Radiol Clin N Am 42 (2004) 417 425

Emergency ultrasound in trauma patients

John P. McGahan, MDa,*, John Richards, MDb, Maria Luisa C. Fogata, MDa
a

Division of Diagnostic Radiology, University of California, Davis, School of Medicine, 4860 Y Street, Suite 3100, Sacramento, CA 95817, USA b Division of Emergency Medicine, University of California, Davis, School of Medicine, 2315 Stockton Boulevard, PSSB 2100, Sacramento, CA 95817, USA

Although ultrasound (US) was first described in the detection of blunt traumatic splenic injuries more than 30 years ago [1], it was never widely advocated until approximately 10 years ago [2 4]. There are probably two reasons for the initial limited use of sonography in blunt traumatized patients. The first is that the use of CT evolved at approximately the same time and was shown to be highly sensitive for evaluation of blunt abdominal trauma [5]. CT not only detected free fluid but also directly demonstrated the organ injury. Sonography also was used initially to detect specific organ injury rather than the free fluid associated with the injury. There were limitations in the ability and sensitivity of sonography in directly demonstrating the injured organ. It was not until the 1990s that the focused abdominal sonography for trauma (FAST) was developed for the main objective of detecting free fluid in patients with blunt abdominal trauma [2 4].

Sonographic examination The initial focus of sonographic examination was a single view of the hepatorenal fossa (Morisons pouch) [2]. It was soon realized that a more comprehensive examination of the abdomen improved detection of free fluid, however [4]. This included examinations of both upper quadrants, the paracolic gutters, and pelvis. In 1997, McGahan et al [4]

documented that sonographic sensitivity for the detection of free fluid could be improved by having a full bladder. Often in traumatized patients a Foley catheter is placed and the bladder is decompressed, which eliminates the acoustic window in the pelvis needed to detect small or moderate amounts of free fluid. More recently, in an article by Hahn et al [6], patients with proven intra-abdominal injuries after blunt abdominal trauma were evaluated and it was demonstrated that the finding of free fluid with sonography was important. Seventy-eight percent of patients with free fluid on sonography required laparotomy, whereas only 27% without free fluid needed laparotomy. They also showed that examination of Morisons pouch had the highest detection rate of free fluid in these patients (66%), whereas free fluid was detected 56% of the time in the upper quadrants, 48% of the time in the paracolic gutters, and 36% of the time in the pelvis. Examination of all areas was important, however, because 3 of the 604 patients with intra-abdominal injuries had free fluid only in paracolic gutters [6]. At our institution we always include an examination of the heart for pericardial fluid as a part of the FAST scan. US is also useful in examinations of the chest for pneumothorax or pleural effusion, which are discussed later in this article.

Sonographic findings Free fluid

* Corresponding author. E-mail address: john.mcgahan@ucdmc.ucdavis.edu (J.P. McGahan).

Free fluid typically appears as a hypoechoic region within the peritoneal cavity or pelvis and is usually linear or triangular in shape (Fig. 1). The

0033-8389/04/$ see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.rcl.2003.12.005

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Fig. 1. Patterns of free fluid. (A) Real-time US examination of the right upper quadrant demonstrates small triangular-shaped hypoechoic region (arrow) that corresponds to free fluid. (B) Real-time US of the right upper quadrant demonstrates larger hypoechoic region, with acute angles (arrow), noted just inferior to the liver and the right kidney that corresponds to free fluid. (C) In the same patient as B, linear hypoechoic region in the hepatorenal fossa (Morisons pouch) corresponds to free fluid (arrow).

shape of the fluid depends on its compression by the surrounding structures. For instance, in Morisons pouch, the fluid between the kidney and liver usually has a linear shape (see Fig. 1). Fluid that surrounds bowel often appears triangular. Fluid often accumulates at the site of injury but then flows throughout the abdomen and into the pelvis. At the site of injury, the blood may appear echogenic as it forms a clot adjacent to the injured organ (Figs. 2, 3). There maybe several pitfalls in recognition of free fluid within the abdomen (Box 1). Pitfalls Patients with pre-existing ascites or iatrogenic free fluid (eg, dialysis patients) may have falsepositive sonogram results. It is impossible in these patients to know if the free fluid is caused by preexisting ascites, traumatic injury, or a combination of the two. In women of childbearing age, a small amount of physiologic free fluid may be noted in the pelvis. It is important to recognize that although this free fluid is most likely pre-existing and probably

physiologic, it may be secondary to an injury. In this situation, searching for free fluid in other sites is important. Loops of fluid-filled bowel should not be confused with free intraperitoneal fluid. Bowel loops can be distinguished from free fluid because they are round and have peristalsis. This should cause little confusion. In almost all recent studies of the use of sonography for detection of free fluid in patients with blunt abdominal trauma, the specificity of sonography is high [4]. In some cases sonography may detect small amounts of free fluid that are not visualized with CT [4]. Sonographic sensitivity in detecting injuries in patients with blunt abdominal trauma may be decreased for several reasons. The sensitivity of sonography for detection of free fluid in the pelvis may be decreased if a full bladder is not used. With the bladder decompressed after placement of a Foley catheter, free fluid in the dependant portion of the pelvis can be missed. Another potential pitfall of US detection of free fluid is that hematomas may appear echogenic. With severe injury, clotted blood at the

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Fig. 2. Echogenic clot/liver laceration. (A) Real-time US examination of the right upper quadrant of the abdomen shows right kidney (RTK) and echogenic clot anterior to the liver (RT LOBE). (B) Real-time examination of the liver demonstrates fairly well marginated echogenic region in the liver (arrows) that corresponds to liver laceration.

site of the injury may be echogenic and should not be overlooked (see Figs. 2, 3). Finally, there is often no free fluid associated with contained injuries of solid organs, such as the liver, spleen, or kidney. In the article by Hahn et al [6], in several patients no free fluid was detected, yet 27% of these patients required laparotomy. This may be the greatest pitfall of the FAST scan and is discussed later in this article. Finally, sonography is limited and unable to show some types of injuries, including spinal and pelvic fractures, bowel and mesentery injuries, pancreatic injuries, vascular injuries, diaphragmatic ruptures, and adrenal injuries [4].

Free fluid scoring systems Scoring systems have been developed to help stratify patients into groups who may or may not require laparotomy. Others have stratified patients based on either the amount of free fluid in one location or the number of locations in which free fluid was detected. For instance, Sirlin et al [7,8] described a scoring system based on the location of the fluid. For each anatomic region in which fluid was detected, one point was given. The percentage of patients with a score of 0 who had intra-abdominal injury or required surgical intervention (based on this scoring system) was 1.4% and 0.4%, respectively. For the score of 1, the rate of intra-abdominal injury was 59%, and the rate of surgical intervention was 13%. The rate of intra-abdominal injury increased to 85% and rate of surgical intervention was 36%, for a score of 2. For a score of 3, the percentage of pa-

Box 1. Pitfalls in examination of the abdomen for free fluid

 Pre-existing fluid (ascites)  Iatrogenic free fluid as in dialysis or Fig. 3. Subcapsular hematoma of the spleen. Longitudinal real-time US of the spleen demonstrates well-demarcated, slightly hyperechoic region along the anterior aspect of the spleen (arrow) that corresponds to subcapsular hematoma. (From McGahan JP, Wang L, Richards JR. From the RSNA refresher courses: focused abdominal US for trauma. Radiographics 2001;21(Spec No):S191 9; with permission.)     

direct peritoneal lavage Pelvic fluid (female) Loops of fluid filled bowel Incomplete or empty bladder Echogenic clot Contained injury

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tients with intra-abdominal injury remained static at 83%, but rate of surgical intervention was 63%. The higher the score, the higher the injury rate and the greater the need for laparotomy. Others have advocated scoring systems based on the number of free fluid sites or the vertical height of free fluid [9,10]. A common theme would be the more the amount of free fluid, the greater the likelihood of injury or the need for surgical intervention. Sensitivity of sonography The sensitivity of sonography depends on what is used as the gold standard to which US is compared. When sonographic results are compared with clinical outcome, the sensitivity rates of sonography are high, usually more than 95% [11 13]. McGahan et al [4] calculated a sensitivity rate of only 63% when sonography was compared with CT or laparotomy and not using clinical observation as a gold standard. The probable reason for this discrepancy in sensitivities is that McGahan et al [4] showed that several minor lacerations of the liver or spleen were detected on CT but not detected by FAST. These patients did not require surgical intervention, and all improved clinically. If clinical improvement had been used as the gold standard, these patients would have been deemed as having true negative results. When using CT as the gold standard, however, they were deemed as having false-negative results. This is the main reason for discrepancies in the sensitivities of FAST scan. Numerous other studies have been published on the topic of the sensitivity of FAST. For instance, in 744 pediatric patients with blunt abdominal trauma, Richards et al [14] demonstrated a sonographic sensitivity rate of 68% for detecting free fluid or solid organ injuries. In a large review of 3264 patients, this same study group showed that sonography had a sensitivity rate of 67% in detection of intra-abdominal injury [15]. Other results from recent literature vary. Miller et al [16] reported a sensitivity rate of 42% for the FAST scan when compared with CT. Polletti et al [17] demonstrated a sensitivity rate of 93% for sonography, however. Other studies have shown that sonography may miss injuries that may require surgery. Dolich et al [18] reported on 43 patients with false-negative sonography results, 10 of whom (33%) required surgery. Shanmuganathan et al [19] studied the use of sonography in more than 11,000 patients with blunt abdominal trauma: 467 patients had intraabdominal injury, 310 (66%) of whom had free fluid detected by sonography. This detection rate is similar to past studies. In this larger study by Shanmuga-

nathan et al, 157 patients (34%) with intra-abdominal injury had no free fluid, and 26 of these patients required surgery or further intervention. Sonography can be used to triage patients, but one must remember that it may miss significant injuries that require further intervention. CT should be used for patients with a negative sonography result in whom there is a suggestion of intra-abdominal injury [20,21].

Solid organ injury After the initial studies on the use of sonography in detecting organ injuries in the 1970s [1], more recent studies focused on the detection of free fluid [11 13]. A few recent studies have demonstrated the ability of sonography to detect parenchymal organ abnormalities directly. Rothhin et al [12] reported a sensitivity rate of 41.4% for the direct detection of solid organ injuries by sonography. McGahan et al [4] also reported a sensitivity rate of 41% detection in solid organ injuries. More recently, Polletti et al [17] showed a sensitivity rate of 41% for direct demonstration of organ injury. Stengel et al [22] showed that a 7.5-MHz linear ray probe detected solid organ injuries much more readily than a 3.5-MHz convex probe.

Sonographic appearance of solid organ injuries Much of the work on sonographic classification and appearance of solid organ injuries has been performed by McGahan et al [23,24] and Richards et al [25,26]. When identified, acute solid organ injuries are often echogenic on sonography. A diffuse heterogeneous echogenic pattern is the predominant

Fig. 4. Splenic laceration. US examination of the left upper quadrant demonstrates poorly marginated spleen with mixed echo pattern (arrows), which corresponds to severe splenic laceration.

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pattern identified with splenic injuries (Fig. 4). A discrete hyperechoic or diffuse hyperechoic pattern is seen with hepatic injuries (see Fig. 2). Renal injuries are echogenic, with a disorganized appearance that occurs with severe renal lacerations (Fig. 5). More recently, contrast-enhanced abdominal US has been used in the evaluation of solid organ injuries in trauma patients (Fig. 6). For instance, Martegani et al [27] presented the preliminary evaluation of micro-bubble enhanced US of abdominal organs in blunt and penetrating trauma. They evaluated 14 patients with abdominal trauma who were scanned with unenhanced US and contrast-enhanced sonography. These authors use SonoVue (Bracco/ ALTANA Pharm, Konstanz, Germany), a phospholipid coated micro-bubble, at the dose of 1.2 to 2.4 mL scanned with a low mechanical index. The liver, spleen, and kidneys were studied over a 3- to 5-minute interval. They demonstrated that on the unenhanced scan, no lesions were confidently visualized. Excellent enhancement of the parenchymal organs was obtained in all cases using contrast-enhanced sonography, however. They detected injuries in the liver in 5 patients, the spleen in 5 patients, and the kidney in 4 patients. In 7 patients there was confirmation with CT, and there was good correlation between contrastenhanced sonography and contrast-enhanced CT in terms of the position and size of the abnormality. The authors believed that the contrast-enhanced sonography might expedite management of trauma patients [27]. The chest Sonography has been shown to detect pleural effusions [28]. In traumatized patients, sonography

can be used to diagnose pneumothorax or free fluid within the thorax. More recently, sonography also has been shown to be helpful in diagnosing pericardial effusions [29,30] in traumatized patients. The main reason for diagnosing pericardial effusions is to prevent patients from having a traumatically induced pericardial tamponade. We incorporate the subcostal view of the heart as a portion of the FAST scan in all patients with blunt abdominal trauma. This is helpful in diagnosing pericardial effusions (Fig. 7). It must be emphasized that inexperienced examiners often have problems diagnosing pericardial effusions. For instance, Blavias et al [30] set up a study with emergency medicine residents and fellows trained in sonography. They had trouble discerning the epicardial fat, which appeared hypoechoic on US, from a true pericardial effusion. Sonography had a sensitivity rate of 73% and a specificity rate of only 44% in this study [30]. With more experienced examiners, sonography may be useful in detecting moderate pericardial effusions. More recently, sonography also has been proved to be useful in diagnosing pneumothorax [31,32]. The parietal pleura adheres to the inner muscle of the thorax, whereas the visceral pleura adheres to the lung. During inspiration and expiration the visceral pleura slides back and forth adjacent to the parietal pleura. The bright echogenic line of the visceral pleura, which adheres to the lung as it moves and slides during normal inspiration and expiration, may be observed on real-time sonography and is a normal finding (Fig. 8). Absence of the sliding lung is a direct sign of pneumothorax (Fig. 9). Remembering that the free air within the thorax rises to the most nondependent portion of the thoracic cavity, the US probe is placed in this area to check for pneumotho-

Fig. 5. Renal laceration. (A) Longitudinal scan of the right upper quadrant of the abdomen demonstrates ill-defined region without reniform shape, which corresponds to severe renal laceration (shattered kidney) (arrows). Right nephrectomy was performed immediately after the US examination. (B) Real-time US examination of the right paracolic gutter demonstrates an echogenic region inferior to the kidney in the right paracolic gutter that corresponds to hematoma (arrow).

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Fig. 6. Contrast-enhanced US of splenic laceration. (A) Noncontrast US of the spleen appears normal. (B) Contrast-enhanced US with SonoVue demonstrates a large, wedge-shaped defect in the central portion of the spleen. (C) Correlative CT demonstrates splenic laceration. (Courtesy of Thomas Albrecht, MD, FRCR, Berlin, Germany.)

rax. Either a curved array probe or, better yet, a linear array probe may be used to detect pneumothorax. The US probe is placed in the intercostal space. The normal to and fro motion of the visceral pleura against the parietal pleura is observed in a normal

Fig. 7. Pericardial effusion. Subcostal real-time US of the heart demonstrates anechoic region (long arrow) anterior to the heart, which corresponds to pericardial effusion.

patient. The normal motion of the visceral pleura against the parietal pleura is absent with pneumothorax, however. In a normal patient, a reverberation artifact usually is noted posterior to the parietal visceral pleura interface in a normal patient (see Fig. 8). This is observed as lines that are equally spaced from one another and gradually decrease in echogenicity. This is the reverberation of the US beam as it strikes the interface between the parietal and visceral pleura and the air in the lung and is reflected back to the transducer. This reverberation produces multiple equally spaced echoes. The reverberation artifact is not identified when there is a pneumothorax. A pneumothorax may produce acoustic shadowing. Absence or decrease of the reverberation artifact also may occur in a normal patient if the gain settings are set too low. An article by Rowan et al [33] compared the accuracy of sonography with that of the supine chest radiograph in detecting traumatic pneumothorax, with CT serving as the reference or gold standard. They studied 27 patients who sustained

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Fig. 8. Normal lung. (A) Real-time US examination using linear array probe demonstrates the appearance of the normal lung on US. Note that the first echogenic line (open arrow) corresponds to the interface between the parietal and the visceral pleura. Parallel equally spaced lines of decreasing echogenicity are observed posterior to this, which corresponds to reverberation artifacts (arrows). (B) Drawing of reverberation artifact. The US probe is placed on the skin surface (S). R refers to the interface between the parietal and visceral pleura. Lines labeled as numbers 1 and 2, which are of decreasing echogenicity posterior to this, correspond to reverberation artifacts caused by the US beam reverberating or bouncing between the pleura and transducer. (C) Similar pattern is seen with sector scan of the lung in another patient.

blunt thoracic trauma and had US. The radiographic and US findings were compared with CT findings. Eleven of 27 patients had pneumothoraces as seen with CT. All of the pneumothoraces were detected by sonography, for a sensitivity rate of 100%. The

specificity rate of sonography was 94%, and 1 of 16 patients had a false-positive diagnosis of pneumothorax. Supine chest radiography had a sensitivity rate of only 36% (4 of 11 patients), with a specificity rate of 100%. In their study, US was more sensitive

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shown to be sensitive in detecting pneumothoraces in traumatized patients.

References
[1] Kristensen JK, Buemann B, Kuehl E. Ultrasonic scanning in the diagnosis of splenic haematomas. Acta Chir Scand 1971;137:653 7. [2] Jehle D, Guarino J, Karamanoukian H. Emergency department ultrasound in the evaluation of blunt abdominal trauma. Am J Emerg Med 1993;11:342 6. [3] Kimura A, Otsuka T. Emergency center ultrasonography in the evaluation of hemoperitoneum: a prospective study. J Trauma 1991;31:20 3. [4] McGahan JP, Rose J, Coates TL, Wisner DH, Newberry P. Use of ultrasonography in the patient with acute abdominal trauma. J Ultrasound Med 1997;16: 653 62. [5] Federle MP, Griffiths B, Minagl H, Jeffrey Jr RB. Splenic trauma: evaluation with CT. Radiology 1987; 162:69 71. [6] Hahn DD, Offerman SR, Homes JF. Clinical importance of intraperitoneal fluid in patients with blunt intra-abdominal injury. Am J Emerg Med 2002;20: 595 600. [7] Sirlin CB, Casola G, Brown MA, Patel N, Bendavid EJ, Hoyt DB. Patterns of fluid accumulation on screening ultrasonography for blunt abdominal trauma: comparison with site of injury. J Ultrasound Med 2001;20:351 7. [8] Sirlin CB, Casola G, Brown MA, Patel N, Bendavid EJ, Hoyt DB. Quantification of fluid on screening ultrasonography for blunt abdominal trauma: a simple scoring system to predict severity of injury. J Ultrasound Med 2001;20:359 64. [9] Huang MS, Liu M, Wu JK, Shih HC, Ko TJ, Lee CH. Ultrasonography for the evaluation of hemoperitoneum during resuscitation: a simple scoring system. J Trauma 1994;36:173 7. [10] McKenney KL, McKenney MG, Nunez DB, et al. Interpreting the trauma ultrasound: observations in 62 positive cases. Emerg Radiol 1996;3:113 7. [11] McKenney MG, Martin L, Lentz K, Lopez C, Sleeman D, Aristide G, et al. 1,000 consecutive ultrasounds for blunt abdominal trauma. J Trauma 1996;40:607 10. [12] Rothlin MA, Naf R, Amgwerd M, Candinas D, Frick T, Trentz O. Ultrasound in blunt abdominal and thoracic trauma. J Trauma 1993;34:488 95. [13] Rozycki GS, Ochsner MG, Jaffin JH, Champion HR. Prospective evaluation of surgeons use of ultrasound in the evaluation of trauma patients. J Trauma 1993; 34:516 26. [14] Richards JR, Knopf NA, Wang L, McGahan JP. Blunt abdominal trauma in children: evaluation with emergency US. Radiology 2002;222:749 54. [15] Richards JR, Schleper NH, Woo BD, Bohnen PA, McGahan JP. Sonographic assessment of blunt ab-

Fig. 9. Small pneumothorax. Real-time US examination of thorax in this patient with a small pneumothorax demonstrates the echogenic line that corresponds to the parietal and visceral pleura, which is noted to the left side of image. Note more distal reverberation artifacts. To the right side of the image there is loss of this pattern because of a small pneumothorax.

than chest radiography in the detection of traumatic pneumothoraces.

Summary US will be used more frequently in the future for the evaluation of traumatized patients. Previously, the main focus of the sonographic examination was for the detection of free fluid. Unstable patients with free fluid often can be triaged to the operation room without further imaging tests. In patients who are more stable or in whom US results are negative, CT is required. Based on recent studies, sonography has a sensitivity rate of approximately 40% in direct detection of solid organ injuries. In the future, however, with the use of contrast-enhanced agents, sonography may more reliably detect solid organ injuries. Within the chest, US has been shown to be helpful in detecting pleural effusions and may be useful in detecting pericardial effusions. US has been

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