26 diagnostic ultrasound diagnostic ultrasound 2

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26 Diagnostic ultrasound Diagnostic ultrasound
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2 Focused assessment with sonography in trauma (FAST) Introduction Ultrasound (US) was first used in the evaluation of trauma patients in Europe in the 1970s. The German surgery board has required certification in ultra- sound skills since 1988. Since the mid 1980s in the United States, the use of ultrasound in trauma has become more widespread and has all but replaced diagnostic peritoneal lavage (DPL) in most trauma centers. The FAST exam has been included as part of the advanced trauma life support course since 1997 [ 1 ]. In addition, the American College of Surgeons has included ultra- sound as one of several “new technologies” that surgical residents must be exposed to in their curriculum. Both the American College of Emergency Physicians and the Society for Academic Emergency Medicine support the use of ultrasound to evaluate blunt abdominal trauma as well. Since 2001, training in emergency ultrasound has been required for all emergency medi- cine residents [ 2 –4]. Therefore, all physicians who will be evaluating trauma patients must become proficient in the use of trauma ultrasound. The objective of the FAST exam is to detect free intraperitoneal, intra- thoracic, and pericardial fluid in the setting of trauma. The cardiac windows are especially critical in penetrating trauma and are reviewed in this section and in Chapter 3 . Not only can the physician identify free intraperitoneal fluid with the FAST exam, but pleural fluid and other signs of thoracic injury can be assessed as well. Although computed tomography (CT) provides excellent and more detailed solid-organ evaluation, it often requires trans- portation of the patient to a less monitored setting (thus the trauma adage, “death begins in radiology”). In addition, CT requires exposure to radiation and is more expensive. DPL is more sensitive for detecting intraperitoneal blood than ultrasound. It is considered positive with 100 000 red blood cells (RBCs)/mm 3 , which is 20 mL of blood per liter of lavage fluid. However, DPL is an invasive test that can be complicated by pregnancy, previous surgery, and operator inexperience. In addition, DPL’s high sensitivity leads to false positives (in the form of non-therapeutic laparotomies) at reported rates of 6–26% [ 5 ]. The evolution from surgical treatment of many splenic and liver injuries to non-operative management means that the high sensitivity and invasive nature of the DPL has become less useful [ 5 –8]. Ultrasound can reliably detect as little as 250 mL of free fluid in Morison’s pouch [ 9 ]. It is also inexpensive, rapid, and easily repeated. In addition, ultrasound has a higher specificity for therapeutic laparotomy than DPL [ 10 ]. To take advantage of the strengths and weaknesses of all three diagnostic options for trauma (CT, US, and DPL), a combination approach is best. There Diagnostic ultrasound 27 Focused assessment with sonography in trauma (FAST)
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is an overwhelming amount of data supporting the use of the FAST exam as
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