Hypotensive Patients with Blunt Abdominal Trauma: Performance of Screening US

Lessons learned from blunt trauma abdomen: Surgical experience in level I trauma centre

Objective: The number of accident cases is increasing day by day, so as the challenges. With an emphasis on trauma care, the government started a 120 bedded level I trauma centre in northern India catering to a population of 2.8 million in June 2018. Through this article, we aimed to share our experience of blunt abdominal trauma management from a new level I trauma centre.

Material and Methods: In this retrospective observational study, historical analysis of all available records from July 2018 to March 2020 was done. Inclusion criteria included blunt trauma abdomen with or without associated injuries. Data regarding age, sex, mechanism of injury, time taken to reach the hospital, the pattern of solid organs and hollow viscus injuries, associated extra abdominal injuries, mode of treatment, complications, length of ICU and hospital stay, and mortality were reviewed.

Results: Overall, 154 cases sustained abdominal injuries during the study period. Seventy-five percent were male. The most common cause of blunt trauma abdomen was road traffic crashes. Operative management was required in 57 (37.01%) cases while 97(62.98%) were managed non-operatively (NOM). Mean ICU stay was 05.73 days, while the average hospital stay was 12 days (range 10-60 days). Procedures performed included splenectomy, liver repair, primary closure of bowel injury, and stoma formation. Complications occured in 16.88% cases and the overall mortality rate was 11.68%.

Conclusion: The study revealed that among 154 cases of fatal blunt abdominal trauma, road traffic crash was the most common cause of blunt abdominal trauma, predominantly affecting males. The visceral and peritoneal injury frequently perceived was liver in 40 cases (25.9%), spleen 66 (43%), intestine 21(13.6%) and kidney 13 cases (09%). Abdominal injury was associated with other injuries like head, chest and extremity injuries in 52.5% cases. Duration of injury, presence of associated injury and preoperative ventilation requirement were independent predictors of mortality apart from contributary factors such as clinical presentation, organ involved and presence of complications.

Mors Gaudet Succurrere Vitae. The Role of Clinical Autopsy in Preventing Litigation Related to the Management of Liver and Digestive Disorders

Over the last 50 years, the number of clinical autopsies has decreased, but their role in assessing cause of death and clinical performance is still acknowledged. Few publications have studied their role in malpractice claim prevention. The paper aims to highlight the role of clinical autopsy in preventing errors and improve healthcare quality. A retrospective study was conducted on 28 clinical autopsies performed between 2015 and 2021 on patients dead unexpectedly after procedures for the diagnosis and treatment of digestive and hepatic diseases. After an accurate analysis of medical records and consultation with healthcare professionals, all cases were subjected to autopsy and histopathology. The data obtained were analyzed and shared with the risk-management team to identify pitfalls and preventive strategies. Post-mortem evaluations confirmed the clinical diagnosis only in six cases (21.4%). Discordances were observed in 10 cases (35.7%). In the remaining 12 cases (42.9%) the clinical diagnosis was labeled as "unknown" and post-mortem examinations made it possible to document the cause of death. Post-mortem examinations can concretely enrich hospital prevention systems and improve patient safety. The methodological approach outlined certainly demonstrates that, even in the risk-management field, "mors gaudet succurrere vitae" ("death delights in helping life").

ACR Appropriateness Criteria® Major Blunt Trauma

This review assesses the appropriateness of various imaging studies for adult major blunt trauma or polytrauma in the acute setting. Trauma is the leading cause of mortality for people in the United States <45 years of age, and the fourth leading cause of death overall. Imaging, in particular CT, plays a critical role in the management of these patients, and a number of indications are discussed in this publication, including patients who are hemodynamically stable or unstable; patients with additional injuries to the face, extremities, chest, bowel, or urinary system; and pregnant patients. Excluded from consideration in this review are penetrating traumatic injuries, burns, and injuries to pediatric patients. Patients with suspected injury to the head and spine are also discussed more specifically in other appropriateness criteria documents. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Emergency Focused Assessment with Sonography in Blunt Trauma Abdomen

Background:

Focused assessment with sonography in trauma (FAST) being a rapid noninvasive examination is used primarily to evaluate for the evidence of traumatic free fluid suggestive of injury in the peritoneal, pericardial, and pleural cavities. It is widely recognized as a mainstream emergency skill in the management of trauma.

Aim:

The aim of the study is to evaluate the accuracy of FAST in patients presenting with blunt abdominal trauma.

Methods:

Data were collected prospectively from FAST scans conducted in blunt trauma abdomen (BTA) patients. Positive and negative FAST scans were confirmed either with contrast-enhanced computed tomography (CECT) abdomen or with exploratory laparotomy, thus dividing it further into four groups, i.e., true-positive, false-positive, true-negative, and false-negative scans. After collecting the data, accuracy of FAST was calculated.

Results:

In this study, a total of 104 patients were included. The mean age was 38.17 years. Most common cause of BTA was road traffic accident. The overall sensitivity, specificity, and accuracy of FAST were 69.8%, 92.1%, and 80.8%, respectively.

Conclusion:

This study showed that FAST is of paramount importance in patients who are hemodynamically unstable as it has a high positive predictive value. However, a FAST-negative result should always be confirmed by other modalities.

Too fast, or not fast enough? The FAST exam in patients with non-compressible torso hemorrhage

BACKGROUND

Focused assessment with sonography for trauma (FAST) performance metrics are unknown in patients with non-compressible torso hemorrhage (NCTH).

METHODS

Retrospective review of a dedicated NCTH database from four level 1 trauma centers (2008-2012). NCTH was defined as (1) named axial torso vessel disruption; (2) AIS chest or abdomen >2 with shock (base deficit < -4) or truncal operation in ≤ 90 min; or (3) pelvic fracture with ring disruption. Patients were grouped by cavity of hemorrhage source and by shock (SBP ≤ 90).

RESULTS

274 patients had a FAST prior to diagnosis of NCTH. FAST was positive in 51% of patients with abdominal/pelvic hemorrhage for a false negative rate (FNR) of 49%. FNR was higher for pelvic (61%) versus abdominal (43%) sources (p = 0.02). There was no difference between FAST negative or positive patients for ISS, shock, length of stay, or mortality (all p = NS). FNR was not improved among the subgroup of NCTH patients with shock (p = NS).

CONCLUSION

FAST identified abdominal/pelvic hemorrhage in approximately half of NCTH patients, and this was not improved among patients presenting with shock.

The focused assessment with sonography in trauma (FAST) in hypotensive injured patients frequently fails to identify the need for laparotomy: a multi-institutional pragmatic study

Background

The ability of focused assessment with sonography for trauma (FAST) to detect clinically significant hemorrhage in hypotensive injured patients remains unclear. We sought to describe the sensitivity and specificity of FAST using findings at laparotomy as the confirmatory test.

Methods

Patients from the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study that had a systolic blood pressure < 90mm Hg and underwent FAST were analysed. Results were compared with findings at laparotomy. A therapeutic laparotomy (T-LAP) was defined as an abdominal operation within 6 hours in which a definitive procedure was performed. The sensitivity and specificity of FAST were calculated.

Results

The cohort included 317 patients that underwent FAST (108 positive, 209 negative). T-LAP was performed in 69% (n=75) of FAST(+) patients and 22% (n=48) of FAST(−) patients. FAST had a sensitivity of 62% and specificity of 83%.

Conclusions

In our multicenter cohort, 22% of FAST(−) patients underwent T-LAP within 6 hours of admission. In hypotensive patients with a negative FAST, clinicians should still maintain a high index of suspicion for significant abdominal hemorrhage.

Level of evidence

Level IV.

Resuscitation Resequenced: A Rational Approach to Patients with Trauma in Shock

Trauma resuscitation is a complex and dynamic process that requires a high-performing team to optimize patient outcomes. More than 30 years ago, Advanced Trauma Life Support was developed to formalize and standardize trauma care; however, the sequential nature of the algorithm that is used can lead to ineffective prioritization. An improved understanding of shock mandates an updated approach to trauma resuscitation. This article proposes a resequenced approach that (1) addresses immediate threats to life and (2) targets strategies for the diagnosis and management of shock causes. This updated approach emphasizes evidence-based resuscitation principles that align with physiologic priorities.

Emergency Laparotomies at a Tertiary Care Center-a Hospital-Based Cross-Sectional Study

Emergency laparotomy is a common high-risk surgical procedure, but with a few outcome data and few data on postoperative care. This was a hospital-based descriptive study of 376 consecutive emergency midline laparotomies performed in a tertiary care center. The aim of the study was to identify the clinical presentation, surgical indications, preoperative delay, intraoperative findings, and postoperative complications. Majority of the patients belonged to the 40-80-year age group. Broadly, the indications could be divided into acute abdomen and trauma. Most of the cases (82 %) presented with acute abdomen, out of which 57 % cases had gastrointestinal perforation, and 33 % had intestinal obstruction. In trauma laparotomies, 63 % of cases were done for blunt abdominal trauma and the rest for penetrating injury. The clinical features were analyzed, of which most frequent were abdominal tenderness (88.8 %), abdominal distension (88 %), tachycardia (74.2 %), and guarding (70.7 %). Nearly three fourths of the patients underwent laparotomy within 24 h of entry to the casualty. The most common condition that resulted in an emergency laparotomy was duodenal perforation which was seen in 93 patients, followed by gastric perforation in 60 patients. Postoperatively, 54.5 % of patients did not develop any complication. The most common complication encountered was wound infection (26.6 %). Mortality following emergency laparotomy was 13 %. Age-specific mortality was maximum in patients with age more than 80 years. The diagnosis-specific mortality was higher for large bowel perforation and mesenteric ischemia among the acute abdomen cases, and liver injury or great vessel injury among the trauma cases.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

BACKGROUND

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

RESULTS

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Complete ultrasonography of trauma in screening blunt abdominal trauma patients is equivalent to computed tomographic scanning while reducing radiation exposure and cost

BACKGROUND

Liberal use of computed tomography of the abdomen and pelvis (CTAP) in the screening of blunt abdominal trauma (BAT) has heightened concerns for increased radiation exposure and costs. We sought to demonstrate that in a select group of BAT patients, complete ultrasonography of trauma (CUST) is equivalent to routine CTAP but with significantly decreased radiation and costs.

METHODS

A retrospective analysis of patients screened for BAT from 2000 to 2011 in a Level 1 trauma center was performed. CUST was available from 8:00 AM to 11:00 PM daily, while CTAP was performed thereafter. Decision to perform CTAP or CUST overnight was made by the attending surgeon based on clinical examination. False negatives (FNs) were described as either a negative CUST or CTAP finding, which later required exploratory laparotomy. Medicare rates and previous data were used for the estimation of cost and radiation exposure.

RESULTS

There were 19,128 patients screened for BAT. A total of 12,577 patients (65.8%) initially underwent CUST, and 6,548 (34.2%) underwent CTAP; 11,059 patients (58% of the total BAT patients) avoided a CTAP, yielding an estimated savings of $6.5 million and 188,003 mSv less radiation during the course of the study. Compared with the CTAP group, patients undergoing CUST had lower Injury Severity Score (ISS) (8.1 vs. 9.6), were older (44.7 years vs. 35.2 years), and experienced less traumatic brain injury (61.4% vs. 69.3%) (all with p < 0.002). Mortality was higher in the CUST group (1.8% vs. 1.2%, p = 0.02), but it was insignificant when adjusted for age older than 65 years (1.1% vs. 0.9%, p = 0.23) or head injury (0.6% and 0.3%, p = 0.4). FN CUST and FN CTAP were 0.29% and 0.1%, respectively (p = nonsignificant), with similar mortality (20% vs. 0%, p = 0.44).

CONCLUSION

CUST is equivalent to routine CTAP for BAT screening and leads to an average of 42% less radiation exposure and more than $591,000 savings per year.

LEVEL OF EVIDENCE

Diagnostic study, level IV; therapeutic/care management study, level IV.

The utility of FAST for initial abdominal screening of major pelvic fracture patients

BACKGROUND

Focused Assessment with Sonography for Trauma (FAST) is widely used in pelvic fracture patients. We examined the performance of FAST for detecting hemoperitoneum and predicting the need for intra-abdominal hemorrhage control in major pelvic fracture patients.

METHODS

A 5-year retrospective study of major pelvic fracture patients was performed. The presence of hemoperitoneum was confirmed on CT or at laparotomy. The need for hemorrhage control was defined as requiring a surgical or radiological intervention for intra-abdominal bleeding. Hemorrhagic shock (HS) patients had a systolic blood pressure ≤ 90 mmHg or base deficit of ≥ 6 mEq/L on admission.

RESULTS

A total of 120 patients were included, 42 (35 %) of which had any hemoperitoneum and 21 (18 %) had a moderate-large amount. The sensitivity, specificity, and positive and negative predictive values of FAST for any hemoperitoneum were 64, 94, 84, and 83 % and for a moderate-large amount they were 86, 86, 56, and 97 %. In HS patients the indices were 68, 93, 88, and 78 % for any hemoperitoneum and 79, 83, 65, and 91 % for a moderate-large amount. For the need for hemorrhage control, FAST had a positive predictive value of 50 % (16/32) in all and 71 % (12/17) in HS patients. The negative predictive value was 99 % (87/88) in all and 97 % (31/32) in HS patients.

CONCLUSION

FAST had a good to excellent diagnostic accuracy, depending on the size of hemoperitoneum. A positive FAST result (even in HS patients) does not reliably predict the need for immediate intra-abdominal hemorrhage control but a negative FAST result renders the need for an intervention highly unlikely.

Focused Assessment with Sonography for Trauma in patients with confirmed liver lesions

BACKGROUND AND AIMS

The objective was to determine the sensitivity and specificity of Focused Assessment with Sonography for Trauma (FAST) in patients with confirmed liver lesions and also to compare results from surgeons trained in FAST with results from radiologists trained in general abdominal ultrasound as part of the specialist training. Explorative laparotomy or CT served as gold standard.

MATERIALS AND METHODS

This retrospective study included all patients admitted to our institution from 2003 to 2010 registered with the diagnosis "Injury of the liver or gallbladder". Of 405 patients, 135 patients were eligible for analysis. Seventy-two patients were examined by radiologists and 63 by surgeons.

RESULTS

We found FAST to have a sensitivity, specificity, PPV, and NPV of 79.6%, 100%, 100%, and 68.9%. There was no statistically significant difference between FAST performed by radiologists and surgeons trained in FAST.

CONCLUSION

FAST remains an important screening tool in abdominal trauma including liver lesions, and can be performed at a satisfactory level by surgeons trained in the FAST procedure only.

Smartphone-Compatible Ultrasound Probe

Smartphones are one of the most widely used cell phones in the United States today. They perform multiple functions, and in April 2009, another capability was added to that list. Smartphones are now able to display sonographic images of the human body and organs through use of a smartphone-compatible ultrasound probe. The probe can be plugged into the USB slot of a smartphone and used to allow gray-scale image visualization. This article discusses the function and structure of this new and emerging technology while looking at the impact of this technology on the field of sonography.

A haemoperitoneum does not indicate active bleeding in the peritoneum in 50% of hypotensive blunt trauma patients: a study of 110 severe trauma patients

BACKGROUND

We hypothesised that in blunt trauma patients with haemodynamic instability and haemoperitoneum on hospital admission, the haemorrhagic source may not be confined to the peritoneum. The purpose of this study was to describe the incidence and location of bleeding source in this population.

METHODS

The charts of trauma patients admitted consecutively between January 2005 and January 2010 to our level I Regional Trauma Centre were reviewed retrospectively. All hypotensive patients presenting a haemoperitoneum on admission were included. Hypotension was defined by a systolic blood pressure ≤ 90 mmHg. The haemoperitoneum was quantified on CT images or from operative reports as moderate (Federle score<3 or between 200 and 500 ml) or large (Federle score ≥ 3 or >500 ml). Active bleeding (AB) was defined as injury requiring a surgical or radiologic haemostatic procedure, regardless of origin (peritoneal (PAB) or extraperitoneal (EPAB)).

RESULTS

Of 1079 patients admitted for severe trauma, 110 patients met the inclusion criteria. Seventy-eight (71%) were male, mean age 35.3 (SD 19) years and mean ISS 36.5 (SD 20.5). Among the 91 patients who had AB, 37 patients (41%) had PAB, 34 (37%) had EPAB and 20 had both (22%). Forty-eight (53%) of them had moderate haemoperitoneum and 43 (47%) had large haemoperitoneum. A large haemoperitoneum had positive predictive value for PAB of 88% (95% CI 75-95%) and negative predictive value of 65% (95% CI 49-79%). The corresponding values in the subgroup of patients with EPAB were 65% (95% CI 38-86%) and 76% (95% CI 59-88%).

CONCLUSION

Haemoperitoneum was associated with PAB in only 52% of hypotensive blunt trauma patients and 63% of bleeding patients. In contrast, 59% of bleeding patients had at least one EPAB. The screening of a haemoperitoneum as a marker of active haemorrhagic source may be confusing and lead to misdiagnosis and inappropriate strategy. Clinician should exclude carefully the presence of any EPAB explaining haemorrhagic shock, before to decide haemostatic treatment.

Emergency focussed assessment with sonography in trauma (FAST) and haemodynamic stability

Background

Focussed assessment with sonography in trauma (FAST) has assumed a key role in the rapid non-invasive assessment of thoracoabdominal trauma and assists in decreasing disposition time. This study evaluates FAST's efficacy with respect to haemodynamic stability in a South African emergency department (ED).

Methods

Data were collected prospectively by four emergency medicine doctors trained in emergency ultrasonography. FAST scans were performed by one ED doctor and timings, scan result and disposition were recorded. Patient haemodynamic stability was assessed by the emergency doctor performing the scan; subjectively at the time of scanning and objectively using calculation of the shock index. All scan results were subsequently verified by a second ED doctor in a blinded fashion and by CT scanning or operative intervention when clinically indicated.

Results

166 FAST scans were conducted of which 36 (21.7%) were positive. Mean age was 30.6 years (SD 12.8). 74.1% of patients sustained blunt traumatic injury. Doctors’ subjective haemodynamic stability assessments had higher specificity, sensitivity and predictive values than shock index alone. Haemodynamic instability and a positive FAST result were significantly related (p=0.004). Sensitivities and specificities of FAST scans for blunt and penetrating trauma were 93.1% and 100%, and 90.0% and 100%, respectively. Corresponding values for pneumothoraces were 84.6% and 100%.

Discussion

This study showed a valuable role for FAST in all traumas, particularly in haemodynamic compromise. As an addition to the physician's repertoire of bedside assessment tools, it improves diagnostic capabilities in comparison with simple haemodynamic assessments alone.

Does the size of the hemoperitoneum help to discriminate the bleeding source and guide therapeutic decisions in blunt trauma patients with pelvic ring fracture?

BACKGROUND

In blunt trauma patients with a hemoperitoneum and a pelvic injury, multiple sources of active bleeding may exist. The purpose of this study was to determine whether the size of the hemoperitoneum helps to establish the bleeding source and guide therapeutic decisions in patients with pelvic fractures.

METHODS

The charts of patients with pelvic fractures admitted to a trauma intensive care unit from January 2005 to December 2009 were reviewed retrospectively. The hemoperitoneum size was defined by semiquantitative analysis (minimal/none, moderate, and large) using the Federle score on computed tomographic scan or during laparotomy. Active peritoneal hemorrhages requiring immediate laparotomy were compared according to hemoperitoneum size.

RESULTS

Of 185 patients, hemoperitoneum did not occur in 116 patients, moderate in 43, and large in 26. Among 102 patients (55%) who were hypotensive (systolic blood pressure <90 mm Hg) on admission, 27 needed therapeutic laparotomy and 15 needed pelvic embolization. Laparotomy (39% vs. 2%) and pelvic embolization (22% vs. 4%) were required significantly more often in patients with hemoperitoneum (moderate or large) than those without hemoperitoneum. The positive predictive value for an active peritoneal hemorrhage derived from qualitative analysis of the hemoperitoneum (moderate or large) was 39% (4% in hypotensive patients and 40% in those requiring pelvic embolization). The corresponding values for large hemoperitoneum only (semiquantitative analysis) were 62%, 70%, and 67%, respectively.

CONCLUSION

In patients with pelvic fractures, hemoperitoneum does not mean peritoneal injury requiring hemostatic procedure. Semiquantitative analysis of the hemoperitoneum improves predictability of peritoneal hemorrhage than qualitative analysis of hemoperitoneum. However, there remains numerous false-positives even in presence of large hemoperitoneum associated with hypotension.

Hemoperitoneum semiquantitative analysis on admission of blunt trauma patients improves the prediction of massive transfusion

BACKGROUND

The purpose of this study was to define whether the semiquantitative analysis of hemoperitoneum increases the accuracy of early prediction of massive transfusion (MT).

METHODS

A retrospective review of severe trauma patients consecutively admitted to our trauma intensive care unit between January 2005 and December 2009 was conducted. Patients diagnosed with blunt abdominal trauma who had a computed tomography scan on admission were included. The hemoperitoneum size was defined using the Federle score on computed tomography as large, moderate, or minimal/none. The association between MT (≥10 U of packed red blood cells in the first 24 h) and moderate and large sizes of hemoperitoneum was assessed using a multiple logistic model.

RESULTS

Of the 381 patients meeting the inclusion criteria, 270 (71%) were male; the mean age was 35.5 ± 18.2 years and mean injury severity score was 23.4 ± 17. Ninety-seven (26%) had large hemoperitoneum, 107 (28%) had moderate hemoperitoneum, and 177 (46%) had minimal/no hemoperitoneum. Eighty-three patients (22%) required MT. The positive predictive value for MT of a large hemoperitoneum was 41%, 23% for a moderate hemoperitoneum, and 10% for minimal/no hemoperitoneum (P < .001). The corresponding values for hypotensive patients were 61%, 32%, and 25%, respectively (P < .001). In the multivariate analysis model, only the large size of hemoperitoneum was significantly associated with MT (OR 6.4, 95% CI 2.9-14, P < .001, r(2) = 0.47).

CONCLUSION

The assessment of the size of hemoperitoneum on admission substantially improves the prediction of MT in trauma patients and should be used to trigger and guide initial haemostatic resuscitation.

Accuracy of FAST scan in blunt abdominal trauma in a major London trauma centre

INTRODUCTION

Blunt abdominal trauma (BAT) is a leading cause of morbidity and mortality. Rapid diagnosis and treatment with the Advanced Trauma Life Support guidelines are vital, leading to the development of Focused Assessment with Sonography in Trauma (FAST).

METHODS

A retrospective study carried out from January 2007-2008 on all patients who presented with BAT and underwent FAST scan. All patients subsequently had a CT scan within 2 h of admission or a laparotomy within two days. The presence of intra-peritoneal free fluid was interpreted as positive.

RESULTS

100 patients with BAT presented; 71 had complete data. The accuracy of FAST in BAT was 59.2%; in these 31 (43.7%) were confirmed by CT and 11 (15%) by laparotomy. There were 29 (40.8%) inaccurate FAST scans, all confirmed by CT. FAST had a specificity of 94.7% (95% CI: 0.75-0.99) and sensitivity of 46.2% (95% CI: 0.33-0.60). Positive Predictive Value of 0.96 (0.81-0.99) and Negative Predictive Value of 0.39 (0.26-0.54). Fisher's exact test shows positive FAST is significantly associated with Intra-abdominal pathology (p=0.001). Cohen's chance corrected agreement was 0.3. 21 out of 28 who underwent laparotomies had positive FAST results indicating accuracy of 75% (95% CI: 57%-87%).

CONCLUSION

Patients with false negative scans, requiring therapeutic laparotomy is concerning. In unstable patients FAST may help in triaging and identifying those requiring laparotomy. Negative FAST scans do not exclude abdominal injury. Further randomised control trials are recommended if the role of FAST is to be better understood.

False-negative FAST examination: associations with injury characteristics and patient outcomes

STUDY OBJECTIVE

Focused assessment with sonography in trauma (FAST) is widely used for evaluating patients with blunt abdominal trauma; however, it sometimes produces false-negative results. Presenting characteristics in the emergency department may help identify patients at risk for false-negative FAST result or help the physician predict injuries in patients with a negative FAST result who are unstable or deteriorate during observation. Alternatively, false-negative FAST may have no clinical significance. The objectives of this study are to estimate associations between false-negative FAST results and patient characteristics, specific abdominal organ injuries, and patient outcomes.

METHODS

This was a retrospective cohort study including consecutive patients who presented to an urban Level I trauma center between July 2005 and December 2008 with blunt abdominal trauma, a documented FAST, and pathologic free fluid as determined by computed tomography, diagnostic peritoneal lavage, laparotomy, or autopsy. Physicians blinded to the study purpose used standardized abstraction methods to confirm FAST results and the presence of pathologic free fluid. Multivariable modeling was used to assess associations between potential predictors of a false-negative FAST result and false-negative FAST result and adverse outcomes.

RESULTS

During the study period, 332 patients met inclusion criteria. Median age was 32 years (interquartile range 23 to 45 years), 67% were male patients, the median Injury Severity Score was 27 (interquartile range 17 to 41), and 162 (49%) had a false-negative FAST result. Head injury was positively associated with false-negative FAST result (odds ratio [OR] 4.9; 95% confidence interval [CI] 1.5 to 15.7), whereas severe abdominal injury was negatively associated (OR 0.3; 95% CI 0.1 to 0.5). Injuries to the spleen (OR 0.4; 95% CI 0.24 to 0.66), liver (OR 0.36; 95% CI 0.21 to 0.61), and abdominal vasculature (OR 0.17; 95% CI 0.07 to 0.38) were also negatively associated with false-negative FAST result. False-negative FAST result was not associated with mortality (OR 0.89; 95% CI 0.42 to 1.9), prolonged ICU length of stay (relative risk 0.88; 95% CI 0.69 to 1.12), or total hospital length of stay (relative risk 0.92; 95% CI 0.76 to 1.12). However, patients with false-negative FAST results were substantially less likely to require therapeutic laparotomy (OR 0.31; 95% CI 0.19 to 0.52).

CONCLUSION

Patients with severe head injuries and minor abdominal injuries were more likely to have a false-negative than true-positive FAST result. On the other hand, patients with spleen, liver, or abdominal vascular injuries are less likely to have false-negative FAST examination results. Adverse outcomes were not associated with false-negative FAST examination results, and in fact patients with false-negative FAST result were less likely to have a therapeutic laparotomy. Further studies are needed to assess the strength of these findings.

Review article: Use of ultrasound in the developing world

As portability and durability improve, bedside, clinician-performed ultrasound is seeing increasing use in rural, underdeveloped parts of the world. Physicians, nurses and medical officers have demonstrated the ability to perform and interpret a large variety of ultrasound exams, and a growing body of literature supports the use of point-of-care ultrasound in developing nations. We review, by region, the existing literature in support of ultrasound use in the developing world and training guidelines currently in use, and highlight indications for emergency ultrasound in the developing world. We suggest future directions for bedside ultrasound use and research to improve diagnostic capacity and patient care in the most remote areas of the globe.

Microscopic hematuria as a marker of blunt abdominal trauma in rats: description of an experimental model

BACKGROUND

Microscopic hematuria is an extremely important sign in blunt abdominal trauma (BAT) patients. Controversies still exist in the literature on whether microscopic hematuria is a sign of intra-abdominal extrarenal organ injury and is an indication for radiographic assessment of BAT patients. In this study, a new BAT rat model was developed, and we tried to determine the relationships between microscopic hematuria and extrarenal intra-abdominal organ injury.

METHODS

After verifying our model, lethal and maximal sublethal intensity of impact energy determined in the rats. Animals allocated into six sublethal impact energy groups. BAT was induced by dropping a standard mass from variable heights. After 2 hours of examining period, macroscopic laparotomy findings, histopathological liver, spleen and renal injury grades, and microscopic hematuria levels were recorded in these six groups.

RESULTS

According to our results, while the trauma intensity increase severity of the histopathological injury increases for all organs. Although there was a significant correlation between microscopic hematuria and trauma intensity, we could not show same relationship between microscopic hematuria and histopathological organ injury. On the other hand, microscopic hematuria was correlated with the macroscopic laparotomy findings.

CONCLUSIONS

Microscopic hematuria could serve as a predictor of the severity of trauma and intra-abdominal organ injury. This study would support the use of abdominal imaging and attentive assessment for intra-abdominal organ injury in stable BAT patients with hematuria. The laparotomy threshold may be lowered for unstable BAT patients with hematuria.

FAST scan: is it worth doing in hemodynamically stable blunt trauma patients?

BACKGROUND

During the last decade, focused assessment with sonography for trauma increasingly has become the initial diagnostic modality of choice in trauma patients. It is still questionable, however, whether its use results in the underdiagnosis of intra-abdominal injury. It also remains doubtful whether a positive focused assessment with sonography for trauma affects clinical decision making in hemodynamically stable blunt trauma patients as evidenced through abdominal computerized tomography use. The aim of this study was to evaluate the results of focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients and to determine its role in the diagnostic evaluation of these patients.

METHODS

We reviewed our prospectively maintained trauma database. In trauma patients at our institute, focused assessment with sonography for trauma examinations are performed by surgery residents and are considered positive when free intra-abdominal fluid is visualized. Abdominal computerized tomography, diagnostic peritoneal lavage, or exploratory laparotomy findings were used as confirmation of intra-abdominal injury.

RESULTS

In our 7-year study period, 2,980 trauma patients were evaluated at our institute, of which 2,130 patients underwent a focused assessment with sonography for trauma. In all, 18 patients had an inconclusive focused assessment with sonography for trauma, whereas 7 patients died on arrival, leaving 2,105 patients for our analysis. A total 88 true positive focused assessment with sonography for trauma were conducted. All hemodynamically stable blunt trauma patients who had a positive focused assessment with sonography for trauma (70/88) were confirmed by computerized tomography. Patients who underwent exploratory laparotomy directly (17/88) or diagnostic peritoneal lavage (1/88) as confirmation either had penetrating trauma or became hemodynamically unstable. A total of 1,894 true negative focused assessments with sonography for trauma scans were conducted, with 1,201 confirmed by computerized tomography and the rest by observation. In all, 118 false negative focused assessment with sonography for trauma were performed, of which 44 (37.3%) subsequently required exploratory laparotomy. Five patients had false positive focused assessment with sonography for trauma scans. Focused assessment with sonography for trauma scan had an overall sensitivity of 43%, a specificity of 99%, and positive and negative predictive values of 95% and 94%, respectively. Accuracy was 94.1%. In the hemodynamically stable blunt trauma group, there were 60 patients with true positive focused assessment with sonography for trauma examinations and 87 patients with false negative focused assessment with sonography for trauma examinations. In this group of patients, focused assessment with sonography for trauma had a sensitivity of 41%, specificity of 99%, and positive and negative predictive values of 94% and 95%, respectively. The overall accuracy was 95%.

CONCLUSION

Given the low sensitivity, a negative focused assessment with sonography for trauma without confirmation by computerized tomography may result in missed intra-abdominal injuries. It is also observed in all focused assessment with sonography for trauma positive hemodynamically stable blunt trauma patients, confirmation is preferred through the use of a computerized tomography for better understanding of the intra-abdominal injuries and to decide on operative versus no-operative management. Thus, the use of focused assessment with sonography for trauma in hemodynamically stable blunt trauma patients seems not worthwhile. It should be reserved for hemodynamically unstable patients with blunt trauma.

Accuracy of peritoneal fluid measurements by transvaginal ultrasonography

OBJECTIVE

To assess the accuracy of the assessment of peritoneal fluid volumes of up to 1 L by transvaginal ultrasonography and to re-evaluate the formula used to calculate total volume from the dimensions of the largest pocket.

METHODS

Patients (n = 13) enrolled for a minor laparoscopic procedure were prospectively recruited. At the end of the procedure, with the patient in the 30 degrees anti-Trendelenburg position, Ringer's lactate was instilled into the abdomen in discrete steps up to 1 L. Following equilibration the diameters of the single pocket of fluid were measured by transvaginal ultrasonography in order to calculate the volume, and regression models were used to determine the relationship between this and the instilled volume. The body mass index (BMI) of the patient was evaluated as a parameter for predicting the instilled volume more accurately.

RESULTS

The intra-abdominal fluid volume could be calculated from the measured volume using a quadratic regression equation with an overall coefficient of variation of 19%. In individual patients, changes in volume could be assessed with a coefficient of variation of 7.3%. BMI was not found to be a significant parameter in relating the measured to the instilled volume.

CONCLUSION

Transvaginal ultrasound in a standardized setting can accurately estimate the volume of peritoneal fluid, with the accuracy consistent for small and large volumes. Changes in peritoneal fluid volume over time in the same individual can be measured more accurately than the total volume present.

An Evidence-Based Approach for Integrating Bedside Ultrasound Into Routine Practice in the Assessment of Undifferentiated Shock

Undifferentiated hypotension remains a central diagnostic and therapeutic challenge in emergency and critical care medicine. Increasingly, bedside ultrasound conducted by intensivists and emergency medicine providers is assuming a central role in diagnosis and resuscitation of hypotension. This review discusses sample algorithms for the bedside ultrasonographic assessment of undifferentiated shock and outlines an evidence-based framework for the intensivist seeking to incorporate bedside ultrasound into daily clinical practice. The literature regarding specific applications including cardiac, thoracic, pulmonary, and vascular assessment is briefly reviewed, as is the evidence pertaining to effective implementation, training, credentialing, and ongoing quality assurance.

Management of bleeding following major trauma: an updated European guideline

INTRODUCTION

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

RESULTS

Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

CONCLUSIONS

This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

[Mountain biking : Breezy ups and traumatic downs]

For more than two decades the popularity of mountain biking as a national pastime as well as a competitive sport has been undiminished. However, its related risks are not monitored as closely as those, for example, of skiing. The injuries caused by mountain biking are specific and cannot be compared with those caused by other cycling sports. This is due not only to the characteristics of the terrain but also to the readiness to assume a higher risk compared to cycle racing.The particular value of radiology is in the acute trauma setting. Most often musculoskeletal lesions must be examined and digital radiography and MRI are the most useful techniques. Severe trauma of the cranium, face, spine, thorax and abdomen are primarily evaluated with CT, particularly in dedicated trauma centers. Therefore, radiology can play a role in the rapid diagnosis and optimal treatment of the trauma-related injuries of mountain biking. Thus, the unnecessarily high economical damage associated with mountain biking can be avoided.

Ultrasound performed by radiologists-confirming the truth about FAST in trauma

BACKGROUND

For hemodynamically stable patients with suspected abdominal injuries, the diagnostic accuracy of computed tomographic scans remains unmatched. Focused assessment with sonography for trauma (FAST) is useful in trauma evaluation to identify intraabdominal fluid early in the unstable patient. In skilled hands, sensitivity is shown to be close to 100%. However, some recent studies have questioned its sensitivity in subgroups at risk of bleeding. In most studies, hemodynamic markers of instability have been limited to hypotension. The purpose of this study was to determine the sensitivity and specificity of initial FAST for detection of hemoperitoneum in the potentially unstable patient as judged by objective hemodynamic parameters available early during resuscitation.

METHODS

Prospective observational study at a major European trauma center. FAST was performed in trauma patients by the trauma team radiologist. The study population consisted of the subgroup deemed potentially unstable on arrival as defined by systolic blood pressure < or =90 mm Hg, pulse rate > or =120, or base deficit > or =8. Results were compared with one of the following reference standards: computed tomographic scan, diagnostic peritoneal lavage, exploratory laparotomy, or observation.

RESULTS

One hundred and four patients constituted the study group. There were 75 true-negative, 10 false-negative, 16 true-positive, and 3 false-positive FAST results. Sensitivity and specificity were 62% and 96%, positive and negative predictive values 84% and 89%, respectively, and overall accuracy was 88%.

CONCLUSION

A negative initial FAST in hemodynamically unstable patients, even in the hands of radiologists, cannot reliably exclude intraabdominal bleeding. These patients should undergo additional diagnostic tests to exclude intraperitoneal hemorrhage.

Exsanguination in trauma: A review of diagnostics and treatment options

Trauma patients with haemorrhagic shock who only transiently respond or do not respond to fluid therapy and/or the administration of blood products have exsanguinating injuries. Recognising shock due to (exsanguinating) haemorrhage in trauma is about constructing a synthesis of trauma mechanism, injuries, vital signs and the therapeutic response of the patient. The aim of prehospital care of bleeding trauma patients is to deliver the patient to a facility for definitive care within the shortest amount of time by rapid transport and minimise therapy to what is necessary to maintain adequate vital signs. Rapid decisions have to be made using regional trauma triage protocols that have incorporated patient condition, transport times and the level of care than can be performed by the prehospital care providers and the receiving hospitals. The treatment of bleeding patients is aimed at two major goals: stopping the bleeding and restoration of the blood volume. Fluid resuscitation should allow for preservation of vital functions without increasing the risk for further (re)bleeding. To prevent further deterioration and subsequent exsanguinations 'permissive hypotension' may be the goal to achieve. Within the hospital, a sound trauma team activation system, including the logistic procedure as well as activation criteria, is essential for a fast and adequate response. After determination of haemorrhagic shock, all efforts have to be directed to stop the bleeding in order to prevent exsanguinations. A simultaneous effort is made to restore blood volume and correct coagulation. Reversal of coagulopathy with pharmacotherapeutic interventions may be a promising concept to limit blood loss after trauma. Abdominal ultrasound has replaced diagnostic peritoneal lavage for detection of haemoperitoneum. With the development of sliding-gantry based computer tomography diagnostic systems, rapid evaluation by CT-scanning of the trauma patient is possible during resuscitation. The concept of damage control surgery, the staged approach in treatment of severe trauma, has proven to be of vital importance in the treatment of exsanguinating trauma patients and is adopted worldwide. When performing 'blind' transfusion or 'damage control resuscitation', a predetermined fixed ratio of blood components may result in the administration of higher plasma and platelets doses and may improve outcome. The role of thromboelastography and thromboelastometry as point-of-care tests for coagulation in massive blood loss is emerging, providing information about actual clot formation and clot stability, shortly (10min) after the blood sample is taken. Thus, therapy guided by the test results will allow for administration of specific coagulation factors that will be depleted despite administration with fresh frozen plasma during massive transfusion of blood components.

[Evidence-based diagnosis of abdominal trauma]

Abdominal trauma is a common cause of death particularly in patients up to 40 years of age. In order to reduce mortality a rapid radiologic diagnosis is essential. At present, sonography plays a role only in the evaluation of minor trauma and as a "focused assessment with sonography for trauma" (FAST) to clarify free intraperitoneal fluid immediately on admittance in severely injured patients. However, computed tomography has proven to be a potent tool for the triage of patients with abdominal trauma, because, based on the results of the CT scan, patients can be referred for laparotomy or safely classified for "wait and see" treatment. Therapeutic decisions are largely based on injury severity scores and the radiologist must be familiar with them as well as with the associated therapeutic consequences.

Current Role of Emergency US in Patients with Major Trauma

In patients with major trauma, focused abdominal ultrasonography (US) often is the initial imaging examination. US is readily available, requires minimal preparation time, and may be performed with mobile equipment that allows greater flexibility in patient positioning than is possible with other modalities. It also is effective in depicting abnormally large intraperitoneal collections of free fluid, which are indirect evidence of a solid organ injury that requires immediate surgery. However, because US has poor sensitivity for the detection of most solid organ injuries, an initial survey with US often is followed by a more thorough examination with multidetector computed tomography (CT). The initial US examination is generally performed with a FAST (focused assessment with sonography in trauma) protocol. Speed is important because if intraabdominal bleeding is present, the probability of death increases by about 1% for every 3 minutes that elapses before intervention. Typical sites of fluid accumulation in the presence of a solid organ injury are the Morison pouch (liver laceration), the pouch of Douglas (intraperitoneal rupture of the urinary bladder), and the splenorenal fossa (splenic and renal injuries). FAST may be used also to exclude injuries to the heart and pericardium but not those to the bowel, mesentery, and urinary bladder, a purpose for which multidetector CT is better suited. If there is time after the initial FAST survey, the US examination may be extended to extra-abdominal regions to rule out pneumothorax or to guide endotracheal intubation, vascular puncture, or other interventional procedures.

Blunt abdominal trauma: current imaging techniques and CT findings in patients with solid organ, bowel, and mesenteric injury

Imaging plays a critical role in the evaluation of patients with blunt abdominal trauma. In most institutions, computed tomography (CT) is the modality of choice when evaluating such patients. The purpose of this review is to highlight current techniques in trauma imaging and to review CT findings associated with solid organ, bowel, mesenteric, and diaphragmatic injury. In particular, emphasis is placed on the use of multidetector CT technology (MDCT), especially 64-row detector CT. The role of various techniques, including the use of oral and intravenous contrast, as well as the potential benefit of delayed imaging, is discussed.

Advances in Abdominal Trauma

Emergency practitioners routinely encounter patients who suffer from abdominal trauma, be it blunt or penetrating. These injuries are often confounded by altered mental status, distracting injuries, or lack of historical information, and may present challenges in management. However, in the last several years new approaches to the diagnosis and management of abdominal trauma, including bedside ultrasound, newer generation computed tomography scans, laparoscopy, and the ability for selected nonoperative management expedite identification of life threatening injury and offer new options in treatment.

Advanced Trauma Life Support. ABCDE from a radiological point of view

Accidents are the primary cause of death in patients aged 45 years or younger. In many countries, Advanced Trauma Life Support® (ATLS®) is the foundation on which trauma care is based. We will summarize the principles and the radiological aspects of the ATLS®, and we will discuss discrepancies with day to day practice and the radiological literature. Because the ATLS® is neither thorough nor up-to-date concerning several parts of radiology in trauma, it should not be adopted without serious attention to defining the indications and limitations pertaining to diagnostic imaging.

Clinician-performed focused sonography for the resuscitation of trauma

Traumatic death remains pandemic. The majority of preventable deaths occur early and are due to injuries or physiologic derangements in the airway, thoracoabdominal cavities, or brain. Ultrasound is a noninvasive and portable imaging modality that spans a spectrum between the physical examination and diagnostic imaging. It allows trained examiners to immediately confirm important syndromes and answer clinical questions. Newer technologies greatly increase the fidelity, accessibility, ease of use, and informatic manipulation of the results. The early bedside use of focused ultrasound as the initial imaging modality used to detect hemoperitoneum and hemopericardium in the resuscitation of the injured patient has become an accepted standard of care. Widespread dissemination of basic ultrasound skills and technology to facilitate this brings ultrasound to many resuscitative and critical care areas. Although not as widely appreciated, the focused use of ultrasound may also have a role in detecting hemothoraces and pneumothoraces, guiding airway management, and detecting increased intracranial pressure. Intensivists generally utilize a treating philosophy that requires the real-time integration of many divergent sources of information regarding their patients' anatomy and physiology. They are therefore positioned to take advantage of focused resuscitative ultrasound, which offers immediate diagnostic information in the early care of the critically injured.

Focused ultrasound training for clinicians

Clinician use of diagnostic ultrasound, particularly at point of care and in emergency situations, is well established. The standard of training courses and of postcourse supervision and accreditation is variable, and international standards are required to maintain safety, accuracy, and credibility of the technique. The accuracy of the technique by trained personnel has been well documented. There is evidence that prereading, a course involving theoretical and practical training, and ongoing mentoring (proctoring) provides high standards of practice. Regular accreditation and continuous comparison with gold standards is required to maintain this level. Most areas of the body are now accessible to clinicians of varied specialties, even those previously thought impossible for ultrasound examination, such as the chest and bone. Training and supervision in rural, remote, and austere environments provides added challenges.

The Utility of Sonography for the Triage of Blunt Abdominal Trauma Patients to Exploratory Laparotomy

OBJECTIVE

The purpose of this study was to assess the utility of focused abdominal sonography for trauma (FAST) in the triage of hypotensive and normotensive blunt abdominal trauma patients to exploratory laparotomy.

MATERIALS AND METHODS

Data entered in a trauma registry database were retrospectively reviewed and were correlated with medical records, radiology reports, and surgical laparotomy reports. In the setting of blunt abdominal trauma, hypotensive patients were compared with normotensive patients who underwent FAST.

RESULTS

During the 6-year study period, 4,029 patients with blunt abdominal trauma underwent sonography, 122 of whom were hypotensive on arrival and underwent FAST. Of 87 hypotensive patients with positive findings on FAST, 69 (79%) were taken directly to exploratory laparotomy without the need for CT. In predicting the need for therapeutic laparotomy in hypotensive patients, the sensitivity of FAST was 85%, specificity was 60%, and accuracy was 77%. Of the 3,907 normotensive patients, 3,584 had negative FAST findings, whereas 323 had positive FAST findings. In normotensive patients, the sensitivity of FAST was 85%, specificity was 96%, and accuracy was 96%. In the combined patient population (all hypotensive and normotensive patients), 4,029 patients with blunt abdominal trauma underwent sonography: 3,619 had negative and 410 had positive FAST findings. In all patients regardless of blood pressure, the sensitivity of FAST was 85%, specificity was 96%, and accuracy was 95%.

CONCLUSION

Hypotensive patients screened in the emergency department with positive FAST findings may be triaged directly to therapeutic laparotomy, depending on the results of the sonography examination, without the need for CT.

Management of bleeding following major trauma: a European guideline

INTRODUCTION

Evidence-based recommendations can be made with respect to many aspects of the acute management of the bleeding trauma patient, which when implemented may lead to improved patient outcomes.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing guidelines for the management of bleeding following severe injury. Recommendations were formulated using a nominal group process and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) hierarchy of evidence and were based on a systematic review of published literature.

RESULTS

Key recommendations include the following: The time elapsed between injury and operation should be minimised for patients in need of urgent surgical bleeding control, and patients presenting with haemorrhagic shock and an identified source of bleeding should undergo immediate surgical bleeding control unless initial resuscitation measures are successful. A damage control surgical approach is essential in the severely injured patient. Pelvic ring disruptions should be closed and stabilised, followed by appropriate angiographic embolisation or surgical bleeding control, including packing. Patients presenting with haemorrhagic shock and an unidentified source of bleeding should undergo immediate further assessment as appropriate using focused sonography, computed tomography, serum lactate, and/or base deficit measurements. This guideline also reviews appropriate physiological targets and suggested use and dosing of blood products, pharmacological agents, and coagulation factor replacement in the bleeding trauma patient.

CONCLUSION

A multidisciplinary approach to the management of the bleeding trauma patient will help create circumstances in which optimal care can be provided. By their very nature, these guidelines reflect the current state-of-the-art and will need to be updated and revised as important new evidence becomes available.

Portable ultrasound in pre-hospital emergencies: a feasibility study

BACKGROUND

Ultrasound plays a central role in the evaluation of both trauma and medical emergencies. The development of portable sonography devices could extent its application into the pre-hospital arena. The aim of our study was to evaluate feasibility of pre-hospital ultrasound in the Norwegian Air Rescue setting.

MATERIAL AND METHODS

During a 3-month period, we conducted a prospective study using sonography in pre-hospital patient management. All examinations were carried out by the same ultrasound-certified physician using a Primedic Handyscan in a standardized focused protocol for abdominal and lung sonography and a subcostal 2-chamber long axis view. Inclusion criteria were abdominal/thoracic and obstetric trauma, circulatory/respiratory compromise, pulseless electric activity (PEA) in cardiac arrest, acute abdomen and monitoring during transport. Allowed examination time was restricted to 3 min on the scene. The patient's gender, age, symptoms, trauma mechanism, quality of visualization and diagnose made were recorded. Pre-hospital results were compared with in-hospital findings.

RESULTS

Thirty-eight patients were entered into the study. Three patients had to be excluded due to technical difficulties. Nineteen medical, 15 traumas and 1 obstetric patient were included. Good visualization was obtained in 74% (n= 26), moderate in 26% (n = 9). Median examination time was 2.5 min (range 1-3 min). Nine patients (26%) showed positive sonography findings. Sensitivity was 90%, specificity 96%. Diagnostic usefulness was high in undetermined cardiac arrest and hypotension and massive hematoperitoneum.

CONCLUSION

Pre-hospital ultrasound when applied by an proficient examiner using a goal-directed, time sensitive protocol is feasible, does not delay patient management and provides diagnostic and therapeutic benefit. Further studies are warranted to identify the exact indications and role of pre-hospital sonography.

Color power Doppler US and contrast-enhanced US features of abdominal solid organ injuries

Utilization of color power Doppler and sonographic contrast agents to basic ultrasound (US) further improve the detection and characterization of abdominal injuries, increasing the diagnostic accuracy and value of US as an important technique in the evaluation of the abdominal trauma. This paper provides an illustrated summary of our clinical experience with color power Doppler US (CD-US) and contrast-enhanced US (CE-US) in the evaluation of abdominal solid organ injuries, involving 32 documented cases over a 2-year period. The findings of the CD-US and CE-US were compared with those provided by state-of-the-art contrast-enhanced multidetector 16-row CT.