Welcome to the Ultrasound Leadership Academy (ULA) summary blog series. This week, we discuss advanced ultrasound in trauma. The ULA is essentially an online advanced ultrasound education experience put on by the team from Ultrasound Podcast which brings cutting edge learning to emergency medicine personnel through a variety of interactive platforms including video lectures, google hangouts with experts, simulation, live conferences and real time scanning with a pocket-sized ultrasound device known as a Vscan.
Over the next year I will be posting summaries of the key learning points from my experience. If you want to learn more about the program you can visit Ultrasound Leadership Academy or Ultrasound Podcast to see more from the hosts of this awesome program.
If you thought that the EFAST would be the only use of ultrasound in trauma then you were wrong. We are just beginning to touch on the extended utility of ultrasound in trauma. Not only is ultrasound critical for diagnosing major life-threatening bleeding in the abdomen, chest and around the pericardium, it is quickly becoming a useful adjunct to assessing your A-B-Cs in trauma. Ultrasound is not necessarily replacing our standard imaging adjuvants, but is rather a compliment to them, and can be used dynamically during resuscitation of the trauma patient to guide both clinical decisions and interventions.
Today we will discuss a few ultrasound tricks that you will be able to use during trauma resuscitation when performing your primary survey.
Confirm intubation: While end-tidal CO2 remains our gold standard for confirming ETT placement, in a trauma setting where time is of the essence, dynamic visualization of tube placement may facilitate rapid recognition of esophageal intubation.
Bilateral Ventilation: Now that you have confirmed your tube is in the trachea, it may be useful to confirm that you are not in the right mainstem bronchus. Assess for lung sliding (review lung US here) bilaterally during each ventilation breath. If you are not seeing sliding on the left, pull back the ETT a centimeter at a time until you do.
Pre-mark neck for potential cricothyrotomy: Not everyone has a thin neck with great landmarks. If you have a bad trauma with significant facial trauma, it may be a good idea to evaluate the neck and identify the cricothyroid membrane in anticipation of a potential difficult airway. You will be using a linear probe in a midline sagittal plane. You are looking for thyroid cartilage, the cricothyroid membrane and the cricoid cartilage. Go to minute 9:45 in the US Cric video below to see dynamic explanation of the anatomy.
We know that ultrasound is more sensitive that CXR for picking up a pneumothorax in blunt trauma, so it should already be standard to be performing the EFAST (E for extended) exam versus the original FAST to evaluate for both pneumothorax and hemothorax. This should take you less than 1 additional minute over the basic FAST exam. Review the EFAST here.
You can also pick up on more subtle findings such as lung contusions. When examining the lung fields with ultrasound, you will need to be looking for focal B-lines that represents localized lung damage. Review lung ultrasound here, including essential artifacts that help us understand the air-fluid balance within lung tissue.
You will already be checking a cardiac window during your FAST exam. Remember that on obese patient's the subxiphoid view will be difficult to obtain so you can always rely on your parasternal long axis view when you need it. Be sure to check for a pericardial effusion but also look at the LV function and assess if it is depressed or hyperdynamic. Review basic cardiac US here.
You then will want to turn your attention to the IVC and assess its diameter and how it changes with respiration. This will assist you in determining how severe their hypovolemia/hemorrhage is and whether then may need some blood super stat. A flat, collapsing IVC suggests the tank is empty. Also consider that a plump, non collapsing IVC with a pericardial effusion suggests a pericardial sac that may need to be drained. Basics of IVC ultrasound here with Scott Weingart.
THAT'S IT FOR THIS WEEK
If you are interested in learning more about the ULA learning experience, visit their website below:
All images are courtesy of the ULA online video course unless otherwise stated. More on DVT ultrasound can be found in "Introduction to Bedside Ultrasound," Volume 1 & 2, from Dr. Mallin and Dr. Dawson. If you are interested in purchasing these ebooks for less than $1, visit Ultrasound Podcast Consumables.
- Ultrasound Leadership Academy Advanced Trauma
- Rippey et al. Ultrasound in Trauma. Best Practice & Research Clinical Anaesthesiology. 2009 March;23(3): 343-362.
- Muslu et al. Use of sonography for rapid identification of esophageal and tracheal intubations in adult patients. J Ultrasound Med. 2011 May;30(5):671-6.