Focused Assessment with Sonography in Trauma (FAST): An Overview

Traumatic injuries are one of the leading causes of death, and intraperitoneal bleeds occur in approximately 12% of blunt traumas [1]. A quick assessment of trauma and detection of intraperitoneal fluid is increasingly essential in trauma patients’ assessment. The implementation of point-of-care ultrasound (POCUS) has had a significant impact on patient management, especially in a trauma setting. POCUS is easy to use at the bedside, non-invasive and inexpensive.

The Focused Assessment with Sonography in Trauma (FAST) is an ultrasound protocol used to assess hemoperitoneum and hemopericardium [2]. The FAST protocol is sensitive and specific for detecting intraperitoneal free fluid. According to previous studies, sensitivity ranges from 75-100%, and specificity ranges from 88-100% [3]. The FAST exam is rapid and can be completed in less than 5 minutes. It also has multiple advantages, including decreased time to interventions like surgery and length of stay at the hospital [4]. The Extended FAST (eFAST) protocol, which involves examinations of each hemithorax for hemothorax and pneumothoraces, has recently been introduced by several institutions [2].

Regions Examined

The FAST exam assesses the pericardium and multiple potential spaces within the peritoneal cavity for free fluid. The patient is often assessed in the supine position.

The right flank or right upper quadrant (RUQ) view assesses the hepatorenal recess (also known as Morrison’s pouch), as well as the right paracolic gutter, the hepato-diaphragmatic area, and the caudal edge of the left liver lobe [2]. The pericardial view, also known as the subcostal or the subxiphoid, is usually assessed next. The liver is commonly used as a sonographic window of the heart to evaluate pericardium. Ultrasound can detect little pericardial fluid with sensitivity and specificity approaching 100% [5]. The pericardial view also helps to differentiate between pleural and pericardial effusions and visualize right ventricular collapse during diastole [2]. Next, the left upper quadrant (LUQ) is used to visualize the splenorenal recess, the subphrenic space and the left paracolic gutter. If the eFAST protocol is being conducted, the RUQ and LUQ views are also used to examine the left and right hemithorax. Lastly, the pelvic or the suprapubic view is used to assess for free fluid in the rectovesical pouch in males and rectouterine and vesicouterine pouches in women [2]. The bladder acts as a sonographic window for this view.

Complications

While there are no complications related to the FAST exam itself, the use of ultrasound does have some limitations, one of which is the requirement for at least 150-200 cc of intraperitoneal fluid for an ultrasound to be able to detect. This can lead to false negatives when free fluid is in fact present [6]. False positives in the FAST exam may also occur and can be due to the presence of ascites, pre-existing pleural or pericardial effusions unrelated to the trauma, ruptured ovarian cysts or ruptured ectopic pregnancies [2]. Healthcare workers should be aware that POCUS and the FAST protocol have limitations dependent on the provider’s experience and the patient’s body habitus.   

Further Reading and Free Online Course

References

  1. Poletti, P. A., Mirvis, S. E., Shanmuganathan, K., Takada, T., Killeen, K. L., Perlmutter, D., Hahn, J., & Mermillod, B. (2004). Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography?. The Journal of Trauma57(5), 1072–1081. https://doi.org/10.1097/01.ta.0000092680.73274.e1
  2. Bloom, B. A., & Gibbons, R. C. (2020). Focused Assessment with Sonography for Trauma. https://www.ncbi.nlm.nih.gov/books/NBK470479/
  3. Brenchley, J., Walker, A., Sloan, J. P., Hassan, T. B., & Venables, H. (2006). Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians. Emergency Medicine Journal23(6), 446–448. https://doi.org/10.1136/emj.2005.026864
  4. Melniker, L. A., Leibner, E., McKenney, M. G., Lopez, P., Briggs, W. M., & Mancuso, C. A. (2006). Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Annals of Emergency Medicine48(3), 227–235. https://doi.org/10.1016/j.annemergmed.2006.01.008
  5. Mandavia, D. P., Hoffner, R. J., Mahaney, K., & Henderson, S. O. (2001). Bedside echocardiography by emergency physicians. Annals of emergency medicine38(4), 377–382. https://doi.org/10.1067/mem.2001.118224
  6. Von Kuenssberg Jehle, D., Stiller, G., & Wagner, D. (2003). Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. The American journal of emergency medicine21(6), 476–478. https://doi.org/10.1016/s0735-6757(03)00162-1
Cite this article as: Maryam Bagherzadeh, Canada, "Focused Assessment with Sonography in Trauma (FAST): An Overview," in International Emergency Medicine Education Project, September 20, 2021, https://iem-student.org/2021/09/20/sonography-in-trauma-fast/, date accessed: September 24, 2021

Acromioclavicular Joint Injuries Illustrations

Acromioclavicular joint (AC) injuries are associated with damage to the joint and surrounding structures.

ANATOMY

The acromioclavicular joint, together with the sternoclavicular joint, connects the upper limb to the skeleton.

The support of the acromioclavicular joint is provided by the ligament and muscle surrounding the joint. The capsule surrounding the acromioclavicular joint is strengthened by the acromioclavicular ligaments. The joints are acromioclavicular ligaments that provide horizontal stability.

The coracoclavicular ligaments consist of two parts, the lateral trapezoid, and the medial conoid, and connect the distal lower clavicle to the coracoid process of the scapula. The coracoclavicular ligament is the main stabilizing ligament of the upper limb.

Acromioclavicular joint injuries occur at all ages, but are most common in the 20-40 year age group, 5x times more common in men than women. It is a common contact sports injury in young male athletes (1).

There are two main mechanisms of acromioclavicular joint injury; direct and indirect (2). A direct blow or fall to the shoulder results in a superior force on the acromion with restricted clavicular movement in the joint, the acromion is forcibly pushed down and medially relative to the clavicle. It can occur indirectly as a result of a fall on the hand or elbow, causing the humerus to be pushed into the acromion, resulting in lower-grade injuries that typically protect the coracoclavicular ligament.

Imaging can be used to classify acromioclavicular injuries and is the most widely used Rockwood classification. 

ROCKWOOD CLASSIFICATION

References and Further Reading

  1. Dyan V. Flores, Paola Kuenzer Goes, Catalina Mejía Gómez et-al. Imaging of the Acromioclavicular Joint: Anatomy, Function, Pathologic Features, and Treatment. (2020) RadioGraphics. 40 (5): 1355-1382.
  2. Vanhoenacker F, Maas M, Gielen JL. Imaging of Orthopedic Sports Injuries. (2006)
  3. Tintinalli’s Emergency Medicine, A Comprehensive Study Guide 9th edition. ( 2019)
  4. Rockwood classification of acromioclavicular joint injury

  5. Acromioclavicular injury

 

Cite this article as: Murat Yazici, Turkey, "Acromioclavicular Joint Injuries Illustrations," in International Emergency Medicine Education Project, June 30, 2021, https://iem-student.org/2021/06/30/acromioclavicular-joint-injuries-illustrations/, date accessed: September 24, 2021

 

iEM Image Feed: Star shape wound on forehead

iem image feed
Star shaped wound

A 17-year-old female patient presented to ED after hitting a metal piece on the wall.

How would you like to suture this patient?

Here is one clue!

Cite this article as: iEM Education Project Team, "iEM Image Feed: Star shape wound on forehead," in International Emergency Medicine Education Project, May 19, 2021, https://iem-student.org/2021/05/19/iem-image-feed-star-shaped-wound-on-forehead/, date accessed: September 24, 2021

iEM Image Feed: Scaphoid fracture

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87 - Figure 6 - Fracture of the proximal pole of the scaphoid
  • Falling on an Out-Stretched Hand (FOOSH) is the most common mechanism of wrist injuries, with the wrist in extension.
  • Immature, weaker epiphyseal plate or metaphysis of the radius in children are more likely to sustain injuries, sparing the still-cartilaginous carpal bones.
  • Young adults with active lifestyles are more likely to be injured with greater forces.
  • In the elderly, especially in women with some degree of osteoporosis, distal radial metaphysis is more fragile resulting in Colles fracture.
  • “Anatomic snuffbox’’ on the dorsum of the wrist is an important landmark. Because the scaphoid is palpable with its triangle by styloid, extensor pollicis brevis tendon and the extensor pollicis longus tendon. Tenderness in this area may indicate a scaphoid fracture. The image above shows scaphoid fracture.
  • The examination should include assessment of neurovascular status motor and sensory function of the median, radial and ulnar nerves. Because acute median nerve compression is a common occurrence, the sensation of thumb and index fingers is important, especially with severely displaced fractures. In all injuries to the wrist, radial and ulnar pulses should be evaluated.

Further reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Scaphoid fracture," in International Emergency Medicine Education Project, May 12, 2021, https://iem-student.org/2021/05/12/iem-image-feed-scaphoid-fracture/, date accessed: September 24, 2021

iEM Image Feed: Penetrating eye injury

iem image feed

A 42 years old male, presents to the ED 1 hour after he was hammering a nail onto a wooden shelf, where the nail flew and strike his left open eye. In an attempt to help, his friend immediately removed the nail.

After that, he has been having severe sharp pain and blurry vision in his left eye.

On examination, the left eye had poor visual acuity, and he could only perceive light and movement. The pupil was fixed, dilated and non-reactive to light. Right eye examination was normal.

819.2 - eye penetran trauma 2 -siedel sign

Further reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Penetrating eye injury," in International Emergency Medicine Education Project, April 28, 2021, https://iem-student.org/2021/04/28/iem-image-feed-penetrating-eye-injury/, date accessed: September 24, 2021

iEM Image Feed: Plateau Fracture

iem image feed

A 60-year-old man known to have DM type 2 was brought by the family as a camel hit his knee. He was not able to walk on it at the scene and in ED. It was swollen with no open wound.

Tips
Although patients come with isolated injuries, we always have to make sure that they do not have other injury findings. Therefore, approaching systematically to the patient is important. At this moment, please remember primary and secondary surveys of multiple trauma. The animal attacks may create multiple injuries on patients, and they should be evaluated as multiply injured patients. After you ruled our multiple or life, organ, extremity threatening injury, you can deep dive into isolated injuries. In this case, knee injury after a direct hit.

Of course, inspection and palpation are essential in every extremity injury. Evaluating the patient for neurovascular problems and range of motions are applied in almost every extremity trauma. But sometimes, clinical presentations or findings can be subtle and you may need a better tool. In these case, we recommend using Ottawa Knee Rules.

The image shows tibia plateau fracture on AP knee x-ray.

885.1 plateau fracture
885.2 plateau fracture copy

Additional reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Plateau Fracture," in International Emergency Medicine Education Project, April 7, 2021, https://iem-student.org/2021/04/07/plateau-fracture/, date accessed: September 24, 2021

iEM Image Feed: Radius and Ulna Fracture

iem image feed radius and ulna fracture
radius and ulna fracture

Her father brought a 9-year-old girl due to deformed right extremity. He was playing at home and fell from a hight on his hand. No open wounds. No past medical and surgical. Vaccination: up to date.

Examination: radial pulse is intact. He can move the fingers but with limitation due to pain. Sensation is normal. The X-ray showed both radius and ulna fracture. The patient underwent procedural sedation with IV ketamine, and the reduction was made with ortho oncall.

Cite this article as: iEM Education Project Team, "iEM Image Feed: Radius and Ulna Fracture," in International Emergency Medicine Education Project, March 31, 2021, https://iem-student.org/2021/03/31/radius-and-ulna-fracture/, date accessed: September 24, 2021

iEM Image Feed: Humerus Shaft Fracture

image feed
humerus fracture
humerus fracture 2

The EMS brought a 39-year man as his right upper extremity was stuck in a machine in a factory where he works. He came with deformity and severe pain in his right arm. Pain management was given. He received tetanus toxoid as well. X-ray shows oblique humeral shaft fracture with shortening and angulation. He underwent procedural sedation to reduce it.

Cite this article as: iEM Education Project Team, "iEM Image Feed: Humerus Shaft Fracture," in International Emergency Medicine Education Project, March 17, 2021, https://iem-student.org/2021/03/17/humerus-shaft-fracture/, date accessed: September 24, 2021

Special Populations in the ED: Athletes

special populations in the ED athletes

It is common to hear that “when you work in an Emergency Department (ED), you have to be prepared for everything”. In my experience as a medical student, this could not be more true. I’ve seen tea overdose, collision scooter vs horse, and anything in between. All these experiences will contribute to my formation and made me realize that we are not prepared for many situations. Some of these situations may involve specific populations we’re not so familiarized with and sometimes can change the way we manage an emergency.

Here, I want to discuss some of these “special populations” which may demand a different approach than the usual – and that is what makes emergency medicine so interesting. Let’s talk about one of these subgroups of patients: athletes, and what makes them unique.

Athletes: What do I need to know about them?

  • Heart and Hemodynamic: The “athlete’s heart syndrome (1)”
    • Morphological, functional and electrical changes
      • Lower heart rate;
      • Hypertrophic left ventricle (LV)
      • Lifelong cardiac remodelling could lead to arrhythmogenic pathways
  • Changes in autonomic nervous system – vagal tonus
  • Pulmonary efficiency:
    • Unlike what may be the first thought, the respiratory system does not differ greatly in athletes from non-athletes (2).
  • High energy trauma:
    • Be aware that professional athletes are constantly at risk of high energy traumas, in special head traumas (concussions) and limb trauma (fractures);

How could this be a problem?

  • Late signs of hypovolemia
    • The athlete’s autonomic nervous system has pronounced vagal tonus, which leads to the famous resting bradycardia – this could disguise a tachycardia, one of the early signs of hypovolemia (2).
  • Delay in seeking help
    • Elite athletes may delay seeking help or admit they are not feeling well for fear of losing a competition or training sessions.
    • Besides that, in amateur (and sometimes even in professional) level competitions, staff and coaches often are not trained to identify conditions that need prompt medical assistance

Common situations and how to manage

Exercise and health always have been put together in a “cause and consequence” relation. Besides their undeniable positive effects, exercise on the professional level also has its sidebacks and associated risks. Here I want to discuss some physiological changes we observe in the elite athletes and a very common condition in the ED: the sport-related concussion.

Sport-related concussion (3,4) is a traumatic brain injury induced by biomechanical forces. It may be caused either by a direct impact to the head or by a force transmitted from the impact elsewhere in the body; It typically presents with rapid onset of short-lived signs and symptoms; However, the course is sometimes unpredictable and may evolve in minutes to hours; It may or may not have a decreased level of counsciousnes.

The current literature organize the signs and symptoms of sport-related concussion in 4 domains

  1. Somatic
    • Headache, dizziness, gait disturbances, vertigo, nausea and vomiting, near vision impairment
  2. Cognitive
    • Impaired memory (amnesia), slowed speech, confusion,
  3. Sleep
    • Insomnia
  4. Emotional
    • Irritability, labile humour

Given the rapid onset and short duration, the patient might present to the ED with minor or no symptoms; However, the emergency physician still plays an important role, providing supportive care to relieve remaining symptoms and rule out more severe conditions.

Attention

  • Due to the mechanism of trauma, always rule out cervical spine lesions or instability.
  • Also, signs of basilar skull fracture (racoon eyes, Battle’s sign, CSF rhinorrhea)
  • A Glasgow Coma Scale < 13 should raise awareness for a more severe brain lesion.
  • Does this patient need a head CT?
    • Canadian CT head rule (adults)
    • PECARN CT rule (under 16)   

Management (4)

Headache: 86% had significant pain reduction, and 52% had complete headache resolution after receiving an intravenous dose of one or more of the following: ketorolac, prochlorperazine, metoclopramide, chlorpromazine, and ondansetron. Common orally administered analgesics such acetaminophen, non-steroidal anti-inflammatories and triptans have shown efficacy for pain relief, but there are no studies in the ED setting.
 
Dizziness: Suspicion for peripheral vertigo can be confirmed by the Dix-Hallpike manoeuvre and treated with the Epley manoeuvre. Meclizine (vestibular suppressant) and diazepam can be used with caution because of potential side effects on cognition and alertness.
 
To date, rest continues to be recommended for the acute (24-48h) injury period. After that period, patients can be encouraged to become gradually more active, always below their cognitive and physical limits.

When to admit

This decision is based on the patient’s clinical status. Persistent symptoms and alterations on head CT are the most common indications for admission. 
 
Discharging to home: Education is key for recovery and prevention of recurrence (4). Current evidence indicates that written educational material is more effective than orally given instructions only; Important information that should be present in the educational material are expected symptoms, their management and a timeframe of resolution. 
Cite this article as: Arthur Martins, Brasil, "Special Populations in the ED: Athletes," in International Emergency Medicine Education Project, March 8, 2021, https://iem-student.org/2021/03/08/special-populations-in-the-ed-athletes/, date accessed: September 24, 2021

Recent Blog Posts by Arthur Martins

References and Further Reading

  1. Carbone A, D’Andrea A, Riegler L, Scarafile R, Pezzullo E, Martone F, America R, Liccardo B, Galderisi M, Bossone E, Calabrò R. Cardiac damage in athlete’s heart: When the “supernormal” heart fails! World J Cardiol 2017; 9(6): 470-480 Available from: URL: http://www.wjgnet.com/1949-8462/full/v9/i6/470.htm DOI: http://
    dx.doi.org/10.4330/wjc.v9.i6.470
  2. ACSM’s advanced exercise physiology. — 2nd ed.;Peter A. Farrell, Michael Joyner, Vincent Caiozzo ISBN 978-0-7817-9780-1
  3. McCrory P, Meeuwisse W, Dvorak J, et al. Br J Sports Med 2018;51:838–847
  4. Bazarian JJ, Raukar N, Devera G, et al. Recommendations for the Emergency Department Prevention of Sport-Related Concussion. Ann Emerg Med. 2020;75(4):471-482. doi:10.1016/j.annemergmed.2019.05.032

iEM Image Feed: Mandibular Fracture

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mandibular fracture

A 39-year-old woman presented to ED with mouth pain. She was cleaning the bathroom and suddenly slipped and fell. She hit her mandible with the floor. She was able to speak minimally—no avulsed teeth. She had teeth 23 and 24 subluxations.

This is a high energy impact trauma. Ensure that you evaluate the patient systematically for trauma and not forget to pay attention to a neck injury. Violence, assault, partner abuse should be in your mind. Specific mandibular and panoramic imaging may give excellent views for diagnosis. In some cases, CT may be necessary to evaluate the maxillofacial injury. Besides, know the teeth universal numbering. If you see this kind of damage in the examination, always rule out an alveolar fracture.

Cite this article as: iEM Education Project Team, "iEM Image Feed: Mandibular Fracture," in International Emergency Medicine Education Project, March 3, 2021, https://iem-student.org/2021/03/03/mandibular-fracture/, date accessed: September 24, 2021

iEM Image Feed: Camel Bite

iem image feed camel bite
camel bite injury

EMS brought a 24-year-old man due to camel bite happened while feeding the camel in the early morning. The injury was basically on the right arm and forearm. No other injuries, vitally stable.

Students should know the following while taking care of these patients.

  1. Systematic evaluation of the patient – remember ATLS, primary and secondary survey.
  2. Focused neurologic and vascular examination.
  3. Exposing the wound and ordering an x-ray
  4. Wound cleaning and management
  5. Be aware of fracture – Open Fracture!
  6. Antibiotic coverage and tetanus toxoid/IG
  7. For open fractures – Look for Gustilo-Anderson Classification and choose appropriate antibiotics.  
  8. Do not forget – pain medication.
Cite this article as: iEM Education Project Team, "iEM Image Feed: Camel Bite," in International Emergency Medicine Education Project, February 10, 2021, https://iem-student.org/2021/02/10/camel-bite/, date accessed: September 24, 2021

Pathological Brain CT Findings – Illustration

Pathological Brain CT Findings

In this post, we will share the traumatic (Epidural, subdural, cerebral contusion, subarachnoid hemorrhage, cerebral edema) and atraumatic (intracranial parenchymal hemorrhage, subarachnoid hemorrhage) brain computerized tomography (CT) findings. We will also provide GIF images and one final image, which includes all pathologies in one image.

ATRAUMATIC PATHOLOGICAL BRAIN CT FINDINGS

TRAUMATIC PATHOLOGICAL BRAIN CT FINDINGS

ATRAUMATIC PATHOLOGICAL BRAIN CT FINDINGS – GIF

TRAUMATIC PATHOLOGICAL BRAIN CT FINDINGS  – GIF

PATHOLOGICAL BRAIN CT FINDINGS  – ONE POST

References and Further Reading

  1. https://iem-student.org/2019/09/04/cranial-ct-anatomy-a-simple-image-guide-for-medical-students/
  2. The Atlas of Emergency Radiology
Cite this article as: Murat Yazici, Turkey, "Pathological Brain CT Findings – Illustration," in International Emergency Medicine Education Project, November 18, 2020, https://iem-student.org/2020/11/18/pathological-brain-ct-findings-illustration/, date accessed: September 24, 2021