Marta Kot Update on ultrasound in trauma assessment and ...

Integrated Assessment and Management 

<strong>Update</strong> 

Critical Care US and Echocardiography 

Dr <strong>Marta</strong> <strong>Kot</strong> 

Staff Specialist – Intensive Care 

The Canberra Hospital – Australia 

MARTA.KOT@ACT.GOV.AU

Disclosing potential conflicts 

• GE South Africa 

of interest 

• Sponsor for traveling and 

accommodation 

• No restrictions in content or structure 

of the US & lectures 

• Used different Ultrasound Machines 

(Ultrasounds showed in the 

presentations) 

• Demo machines: 

• GE Australasia, SonoSite, Phillips 

Thanks 

• 4 Africa organizers: Dankie vir die uitnodiging 

• Hyla Kluyts 

• Marizaan Vanschalkwyk 

• Marlice Van der Westhuyzen 

• My great South African friends and colleagues 

• Lisa Zuccherelli, Derek Poitgier, Vaughn Oerder, 

Simon Robertson, Peter Velloza… 

• My mentors in Australia 

• Dr Bob Wright (St Vincent’s, Sydney) 

• Prof Tony McLean & Marek Nalos (Nepean, 

Sydney) 

• My inspiration for CC Ultrasound 

• Daniel Lichtenstein (Paris) 

• Paul Mayo (New York) 

Dr <strong>Marta</strong> <strong>Kot</strong>

FOCUSED ASSESMENT 

•Answers relevant clinical 

questions 

•Goal directed Management 

•Prioritized 

INTERVENTION 

THERAPY 

RE 

ASSESSMENT 

SCREENING TEST 

•Triage for Interventions 

DIAGNOSTIC 

TEST 

CLINICAL 

EXAMINATION 

INTEGRATED 

POINT OF CARE 

•Rapid & Available 24/7 

•Portable (ED,OT,ICU) 

•Non invasive 

•Repeatable 

INTO DECISION MAKING AND 

MANAGEMENT 

•Extension of Clinical Examination 

• Unreliable physical exam – 42% accuracy 

•Decision making tool TIMELY 

• Diagnostic test DOES NOT change outcomes 

Management based on information 

PROTOCOLS 


PAST 

•1965: DPL 

• Non therapeutic laparotomies 

•1970s: US Case reports - Europe (Germany) 

•1980s: CT Available 

• Non therapeutic laparotomies (transport , 

radiation, contrast, pregnancy) 

•1992: US – Trauma Surgeons 

• 2 hrs training 

•1990s: Free fluid scoring systems 

•Prediction for Laparotomy 

•1996: FAST (Rozycki) 

•1997: FAST in ATLS (OSCE) 

•1999: Consensus Conference 

•2001: ACEP (ED US guidelines) 

Crit Care Med 35 (2007) S126-S130 

Emerg Med Clin N Am 22 (2004) 581-599 

US 

applications 

CT 

US 

DPL 

FAST 

1960 1970 1980 1990 2000 2010 


MECHANISM OF TRAUMA 

PHYSICAL EXAMINATION 

XR – DPL FAST 

Blood Tests - OT - CT 

TRAUMA 

1 ST SURVEY 

Resuscitation 

2 nd SURVEY 

Re-Assessment 

FAST: 

Focused 

Assessment 

(Abdomen) 

with Sonography 

for Trauma 

TRAUMA 

MECHANISM OF TRAUMA 

STABLE 

1 ST SURVEY 

Resuscitation 

PHYSICAL EXAMINATION 

UNSTABLE 

FAST: ABDO 

Free fluid 

LAPAROTOMY 

EMBOLIZATION 

ULTRASOUND 

eFAST: TTE 

Pericardial effusion 

PERICARDIOCENTESIS 

THORACOTOMY 

2 nd SURVEY 

Re-Assessment 

US: 

Triage for 

interventions 

eFAST: CHEST 

Pneumothorax 

Haemothorax 

THORACOCENTESIS 

CHEST DRAIN 

THORACOTOMY 

Blood Tests - XR - CT 

VASC ACCESS 


Pericardic 

R chest 

Subcostal 

L chest 

Pleura 

Pulmon = Lung 

Hepatorrenal 

Splenorrenal 

Pelvis 

Peri Hepatic 

Pelvis (43%) 

Peri Spleen

SCORING SYSTEMS: Predictor of intervention…(Huang – 

McKenney) 

Non operative management of solid organ injury 

Haemodynamic instability determines surgical / 

interventional strategy 

SCANNING TECHNIQUE: 

1. Sequence: RUQ-Subcostal-LUQ-Pelvis 

• e-FAST: Chest – Paracolic Gutters 

2. Clinically focused – Management enhancement 

• ABCD 

3.Secondary and tertiary survey 


TCD 

OCULAR 

A B C D ... 

CVC 

CERVICAL 

Crycoidothomy 

Tracheostomy 

LUNG 

PLEURAL 

Pneumothorax 

Haemothorax 

Contusion 

Atelectasis 

Alveolo- 

Interstitial 

Syndrome 

Bronchial 

intubation 

Rib fractures 

Diaphragm 

ECHO 

ABDO 

VASCULAR 

Pericardial 

effusion 

Cardiac 

dysfunction 

Preload 

Pacing 

DVT - PE 

Vascular access 

Free fluid 

Pregnancy 

Sepsis 

OCULAR 

NEURO 

Eye Trauma 

OSND 

Brain Neonate 

Transcranial 

TCD 

Spine - Nerve 

Soft 

Tissues 

Bone 

fractures 

Joints 

ART 

PICC 

LUNG 

FREE 

FLUID 

RENAL 

ART 

CVC 

GB 

TRACHY 

TTE 

AAA 

FREE 

FLUID 

BLADDER 

PLEURA 

FREE 

FLUID 

Bowel 

DVT 

SOFT 

TISSUES 

JOINTS 

Dr <strong>Marta</strong> <strong>Kot</strong> 


Curr Opin Crit Care 17 (2011) 606-612 

http://trauma.winfocus.org 

Whole Body Ultrasound, Book, D. Lichtenstein 

NERVE 

BONE

http://trauma.winfocus.org 



A 

B 

Trachea & ETT 

Pneumothorax 

Pleural effusion 

C 

CPR – Pericardial effusion 

FAST – Spleno renal free fluid 

D 

EYE 

OSND 

BRAIN 

Ventricular Blood

LIMITATIONS 

• Obesity – Subcutaneous emphysema (INDETERMINATE) 

• Retroperitoneum – Vascular 

• Bowel - Diaphragm 

• Solid Organ Injury 

• Empty Bladder Saline Filling 

• GAS – BONE 

PITFALLS 

• Bleeding: Early FALSE NEGATIVE Dynamic Reassessment 

• Bleeding Anechoic (acute)- Isoechoic (clot) Hypo–anechoic 

(lysis) 

• Non traumatic Ascites, PD, Women (pelvis) 

• Non free fluid Bowel loop 

• Pelvic fracture Pre–pubic haematoma 

• Abdominal fat 


FREE FLUID 

PHYSICAL 

EXAMINATION 

SENSITIVITY 

SPECIFICITY 

FOCUSED 

ULTRASOUND 

OVERALL ACCURACY 88% 

CT 

SENSITIVITY SPECIFICITY SENSITIVITY SPECIFICITY 

79% (42–97) 99.2% (98–100) 

GOLD STANDARD 

Evidence Based 

Medicine: 

PERICARDIAL 

EFFUSION 

SOLID ORGAN 

INJURY 

~ 50% 

100% 97-99% 

43 - 56 % 

(IV contrast 91%) 

69 – 86% 

(IV contrast 100%) 

GOLD STANDARD 

RCT … difficult to accept 

a control group as FAST 

is considered Standard of 

Care 

RETROPERITONEAL 

BOWEL INJURY 

31 – 42 % 69 – 95 % 95 -100% 

PENETRATING 

INJURIES 

78.6 % (46-71) 97.4 % (94-100) 

Intrinsic Value 

of Imaging 

ADVANTAGES 

STANDARD OF 

CARE 

POINT OF CARE 

TRIAGE FOR INTERVENTIONS 

MULTIPLE APPLICATIONS 

RE-ASSESSMENT 

REMOTE – AEROSPACE – DISASTERS - WAR 

ACCURACY – FIDELITY 

AVAILABILITY 

MDCT: FASTER – MORE ACCURATE 

(unrelated to 

treatment): 

DISADVANTAGES 

UNRELIABLE 

POOR SENSITIVITY 

& SPECIFICITY 

OPERATOR DEPENDENT 

LIMITATIONS (SOLID ORGAN – BOWEL – 

RETROPERITONEUM – DIAPHRAGM - VASCULAR ) 

TRANSPORT 

RADIATION 

CONTRAST 

Not well defined or 

incorporated into costanalysis 




J Trauma (2005) 59: 933-939 

J Trauma (2009) 67: 232-329 

Crit Care Med 35 (2007) S162-172 


Academic Radiology (2012) 19: 

Ultrasound 5 Clin 3 (2008) 23-31 


CLINICAL 

TYPES OF TRAUMA 

Low Clinical 

Suspicion 

Period Clinical 

Observation 

STABLE 

Controversial 

- 

LOW 

SENSITIVITY 

FOR ORGAN 

INJURY 

+ 

UNSTABLE 

Early triage 

- 

SENSITIVE & 

SPECIFIC FOR FREE 

FLUID 

NON ACCURATE 

FOR ORGAN 

INJURY 

BLUNT 

Early triage 

+ 

Intervention 

Surgery 

PENETRATING 

Directs surgical 

priorities 

+ - 

GOOD 

SPECIFICITY 

LOWER 

SENSITIVITY 

(bowel – 

diaphragm) 

UNSTABLE 

US = Initial 

diagnostic 

modality 

Level B ✪ 

False FAST NEGATIVE 

Missed injuries 

Likelihood ratio 0.2- 

0.35 






Ultrasound Clin 3 (2008) 23-31 

J Trauma (2005) 59: 933-939 

Other Diagnostic Strategy 

(CT – ANGIO – SURGERY) 

Crit Care Med 35 (2007) S162-172 


Ann Emerg Med (2011) 57; 387-404 ✪ 


• ACEP (American College of Emergency 

Physicians): Policy Statement – Emergency US 

Guidelines 

Ann Emerg Med 53 (2009) 550-570 

• WINFOCUS: Echocardiography Training (World 

Interactive Network Focused on Critical Ultrasound) 

Cardiovascular Ultrasound 6 (2008): 49 

• American College of Chest Physicians / La 

Societe de Reanimation de Langue Francoise 

Statement on Competence in Critical Care 

Ultrasonography 

Chest 135 (2009) 1050-1060 

• International Expert Statement: Training 

standards for Critical Care Ultrasonography. 

• CEUS (Canadian Emergency Ultrasound Society) 

Recommended Standards 

Intensive Care Med 34 (2011) 2246-9 

W W W. cesus.ca 


PAST PRESENT FUTURE 

TECHNOLOGY 

LIMITED 

PORTABLE – HAND HELD 

HIGH FIDELITY – SIMPLIFIED 

RESISTANT - BATTERY POWERED 

REDUCED COST 

MULTIPLANE - MATRIX 

DATA PROCESSING 

3D – 4D 

PATTERN RECOGNITION 

VOLUME QUANTIFICATION 

DISPOSABLE PROBES 

CONTRAST ENHANCED US 

DIGITAL DATA –VIRTUAL REALITY 

US APPLICATIONS 

SPECIALITY 

DRIVEN 

FOCUSED 

POINT OF CARE 

BEYOND FAST 

TRAINING 

PROCTORED 

SELF – TAUGHT 

FORMAL – STRUCTURED 

e-LEARNING 

SIMULATION 

DEFINED -STRUCTURED 

HIGH FIDELITY SIMULATION 

“TELE – MENTORING” 

CREDENTIALING 

ONLY 

SPECIALITIES 

DESIRABLE 

MANDATORY 

MEDICAL SCHOOL - UNDERGRADUATE 

ENVIRONMENTS 

CARDIOLOGY 

RADIOLOGY 

PORTABLE: ED, OT, ICU 

MILITARY, DISASTERS, AEROSPACE, 

CRUISE 

REMOTE AREAS 

PORTABLE 

TELEMEDICINE: “TELE – SONOGRAPHY” 

MANAGEMENT 

LAPAROTOMY 

NON SURGICAL MANAGEMENT 

ENDOVASCULAR INTERVENTION 

PERCUTANEOUS INTERVENTIONS ? 

Tele-Ultrasound and Paramedics. Remote physician guidance 

Am Journal Emerg Med 29 (2011) 477-481 

Ann Emerg Med 56 (2010) 660-667 

J Trauma, 2010; 68; 2-8 

Acad Radiol (2010); 17; 535 -540 


DIFFERENT GOALS 

• Extension of the Physical examination 

• Answer Relevant Clinical questions 

• Early Triage for Interventions 

• Enhancement and safety for high risk interventions 

• Does not compete with Clinical Examination or CT 

• Multimodality 

FAST 

• Not organ specific 

• More accurate Blunt Trauma & Unstable patients 

• Penetrating injury Good predictor of organ injury (Misses 

diaphragmatic and hollow visceral injury) 

• FAST in a stable patient is controversial 

• Negative Does not exclude intra-abdominal injury 

• Requires complementary diagnostic studies 

e-FAST: 

• Accurate for diagnosis of PTX and Haemothorax 

Management is a clinical decision 

TTE: Pericardial effusion ≠ Pericardial Tamponade 

VASCULAR: Vascular access, DVT 

FUTURE: 

• Novel applications, Improved Technology, 

Telemedicine, High Fidelity Simulation, Credentialing

Marta Kot Update on ultrasound in trauma assessment and ...

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