Ultrasound Empowered Trauma Management

Abstract

Using ultrasound to empower the way of traumatic patient early and by-side management as its ability to discover what bare eyes and hands could not find out solely. The most known EFAST protocol for traumatic patients management may be extended more wisely by introducing the ultrasound probe(s) through a head-to-toe secondary survey and giving a better idea of what is going on with the patient before transferring him/her out of the emergency department and could save the time and the patient’s condition. This chapter would summarize what we know about ultrasound application on a traumatic patient by his/her side before sending him/her out for any further investigation, a new point of care for the standard of patient management by ultrasound.

1. Introduction

Observation has been one of the essentials of the clinical examination that can be found in almost every medical textbook. The use of various examination equipment due to the development of technology has improved clinical examinations and patient care. For example, we can mention the history of the invention of the stethoscope. Before the stethoscope was produced, physicians used to place their ears directly on the patient’s body for auditory examinations, which was sometimes beyond the considerations of society; for this purpose, the first tool was made of a piece of paper, and later, better and advanced types were prepared, produced, and distributed.

It was mentioned the necessity of observation as one of the first steps of examining people; the possibility of using ultrasound to examine the internal organs of the body makes this purpose possible for a physician to observe and examine the inside of the patient’s body by using an ultrasound probe even before auscultation, palpation, and percussion. By using ultrasound, the examiner can make a better clinical diagnosis of the patient. Also, due to the low invasiveness of this technology, it is possible to use it near the patient and reduce the complications caused by the clinical procedures, e.g., the success of the venipuncture with the use of ultrasound is more than the usual IV cannulation [1, 2, 3, 4].

In this chapter, we will refer to the various applications of ultrasound from the perspective of its use in the management and treatment of trauma patients. And for detailed consideration, the tutorial videos are referenced from Youtube and Aparat streaming channels.

2. Orientation to the machine and probes

Proper recognition of a tool will make its use much more effective and efficient. For a more detailed understanding of the possible software and hardware features of the device, one should get familiar with the machine’s instruction manual. However, in this chapter, we will discuss how to properly place the probes on the patient’s body and the general tips for using medical ultrasound machines.

The ultrasound device’s probes with an indicator will determine whether we should approach the patient. The placement of the piezoelectric crystals on the probe is in the same direction, and this will create only one row of sound that is interpreted by the operator in the plane of axial, coronal, or sagittal images (Figures 1 and 2).

Figure 1.

How the image changes with different positioning of the probe (Courtesy of Dr. John Christian Fox).

Figure 2.

Probes’ indicators (Courtesy of Dr. John Christian Fox).

At the beginning and for a general purpose, like other standard radiological images, the right side of the patient must be on the right side of the screen. For this purpose, the indicator is placed on the patient’s right side and the resulting image is interpreted. On the other hand, if a coronal or sagittal view is needed, the indicator is placed toward the patient’s head, which makes the image from the head toward the patient’s feet.

Three common probes are:

• High-frequency Linear

• Low-frequency Convex

• Phased-Array (Echo), which is also a low-frequency probe

A little physics of wave may be useful here; as the wave moves in the surrounding medium (environment), they have interactions with each other; the medium may reflect, absorb, or pass (with some changes) the wave, and what we see on the ultrasound machine’s screen are those reflected from the medium. The body as a medium may absorb most of the high-frequency waves; however, the low-frequency waves may travel through the body more easily (Figure 3).

Figure 3.

Diverse types of probes (Courtesy of Dr. John Christian Fox).

The air and bone are the two most reflective media (sound waves cannot penetrate them and may reflect through making an acoustic shadow phenomenon); however, other media (such as musculature, fat, fibro-skeletal, and internal solid organs) may pass the wave with some interactions on its amplitude (power) or velocity (speed); however, water and liquid may pass almost every part of the wave but when the wave reaches to the other medium due to media difference, it may get reflected and make acoustic echo phenomenon (Figures 4–6).

Figure 4.

Posterior shadow (Courtesy of Dr. John Christian Fox).

Figure 5.

Posterior echo (Courtesy of Dr. John Christian Fox).

Figure 6.

Gas scattering (Courtesy of Dr. John Christian Fox).

Though the high-frequency probes are used for surface study, their wave cannot penetrate deep into the body. But low-frequency probes are used for deeper studies. However, some use low-frequency convex probes for surface studies by reducing their penetrating depth, it may speed up their examination of the patient but could not display the detailed view like a high-frequency probe can.

By the way, the higher frequency of a wave makes it for better images, (e.g., 60 Hz vs. 90 Hz vs. 120 Hz commercial displays may be a good example of image sharpness and brings this topic to mind) (Video 1, https://www.youtube.com/watch?v=VBHCmw8iHCc&list=PL539B142177BA83F7, https://www.aparat.com/v/9ifZw).

3. Empowering airway assessment

Guidelines of the ATLS emphasize on airway as a priority in the ABCDE approach; for airway assessment other than using LEMON criteria, the ultrasound could be used for further evaluation and even intubation confirmation; however, as ultrasound is non-penetrating through the air, it may be out of mind. Here’s how we could use ultrasound for assessing airway:

For assessing the larynx and its cartilages, put the linear probe with the indicator pointing to the patient’s head on the anterior cervical mid-line. A white line should be observed, which may show the triangular shape on the beginning and right side of the screen, it is the thyroid cartilage, above this structure (right side of the screen), the hyoid bone (and vocal cords) could be studied, and beneath the thyroid cartilage is the place for cricoid and three or four tracheal rings (above manubrium), the thyroid gland, which is a normo-echoic structure, is placed superficial to these beneath structures.

By turning the probe’s indicator to the right side, it provides axial plane images from the body, the vocal cords may be seen in this way more accurately; however, for evaluating and confirmation of the endo-tracheal tube (ETT) with ultrasound, the most specific approach is to not find it through the esophagus, which mostly lay right-posterior to the trachea. Also, the ETT has air inside the tube and reflects the ultrasound wave in a scattering pattern (Video 2, https://www.aparat.com/v/0cZr5?t=638).

This method may also be useful in forecasting the size of the trachea, ETT, and LMA size(s) too [5].

4. Empowering breathing assessment

As lung ultrasound was introduced with BLUE protocol about 10–15 years ago, it could even change the FAST exam into E-FAST [6]. However, searching for pneumothoraces or hemothoraces is not the only application of the lung ultrasound, searching for rocket b-lines (b-lines that extend more deep in the field), vascular profile, etc., may help the physician for diagnosing the probable reasons for the acute respiratory failure (Figure 7 and Video 3, https://www.youtube.com/watch?v=RFrPO-8jQP4&list=PL2AGl6-lzXJQt3LGH0Fqc5rjIn_hwmfhZ, https://www.aparat.com/v/aqSYt?t=664). Because it’s out of consideration for trauma management, we leave it for your own for further investigation. The latest chest journal paper in 2015 is highly recommended [7]. Also the E-FAST and RUSH protocols are covered in the circulation section.

Figure 7.

BLUE-protocol algorithm.

5. Empowering circulation assessment

The Focused Abdominal Sonography for Trauma (FAST) was first introduced to get a surrogate for Deep Peritoneal Lavage (DPL), it covered only three windows: right-side hepato-renal (Morrison Punch), left-side splenorenal, and supra-pubic peri-vesical views. Then it has been changed into Focused Assessment Sonography for Trauma (FAST) due to the advancement of the 4th window, Sub-Xiphoid pericardial assessment, and nowadays the Extended-Focused Assessment Sonography for Trauma(E-FAST) protocol took place for this purpose by assessing for the pneumothorax and hemothorax [6, 8].

To cover this examination by patient side, mostly we start with a low-frequency probe (To reduce the effects of ribs concealing shadows, most experts use a phased-array probe rather than a convex probe.) from the right hepatorenal side putting the probe in the sagittal plane of the right mid-axillary and beneath 7-8th inter-costal space, indicator of which lays toward the head of the patient; some fanning also could be helpful to find out the right kidney, and the Morrison punch is the potential space between right kidney and the liver, if any kind of fluid (a dark hypoechoic media with bright posterior acoustic echo) may be observed in this place, it would be positive FAST and needs surgical considerations. It’s recommended to not lose as much information as needed and to set the depth of examination up to the posterior spinal column (Figure 8).

Figure 8.

A positive FAST exam on right hepatorenal (Courtesy of Dr. John Christian Fox).

Like the right side, the examination of the splenorenal in the left needs the same approach; however, the left spleen mostly is posterior and superior, which needs probe positioning in the left mid to posterior axillary line and sometimes full inspiration of the patient to the full view of the space (Figure 9).

Figure 9.

A positive FAST exam on left splenorenal (Courtesy of Dr. John Christian Fox).

For studying the suprapubic perivesical site, put the probe with the indicator toward the right side of the body just above the pubic symphysis and slightly tilt and fan the probe toward the pelvic, the bladder will come out as a pouch full of fluid, for determining whether there is any free fluid around the bladder, the most specific site is its posterior (Douglas pouch in female, and also posterior to the womb is potential to get fluid in there); for this goal, just tilt the probe somehow to see the posterior part of the bladder better and then change it into coronal position as the indicator toward the head, this maneuver will change the operator’s point of view from axial into coronal and the posterior side of the bladder may come into the field better, i.e., what is shown on the right side of the screen (probe is indicating toward the head) is lay on the posterior side of the bladder (Figure 10).

Figure 10.

A positive FAST exam on suprapubic perivesial (Courtesy of Dr. John Christian Fox).

Meanwhile, the sub-xiphoid pericardial view is the 4th side of the classic FAST, in case it could not achievable, some recommend for left sternal border window for this goal. However, before starting from the sub-xiphoid, increase the depth of the machine for more than 20 cm in an adult patient, put the probe with the indicator toward the right side, and try to open this window using the liver medium on the right side, because of the scattering phenomenon of the gastric gas that may obscure the field, if the image came out to study the heart as a four-chamber view with right ventricle, which lays on top of the liver (the chamber is near to the probe), the left ventricle is behind it on the screen, the right atrium is the chamber lays on the right side of the screen, and the left atrium is what leftover far from the probe (Figure 11). However, in case this image was not available, more pressure may be needed to better visualize the field, but some references prohibit it in children due to the probability of sudden cardiac arrest, at this time the parasternal view may be much more helpful.

Figure 11.

A positive FAST exam as pericardial effusion (Courtesy of Dr. John Christian Fox).

After completing this four-site ultrasound examination, for extending the assessment for the trauma, it’s time for assessing chest fields for possible pneumothorax or hemothorax. We would expect the gas to be higher and the liquid to be lower, so if pneumothorax is made, it could be on the anterior part of the chest. Using motion mode (M-Mode) should determine the pleural motion better than a normal lung sliding (or sea-shore sign) (Figure 12); however, in pneumothorax, this sliding is not shown because all of the points from the skin to the pleura are standstill (they do not move like normal lung movement), they demonstrate a stratosphere (or barcode) sign, by the way sometimes in pneumothoraces that does not fulfill the field, a lung point be may observed (Figure 13). For this purpose, use a high-frequency linear probe or decrease the depth of the curve probe, which was used during other parts of the FAST exam to 3–4 cm. Put the probe with the indicator toward the patient’s head and start studying the lung for possible pneumothoraces on the anterior part of each side from the upper clavicular region up to down rib cages. For assessing the fluid (e.g., hemothorax or pleural effusion), the best place is superior to the diaphragm, where it’s expected that the chest fluid may be stuck, it could also be examined while hepatorenal and splenorenal examination and considering diminished mirror effect of the diaphragm toward the head site. Video 4 (https://www.youtube.com/watch?v=klqeADRgvkM&list=PL2AGl6-lzXJTRn113DAv1Iybh_AFHBwFX, https://www.aparat.com/v/RBo4v) has a full list play of the E-FAST exam.

Figure 12.

Normal Lung-Sliding (Sea-Shore sign) (Courtesy of Daniel A. Lichtenstein).

Figure 13.

Stratosphere & lung-point signs of pneumothorax (Courtesy of Daniel A. Lichtenstein).

Even IV cannulation is much safer and easier with the power of ultrasound; however, in almost every procedure using ultrasound, two operators are recommended, the sono-expert to hold the probe and bring the good field of action, and the other operator to do the procedure. For this goal, first the vein should find in the axial plane and place the target in mid-line with the probe; measure the depth of the target from the skin (that probe lies on it), with the law of trigonometry in mind, presume an isosceles right triangle by manipulating the needle in the equal length of the target depth in a 45-degree angle. Change the probe position from axial, parallel to the needle that indicates toward needle (this maneuver shows all of the vein in a longitudinal view) and advance the needle then, popping into the vessel could also be seen on the screen, and cannulation is achieved [2]. This technique is the principal for almost every vascular cannulation or regional nerve block, Videos 5 (https://www.youtube.com/watch?v=uHfeyAYiWOc&list=PL9883F0497505F4B1, https://www.aparat.com/v/U1TA0?t=199), 6 (https://www.youtube.com/watch?v=EUMqxKJ2mPA&list=PL2AGl6-lzXJRBLHhfEVsywsfUxqnHBHXG, https://www.aparat.com/v/0cZr5?t=807) and 14 (https://www.youtube.com/watch?v=ndnZxAcNjdg&list=PL09BFE9E4CB8A7050, https://www.youtube.com/watch?v=xvAY_bu_S7A&list=PL2AGl6-lzXJSYEVni4b7V8yAC8pmtccaX) are playlists of these procedures [3, 4, 9].

There’s another ultrasound protocol for critical-care and hypotensive patients that is known as the RUSH exam, the Rapid Ultrasound for Shock and Hemorrhage [1, 10, 11]. It was first described in 2006 and got into medical literature 3–4 years by. Also, trauma patients may be in shock, and other than “Blood on the floor, and four/five more (Chest, Abdomen, Pelvic, Femur(long bones) and SCALP are potential sites for life-threatening bleeding),” a RUSH exam may empower the physicians’ consideration on the possible reason of the shock (other than blood loss). The RUSH protocol divides the homeostatic system into “Pump,” “Tank,” and “Pipes.” Which is an example of “Heart,” “Potential spaces,” and “Vessels,” respectively.

Focused primary echocardiography could study the heart for its musculature and valve movements, their insufficiency could be obtained, and more results could be achieved than just pericardial effusion purpose of the E-FAST exam. For this goal, start with the parasternal, then apical four-chamber, and finally the sub-xiphoid windows. On the long-axis parasternal the indicator of the probe toward the right shoulder, while on the short-axis parasternal, it aims at the left shoulder. The long-axis and short-axis views are demonstrated in Figures 14 and 15 in systole and diastole, also ventricular contractility and LVEF could be obtained through this window using M-Mode, which is demonstrated in Figure 16. for achieving the apical view, put the probe on the Point of Maximum Impulse (PMI) on the left 5–6th mid-clavicular inter-costal space, both the probe and screen indicator should be in the same position (if it wasn’t changed after the short-axis view, it’s expected to be on the left side), what appear in the four-chamber view are two ventricles adjacent to the probe and two atria far from the probe, the right heart is on the right side and the left is on the left-side (pay attention to the probe and screen indicators’ sameness), using Color-Doppler mode could bring the valves functionality and chambers’ flow very well. And finally, the sub-xiphoid view, which is the standard recommended view in the FAST exam and was discussed there (Video 7, https://www.youtube.com/watch?v=1UJ6RodOSTw&list=PL2AGl6-lzXJRp3Dh0t1YZ2qsyic0msYDd, https://www.aparat.com/v/bmzqQ).

Figure 14.

Long-axis parasternal view.

Figure 15.

Short-axis parasternal view for mitral valve (Courtesy of Dr. John Christian Fox).

Figure 16.

Using M-mode for assessing contractility.

The “tank” or potential spaces are mostly covered by E-FAST examinations, the potential spaces for free fluid and great vessels like the Aorta and the IVC. The aorta and IVC both could be part of a cardiac exam too, thus they are great vessels of the body, in a shock patient, the aorta could be torn or aneurysmal, where both could be evaluated in descending abdominal aorta by using low-frequency convex or phased-array probe, both in axial and sagittal planes. Just it should be kept in mind that it may need extra force to pull over intestinal and gastric gas to find out vascular structures, also IVC lay just on the right side of the aorta and could be examined with the aorta or from the right hepatic window in sagittal plain (Figure 17 and Video 8, https://www.youtube.com/watch?v=khD3dnxEt2o&list=PL2AGl6-lzXJRtdqShRXDozbmtx6Pw4fZC, https://www.aparat.com/v/bmzqQ?t=1247).

Figure 17.

IVC size and changes correlation with CVP.

And finally, the “pipes” are mostly referred to deep veins for DVTs. The three-point access that consists of femoral, popliteal, and greater saphenous veins on each side is the acceptable examination for Deep Vein studies (Video 8, https://www.youtube.com/watch?v=khD3dnxEt2o&list=PL2AGl6-lzXJRtdqShRXDozbmtx6Pw4fZC, https://www.aparat.com/v/bmzqQ?t=1247).

All of these exams could be summarized as “HI MAP ED” mnemonic [11]:

• Heart

• IVC

• Morrison pouch and complete FAST exam

• Aorta

• Pleural space and pneumothorax

• Ectopic pregnancy (Video 13, https://www.youtube.com/watch?v=GBpiF7ML1CA&list=PL2AGl6-lzXJT4sk_DMVQtBNapC36AgTZp, https://www.aparat.com/v/ukBwf)

• DVTand the final diagnosis of shock reason could get whether the “pump,” “tank,” or “pipes” are responsible; Figures 18 and 19 summarize the RUSH protocol (Video 9, https://www.youtube.com/watch?v=9UyVHqvGgHE&list=PL2AGl6-lzXJS9fkywFRsQIwzp31-Lc1nX, https://www.aparat.com/v/zEvcw).

Figure 18.

Using the RUSH protocol to diagnose the type of shock.

Figure 19.

RUSH protocol summary.

6. Empowering diagnosis and neurological assessment

The high-frequency linear probe could be used for skin and soft tissue examination, e.g., cellulitis and soft tissue infection’s cobblestone pattern (Video 12, https://www.aparat.com/v/U1TA0?t=71). Using this probe also could be the on-site tool for assessing tendons and muscles movements, bone fractures (also to assess whether fracture bone has been reduced after manipulation), and other orthopedic examinations (Video 11, https://www.youtube.com/watch?v=7G56DN38mz8&list=PLEF41F6DAEE3FD1A8, https://www.aparat.com/v/0cZr5?t=5). As described in IV canulation, the regional nerve block could be done using ultrasound power though with fewer complications (Video 14, https://www.youtube.com/watch?v=ndnZxAcNjdg&list=PL09BFE9E4CB8A7050, https://www.youtube.com/watch?v=xvAY_bu_S7A&list=PL2AGl6-lzXJSYEVni4b7V8yAC8pmtccaX).

However, ocular ultrasound may be the indescribable use of the linear probe in the emergency department, other than studying the orbit structure for lens and retinal placement or detachments, Iris muscles movement and pupil reflex, and anterior and posterior chambers of the eyeball, the rise of Intra Cranial Pressure (ICP) could affect optic nerve (Cranial Nerve II) and widen its diameter, this could be assessed after freezing the image on the screen and measuring the optic nerve’s external diameter in 3 mm length to the orbit entrance, whether this sheath is more than 5 mm in diameter length it shows a rise in ICP, Figure 20 shows retinal detachment, while other ocular ultrasound anatomical structures (Video 10, https://www.youtube.com/watch?v=uPqTz4OuNd0&list=PL2AGl6-lzXJTPj1GxVxCVyeg_srRs7oVg, https://www.aparat.com/v/0cZr5?t=235).

Figure 20.

Retinal detachment in occular B-mode ultrasound.

7. Conclusions

Using ultrasound alongside clinical examinations or during critical-care procedures empowers the ability of healthcare providers and physicians for better clinical decision makings and less invasive procedures. Like other clinical procedures, those who try and study more on the ultrasound could achieve better results, we recommend the use of ultrasound in any possible clinical situation for all providers, and the links that are mentioned in the appendices are highly recommended for reference.

Acknowledgments

I would like to mention the support and consideration of my kind family, especially my lovely wife who has always been there; besides, I need to acknowledge all my colleagues in the emergency department of Imam Khomeini hospital, Sarab, Iran; specifically the ward supervisor Mr. Masoud Abeshzadeh, ward-nurses Mrs. Feyzi, Mr. Reza Sayyareh, Mr. Mohammad Shokri, and my supportive alumni Dr. Roghayyeh Yaghoubi and Dr. Saba Nemati, for all of their kind and support during working shifts and recording tutorial videos. Also, I have to greet whoever tries to make the knowledge and experience sharing free and achievable for all around the world, especially “InTech Open” and “Free Software Foundation.”

Conflict of interest

There is no conflict of interest to report.

1. https://www.aparat.com/v/9ifZw?playlist=1629800 (My Aparat.com channel’s playlist for Ultrasound Tutor—In Persian Language).

2. https://www.youtube.com/c/sonosite (Fujifilm—Sonosite Youtube! Channel).

3. https://www.youtube.com/user/jfoxmd (Dr. John Christian Fox’s Youtube! Channel).

Acronyms and abbreviations

ACS

American College of Surgeons

ACLS

Advanced Cardiac Life Support

AHA

American Heart Association

ATLS

Advanced Trauma Life Support

BLUE

Bedside Lung Ultrasound in Emergency department

COT

Committee On Trauma

DVT

Deep Vein Thrombosis

EFAST

Extended Focused Assessment Sonography for Trauma

ETT

Endo Tracheal Tube

ICP

Intra Cranial Pressure

IVC

Inferior Vena Cava

LEMON

Look externally, Evaluate 3-3-2, Mallampati score, Obstruction, Neck mobility

LMA

Laryngeal Mask Airway

PMI

Point of Maximum Impluse

POCUS

Point Of Care UltraSound

RUSH

Rapid Ultrasound in Shock and Hemorrhage