Sonography in blunt abdominal trauma: a preliminary progress report

Abdominal injuries without hemoperitoneum: a potential limitation of focused abdominal sonography for trauma (FAST)

BACKGROUND

Focused abdominal sonography for trauma (FAST) relies on hemoperitoneum to identify patients with injury. Blunt trauma victims (BTVs) with abdominal injury, but without hemoperitoneum, on admission are at risk for missed injury.

METHODS

Clinical, radiologic, and FAST data were collected prospectively on BTVs over a 12-month period. All patients with FAST-negative for hemoperitoneum were further analyzed. Examination findings and associated injuries were evaluated for association with abdominal lesions.

RESULTS

Of 772 BTVs undergoing FAST, 52 (7%) had abdominal injury. Fifteen of 52 (29%) had no hemoperitoneum by admission computed tomographic scan, and all had FAST interpreted as negative. Four patients with splenic injury underwent laparotomy. Six other patients with splenic injury and five patients with hepatic injury were managed nonoperatively. Clinical risk factors significantly associated with abdominal injury in BTVs without hemoperitoneum include: abrasion, contusion, pain, or tenderness in the lower chest or upper abdomen; pulmonary contusion; lower rib fractures; hemo- or pneumothorax; hematuria; pelvic fracture; and thoracolumbar spine fracture.

CONCLUSIONS

Up to 29% of abdominal injuries may be missed if BTVs are evaluated with admission FAST as the sole diagnostic tool. Consideration of examination findings and associated injuries should reduce the risk of missed abdominal injury in BTVs with negative FAST results.

Prospective study investigating routine usage of ultrasonography as the initial diagnostic modality for the evaluation of children sustaining blunt abdominal trauma

In this prospective study, 217 children sustaining blunt abdominal trauma were initially evaluated with ultrasonography (US) and those with any abnormal ultrasonographic findings were further evaluated with computed tomography. Results of ultrasonographic examination were normal in 157 children and showed abnormalities such as free intraperitoneal fluid (FIF), intra-abdominal organ injury, and intrapleural fluid in 60 children. Computed tomographic examination of the 42 children with organ injury, the seven children with minimal FIF of no definite source, and the three children with intrapleural fluid revealed findings consistent with ultrasonographic findings. Computed tomographic examination of the eight children with more than minimal FIF of no definite source detected by US showed the source as liver injury in one and spleen injuries in two patients. The source of FIF could not be identified with computed tomography in five patients. After clinic follow-up examination, one of these five patients was operated on for abdominal tenderness, fever, and air-fluid levels detected on plain abdominal radiographs, and duodenal perforation was encountered. Clinical courses of the patients with normal ultrasonographic findings were uneventful. We conclude that US, aside from being a screening tool, is alone sufficient in the evaluation of the majority of the children sustaining blunt abdominal trauma. Although this is a preliminary study with further work needed to be done, we propose that further evaluation with computed tomography should be performed on those children in whom more than minimal FIF of no definite source is detected with US.

Use of abdominal ultrasonography to assess pediatric splenic trauma. Potential pitfalls in the diagnosis

OBJECTIVE

The purpose of this study was to evaluate the accuracy of abdominal ultrasonography (US) for screening and grading pediatric splenic injury.

SUMMARY BACKGROUND DATA

The use of abdominal US has increased rapidly as a method of evaluating organ damage after blunt abdominal trauma. Despite US's increasing use, little is known about its accuracy in children with splenic injury.

METHODS

Children (N = 32) suffering blunt abdominal trauma who were diagnosed with splenic injury by computerized tomography (CT) scan prospectively were enlisted in this study. Degree of splenic injury was evaluated by both CT and US. The ultrasounds were evaluated by an initial reading as well as by a radiologist who was blinded as to the results of the CT.

RESULTS

Twelve (38%) of the 32 splenic injuries found on CT were missed completely on the initial reading of the US. When the ultrasounds were graded in a blinded fashion, 10 (31%) of the splenic lacerations were missed and 17 (53%) were downgraded. Seven (22%) of the 32 splenic fractures were not associated with any free intraperitoneal fluid on the CT scan.

CONCLUSIONS

This study has shown that US has a low level of sensitivity (62% to 78%) in detecting splenic injury and downgrades the degree of injury in the majority of cases. Reliance on free intraperitoneal fluid may be inaccurate because not all patients with splenic injury have free intra-abdominal fluid. Based on these findings, US may be of limited use in the initial assessment, management, and follow-up of pediatric splenic trauma.

Trauma ultrasound examination versus chest radiography in the detection of hemothorax

STUDY OBJECTIVE

To compare the sensitivity, specificity, and accuracy of ultrasonography with those of the initial plain chest radiograph for detection of hemothorax in trauma patients.

METHODS

Data from a prior prospective study of trauma ultrasonography at a Level I trauma center were retrospectively analyzed. The medical records of a convenience sample of adult patients who presented with major blunt or penetrating torso trauma during a 17-month period were reviewed. Emergency physicians performed a trauma ultrasound examination, which included evaluation for pleural fluid. Ultrasound interpretations were recorded before other diagnostic tests were obtained and were not used in patient management decisions. Records of the study patients were reviewed for confirmation of the presence or absence of hemothorax by other diagnostic and therapeutic interventions. The chest radiograph and computed tomography (CT) scan interpretations were performed by attending radiologists who were not blinded to patient outcome.

RESULTS

Five of the 245 patients enrolled in the study were excluded because tube thoracostomy was performed before the ultrasound examination was done. Altogether, 26 of the 240 study patients had hemothorax, as confirmed by tube thoracostomy or CT. Both ultrasound examination and the initial chest radiograph resulted in 0 false-positive, 1 false-negative, 25 true-positive, and 214 true-negative findings. Overall, both modailties were 96.2% sensitive, 100% specific, and 99.6% accurate.

CONCLUSION

Ultrasonography is comparable to the initial chest radiograph for accuracy in detection of hemothorax and may expedite the diagnosis and treatment of this condition for patients with major trauma.

Ultrasound in the evaluation and management of blunt abdominal trauma

Failure to detect intraabdominal injury in the patient with blunt trauma may result in significant morbidity and mortality. The diagnosis of abdominal injury remains a clinical challenge. Presented here is a review of recent literature comparing ultrasound with diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma.

Ultrasound evaluation of blunt abdominal trauma: program implementation, initial experience, and learning curve

OBJECTIVE

Although sonographic screening for blunt abdominal trauma is gaining acceptance, standards for implementation, training, credentialing, and quality control remain to be established.

DESIGN

This prospective study examines a Level I trauma service experience with the de novo establishment of a trauma ultrasound (US) program credentialed through the Department of Surgery under the auspices of Continuous Quality Improvement.

MATERIALS AND METHODS

All trauma surgeons attended a combined didactic and "hands on" 8-hour trauma US course. Abdominal sonography was subsequently performed on patients with potential blunt abdominal trauma followed by a standard diagnostic evaluation, which included computed tomographic scan, diagnostic peritoneal lavage, or observation.

MEASUREMENTS AND MAIN RESULTS

Three hundred patients were studied over a 4-month period. They averaged 35 years of age with an average injury severity score of 12. The time required to perform the US examination averaged less than 3 minutes. Standard diagnostic evaluation included computed tomographic scan (21%), diagnostic peritoneal lavage (45%), and observation (34%). US examinations resulted in 277 true negatives, 17 true positives, two false positives, and four false negatives for a sensitivity of 81.0%, a specificity of 99.3%, and an accuracy of 98.0%. Annualized cost savings with the use of US evaluation versus standard diagnostic evaluation would amount to over $100,000.00.

CONCLUSIONS

This experience with the de novo implementation of a trauma US program suggests that the training and credentialing requirements in this study are sufficient to provide surgeon ultrasonographers with acceptable competence in US diagnosis of blunt abdominal trauma.

Emergency department ultrasound services by emergency physicians: model for gaining hospital approval

We anticipate that over the next few years, emergency physician use of emergency department ultrasound will become the standard of care. However, many EDs are hampered in their efforts to gain hospital approval for emergency physician use of ultrasound because of the lack of publicized information regarding the goals of such use, the scope of emergency physician ultrasound privileges, emergency physician ultrasound credentialing criteria, and ED ultrasound quality-improvement plans. In this article we address these issues and provide an example of a proposal used successfully to gain hospital approval for ED use of ultrasound by emergency physicians.

Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage

OBJECTIVE

Trauma victims with hypotension require a rapid and reliable localization of bleeding and expedient surgical triage. Our hypothesis is that emergent abdominal sonography (EAS) is a rapid and accurate test of the need for urgent laparotomy in blunt trauma victims with hypotension.

METHODS

Among 400 blunt trauma victims entered in a prospective blind study of EAS, a subgroup of 69 (17%) patients had a systolic blood pressure < or = 90 mm Hg during their initial assessment. Although the EAS results [(+) = fluid, (-) = no fluid] were not used in clinical decision making, the potential contribution of EAS to patient care was examined.

RESULTS

The mean Injury Severity Score was 32. Twenty-two (32%) patients were EAS (+), of which 19 required an acute laparotomy. No laparotomies were performed in the 47 EAS (-) patients. The EASs required 19 +/- 5 seconds in the EAS (+) group and 154 +/- 13 seconds in the EAS (-) group. Twenty of the 22 positive EASs had free fluid in Morison's pouch. All 13 patients with an ultrasound score > or = 3 had a laparotomy. The primary etiology of hypotension was blood loss in 42 patients, hemoperitoneum in 18, and retroperitoneal hemorrhage in 12.

CONCLUSION

EAS is a rapid and accurate indicator of the need for urgent laparotomy in the hypotensive blunt trauma victim. Further, a negative EAS can hasten the search for other causes of hypotension. Diagnostic peritoneal lavage may become obsolete in centers with EAS capabilities.

Radiographic imaging modalities for the patient in the emergency department with abdominal complaints

The emergency physician should be aware of the sensitivity and specificity of any radiologic study being considered. Radiographic examinations should be used to answer specific questions raised by the history and physical examination. The need to obtain a given radiologic evaluation should be based on the potential information it may reveal and the likelihood that this information will alter patient care. This cost-effective approach minimizes unnecessary radiation exposure and has been advocated by many authorities. The emergency physician should resist the "knee jerk" tendency to order radiographs to reassure himself or herself of the safety of the patient at discharge. Documentational and legal concerns are equally invalid reasons, as is the feeling that "it's what we always order for patients with this abdominal complaint." A given study may be indicated if the yield is acceptable and treatment of the patient may be altered by the results.

Emergency physician use of ultrasonography in blunt abdominal trauma

OBJECTIVE

To evaluate the diagnostic utility of abdominal diagnostic ultrasonography (DUS) performed by emergency physicians for intraperitoneal fluid caused by blunt abdominal trauma (BAT).

METHODS

The design was a prospective, blind, observational study. During a 15-month period, a convenience sample of patients presenting to the ED with BAT necessitating CT scan of the abdomen, diagnostic peritoneal lavage (DPL), or laparotomy was studied. Scans were performed by an emergency medicine (EM) attending, or a resident supervised by an attending, using a real-time sector ultrasound scanner with a 3.5-MHz probe. Training in DUS included a 1-hour didactic session and 1 hour of practice on human volunteers. Free intraperitoneal fluid was defined as an anechoic stripe in the hepatorenal, bladder-rectal, or splenorenal space, and constituted a positive DUS study. Free intraperitoneal fluid detected on abdominal CT scan, DPL, and/or laparotomy was the criterion standard.

RESULTS

Of 110 patients scanned, 13 were excluded secondary to technical difficulty or lack of diagnostic follow-up modalities. Of the remaining 97 patients, there were 24 females and 73 males, ranging from ages 2 to 78 years. DUS detected intraperitoneal fluid in 21 subjects, including 3 false positives. There were 6 false-negative DUS examinations. DUS had a sensitivity of 75% (95% CI 53-90%), a specificity 96% of (95% CI 89-99%), and an accuracy of 91% (95% CI 83-96%). No false-positive or false-negative DUS study occurred after the first 67 cases. The mean interval for a DUS scan was 4.9 +/- 2.9 minutes, ranging from 0.5 to 16 minutes, and the mean intervals were not different between the positive and the negative studies. The accuracies of DUS were similar in the pediatric patients, 97% (95% CI 83-100%), and in the adults, 88% (95% CI 78-95%). The hepatorenal view provided the highest sensitivity as well as the least number of uninterpretable scans of the 3 DUS views.

CONCLUSION

Emergency physicians with minimal training can use DUS with fair sensitivity and good specificity and accuracy to detect free intraperitoneal fluid in both pediatric and adult BAT victims. The hepatorenal view provides the highest sensitivity for intraperitoneal fluid, although the 3-view series (with hepatorenal, bladder-rectal, and splenorenal spaces) can typically be performed within 5 minutes and may increase the specificity and accuracy.

Ultrasound training during ATLS: an early start for surgical interns

OBJECTIVES

Determine if: (1) surgical interns could learn essential ultrasound principles of the focused assessment for the sonographic examination of the trauma patient (FAST) during Advanced Trauma Life Support (ATLS), and (2) swine are adequate models for learning the FAST.

DESIGN

Lecture, videotape, pre/posttests, and practical examination.

METHODOLOGY

Day 1: Survey, pretest, lecture, and videotape. Day 2: Three swine, used in ATLS, had diagnostic peritoneal lavage catheters reinserted to infuse fluid and produce "positive" ultrasound examinations. Two fresh swine were "negatives"; however, all five swine were draped similarly to disguise interventions. Interns were tested individually by surgeon-sonographers to determine whether the ultrasound image was "positive" or "negative." Posttests were completed while surgeons performed postmortem examinations on two swine.

STATISTICS

Paired Student's t test and Wilcoxon Rank Sum test.

RESULTS

Survey (5 min): 48% had exposure to ultrasound. Relationship of test scores showed no significant difference (p = 0.46 to 0.91) between interns with and without ultrasound experience. Tests (30 min): Mean pre- and posttests scores = 65.6 and 90.8, respectively (p < 0.001). Practical examination (140 min): Mean score = 89.6. Postmortem examinations: Left hepatic lobe partially obscured the spleen.

CONCLUSIONS

(1) Surgical interns can learn essential ultrasound principles of the FAST during ATLS (2) Swine are feasible models for learning the FAST.

Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma

Although there is an interest in emergent abdominal sonography (EAS), the clinical utilization of EAS in North America is minimal. The purpose of this study was to develop a new diagnostic algorithm for blunt abdominal injury based on a prospective blinded comparison of EAS, diagnostic peritoneal lavage (DPL), and computed tomography (CT). EAS (+ = fluid, - = no fluid) was performed before the DPL or CT, in 400 patients with a mean Injury Severity Score of 26; 293 had a CT and 107 had a DPL. The EASs required 2.6 +/- 1.2 minutes with 82% < or = 3 minutes. The accuracy of EAS for free fluid was 94% with a positive and negative predictive value of 82 and 96%, respectively. Only 1 of 338 patients with EAS- had an acute therapeutic laparotomy. Three patients with EAS- had a delayed laparotomy based on evolving clinical findings. The radiologists interpretation of the EAS video disagreed with the clinician sonographer in only 3% of cases. Based on these results, a diagnostic algorithm was developed using EAS as a screening test with selective use of DPL and CT. Emergent abdominal sonography performed by clinician sonographers is a rapid and accurate test for peritoneal fluid in blunt trauma victims, and the need for laparotomy in patients with a negative EAS is rare. Our study supports the routine use of EAS as a screening test in a diagnostic algorithm for the evaluation of blunt abdominal trauma.

A prospective evaluation of abdominal ultrasound in blunt trauma: is it useful?

OBJECTIVE

The purpose of this study is to evaluate the utility and feasibility of abdominal ultrasound (US) in blunt trauma patients.

DESIGN

This prospective study examined the operational issues and the diagnostic accuracy of US in selected blunt trauma patients triaged to a Level 1 trauma center.

MATERIALS AND METHODS

All patients were evaluated by an attending trauma surgeon and our usual criteria for objective evaluation of the abdomen were applied. US was performed by US technicians and interpreted by the trauma surgeon. We prospectively evaluated the availability (time to arrival), the ease with which the US could be integrated into the resuscitation (minutes to start after arrival), and the time required to perform the study. The US results were compared to diagnostic peritoneal lavage and computed tomography findings, clinical course, operative findings, and to repeat US examinations to determine sensitivity, specificity, and usefulness.

MEASUREMENTS AND MAIN RESULTS

A total of 800 US studies were performed over 15 months. In four cases (0.5%), the US was incomplete for technical reasons. The results in the remaining 796 studies were as follows: [table: see text] The average time to arrival of the US was 17.3 minutes (range 0-120) and the average minutes to start after arrival was 7.0 (range 1-49). The average time required to perform the study was 10.6 minutes (range 2-26).

CONCLUSIONS

This study demonstrates that US can be obtained rapidly, integrated into the resuscitation, and completed quickly. US provides a highly accurate, noninvasive method to evaluate the abdomen in the blunt trauma patient, and has supplanted the previously used methods at this institution.

Can ultrasonography replace computed tomography in the initial assessment of children with blunt abdominal trauma?

The evaluation of injured children with suspected blunt abdominal trauma (BAT) is clinically challenging. Computed tomography (CT) requires that patients be sedated, stable, and transportable, and even so, it is considered the diagnostic modality of choice for children with BAT. The authors questioned whether abdominal ultrasonography (US) performed during the initial assessment of the injured child is accurate enough to replace CT in the detection of intraabdominal injury. One hundred twenty-four children with BAT aged 2 to 14 years; (average, 8.3) were admitted to the authors' institution during 1992 and 1993. Some had associated injuries (head, 60; chest, 25; extremities, 15; pelvis, 5). The indications for US were pelvic, abdominal, or lower chest trauma, tenderness, or guarding; altered consciousness; microhematuria; and/or low hemoglobin/hematocrit values. Three patients underwent abdominal CT at the time of admission. For 121 children, an emergency US examination was performed using a 3.5-MHz transducer and a portable machine. The examination evaluated the kidneys, liver, and spleen for parenchymal injuries, and the subhepatic, subphrenic, and paracolic spaces and the pelvis for evidence of free peritoneal fluid. The presence of fluid and/or parenchymal injury was interpreted as a positive US result. Twenty-eight patients had positive US findings. Ten of these had a subsequent positive CT result, eight had a normal CT result, and 10 had a negative second US result. Eleven patients (with a total of 17 visceral injuries) were treated conservatively. One patient underwent emergency surgery for liver and caval injuries. Four patients required blood transfusions. Ninety-three of the 121(78%) had a negative US result. For one of these patients, a subsequent CT scan showed a minor subcapsular splenic hematoma, which resolved spontaneously. The authors conclude that US is sensitive in detecting free peritoneal fluid or visceral injuries and is an effective screening modality. It has replaced abdominal CT in 76% of our patients with suspected BAT. In view of the reliability, simplicity, low cost, and bedside availability of US, the authors suggest that this modality be used in the initial assessment and diagnosis of children with suspected intraabdominal injury from blunt trauma.

1,000 consecutive ultrasounds for blunt abdominal trauma

Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities used in the evaluation of patients with suspected blunt abdominal trauma (BAT). DPL is fast and accurate but is associated with complications. CT is also accurate, yet requires stability and transportability of the patients. Ultrasound (US) has been suggested as an aid in evaluating BAT. We evaluated US in the initial assessment of BAT in 1000 patients. Patients were eligible for the study if they met specified trauma criteria and had suspected BAT. We then followed the outcome of the patients and their further work-up. US showed a sensitivity of 88%, a specificity of 99%, and an accuracy of 97% for detecting intraabdominal injuries. We conclude that emergency ultrasound may be used as the initial diagnostic modality for suspected blunt abdominal trauma.

Ultrasonography for the initial evaluation of blunt abdominal trauma: A review of prospective trials

Many trauma centers are considering the addition of diagnostic ultrasonography to their trauma protocols. However, a diagnostic imaging application should not be used in general clinical practice until its efficacy has been demonstrated. A literature search was conducted for prospective trials on the use of ultrasound in evaluation of blunt abdominal trauma. Each study was evaluated with the use of an efficacy assessment model. Within this framework, clinical outcomes were classified according to the following efficacy assessment parameters: technical capacity, diagnostic accuracy, diagnostic effect, therapeutic effect, and patient outcome. This model also provided a systematic process for grading the quality of research methods used to obtain each outcome. Eleven trials were found that fulfilled the study criteria, and all of them concluded that ultrasound was valuable for assessment of blunt intraperitoneal trauma. Frequent methodologic flaws were detected in these studies. None of these trials determined therapeutic effect or patient outcome. The criteria for clinical efficacy were not fulfilled. Additional trials should be conducted before ultrasound is accepted as a standard diagnostic test for the evaluation of blunt abdominal trauma.

Blunt abdominal injuries. Diagnostic peritoneal lavage, ultrasonography and computed tomography scanning

The diagnosis of blunt abdominal injuries is one of the most difficult problems in the management of trauma. There is now better understanding of the diagnostic facilities available. Guidelines regarding the use of diagnostic peritoneal lavage, ultrasonography, or computed tomography scanning should be available in the Accident and Emergency department.

Blunt abdominal trauma

Assessment and management of patients with blunt abdominal trauma remains a challenge for emergency physicians. The spectrum of injury ranges from the trivial to the catastrophic and the initial assessment, resuscitation, and investigation of patients with abdominal trauma must be individualized. This article covers the important aspects of patient history and physical examination and addresses the relevant investigative tools available. An approach to the assessment of patients with abdominal trauma is provided; the goal is to diagnose significant injuries as soon as possible and avoid the pitfall of a delayed or missed diagnosis.

Acute blood loss

Acute blood loss is a common, but often challenging, problem facing emergency physicians. Inadequate or delay in treatment can lead to morbidity or mortality. Standard classifications to quantify blood loss, as well as vital signs alone, are inadequate for guiding therapy. Mechanism of injury, base deficit and blood lactate, central venous oxygen saturation, and oxygen transport parameters should all play a role in deciding the need for further diagnostic studies and resuscitation. Extreme care must be taken to evaluate and resuscitate those with decreased physiologic reserve adequately, such as the elderly. Once bleeding has been identified, expeditious control of bleeding should be accomplished, either operatively or angiographically. Care must be individualized, but adherence to these general guidelines will improve outcome.

Posttraumatic peritoneal fluid: is it a reliable indicator of intraabdominal injury in children?

Clinical data and computed tomographic (CT) scans for 1,486 children evaluated after blunt abdominal trauma were reviewed to determine whether peritoneal fluid is a reliable indicator of the presence and severity of associated intraabdominal injury and the need for laparotomy. The CT scans were assessed for presence, location, and severity of intraabdominal injury, and amount of peritoneal fluid. Type of management (surgical or nonsurgical), indications for surgical management, overall hospital course, and clinical outcome were recorded at the time of discharge. Of the 326 children with abdominal injuries detected by CT, 121 (37%) had no associated peritoneal fluid collections. Eighteen (15%) of these children had injury to more than one abdominal organ. Splenic injuries by CT criteria were more severe in children with associated peritoneal fluid than in those with no associated fluid (P < .003). There were no significant differences in CT grading of liver and renal injuries among those with and without associated peritoneal fluid (P > .67). Two hundred fifty-nine (17%) of the 1,486 children had peritoneal fluid demonstrated by CT. Eighty percent of these children had concomitant intraabdominal injury. Associated injuries included solid organ injuries (in 68% of patients) hollow viscus or mesenteric injury (11%), isolated pelvic fracture (4%), and hypoperfusion syndrome (5%). Thirty-one patients (12%) had injury to more than one abdominal organ. Only 27 (11%) patients had small "unexplained" collections of peritoneal fluid in which no associated injury was detected through CT or clinical follow-up. The authors conclude that (1) solid organ injury is frequently present in the absence of peritoneal fluid, and (2) the identification of peritoneal fluid after blunt trauma should lead one to suspect that a specific intraabdominal injury is the cause of the fluid.

A prospective study of emergent abdominal sonography after blunt trauma

In North America, the role of emergent abdominal sonography [ultrasonography (US)] after blunt trauma requires further definition. The purpose of this prospective study was to compare US to the gold standards, diagnostic peritoneal lavage (DPL), and computed tomography (CT), in a population of adults after blunt trauma. In 206 adults who required either CT or DPL to assess possible abdominal injury, US was performed, before DPL or CT, and was aimed at the detection of intraperitoneal fluid. The mean Injury Severity Score and Glasgow Coma Scale score were 24.0 and 11.9, respectively. One hundred thirty-seven patients (67%) had CT and 69 (33%) had DPL. The positive and negative predictive values of US for intraperitoneal fluid were 90% and 97%, respectively. The sensitivity, specificity, and accuracy of US for free fluid were 81%, 98%, and 96%, respectively. Of the six false-negative USs, only one required surgery. The US examinations required 2.6 +/- 1.4 min. Emergent abdominal sonography is an accurate, rapid test for the presence of intraperitoneal fluid in adult blunt trauma victims and in these patients may prove valuable as a screening test for abdominal injury.

Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid

The minimum volume of intraperitoneal fluid that is detectable in Morison's pouch with ultrasound in the trauma setting is not well defined. To evaluate this question, we used diagnostic peritoneal lavage (DPL) as a model for intraperitoneal hemorrhage and undertook a blinded prospective study of the sensitivity of ultrasound in detecting intraperitoneal fluid. Participants included attending physicians and residents in emergency medicine, radiology, and surgery. During the infusion of the DPL fluid, participants continuously scanned Morison's pouch until they detected fluid. All participants were blinded to the rate of infusion and the volume infused. One hundred patients were entered into the study. The mean volume of fluid detected was 619 mL. Only 10% of participants detected fluid volumes less than 400 mL and the overall sensitivity at one liter was 97%. We conclude that reliable detection of intraperitoneal fluid in Morison's pouch requires a greater volume than has been previously described.

Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians

The objective of this prospective study was to determine the sensitivity, specificity, and accuracy of the rapid trauma ultrasound examination, performed by emergency physicians, for detecting free peritoneal and thoracic fluid in patients presenting to a level I trauma center with major blunt or penetrating torso trauma. Emergency medicine residents and faculty were trained to perform an ultrasound examination of the torso evaluating for free intraperitoneal, retroperitoneal, pleural, and pericardial fluid. In the 245 study patients, emergency physicians examined 975 intracavitary spaces and demonstrated 64 positive findings for free fluid as documented by computed tomography scan, diagnostic peritoneal lavage, exploratory laparotomy, chest radiography, tube thoracostomy, or formal two-dimensional echocardiography. The rapid trauma ultrasound examination was 90% sensitive, 99% specific, and 99% accurate. Ultrasonography can serve as an accurate diagnostic adjunct in detecting free peritoneal and thoracic fluid in trauma patients. Appropriately trained emergency physicians can accurately perform and interpret these trauma ultrasound examinations.

Abdominal ultrasonography in trauma

The use of ultrasonography for the investigation of urgent diagnostic dilemmas is by no means new. Although it has been widely used for almost 40 years, during the past two decades ultrasonography has achieved a primary role in Europe and Asia in the investigation of emergent conditions such as trauma. The use of this bedside diagnostic modality is expanding rapidly and will continue to do so. Emergency physicians have developed a fellowship program in emergency ultrasonography, have set forth a model curriculum for physician training in emergency ultrasonography, and have begun to conduct hands-on courses for academic emergency physicians. Because diagnostic ultrasonography has proven to be of value in the diagnosis and management of a variety of emergent conditions, ultrasound examination, interpretation, and clinical correlation should be immediately available around the clock in resuscitation areas. It is hoped that (1) ultrasound training will be incorporated into general surgical residency programs, (2) ultrasound curriculum and credentialing processes will be established, and (3) more surgeons will have this modality available to them as part of their diagnostic armamentarium in the evaluation of injured patients.

Isolated blunt rupture of the infrarenal inferior vena cava: the role of ultrasound and computed tomography in an occult injury

A case of isolated blunt rupture to the infrarenal vena cava secondary to assault is reported. This case report is presented to heighten awareness of an unusual presentation of this potentially lethal injury and to emphasize that diagnostic modalities may offer subtle or indirect indications of an injury that, when coupled with clinical signs and symptoms, prompt surgical intervention necessary for patient salvage.

Current concepts in splenic trauma

Despite its protected location inside the rib cage, the spleen remains the most commonly injured organ after blunt abdominal trauma. The clinical decision-making process of splenic injury management continues to evolve due to improvements in surgical technique and noninvasive assessment. Splenic preservation techniques and splenic injury grading systems using computerized tomography were developed due to an increased understanding of the spleen's importance in the body's immunological defense system and awareness of the spleen's resiliency after injury. The concept of splenic salvage using splenorrhaphy and nonoperative management was initially applied to the pediatric population during the 1970s, with great success. Application of splenic salvage to hemodynamically stable adult patients with known or unknown splenic injury has demonstrated that adults can be less predictable in their clinical course. Despite the rigorous attention splenic trauma has received, it remains a controversial subject in the surgical and the radiological literature.

Commentary: sonography in the evaluation of children following blunt trauma: is it to be or not to be?

Over the past decade CT scanning has become generally accepted in North America as the diagnostic modality of choice for the evaluation of abdominal injury in children following blunt trauma [1-5]. Recently, there has been increasing interest in the use of sonography as the primary screening examination in this area. Initial studies utilizing sonography in the evaluation of trauma patients focused primarily on identifying hemoperitoneum in adults [6-8]. More recent studies have also attempted to evaluate the accuracy of sonography for the diagnosis of solid viscus injury [9-14]. Filiatraut and colleagues recently reported a long and successful experience using sonography for the investigation of blunt abdominal trauma in children [12]. Their work in this area should be applauded. However, whether widespread application of this modality can be successful remains uncertain. In the space below a critical evaluation of sonography and CT in the assessment of injured children is presented.

Urgent laparotomy versus emergency craniotomy for multiple trauma with head injury patients

In blunt multiple trauma (MT) with head injury (HI) patients, it is difficult to decide whether to proceed with immediate laparotomy or craniotomy. In August 1989, abdominal ultrasonography (US) using a simple US scoring system was introduced for MT and HI patients as an initial rapid screening procedure. In MT and HI patients with a US score > or = 3 (n = 14), urgent laparotomy was the procedure of first choice. However, immediate head CT scan, then emergency craniotomy, may be justified in hemodynamically stable MT and HI patients with a US score < 3 (n = 98). Appropriate decision making can be applied to decide which procedure is most exigent.

Emergency department ultrasound in the evaluation of blunt abdominal trauma

The main objective of this study was to compare bedside sonographic detection of hemoperitoneum with diagnostic peritoneal lavage/laparotomy in the patient with blunt abdominal trauma. A retrospective review was conducted of all blunt trauma patients that underwent emergency department (bedside) sonography to rule out intraperitoneal hemorrhage at a level I trauma center in 1991 to 1992. Patients were included in the study population only if: (1) the results of the ultrasound examination were interpreted before any other diagnostic studies, and (2) a diagnostic peritoneal lavage (DPL) or laparotomy was performed. The ultrasound examination consisted of a single right inter/subcostal longitudinal view with the patient in the trendelenburg position performed by the emergency physician or surgeon. A real-time sector scanner with a 3.5 MHz probe was used. The presence of an anechoic (black) stripe between the liver and the right kidney (Morrison's pouch) was interpreted as a positive study, and the absence of this finding was interpreted as a negative study. A positive DPL was defined as > or = 10 mL of gross blood or a blood cell count > or = 100,000/mm3 in the returned lavage fluid, and a positive laparotomy as > or = 100 mL of intraperitoneal blood. Forty-four patients met the inclusion criteria for the study. Eleven patients (24%) in this population had either a positive DPL or laparotomy. The sensitivity, specificity, and accuracy of bedside sonography in identifying intraperitoneal hemorrhage was 81.8%, 93.9%, and 90.9%, respectively. The ultrasound study provided an answer in less than 1 minute in most patients.(ABSTRACT TRUNCATED AT 250 WORDS)