Over the past 40 years, trauma surgeons in Europe and Japan have demonstrated the proficient use of ultrasonography in evaluating blunt trauma patients.1–9 During the 1990s, emergency physicians and trauma surgeons in North America prospectively evaluated the applications of ultrasonography in trauma and presented results comparable with those of other investigators worldwide.10–18 The use of point-of-care ultrasound has gained wide acceptance and is now considered integral in the training of emergency physicians. The acceptance of emergency thoracic and lung ultrasound in emergency departments around the world is also remarkable, and International Consensus has standardized nomenclature in these areas.19
The focused assessment with sonography for trauma (FAST) examination is a point-of-care screening tool to aid clinicians in identifying free intrathoracic or intraperitoneal fluid. The underlying premise behind the use of the FAST examination is that clinically significant injuries will be associated with the presence of free fluid accumulating in dependent areas. The FAST examination was originally developed as a limited ultrasound examination, focusing primarily on the detection of free fluid, and was not designed to universally identify all sonographically detectable pathology. Over the last decade many groups have proposed additions or modifications to the standard FAST examination, the most popular of which is the Extended FAST (E-FAST) examination, as first described by Kirkpatrick.20 This adds a rapid ultrasound evaluation for pneumothorax when this is a consideration. The essence of the FAST examination is identifying findings that can be interpreted by clinicians within a clinical context. As this approach has grown to the extent that some propose integrating ultrasound completely within the advanced trauma life support (ATLS) sequence,21 the challenge for the future is to efficiently capitalize on the information point-of-care ultrasound provides, while not delaying critical interventions.22
The rapid and accurate diagnosis of injuries sustained by trauma patients can be difficult, especially when they are associated with other distracting injuries or altered mental status from head injury or drug or alcohol use. In North America, the two generally accepted diagnostic techniques for evaluating abdominal trauma patients are computed tomography (CT) of the abdomen and pelvis and ultrasonography. Over time, diagnostic peritoneal lavage (DPL) has fallen out of favor. Each of these diagnostic modalities has its own advantages and disadvantages.
Historically, DPL was a useful screening test for evaluating abdominal trauma. Table 9-1 reviews the advantages and disadvantages of DPL.
TABLE 9-1.ADVANTAGES AND DISADVANTAGES OF DIAGNOSTIC PERITONEAL LAVAGE |Favorite Table|Download (.pdf) TABLE 9-1. ADVANTAGES AND DISADVANTAGES OF DIAGNOSTIC PERITONEAL LAVAGE
Sensitivity for detecting hemoperitoneum
Availability of equipment
Relative speed with which it can be performed
Low complication rate with an experienced operator
Ability to detect early evidence of bowel perforation
Potential for iatrogenic injury
Misapplication for evaluation of retroperitoneal injuries
Lack of specificity