Prospective evaluation of handheld ultrasound in the diagnosis of blunt abdominal trauma

Point-of-care ultrasound with pocket-size devices in emergency department

Point-of-care ultrasound is a useful tool for clinicians in the management of patients. Particularly in emergency department, the role of point-of-care ultrasound is strongly increasing due to the need for a rapid assessment of critically ill patients and to speed up the diagnostic process. Hand-carried ultrasound devices are particularly useful in emergency setting and allow rapid assessment of patient even in prehospital setting. This article will review the role of point-of-care ultrasonography, performed with pocket-size devices, in the management of patients presenting with acute onset of undifferentiating dyspnea, chest pain, and shock in emergency department.

Is E-FAST possible and useful on the battlefield? A feasibility study during medical courses in hostile environment (MEDICHOS): preliminary results

Introduction

The extent of the French forces’ territory in the Sahel band generates long medical evacuations. In case of many victims, to respect the golden hour rule, first-line sorting is essential. Through simulation situations, the aim of our study was to assess whether the use of ultrasound was useful to military doctors.

Methods

In combat-like exercise conditions, we provided trainees with a pocket-size ultrasound. Every patient for whom the trainees chose to perform ultrasound in role 1 was included. An extended focused assessment with sonography for trauma (E-FAST) was performed with six basic sonographic views. We evaluated whether these reference views were obtained or not. Once obtained by the trainees, pathological views corresponding to the scenario were shown to assess whether the trainees modified their therapeutic management strategy and their priorities.

Results

168 patients were treated by 15 different trainee doctors. Of these 168 patients, ultrasound (E-FAST or point-of-care ultrasound) was performed on 44 (26%) of them. In 51% (n=20/39) of the situations, the practitioners considered that the realisation of ultrasound had a significant impact in terms of therapeutic and evacuation priorities. More specifically, it changed therapeutic decisions in 67% of time (n=26/39) and evacuation priorities in 72% of time (n=28/39).

Conclusion

This original work showed that ultrasound on the battlefield was possible and useful. To confirm these results, ultrasound needs to be democratised and assessed in a real operational environment.

Emergency physicians’ attitudes to implementing ultrasound in Dutch emergency departments after a 2-day training: A qualitative study

Background:

Diagnostic ultrasound is increasingly used by nonradiologists in trauma victims and critically ill patients. In the emergency department, the extended focused assessment with sonography for trauma and Polytrauma Rapid Echo-evaluation Program protocol are often used to assess these patients. Dutch Polytrauma Rapid Echo-evaluation Program-trained Emergency physicians are implementing the use of ultrasound in the emergency department but might encounter barriers to overcome.

Objectives:

This study aims to explore individual experiences of Dutch emergency physicians.

Methods:

We performed a qualitative study by conducting semi-structured interviews in Dutch emergency physicians working in a Level 2 emergency department that completed the 2-day Polytrauma Rapid Echo-evaluation Program course at least 1 year before the interviews. Data were analyzed using directed content analysis.

Results:

Eight emergency physicians employed by eight different hospitals were interviewed. Thirteen categories were identified in the transcribed interviews and these were combined into four general themes: (1) the desire to develop the Emergency Medicine specialty, both nationally and local; (2) incentives to start using ultrasound; (3) exploring practical applications of ultrasound; and (4) barriers faced while implementing emergency physician-performed ultrasound on the emergency department. The interviewees regard the course to be a solid base and are eager to independently perform ultrasound examinations, although challenges are faced.

Conclusion:

This exploratory study provides essential insight in Dutch emergency physicians implementing ultrasound in their emergency department. It shows that there is a need to develop a quality assurance system and it identified barriers that have to be dealt with.

FAST in the deployed military setting

INTRODUCTION

Focused assessment with sonography in trauma (FAST) is historically an effective method of assessing the patient in the trauma bay in order to aid decision-making and optimise patient outcomes. However, in the UK civilian practice, the use of FAST may decline given a recent change in National Institute for Health and Care Excellence guidance as a result of improvement in CT availability and resuscitation techniques.

METHOD

In the Role 3 Medical Treatment Facility, Camp Bastion, 187 patients with trauma who received FAST in the trauma bay in 2014 were reviewed to determine the accuracy of FAST in the deployed environment.

RESULTS

The data demonstrates the sensitivity and specificity of FAST to be 75% and 99.3%, respectively.

CONCLUSIONS

This study demonstrates that FAST is accurate on operations. FAST is provided by the integrated radiologist as part of damage control radiology, which gives the team leader rapid diagnostic information to improve decision-making and ultimately patient outcomes. CT is heavily utilised in civilian practice; however, the military operates in a different environment often with multiple casualties and limited access to CT, as a result, portable ultrasound will continue to be a valuable tool on operations if used properly. The next challenge is to develop and maintain this high diagnostic accuracy in future deployments where the memories of our prior success may fade.

Out of hospital point of care ultrasound: current use models and future directions

INTRODUCTION

Ultrasound has evolved from a modality that was once exclusively reserved to certain specialities of its current state, in which its portability and durability lend to its broadly increasing applications.

OBJECTIVES

This review describes portable ultrasound in the hospital setting and its comparison to gold standard imaging modalities. Also, this review summarizes current literature describing portable ultrasound use in prehospital, austere and remote environments, highlighting successes and barriers to use in these environments.

DISCUSSION

Prehospital ultrasound has the ability to increase diagnostic ability and allow for therapeutic intervention in the field. In austere environments, ultrasound may be the only available imaging modality and thus can guide diagnosis, therapeutics and determine which patients may need emergent transfer to a healthcare facility. The most cutting edge applications of portable ultrasound employ telemedicine to obtain and transmit ultrasound images. This technology and ability to transmit images via satellite and cellular transmission can allow for even novice users to obtain interpretable images in austere environments. Portable ultrasound uses have steadily grown and will continue to do so with the introduction of more portable and durable technologies. As applications continue to grow, certain technologic considerations and future directions are explored.

Wireless image streaming in mobile ultrasound

This work evaluates the feasibility of using 802.11 g ad hoc and 3G cellular broadband networks to wirelessly stream ultrasound video in real-time. Telemedicine ultrasound applications in events such as disaster relief and first-response triage can incorporate these technologies, enabling onsite medical personnel to receive assistance with diagnostic decisions by remote medical experts. The H.264 scalable video codec was used to encode echocardiographic video streams at various image resolutions (video graphics array [VGA] and quarter video graphics array [QVGA]) and frame rates (10, 15, 20, and 30 frames/s). The video stream was transmitted using 802.11 g and 3G cellular technologies, and pertinent transmission parameters such as data rate, packet loss, delay jitter, and latency were measured. 802.11 g permits high frame rate and VGA resolution and has low latency and jitter, but it is suitable only for short communication ranges, whereas the 3G cellular network allows medium to low frame rate streaming at QVGA image resolution with medium latency. However, video streaming can take place from any location with 3G service to any other site with Internet connectivity. The transmitted ultrasound video streams were subsequently recorded and evaluated by physicians with expertise in medical ultrasonography who evaluated the diagnostic value of the received video streams relative to the original videos. They expressed the opinion that image quality in the case of both 802.11 g and 3G was fully to adequately preserved, but missed frames could momentarily decrease the diagnostic value. This research demonstrates that 3G and 802.11 g wireless networks combined with efficient video compression make diagnostically valuable wireless streaming of ultrasound video feasible.

Prehospital and Emergency Department Ultrasound in Blunt Abdominal Trauma

Blunt abdominal trauma is a challenging aspect of trauma management. Early detection has a major impact on patient outcome. In contrast to physical examination, computed tomography is known to be a sensitive and specific test for blunt abdominal injuries. However, it is time-consuming and thus contraindicated in hemodynamically unstable patients. Therefore, focused assessment with sonography for trauma (FAST) offers a fast and easily applicable screening method to identify patients for urgent laparotomy without any further diagnostics. FAST detects, with high sensitivity, intraperitoneal fluid that accumulates in dependent areas indicating blunt abdominal trauma. FAST has been established as a gold standard early screening method for blunt abdominal trauma when performing trauma management in the emergency department (ED) based on the Advanced Trauma Life Support(®) algorithm. The development of hand-held ultrasound devices facilitated the introduction of FAST into prehospital trauma management. It was demonstrated that prehospital FAST (p-FAST) can be performed with high sensitivity and specificity, and can lead to significant changes in prehospital trauma therapy and management. Standardized training with both theoretical and hands-on modules is mandatory in order to gain the skills required to perform FAST or p-FAST well.

FAST ultrasound as an adjunct to triage using the START mass casualty triage system: a preliminary descriptive system

OBJECTIVE

To determine whether the FAST examination might be a useful adjunct to simple triage and rapid treatment (START) in the secondary triage of mass-casualty victims already classified as delayed (Yellow).

METHODS

A retrospective chart review was conducted of all adult trauma patients evaluated by the trauma surgery service at a level 1 trauma center between January 1 and December 31, 2003. Patients were retrospectively triaged to one of three START categories: immediate (Red), delayed (Yellow), or expectant (Black). The FAST results were obtained from the medical records.

RESULTS

FAST results were available for 359 patients, of which 27 were classified as positive. Twenty (6.9%) of 286 patients retrospectively triaged as delayed (Yellow) had positive FAST studies. Of these, six underwent operative intervention within 24 hours of arrival. A total of 232 patients had both FAST and computed tomography (CT) studies performed, of which 19 FAST studies were inconclusive. In the remaining 213 patients, six of 27 had falsely positive studies, while 24 of 186 had falsely negative studies.

CONCLUSIONS

Portable ultrasound technology might have identified 20 delayed (Yellow) patients with evidence of hemoperitoneum, thereby expediting evacuation to definitive care. However, only 30% of these patients subsequently underwent an operative intervention within 24 hours of arrival. Both over- and undertriage were significant problems. As such, the current study does not support the routine use of FAST ultrasound as a secondary triage tool.

Prehospital ultrasound imaging improves management of abdominal trauma

BACKGROUND

Blunt abdominal trauma with intra-abdominal bleeding is often underdiagnosed or even overlooked at trauma scenes. The purpose of this prospective, multicentre study was to compare the accuracy of physical examination and prehospital focused abdominal sonography for trauma (PFAST) to detect abdominal bleeding.

METHODS

Six rescue centres took part in the study from December 2002 to December 2003, including 230 patients with suspected abdominal injury. The accuracy of physical examination at the scene and PFAST were compared. Later examinations in the emergency department (ultrasonography and/or computed tomography) were used as the reference standard.

RESULTS

The complete protocol and follow-up was obtained in 202 patients. The sensitivity, specificity and accuracy of PFAST were 93 per cent, 99 per cent and 99 per cent, respectively, compared with 93 per cent, 52 per cent and 57 per cent for physical examination at the scene. Scanning with PFAST occurred a mean(s.d.) 35(13) min earlier than ultrasound in the emergency department. Abdominal bleeding was detected in 14 per cent of patients. Using PFAST led to a change in either prehospital therapy or management in 30 per cent of patients, and a change to admitting hospital in 22 per cent.

CONCLUSION

In this study, PFAST was a useful and reliable diagnostic tool when used as part of surgical triage at the trauma scene.

FAST on operational military deployment

BACKGROUND AND OBJECTIVE

Handheld ultrasound, because of its light weight, size, rugged design, and relative simplicity of use is ideal for use on operational military deployment. These machines have been used in the diagnosis of a range of traumatic conditions including abdominal, thoracic, and extremity trauma in the hospital environment, yet few data exist on their use during military operations. This paper presents experience of handheld focused assessment with sonography for trauma (FAST) on operational military deployment.

METHOD

Over a two month period, handheld FAST was performed by a single surgeon during the circulation phase of the primary survey in trauma patients presenting to the British Military Hospital in Iraq.

RESULTS

Fifteen from casualties underwent a FAST examination. Ten were victims of blunt trauma, two had received injuries anti-personnel mines, and three had penetrating injuries from ballistic trauma. There was one positive FAST, confirmed at laparotomy as bleeding from a liver injury. Thirteen scans were negative and remained negative on repeat FAST at 6 hours. One further patient with a negative FAST underwent laparotomy because of transectory, there was no intra-abdominal blood or fluid at surgery.

CONCLUSION

Handheld FAST is a valuable technique for investigating abdominal or thoracic bleeding in single or multiple casualty events on operational military deployment.

Handheld ultrasound diagnosis of extremity fractures

Hand portable ultrasound has been validated in trauma patients using the FAST technique. The machine's light and rugged design make it suitable for military deployment and they have been successfully used on deployments in Kosovo, Afghanistan and Iraq. Ultrasound is widely accepted in the diagnosis of abdominal and thoracic trauma, however, little work exists on its use in extremity trauma. Although the diagnosis of fractures usually relies on X-ray this may not be readily available at Role 1 or 2. We successfully identified long bone fractures in three patients using hand portable ultrasound during Operation Telic. The technique and ultrasound findings are described and the current literature on this technique is reviewed.