Let's begin with the discussion of abdominal injuries.
Now typically, we think of abdominal injuries as penetrating or blunt.
I'll give you a global overview of important injury patterns.
First, an examination of the patient as you disrobe the trauma in the trauma bay, what are you looking for?
Sometimes a patient may have abdominal bruising.
Other times, patients may have abdominal tenderness.
Overall, however, these studies are neither very sensitive nor specific.
Hiding next to suspension is again important.
Remember, any patient suspected of hemorrhage and hypotensive like our patient,
there are some general concepts to keep in mind.
Number one, replace the blood.
More and more now we're trying to reduce the amount of crystalloid fluid resuscitation
and as you're giving blood, whether it's a few units or a massive transfusion,
you wanna keep it as close to whole blood as possible.
In other words, a 1:1:1 ratio of blood, plasma, and platelets.
This probably has the best outcome in terms of coagulopathy.
Next, it's important to locate the source of the bleeding.
You notice that we replenish blood before knowing exactly where the source is.
I'll discuss a little bit of your options for locating the source of bleeding.
Next, after you've localized the source of bleeding, obviously stop the bleeding as much as you can.
Remember, sometimes in trauma, it's not an actual anatomic bleed and becomes coagulopathic.
These patients are in dire straights.
For the initial assessment, remember, once you've ascertained A and B, we can't go any further past C
because the patient is hypotensive, which falls under the C for circulation.
Very importantly and perhaps most importantly, never take an unstable patient to the radiology suite.
Go straight to the operating room or interventional suite, depending on the scenario.
On the exam, very frequently, patients are hypotensive and you may be tempted to choose a diagnostic study but don't intervene.
What diagnostic study is the most helpful in the evaluation of hemodynamically unstable trauma patient?
I'll give you a second to think about it.
That's right. It's not a CAT scan or an X-ray.
It's the eFAST, extended FAST or focused abdominal stenography of trauma.
Let's discuss eFAST in a little bit of detail.
eFAST examination has really revolutionized how we detect intra-abdominal fluid.
When we detect intra-abdominal fluid in a trauma setting, it's presumed to be blood.
On our model here, you see the ultrasound probe in five directions.
This is the aortic extended portion.
Some years back, we didn't use to do the lung portion to let you evaluate for pneumothorax.
We only did a full quadrant view. Now, the standard across the country is an eFAST.
We'll discuss each view in a little bit more in detail
but basically, we're looking for a right upper quadrant, left upper quadrant, super pubic, cardiac, and lung views.
This is our cardiac view. In the cardiac view, we highlighted an area of fluid in the pericardial space.
As we've discussed in thoracic lectures, any fluid in the pericardial space in a trauma patient is presumed to be traumatic,
unless, the patient has a clear history of a chronic pericardial infusion.
If you find this on the eFAST portion, the appropriate therapy especially if the patient is hypotensive,
is to do a pericardial synthesis. Now, let's take a look at this lung view.
You can see the R's are standing for the ribs and there's a white line which is actually the pleura.
Remember, there's a parietal pleura and a visceral pleura.
As we normally inspire and expire, these pleura linings actually slide past each other, which is visible on the ultrasound.
The lack of lung sliding or opposition of those two layers of the pleura suggests that there may be a pneumothorax.
Lung sliding on eFAST is extremely sensitive and specific. It's a great test.
So much so that oftentimes now while we're assessing whether or not a test tube has adequately trained in pneumothorax,
we go straight to the ultrasound machine.
Remember, the ultrasound machine has added benefit of no radiation.
This, however, like all ultrasound procedures, is operator dependent.
Now, let's take a look at the right upper quadrant.
Here, you noticed that there's an interface between a liver and the kidney.
Again, on ultrasound, blood looks like a black stripe.
Any blood in this hepatorenal space, also known as Morison's pouch,
suggested that there may be an injury to either the kidney or the liver.
However, remember, just because blood is present in a certain quadrant of the abdomen,
doesn't necessarily mean that the actual injury is in that quadrant.
Moving on, we're in the left upper quadrant.
Here, we look at the interface between the spleen and the kidney. Very similar.
eFAST is incredibly useful and that the ultrasound is now so portable
that it's frequently used in Austere environments.
Here, you see the military use of ultrasound on the combat field.
Now, I'd like to challenge you with the ultrasound.
Take a look at the next eFAST image of the abdomen and tell me what you see.
I'll give you a second to take a look.
Now, let's review.
On this image, you see blood around the liver and you actually see blood in the pleural space to the left of the image.
There's usually only one way this can happen, and that's if you have a patient with a diaphragmatic injury.
Again, just like we discussed in the thoracic lecture, diaphragmatic injuries usually give us indirect information.
Clearly, we don't actually see the diaphragmatic injury here.