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Focused Assessment with Sonography for Trauma (FAST)

Focused assessment with sonography Sonography The visualization of deep structures of the body by recording the reflections or echoes of ultrasonic pulses directed into the tissues. Use of ultrasound for imaging or diagnostic purposes employs frequencies ranging from 1. 6 to 10 megahertz. Diagnostic Procedures in Gynecology for trauma is a point-of-care ultrasound examination protocol for the abdominal and thoracic cavities performed in the emergency room as part of the secondary survey Secondary Survey ABCDE Assessment in advanced trauma life support. The main goal of the FAST exam is to identify free intraperitoneal Intraperitoneal Peritoneum: Anatomy fluid (blood) and pericardial effusion Pericardial effusion Fluid accumulation within the pericardium. Serous effusions are associated with pericardial diseases. Hemopericardium is associated with trauma. Lipid-containing effusion (chylopericardium) results from leakage of thoracic duct. Severe cases can lead to cardiac tamponade. Pericardial Effusion and Cardiac Tamponade from trauma. As FAST requires only an ultrasound machine at the bedside and an experienced sonographer, it is widely available, quicker, and less invasive than other image modalities. Focused assessment with sonography Sonography The visualization of deep structures of the body by recording the reflections or echoes of ultrasonic pulses directed into the tissues. Use of ultrasound for imaging or diagnostic purposes employs frequencies ranging from 1. 6 to 10 megahertz. Diagnostic Procedures in Gynecology for trauma has largely replaced diagnostic peritoneal lavage Diagnostic peritoneal lavage Washing out of the peritoneal cavity. The procedure is a diagnostic as well as a therapeutic technique following abdominal trauma or inflammation. Penetrating Abdominal Injury.

Last updated: 14 Mar, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Introduction

Definition

Focused assessment with sonography Sonography The visualization of deep structures of the body by recording the reflections or echoes of ultrasonic pulses directed into the tissues. Use of ultrasound for imaging or diagnostic purposes employs frequencies ranging from 1. 6 to 10 megahertz. Diagnostic Procedures in Gynecology for trauma (FAST) is a point-of-care ultrasound (POCUS) examination protocol of the abdominal and thoracic cavities performed with the goal of identifying free intraperitoneal Intraperitoneal Peritoneum: Anatomy fluid and/or pericardial effusion Pericardial effusion Fluid accumulation within the pericardium. Serous effusions are associated with pericardial diseases. Hemopericardium is associated with trauma. Lipid-containing effusion (chylopericardium) results from leakage of thoracic duct. Severe cases can lead to cardiac tamponade. Pericardial Effusion and Cardiac Tamponade.

Background

  • History and physical exams often lack the necessary sensitivity Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques and specificity Specificity Specificity is the probability of correctly determining the absence of a condition. Immunoassays to diagnose acute traumatic pathology of the abdomen accurately.
  • Free fluid within the peritoneal cavity Peritoneal Cavity The space enclosed by the peritoneum. It is divided into two portions, the greater sac and the lesser sac or omental bursa, which lies behind the stomach. The two sacs are connected by the foramen of winslow, or epiploic foramen. Peritoneum: Anatomy settles into dependent areas within the peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum: Anatomy when the individual is supine and can be detected using ultrasound imaging.
  • Sensitivity Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques of 42% and specificity Specificity Specificity is the probability of correctly determining the absence of a condition. Immunoassays ≥ 98% for free peritoneal fluid
  • 100 mL of free fluid can be seen, though > 500 mL is needed for the common user.
  • Pulmonary ultrasound (in the extended FAST (E-FAST)) has a sensitivity Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques of 95%, specificity Specificity Specificity is the probability of correctly determining the absence of a condition. Immunoassays of 91%, and a negative predictive value Negative predictive value The NPV is the percentage of people with a negative test result who are actually disease free, among all people with a negative result regardless of whether or not they have the disease. Epidemiological Values of Diagnostic Tests of 100%.
  • Diagnostic peritoneal lavage Diagnostic peritoneal lavage Washing out of the peritoneal cavity. The procedure is a diagnostic as well as a therapeutic technique following abdominal trauma or inflammation. Penetrating Abdominal Injury ( DPL DPL Washing out of the peritoneal cavity. The procedure is a diagnostic as well as a therapeutic technique following abdominal trauma or inflammation. Penetrating Abdominal Injury) was previously used as the standard test to help physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship decide which individuals with trauma needed an emergent exploratory laparotomy Exploratory Laparotomy Laparotomy and Laparoscopy.
  • FAST has replaced DPL DPL Washing out of the peritoneal cavity. The procedure is a diagnostic as well as a therapeutic technique following abdominal trauma or inflammation. Penetrating Abdominal Injury and is often beneficial over CT for many reasons.
Table: Advantages and disadvantages of the FAST exam
Advantages Disadvantages
  • Can be performed on any individual
  • Early operative determination
  • ↓ Time to diagnosis for acute abdominal injury
  • Accurately diagnoses hemoperitoneum
  • Noninvasive
  • Integrated into the primary or secondary survey Secondary Survey ABCDE Assessment
  • Can be performed quickly
  • Available at the bedside
  • Ease of use for serial examinations
  • Safe for use in pregnant individuals and children
  • Radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma than CT
  • Leads to ↓ DPL DPL Washing out of the peritoneal cavity. The procedure is a diagnostic as well as a therapeutic technique following abdominal trauma or inflammation. Penetrating Abdominal Injury
  • Can lead to ↓ CT scans
  • Operator-dependent method
  • Only evaluates for the presence of blood within the peritoneal cavity Peritoneal Cavity The space enclosed by the peritoneum. It is divided into two portions, the greater sac and the lesser sac or omental bursa, which lies behind the stomach. The two sacs are connected by the foramen of winslow, or epiploic foramen. Peritoneum: Anatomy and not its source
  • Distortion Distortion Defense Mechanisms of images due to obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity, bowel gas Bowel Gas Imaging of the Intestines, and subcutaneous air
  • Can miss diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy, bowel, and pancreatic injuries
  • Does not assess retroperitoneal Retroperitoneal Peritoneum: Anatomy structures
  • Does not visualize extraluminal air
DPL DPL Washing out of the peritoneal cavity. The procedure is a diagnostic as well as a therapeutic technique following abdominal trauma or inflammation. Penetrating Abdominal Injury: diagnostic peritoneal lavage Diagnostic peritoneal lavage Washing out of the peritoneal cavity. The procedure is a diagnostic as well as a therapeutic technique following abdominal trauma or inflammation. Penetrating Abdominal Injury

Indications

  • Blunt abdominal trauma
  • Penetrating abdominal trauma without other indications for immediate laparotomy Laparotomy Incision into the side of the abdomen between the ribs and pelvis. Laparotomy and Laparoscopy

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation

  • No absolute contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation 
  • Should not delay resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome efforts

Findings

  • + FAST will have 1 of the following:
    • Anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) area (blood) within the pericardial space Pericardial Space Pericardial Effusion and Cardiac Tamponade
    • Anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) area (blood) between the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy and kidney
    • Anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) area (blood) between the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy and spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen: Anatomy
    • Anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) area (blood) between the spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen: Anatomy and kidney
    • Anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) area (blood) between superior and posterior to the posterior wall of the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess
  • + E-FAST can have 1 of the added findings:
    • Anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) area (blood) above the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy between the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy and lung
    • Absent lung sliding
  • – FAST should be repeated if there is a change in the condition of the individual.
Decision making pathway for use of the fast

Decision-making pathway for use of the FAST exam in a trauma setting

Image by Lecturio. License: CC BY-NC-SA 4.0

Basics of Ultrasonography

Imaging

  • Sonography Sonography The visualization of deep structures of the body by recording the reflections or echoes of ultrasonic pulses directed into the tissues. Use of ultrasound for imaging or diagnostic purposes employs frequencies ranging from 1. 6 to 10 megahertz. Diagnostic Procedures in Gynecology is an imaging technique based on ultrasound (high-frequency, inaudible sound waves). 
  • Sound waves having a frequency of 2–18 MHz are used in medical imaging.
  • The equipment utilizes a transducer Transducer A device placed on the patient’s body to visualize a target Ultrasound (Sonography) acting as the emitter and receptor Receptor Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors of sound waves, and a central computer processes the electrical signals to generate the image.

Terminology

  • Hyperechoic Hyperechoic A structure that produces a high-amplitude echo (lighter grays and white) Ultrasound (Sonography) (e.g., surface of bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types, urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy calculi, fat-containing lesions): a structure that produces high-amplitude echo (lighter grays and white)
  • Hypoechoic Hypoechoic A structure that produces a low-amplitude echo (darker grays) Ultrasound (Sonography) (e.g., abscesses without gas, solid tumors without calcifications or fat): a structure that produces low-amplitude echo (darker grays)
  • Anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) (e.g., simple cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change): a structure that produces no echo at all (looks completely black)
  • Isoechoic Isoechoic A structure that produces an echo of a very similar amplitude to its environment and is very difficult to distinguish Ultrasound (Sonography): a structure that produces an echo with an amplitude very similar to that of its environment, which is very difficult to distinguish
Imaging concepts of ultrasound

Imaging concepts of ultrasound

Image by Lecturio. License: CC BY-NC-SA 4.0

Probes

Exam

Select probe Probe A device placed on the patient’s body to visualize a target Ultrasound (Sonography):

Location:

RUQ view (Morison’s pouch or hepatorenal fossa)

  • Probe Probe A device placed on the patient’s body to visualize a target Ultrasound (Sonography) placement:
  • Landmarks:
    • Visualize the hepatorenal interface.
    • Space between the right lobe of the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy and the right kidney = Morison’s pouch
  • Scan anterior to posterior and the superior and inferior poles of the kidney.
  • Liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy tip is a common location for missed free fluid.
  • Intraperitoneal Intraperitoneal Peritoneum: Anatomy fluid + hemodynamic instability → exploratory laparotomy Exploratory Laparotomy Laparotomy and Laparoscopy
  • Anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) image above the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy = pleural effusion Pleural Effusion Pleural effusion refers to the accumulation of fluid between the layers of the parietal and visceral pleura. Common causes of this condition include infection, malignancy, autoimmune disorders, or volume overload. Clinical manifestations include chest pain, cough, and dyspnea. Pleural Effusion

Cardiac view Cardiac View ACES and RUSH: Resuscitation Ultrasound Protocols (subxiphoid view)

  • Probe Probe A device placed on the patient’s body to visualize a target Ultrasound (Sonography) placement:
    • Subxiphoid process: The right and left ventricles should be visualized in a long axis Axis The second cervical vertebra. Vertebral Column: Anatomy.
    • Parasternal long, if abdomen is distended or subxiphoid view difficult to obtain
  • Landmarks:
    • Visualize the heart and pericardium Pericardium A conical fibroserous sac surrounding the heart and the roots of the great vessels (aorta; venae cavae; pulmonary artery). Pericardium consists of two sacs: the outer fibrous pericardium and the inner serous pericardium. The latter consists of an outer parietal layer facing the fibrous pericardium, and an inner visceral layer (epicardium) resting next to the heart, and a pericardial cavity between these two layers. Heart: Anatomy.
    • Scan anterior to posterior through the heart.
    • Note: An anterior fat pad can give the impression of pericardial effusion Pericardial effusion Fluid accumulation within the pericardium. Serous effusions are associated with pericardial diseases. Hemopericardium is associated with trauma. Lipid-containing effusion (chylopericardium) results from leakage of thoracic duct. Severe cases can lead to cardiac tamponade. Pericardial Effusion and Cardiac Tamponade but should not be seen on posterior views.
    • An anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) (black) stripe around the ventricles indicates pericardial effusion Pericardial effusion Fluid accumulation within the pericardium. Serous effusions are associated with pericardial diseases. Hemopericardium is associated with trauma. Lipid-containing effusion (chylopericardium) results from leakage of thoracic duct. Severe cases can lead to cardiac tamponade. Pericardial Effusion and Cardiac Tamponade
Ultrasound after chest injury showing pericardial tamponade

Resuscitative ultrasound image following a penetrating chest injury Chest Injury Pediatric Chest Abnormalities illustrating the presence of a pericardial tamponade Tamponade Pericardial effusion, usually of rapid onset, exceeding ventricular filling pressures and causing collapse of the heart with a markedly reduced cardiac output. Pericarditis from a hemopericardium (*):
Arrowheads illustrate the wall of the right ventricle.
RA: right atrium
LA: left atrium
LV: left ventricle

Image: “Ultrasound after chest injury Chest Injury Pediatric Chest Abnormalities showing pericardial tamponade Tamponade Pericardial effusion, usually of rapid onset, exceeding ventricular filling pressures and causing collapse of the heart with a markedly reduced cardiac output. Pericarditis” by Regional Trauma Services, Calgary Heath Region and Foothills Medical Centre, Calgary, Alberta, Canada. License: CC BY 2.0

Left upper quadrant Left upper quadrant Anterior Abdominal Wall: Anatomy view (splenorenal view or splenorenal fossa)

  • Probe Probe A device placed on the patient’s body to visualize a target Ultrasound (Sonography) placement:
  • Landmarks:
    • Appears similar to Morison’s pouch view
    • Identify the space between the spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen: Anatomy and diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy and the splenorenal interface.
  • Fluid collects cephalad to the spleen Spleen The spleen is the largest lymphoid organ in the body, located in the LUQ of the abdomen, superior to the left kidney and posterior to the stomach at the level of the 9th-11th ribs just below the diaphragm. The spleen is highly vascular and acts as an important blood filter, cleansing the blood of pathogens and damaged erythrocytes. Spleen: Anatomy, beneath the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy.
  • Anechoic Anechoic A structure that produces no echo at all (looks completely black) Ultrasound (Sonography) image above the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy = pleural effusion Pleural Effusion Pleural effusion refers to the accumulation of fluid between the layers of the parietal and visceral pleura. Common causes of this condition include infection, malignancy, autoimmune disorders, or volume overload. Clinical manifestations include chest pain, cough, and dyspnea. Pleural Effusion

Bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess view (pelvic)

Ultrasound of the bladder

Normal ultrasound scan of the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess:
Blood/fluid can be seen above or below the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess.

Image by Lecturio.

Extended FAST pulmonary view

  • Probe Probe A device placed on the patient’s body to visualize a target Ultrasound (Sonography) placement:
  • Landmarks:
    • Identify the interface between the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy and lung on the right and left (curvilinear probe Probe A device placed on the patient’s body to visualize a target Ultrasound (Sonography)).
    • Identify lung sliding between 2 ribs Ribs A set of twelve curved bones which connect to the vertebral column posteriorly, and terminate anteriorly as costal cartilage. Together, they form a protective cage around the internal thoracic organs. Chest Wall: Anatomy over the anterior thorax ( linear probe Linear Probe Ultrasound (Sonography)).
  • Visualization of both hemithorax is included in the protocol to assess the presence of:
    • Hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax
    • Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax
Placement of linear ultrasound

Placement of linear ultrasound probe Probe A device placed on the patient’s body to visualize a target Ultrasound (Sonography) for view of lung pleura Pleura The pleura is a serous membrane that lines the walls of the thoracic cavity and the surface of the lungs. This structure of mesodermal origin covers both lungs, the mediastinum, the thoracic surface of the diaphragm, and the inner part of the thoracic cage. The pleura is divided into a visceral pleura and parietal pleura. Pleura: Anatomy and lung sliding in the evaluation for pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax

Image by Lecturio.

Clinical Relevance

  • Sonography Sonography The visualization of deep structures of the body by recording the reflections or echoes of ultrasonic pulses directed into the tissues. Use of ultrasound for imaging or diagnostic purposes employs frequencies ranging from 1. 6 to 10 megahertz. Diagnostic Procedures in Gynecology: an imaging technique based on ultrasound (high-frequency, inaudible sound waves). Sound waves having a frequency of 2–18 MHz are used in medical imaging. The equipment utilizes a transducer Transducer A device placed on the patient’s body to visualize a target Ultrasound (Sonography) acting as the emitter and receptor Receptor Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors of sound waves, and a central computer processes the electrical signals to generate the image. The general advantages of this type of imaging are its low cost, availability, and safety.
  • Hemopericardium ( tamponade Tamponade Pericardial effusion, usually of rapid onset, exceeding ventricular filling pressures and causing collapse of the heart with a markedly reduced cardiac output. Pericarditis): the accumulation of excess fluid in the pericardial space Pericardial Space Pericardial Effusion and Cardiac Tamponade around the heart, which increases pressure, restricts cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) filling, and results in decreased cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) output. Symptoms include dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension, muffled heart sounds Muffled Heart Sounds Pericardial Effusion and Cardiac Tamponade, jugular venous distension Jugular Venous Distension Cardiovascular Examination, and pulsus paradoxus Pulsus paradoxus A drop in systolic blood pressure of > 10 mm hg during inspiration. Pericardial Effusion and Cardiac Tamponade. Diagnosis is confirmed with echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA). Management is emergent pericardiocentesis Pericardiocentesis Puncture and aspiration of fluid from the pericardium. Cardiac Surgery or pericardiotomy.
  • Hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax: collection of blood in the pleural cavity Pleural cavity Paired but separate cavity within the thoracic cavity. It consists of the space between the parietal and visceral pleura and normally contains a capillary layer of serous fluid that lubricates the pleural surfaces. Pleura: Anatomy that most commonly occurs due to damage to the intercostal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology. Affected individuals present with shortness of breath Shortness of breath Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain, hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension, tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children, decreased lung sounds, and dullness on percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination of the chest. Diagnosis is by chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests. Management is with tube thoracostomy Tube Thoracostomy Surgical procedure involving the creation of an opening (stoma) into the chest cavity for drainage; used in the treatment of pleural effusion; pneumothorax; hemothorax; and empyema. Thoracic Surgery drainage, video-assisted thoracoscopic surgery (VATS), or thoracotomy Thoracotomy Surgical incision into the chest wall. Thoracic Surgery.
  • Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax: a life-threatening condition in which air collects in the pleural space Pleural space The thin serous membrane enveloping the lungs (lung) and lining the thoracic cavity. Pleura consist of two layers, the inner visceral pleura lying next to the pulmonary parenchyma and the outer parietal pleura. Between the two layers is the pleural cavity which contains a thin film of liquid. Pleuritis, leading to lung collapse. Individuals present with chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain, dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, and diminished breath sounds. A diagnosis is made with imaging, though tension pneumothorax Tension Pneumothorax Pneumothorax is a clinical diagnosis. Management is based on the size and stability of the affected individual and can include needle decompression Needle Decompression Pneumothorax and chest tube ( thoracostomy Thoracostomy Surgical procedure involving the creation of an opening (stoma) into the chest cavity for drainage; used in the treatment of pleural effusion; pneumothorax; hemothorax; and empyema. Hemothorax) placement. 
  • Pleural effusion Pleural Effusion Pleural effusion refers to the accumulation of fluid between the layers of the parietal and visceral pleura. Common causes of this condition include infection, malignancy, autoimmune disorders, or volume overload. Clinical manifestations include chest pain, cough, and dyspnea. Pleural Effusion: fluid accumulation between the layers of the parietal Parietal One of a pair of irregularly shaped quadrilateral bones situated between the frontal bone and occipital bone, which together form the sides of the cranium. Skull: Anatomy and visceral pleura Visceral pleura Pleura: Anatomy. Common causes of pleural effusion Pleural Effusion Pleural effusion refers to the accumulation of fluid between the layers of the parietal and visceral pleura. Common causes of this condition include infection, malignancy, autoimmune disorders, or volume overload. Clinical manifestations include chest pain, cough, and dyspnea. Pleural Effusion include infection, malignancy Malignancy Hemothorax, autoimmune disorders, or volume overload. Clinical manifestations include chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain, cough, and dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea. Management is dependent on the underlying condition and whether the effusion is causing respiratory distress.

References

  1. Roberts, J., Custalow, C., Thomsen, T. (2019). Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. Philadelphia, PA: Elsevier.
  2. Bloom, B.A., Gibbons, R.C. (2021). Focused assessment with sonography for trauma. StatPearls. Treasure Island (FL): StatPearls Publishing. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK470479/
  3. American College of Surgeons. (2018). Advanced trauma life support: Student course manual. Chicago, IL: American College of Surgeons.
  4. Natarajan, B., Gupta, P.K., Cemaj S, et al. (2010). FAST scan: Is it worth doing in hemodynamically stable blunt trauma patients? Surgery. 148, 695-700.
  5. Miller, M.T., Pasquale, M.D., Bromberg, W.J., et al. (2003). Not so FAST. J Trauma. 54, 52–59.
  6. Von Kuenssberg, J.D., Stiller, G., Wagner, D. (2003). Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg Med. 21, 476-478.
  7. McKenney, K.L., McKenney, M.G., Cohn, S.M., et al. (2001). Hemoperitoneum score helps determine need for therapeutic laparotomy. J Trauma. 50, 650–654.
  8. Lichtenstein, D.A., Menu, Y. (1995). A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest. 108, 1345–1348.
  9. Chen, M.M., Whitlow, C.T. (2011). Chapter 1. scope of diagnostic imaging. Chen, M.M., & Pope, T.L., & Ott D.J.(Eds.). Basic Radiology, 2e. McGraw-Hill. https://accessmedicine-mhmedical-com.ezproxy.unbosque.edu.co/content.aspx?bookid=360&sectionid=39669007
  10. Zaer, N.F., Amini B, Elsayes, K.M. (2014). Overview of diagnostic modalities and contrast agents. Elsayes, K.M., Oldham, S.A.(Eds.). Introduction to Diagnostic Radiology. McGraw-Hill. https://accessmedicine-mhmedical-com.ezproxy.unbosque.edu.co/content.aspx?bookid=1562&sectionid=95875179

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