without reniform shape.2 to 2. We incorporate the subcostal view of the heart as a portion of the FAST scan in all patients with blunt abdominal trauma. sonography can be used to diagnose pneumothorax or free fluid within the thorax. 6). A discrete hyperechoic or diffuse hyperechoic pattern is seen with hepatic injuries (see Fig. These authors use SonoVue (Bracco/ ALTANA Pharm.32]. The liver. Konstanz. sonography also has been proved to be useful in diagnosing pneumothorax [31. with a disorganized appearance that occurs with severe renal lacerations (Fig. Absence of the sliding lung is a direct sign of pneumothorax (Fig. More recently.4 mL scanned with a low mechanical index. Blavias et al [30] set up a study with emergency medicine residents and fellows trained in sonography. The parietal pleura adheres to the inner muscle of the thorax. For instance. Right nephrectomy was performed immediately after the US examination. which adheres to the lung as it moves and slides during normal inspiration and expiration. the US probe is placed in this area to check for pneumotho- Fig. During inspiration and expiration the visceral pleura ‘‘slides’’ back and forth adjacent to the parietal pleura. Remembering that the free air within the thorax rises to the most nondependent portion of the thoracic cavity. which corresponds to severe renal laceration (shattered kidney) (arrows). a phospholipid coated micro-bubble.P. It must be emphasized that inexperienced examiners often have problems diagnosing pericardial effusions. For instance. 9). 5. This is helpful in diagnosing pericardial effusions (Fig.J. Sonography had a sensitivity rate of 73% and a specificity rate of only 44% in this study [30]. The chest Sonography has been shown to detect pleural effusions [28]. 2). 8). from a true pericardial effusion. at the dose of 1. Martegani et al [27] presented the preliminary evaluation of micro-bubble – enhanced US of abdominal organs in blunt and penetrating trauma. the spleen in 5 patients. They detected injuries in the liver in 5 patients. The main reason for diagnosing pericardial effusions is to prevent patients from having a traumatically induced pericardial tamponade. contrast-enhanced abdominal US has been used in the evaluation of solid organ injuries in trauma patients (Fig. .30] in traumatized patients. The bright echogenic line of the visceral pleura. They demonstrated that on the unenhanced scan. (B) Real-time US examination of the right paracolic gutter demonstrates an echogenic region inferior to the kidney in the right paracolic gutter that corresponds to hematoma (arrow). 4). More recently. sonography may be useful in detecting moderate pericardial effusions. They had trouble discerning the epicardial fat.

a linear array probe may be used to detect pneumothorax. This is the reverberation of the US beam as it strikes the interface between the parietal and visceral pleura and the air in the lung and is reflected back to the transducer. Either a curved array probe or. The reverberation artifact is not identified when there is a pneumothorax. Absence or decrease of the reverberation artifact also may occur in a normal patient if the gain settings are set too low. They studied 27 patients who sustained . which corresponds to pericardial effusion. 8). The US probe is placed in the intercostal space. 7. The normal motion of the visceral pleura against the parietal pleura is absent with pneumothorax. (C) Correlative CT demonstrates splenic laceration. Contrast-enhanced US of splenic laceration. (Courtesy of Thomas Albrecht. This is observed as lines that are equally spaced from one another and gradually decrease in echogenicity. (B) Contrast-enhanced US with SonoVue demonstrates a large. Pericardial effusion. (A) Noncontrast US of the spleen appears normal. a ‘‘reverberation artifact’’ usually is noted posterior to the parietal visceral pleura interface in a normal patient (see Fig. McGahan et al / Radiol Clin N Am 42 (2004) 417–425 Fig. In a normal patient. Berlin. Subcostal real-time US of the heart demonstrates anechoic region (long arrow) anterior to the heart. patient. FRCR. An article by Rowan et al [33] compared the accuracy of sonography with that of the supine chest radiograph in detecting traumatic pneumothorax. with CT serving as the reference or ‘‘gold’’ standard. The normal ‘‘to and fro’’ motion of the visceral pleura against the parietal pleura is observed in a normal Fig. A pneumothorax may produce acoustic shadowing. better yet. 6.P. MD. however. wedge-shaped defect in the central portion of the spleen. Germany.) rax.422 J. This reverberation produces multiple equally spaced echoes.

R refers to the interface between the parietal and visceral pleura. Supine chest radiography had a sensitivity rate of only 36% (4 of 11 patients). US was more sensitive . which are of decreasing echogenicity posterior to this. Note that the first echogenic line (open arrow) corresponds to the interface between the parietal and the visceral pleura. (B) Drawing of reverberation artifact. All of the pneumothoraces were detected by sonography. Lines labeled as numbers 1 and 2.P. correspond to reverberation artifacts caused by the US beam ‘‘reverberating’’ or ‘‘bouncing’’ between the pleura and transducer. McGahan et al / Radiol Clin N Am 42 (2004) 417–425 423 Fig. with a specificity rate of 100%. The US probe is placed on the skin surface (S). The radiographic and US findings were compared with CT findings. and 1 of 16 patients had a false-positive diagnosis of pneumothorax. Parallel equally spaced lines of decreasing echogenicity are observed posterior to this.J. Normal lung. (A) Real-time US examination using linear array probe demonstrates the appearance of the normal lung on US. blunt thoracic trauma and had US. (C) Similar pattern is seen with sector scan of the lung in another patient. Eleven of 27 patients had pneumothoraces as seen with CT. which corresponds to reverberation artifacts (arrows). In their study. 8. The specificity rate of sonography was 94%. for a sensitivity rate of 100%.

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