外伤超音波简介

1、外傷超音波簡介 陳昭文 醫師急診部 外傷科 高雄醫學大學附設中和紀念醫院及時而正確的診斷對嚴重外傷之病患是絕對重要的我們常用的工具:Physical ExaminationDPLFASTAbdominal CT？Scenario XY19歲男性因車禍受腹部鈍傷送入急診, 血壓為80/40 mmHg, 心搏115, 左上腹壓痛; 輸液2000ml給予後血壓未見起色, 你接下來要安排的檢查是?Scenario XX31歲女性於衝突受上腹部刀傷送入急診, 血壓為130/60 mmHg, 心搏95, 上腹稍微壓痛; 初級檢傷後, 除上腹部五公分傷口外無其他外傷; 血壓仍然穩定, 你接下來要安排的檢查是

2、?常用診斷工具DPLSonographic survey (FAST)CTDPL Diagnostic Peritoneal Lavage腹膜腔內灌洗術可近性高, 易於床邊施行侵襲性檢查易有偽陽性Open methodDPA ”A” Closed method判讀方法Open and closed techniques Catheter inserted into the abdomen, aspirate Positive if gross blood, bile, food, stool If aspirate negative, lavage with 1 liter NS positi

3、veLavage fluid 100,000 RBC/mm3, 500 WBC/mm3, Bacteria on Gram stain Abdominal CTComputed tomography, CAT scan 需影像部門配合, 檢查速度不一重裝備, 可近性低亂槍射鳥, 一網打盡, 敏感度高CAT scanFASTFocused Abdominal Sonography for Trauma輕裝備, 易於使用檢查時間短解析度不佳受操作者個人經驗影響FAST主要搜尋腹腔內積液對生命徵象不穩之病患, 先排除腹內出血與心包填塞之可能Basic 4 views 劍突下 Cardiac (sub

4、xyphoid) view 右上腹 RUQ view (Morrisons pouch) 左上腹 LUQ view (splenorenal space) 骨盆腔 Suprapubic view (Cul-de-Sac)Typical 4 viewsRUQ viewLongitudinal scanTransverse scanIntercostal scanHypochondral scanMorison pouchMay observe pleural space10% is identified with infusing 400ml saline97% is noted with in

5、fusing 1L saline Branney et al. J Trauma 1995LUQ viewLongitudinal scanTransverse scanIntercostal scanHypochondral scanSpleen may be obscured during deep inspirationMay observe pleural space simultaneously Same Victim Subcapsular hematoma Pleural effusion Subxyphoid viewPericardiac sacEchogenesity of

6、 bloodPericardial effusion?Heart movement?Decompressive measureEcho guided pericardiocentesisEquipment16-gauge short-bevel large-bore needle30- or 50-mL syringeEcho- guidedLocal anesthesiaSterile supplies and povidone-iodine solutionSuprapubic viewLongitudinal scanTransverse scanBest viewed under fu

7、ll bladderPhysiologic fluidPhysiologic ascites massive pelvic fluidEFASTExtended FAST scanDetect thoracic lesionFocus on occult pneumothorax (OPTX)Gliding pleura signsLung SlidingLung pointHemothoraxRight or left Intercostal viewSubcostal viewBlunt cardiac injuryPericardial effusion and Wall motionV

8、alve injuries ( regurgitate )FAST or not?100 victims of penetrating torso trauma assessed by our trauma teams. 48 stab wounds, 51 gunshot wounds, and 1 puncture wound.The overall accuracy of the US examination in penetrating torso trauma was 87%, with a sensitivity of 64% and a specificity of 96%. T

9、he positive predictive value was 86% and negative predictive value was 87%. The US examination lacks sensitivity to be used alone in determining operative interventionRarely does US information contribute to the management of patients with penetrating abdominal injuries *A PROSPECTIVE EVALUATION OF

10、ULTRASONOGRAPHY DIAGNOSIS OF PENETRATING ABDOMINAL INJURY Dror Soffer MD, Mark McKenney et al. Ann Emerg Med 2003FAST or not?149 patients with suspicion for abdominal trauma were evaluatedleaving 134 patients for analysis. There were 111 true negative FAST exams, 5 true positives, 17 false negatives

11、, and 2 false positives. Chi-square analysis showed significant discordance between FAST and CT (p0.001).Utilization of FAST as a screening tool for BAI in hemodynamically stable trauma patients results in under-diagnosis of intraabdominal injury Patients with suspected abdominal trauma should under

12、go routine CT scanning. *Not So Fast! M.T. Miller, ND, M.D. Pasquale et al. J Trauma 2002PitfallOperator-dependent: skillReliable?SensitivityMissed injuriesPelvic fluid Full BladderSerial examinationDelayed onsetSubcutaneous emphysema Gas blockThe new ABCsAdmitBeginCT scan如何運用工具?When?Why?Why not?DPL

13、When需立即作YES或NO決定時Hemodynamic instability需進行大手術但無CT 檢查時Rare these days意識不清但需排除腸道損傷時DPLWhyQuick decisionsLooking primarily for gross bloodDPLWhy not為侵襲性檢查Possible complication非治療性開腹手術比率過高Non-therapeutic lap rate app 30%!對穩定血行之病患並不適合FASTWhen需立即作YES或NO決定時Hemodynamic instability穿刺傷之心包膜腔檢視Detect for fluid

14、FASTWhen69 patients with initial BP 90 mmHg22 with positive FAST19(86%)needed a laparotomy47 with negative FAST0(0%) needed a laparotomyWherrett LJ. J Trauma 1996FASTWhy檢查迅速耗時短為非侵襲性檢查 FASTWhyCan be done rapidly!Positive FASTTime required 19+/-5 sec.Just for internal bleeding or cardiac tamponadeNega

15、tive FAST Time required 154+/-13 sec.Wherrett LJ. J Trauma 1996FASTWhy not對穿刺傷敏感度不佳評估損傷不夠全面操作者水平影響判讀無法成為標準篩檢工具 Abdominal CTWhy廣泛檢視腹部器官Solid organ, retroperitoneum, fluid敏感度高非侵襲性Accuracy Vs. Sensitivity正確率Accuracy 敏感度SensitivityDPL98%99%FAST96%75-93%ABD CT99%99%Portable CAT scanHMC SeattleAbdominal C

16、TWhen不必考量時間因素廣泛損害評估是我們的目標病患需接受其他部位CT檢查穿刺腹部彈道之評估Abdominal CTWhy not時間緊繃病患生命徵象不穩作CT耗時又冒險腹膜炎癥象已現作CT不影響開刀之決定Abdominal CTWhy notMulti-institutional study for small bowel injury13% without CT findings21% with solid organ injuries33% with peritoneal signsFakhry J Trauma 2003Digest time了解各檢查工具的優缺點避免無謂的時間浪費正

17、確的醫療處置處理流程 A腹部穿刺傷生命徵象不穩定腹膜炎(+)生命徵象穩定腹膜炎(-)開腹探查 可能合併心臟外傷穿刺傷或彈道需進一步探查FAST Pericardial view其他CTYourchoiceResuscitationOther injury?開腹探查 處理流程 B腹部鈍傷生命徵象不穩定腹膜炎(+/-)FAST 優先無超音波DPL檢查結果(+)檢查結果(-)Solid organ injuryRetroperitoneal injuryObservationLOCDPL處理流程 C腹部鈍傷生命徵象穩定腹膜炎(-)CT Scan檢查結果(-)檢查結果(+)(-) OBS/Tx(+)

18、Exp-lap?Can you make your decision now?Scenario XX52歲女性因車禍受腹部鈍傷送入急診, 血壓為80/40 mmHg, 心搏115, 左上腹壓痛; 輸液2000ml給予後血壓未見起色, 你接下來要安排的檢查是?ResuscitationOther injury?開腹探查 處理流程 B腹部鈍傷生命徵象不穩定腹膜炎(+/-)FAST 優先無超音波DPL檢查結果(+)檢查結果(-)HemodynamicInstablity FASTFree fluid(+)Scenario XY31歲男性於衝突受上腹部刀傷送入急診, 血壓為130/60 mmHg, 心

19、搏95, 上腹稍微壓痛; 初級檢傷後, 除上腹部五公分傷口外無其他外傷; 血壓仍然穩定, 你接下來要安排的檢查是?處理流程 A腹部穿刺傷生命徵象不穩定腹膜炎(+)生命徵象穩定腹膜炎(-)開腹探查 可能合併心臟外傷穿刺傷或彈道需進一步探查FAST Pericardial view其他CTYourchoiceStable Vital signsConclusionDont get “ABC” syndromeGood Decision Favorable outcomeGood Practice Favorable outcomeTime pressureBedside survey?THANK

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