FAST- FOCUS ABDOMINAL SONOGRAPHY IN TRAUMA.

Clinical Questions-  žIS THERE A FREE FLUID?

YOUR EXPECTATIONS CAN BE :-

A)  DO NOT EXPECT- 1. TO DETECT ALL OR ALMOST ALL PATHOLOGY PRESENT.

                                       2. EVERY PATIENT TO GIVE YOU "PRETTY" PICTURE.

                                       3. ALL OF THE DATA OF A FORMAL ULTRASOUND EXAM.

B)       DO EXPECT    - 1.  BETTER CLINICAL DATA THAN PHYSICAL EXAMINATION.

                                       2. IMPORTANT TIME SAVING INFORMATION.

                                       3. QUICK DETERMINATION OF PRESENCE OF FLUID COLLECTION.

THE QUESTION IS- WHAT YOU SHOULD GET FROM FAST SCAN AND WHATS THE REASONABLE EXPECTATION?

YOU SHOULD KNOW FOUR IMPORTANT TIPS- 

1. PRESENCE OR ABSENCE OF FREE FLUID IN ABDOMEN.

2. PRESENCE OR ABSENCE OF FREE FLUID IN THE CHEST.

3. PRESENCE OR ABSENCE OF FREE FLUID IN THE PELVIS. 

4. PRESENCE OR ABSENCE OF FREE FLUID IN CARDIAC ACTIVITY.

WHAT IS THE FAST PRINCIPLES?

1. DETECTS FREE INTRAPERITONEAL FLUID.

2. BLOOD/FLUIDS POOLS IN DEPENDENT AREAS.

3. PELVIS- THE MOST DEPENDENT.

4. HEPATORENAL FOSSA- MOST DEPENDENT AREA IN SUPRAMESOCOLIC REGION.

5. PELVIS AND SUPRA-MESOCOLIC AREAS COMMUNICATE- PHRENICOLIC LIGAMENT   

    PREVENTS TO FLOW.

6. LIVER/SPLEEN INJURY-REPRESENTS 2/3 OF CASES OF BLUNT ABDOMINAL TRAUMA.

7. INTRAPERITONEAL FLUID MAY BE SUCH AS BLOOD, PRE-EXISTING ASCITES, URINE, 

    INTESTINAL CONTENTS.

REMEMBER- THIS ALL SHOULD BE DOING WHEN PERFORMING RESUSCITATION,PHYSICAL EXAM AND STABILIZATION.       

WHEN FAST CAN DO?

IT SHOULD BE PERFORMED IMMEDIATELY AFTER THE PRIMARY SURVEY. MANY LIFE THREATENING INJURIES CAUSE BLEEDING AS WE ALL KNOW. ALTHOUGH ULTRASOUND IS NOT 100% SENSITIVE FOR IDENTIFYING ALL BLEEDING, IT IS NEARLY PERFECT FOR RECOGNIZING INTRAPERITONEAL BLEEDING IN HYPOTENSIVE PATIENTS THAT NEED AN EMERGENT LAPAROTOMY AND FOR DIAGNOSING CARDIAC INJURIES FROM PENETRATING TRAUMA.

INDICATIONS OF FAST

1. HEMODYNAMICALLY UNSTABLE PATIENTS-CAUSE OF HYPOTENSIONN IS UNCLEAR.

2. EMERGENT BEDSIDE PROCEDURE.

3. PATIENTS WHO REQUIRE TRANSFER.

4. INTOXICATED PATIENTS WHO CAN BE OBSEVED AND REEXAMINED.

5. PATIENTS WITH PENETRATING TRAUMA WITH MULTIPLE WOUNDS OR UNCLEAR  

   TRAJECTORY.

6. PATIENT WITH A CONCERNING MECHANISM OF INJURY BUT NO INDICATION FOR 

   CT- PERIOD OF OBSERVATIONAND SERIAL FAST EXAMS.

THIS IS THE ANATOMY OF PERITONEAL CAVITY.

CORONAL SECTION-INTRA ABDOMINAL POTENTIAL SPACE

ANATOMY- CARDIAC

                                                                  SUBXIPHOID

                                                                   PARASTERNAL

SCANNING TECHNIQUE & NORMAL FINDINGS

FAST EXAMS IS TO FIND FREE FLUIDS (USUALLY  BLOOD)-PERICARDIAL,PLEURAL AND INTRAPERITONEAL SPACES.

" FREE FLUIDS IS LIKE JET BLACK AND TENDS TO COLLECT IN THE MOST DEPENDENT AREAS AND SURROUND THE ORGANS"

SCANNING TECHNIQUE

  FAST PROTOCOL

- SUBXIPHOID CARDIAC VIEW

- LEFT CORONAL & INTERCOASTAL OBLIQUE VIEW

- RIGHT CORONAL & INTERCOASTAL OBLIQUE VIEW

- PELVIC VIEW

SUBXIPHOID VIEW

PROBE- SUBXIPHOID AREA ANGLETOWARDS LEFT SHOULDER  

PARASTERNAL LONG AXIS VIEW

PROBE- MARKER DIRECTED TO PTS RIGHT SHOULDER

 (10 o' CLOCK)

RIGHT CORONAL AND INTERCOASTAL OBLIQUE VIEWS- HEPATORENAL RECESS

PROBE- RIGHT MID AXILLARR LINE BETWEEN 8th AND 11th RIBS, MARKER DIRECTED AT RIGHT POSTERIOR AXILLA.

RIGHT CORONAL AND INTERCOSTAL OBLIQUE VIEWS

PROBE- RIGHT MID AXILLARY LINE BETWEEN 8th & 11th RIBS, MARKER DIRECTED AT RIGHT POSTERIOR AXILLA

LEFT CORONAL AND INTERCOASTAL OBLIQUE VIEWS OF SPLEENORENAL RECESS

PROBE- LEFT POSTERIOR AXILLARY LINE BETWEEN 8th & 11th RIBS, MAKER TOWARDS LEFT POSTERIOR AXILLA.

PELVIC VIEWS- LONGITUDITIONAL

PROBE- 2CM ABOVE SYMPHYSIS PUBIS ALONG MIDLINE, PLACE IT LONGITUDITIONALLY AND TRANSVERSELY.

PELVIC VIEW- TRANSVERSE

PROBE- RIGHT MID AXILLARY LINE BETWEEN 8th & 11th, MARKER DIRECTED AT RIGHT POSTERIOR AXILLA

PEARLS & PITFALLS

-DIMMING THE LIGHT

-NOT ALL ABDOMINAL INJURIES PRODUCE FREE FLUID

-IF THAT INITIAL FAST EXAM IS NEGATIVE AND CLINICAL SUSPICION REMAINS HIGH, CONSIDER A REPEAT FAST EXAM OR SERIAL FAST.

-TRENDELENBURG POSITION TO VISUALISE FREE FLUID AT PERIHEPATIC & PERISPLENIC EXAMINATION.

-CONSIDER REVERSE TRENDELENBURG POSITION WHILE EVALUATING FOR HEMOTHORAX OR PELVIC FREE FLUID.

-MULTIPLE WINDOWS MAY BE REQUIRE TO FULLY EVALUATE FOR FREE FLUID.

-IF VISUALIZATION OF THE PERISPLENIC VIEW IS INADEQUATE, MOVING THE PROBE CAUDAD AND POSTERIOR MAY IMPROVE THE WINDOW.

-SUBCUTANEOUS EMPHYSEMA OBSCURE VISUALIZATION.

- PERICARDIAL ANECHOIC/HYPOECHOIC STRIPES THAT ARE CIRCUMFERENTIAL USUALLY REPRESENT PERICARDIAL FLUID,WHEREAS A FOCAL ANTERIOR HYPOECHOIC REGION MAY BE NORMAL PERICARDIAL FAT.

-PERICARDIAL EFFUSION USUALLY WRAPS AROUND THE APEX OF THE HEART.

-FREE FLUID ISN'T ALWAYS BLOOD, CONSIDER ASCITES, FLUID RELATED TO A RUPTURED OVARIAN CYST, RUPTURED BLADDER OR PERITONEAL DIALYSIS.

-CONSIDER COMPARISON VIEWS BETWEEN EACH KIDNEY.

-CLOTTED BLOOD CAN GENERATE VARIOUS DEGREES OF ECHOGENICITY.

CAUTIONS

URGENT SURGICAL CONSULTATION IS MANDATORY IN THE UNSTABLE TRAUMA, PATIENTS THAT SUSPECTED OF INTRAABDOMINAL INJURY, AND NOT INDICATE IN PATIENT WITH CLEAT INDICATION OF LAPAROTOMY.

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BASIC CLINICAL HISTORY OF THE SYSTEMS. 

Chapter 2: Step's of History Taking 

In this chapter, i will be covering the 'basics history' that need to know for an early diagnosed be made. I will be covering few systems, that will be the basic but most impotent question that you should ask the patient. The complete of the systems, i will be covering in chapter 3, that it will be covering up the systems and psychical examination. 

1. Cardiovascular System

Breathlessness, short of breath (sob), difficult in breathing- onset, when, eg: worse on exertion, at night- may be can be PND, or ask the patients how many pillows are they using to sleep, more than 1-should be ortopnea. Ask the patient whats the relieving factors. Listen to the breath sounds, any wheeze and see the style of breathing. (will be covering in chapter 3). 

chest pain- ask when, is it the pain started suddenly or when doing some works. The types of pain-duration,severity,radiation, exacerbating factors and relieving factors,  any associated features, any diaoporesis occur. 

Palpitations- when it started,how is the feelings and if can ask the patient to tap out a rhythm. 

Ankle swelling- where,(leg or face), when, how bad it is, when it resolve, any difficult in breathing.

2. Respiratory system

Cough- productive and colour of the sputum, night sweats, 

haemoptysis- sputum with blood 

breathlessness- see whether got cyanosis.

3. Gastrointestinal system

appetite- suddenly loss in appetite, favourite food, weight-(whether increasing, steady or falling), 

dysphagia and dyspepsia

bowel habit-is it suddenly change from normal, stool colour (malena stool, pale,the smell) and consistency, the tendency to float, rectal bleeding or mixed with stool, 

any abdominal pain, any GERD feelings, 

vomiting-the food, blood and how times.

4. Genito Urinary System

urinary frequency- how many times, when usually- at night. when it started.

dysuria- any pain when want to pee or it hesitancy and dribbling

incontinence

haematuria or altered colour- smoky colour

menstrual cycle- any change from usual

impotence- erectile dysfunction

sexual orientation

5. Musculoskeletan system

mobility, any types of arthralgia, joint stiffness or swelling.

6. Central Nervous System

sense of taste and smell- sudden change of taste and smell

weakness and headache-body weakness not due to age, severe headache on and off- not because migraine or tension headache

dizzy spells, faint and falls- feeling dizziness suddenly and almost want to fainted- may be syncopal attack

numbness- sudden numbness an some area of body, continues the feeling of numbness

eyesight- sudden diplopia,vertigo

tremor or involuntary movement- tremor on hands with on and off or continuously

dysarthria and dysphasia.

HISTORY TAKING FROM THE PATIENT.

OBJECTIVE: EASILY TO DIAGNOSE A PATIENT.

Step's of History Taking towards the patient chapter 1.

Steps of history taking:- First of all, introduce yourself to the patient and ask permission to interview and examine the patient, (depends to the situation). If the patient is female, please ask a female staff nurse to assist you as chaperon. Developing a good rapport between a patient is essential for a good interview, and diagnose can made easily. This skills only come with practises. Ask the question relevant to the system suspected of being involved.

 1. Patients important data- name, address, age, sex, occupation, family burden's.

 2. History of presenting illness- ask the patient about the chief complain. ex: fever, since when (the duration of fever), condition of fever since started,(sweating too much,rigor,or fever in      phase's like malaria fever), try to find the source of infection.

3. Past medical and surgical history- ask the patients disease that patient having for a long time and short time such as diabetes mellitus, hypertension, tuberculosis, epilepsy, any heart and lungs disease, any operation that patient undergone, try to gather as much can. This information are very important to the diagnose because most of them can have secondary disease from their past diseases.

4. Drugs- Find out what drugs patients using for long and short time period. The purpose of uses the drugs. Any allergies from drugs. Currently on  medication. Obtain as much information as possible.

5. Smoking history and alcohol consumption- past and present.

6. Social and family history-marital status- home condition, ask any disease from the family, heritage diseases, any recent overseas travel.

7. Gynaecology- Find out information for female patient about their period and delivery types. 




Second Chapter will be coming soon, i will touch about the systems and chapter 3 will touch about psychical examination.