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Ultrasound for Acute Care Surgeons

Series Editor: Mauro Zago

Mauro Zago Editor

US for Trauma:
Mauro Zago

Essential US for Trauma:

Mauro Zago, MD
General Surgery Department
Minimally Invasive Surgery Unit
Policlinico San Pietro

ISBN 978-88-470-5273-4 ISBN 978-88-470-5274-1 (eBook)

DOI 10.1007/978-88-470-5274-1
Springer Milan Heidelberg New York Dordrecht London

Library of Congress Control Number: 2014939932

Springer-Verlag Italia 2014

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To my five darlings

Life-and-death situations make trauma surgery one of the most important medical
specialties. In their everyday work, surgeons see the most varied aspects of trauma-
tology. Nonetheless, only those few surgeons who deal with major trauma on a daily
basis have the necessary know-how and skills to save the severely injured patient
from permanent disability or death. There has been one positive spin-off from the
many wars that have been waged in the past centuries: much of what surgeons have
learned on the battlefield has come to benefit civil traumatology.
It is not enough to be a good surgeon with excellent technique. If lives are to be
saved, possible fatal injuries must be recognized at once and dealt with without
delay. The surgeons first-line technical resource is radiodiagnostics. The choice of
diagnostic modality will depend on the injury mechanism, the injuries to be expected
therefrom, and finally the patients hemodynamic situation. An ultrasound study
will almost always be made. In the hands of the surgeon, this is one of the most
valuable tools for decision-making. Depending on the patients stability, a survey
can be made of organ injuries and the presence of blood in the peritoneal space,
pleural cavity, and pericardium diagnosed whereby all of these findings can contrib-
ute importantly to the right decision.
Ultrasound (US) is the most used imaging technology, and this book provides
important perspectives on its use in trauma. It is written by experts to provide sug-
gestions, tips, and tricks for the routine clinical use of US. The sonographic anat-
omy of the thoracic and abdominal organs is presented clearly and understandably.
In each chapter, care has been taken to show not just the normal situation but also
abnormal images. The truth of the saying that one picture is worth a thousand
words is proven many times over in the clinical scenarios. The E-FAST protocol
and the algorithm for sonography in visceral trauma are new milestones in trauma
Not to be forgotten is contrast-enhanced ultrasound (CEUS), which is opening
new horizons and becoming increasingly popular. In 2004, the European Federation
of Societies for Ultrasound in Medicine and Biology (EFSUMB) published interna-
tional guidelines for the use of US contrast media. Echo enhancement with CEUS
has significantly improved the sensitivity of detection and visualization of solid
organ injuries. CEUS has its very important advantages over CT and MRI with their
risks and contraindications (among them exposure to radiation, thyrotoxicosis, kid-
ney failure, and anaphylactic shock), loss of time, far greater expense, and lack of

viii Foreword

availability in many hospitals. CEUS is now recommended in addition to FAST in

the evaluation and follow-up of traumatic solid organ injuries in stable patients.
Mauro Zago, the editor, took the initiative to create this first volume in a series
devoted to US in routine clinical use in all forms of acute care surgery. This pocket
companion for trauma is intended to help the surgeon performing US in critical situ-
ations to make quicker and better assessments and decisions. Dr. Zago and his con-
tributing authors deserve great thanks for sharing with the reader their knowledge
and their immense experience with ultrasound diagnostics in trauma.

Selman Urans, MD, FACS

Department of Surgery
Medical University of Graz
European Society for Trauma and
Emergency Surgery (ESTES) Past President
International Association for Trauma Surgery and
Intensive Care (IATSIC) Past President

Welcome to this first issue of the new Springer series, Ultrasound for Acute Care
Surgeons. Ultrasound has a well-established diagnostic role in many surgical dis-
eases, and for specific applications (for instance, breast, liver, and vascular surgery),
and is carried out by the surgeons themselves. In the acute setting, however, it is still
not the norm for the surgeon to perform ultrasound. This is a situation that needs to
be addressed, as clinical point-of-care ultrasound frequently assists in the prompt
and appropriate decision-making so important in emergencies. The series is not
intended to reinvent the wheel; rather, it simply aims to provide surgeons with
an additional and, in many respects, extraordinary tool that improves the making
of critical (time- and resource-dependent) decisions in numerous clinical situations
confronted in daily practice.
The practical design of each volume in the series is intended to ensure that no
time is lost during consultation. If you are already trained in ultrasound but have
limited experience in this specific application, you will be able to rapidly review
technical points, profit from the described tricks and tips, and go deeper in the clini-
cal chapters. If you are a beginner, trust that learning E-FAST is the easiest way to
gain confidence with ultrasound and you will rapidly ask to learn more and more
ultrasound applications. If you are not personally interested in applying ultrasound
but are convinced that you must understand the role of E-FAST, you are a smart
doctor, and this book is for you, too.
Sections that at first glance might appear rather technical or boring, such as those
describing knobology or scanning techniques, deserve also to be read by the doctor
already trained in ultrasound. Here, technique is rendered clinically relevant.
Furthermore, every effort has been made to facilitate comprehension and to allow
readers to avoid common mistakes and profit from the authors years of experience
in the specific field of trauma ultrasound.
Nothing can replace a formal practical course followed by proctored practice.
However, this book will serve as an ideal quick reference for your personal training:
it will increase your confidence in the use of ultrasound faster than might be
The expertise of the authors and the efforts they have expended in ensuring that
this is a very practical book deserve to be highlighted, and I personally thank all of

x Preface

them. Finally, special thanks are due to the editorial staff of Springer: they are a
marvelous team, providing invaluable support and maintaining immense patience
with the editor.

Bergamo, Italy Mauro Zago


1 Basic Ultrasound Physics, Instrumentation,

and Knobology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Fikri M. Abu-Zidan
2 Introduction and Focused Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Mauro Zago
3 Abdominal Views: Technique, Anatomy,
Abnormal Images, Scanning Tips, and Tricks . . . . . . . . . . . . . . . . . . . 19
Fernando Ferreira, Eva T. Barbosa, and Antnio R. Silva
4 Thoracic Views: Anatomy, Techniques,
Scanning Tips and Tricks, Abnormal Images . . . . . . . . . . . . . . . . . . . . 39
Andrea A. Casamassima and Mauro Zago
5 Including EFAST in Trauma Algorithms: When?
What Now? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Diego Mariani and Mauro Zago
6 The Role of EFAST in a Comprehensive US Trauma
Management (ABCDE-US): Facing with Clinical Scenarios. . . . . . . . 65
Mauro Zago and Diego Mariani
7 Prehospital Ultrasound in Trauma: Role and Tips. . . . . . . . . . . . . . . . 85
Miriam Ruesseler
8 CEUS: What Is It? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Massimo Valentino, Libero Barozzi, and Cristina Rossi

Basic Ultrasound Physics,
Instrumentation, and Knobology 1
Fikri M. Abu-Zidan

1.1 Introduction

Using ultrasound in life-threatening conditions is one of the successful stories of

carrying portable technology to sick patients so as to improve outcome of their
management. The value of ultrasound will be optimized only after understanding its
limitations and pitfalls. This cannot be achieved without understanding basic ultra-
sound physics. This chapter will present basic physics in a simple way that is rele-
vant to clinicians who are keen to start using ultrasound in their clinical practice.
Practical issues will be explained without going into details.

1.2 Basic Ultrasound Physics

Ultrasound is a sound wave having a frequency higher than 20,000 Hz, which is
above the range of human hearing. It is a type of energy that can transmit through
air, fluid, and solid material. Medical ultrasound machines generate ultrasound
waves and receive the reflected echoes. B mode (brightness mode), which gives
black and white images, is the basic mode that is usually used in trauma patients.
The sound waves are emitted from piezoelectric crystals from the ultrasound
transducer. As ultrasound waves pass through various body tissues, they are reflected
back to the transducer creating an image on the monitor. The resistance to propaga-
tion of ultrasound waves (acoustic impedance) will vary depending on the density
of material particles. As the material gets more solid, the particles will become
denser. The denser the material is, the more it reflects the sonographic waves
(Fig. 1.1). Fluid transmits sound waves and has less waves reflected back. This

F.M. Abu-Zidan, MD, FRCS, FACS, PhD, DipApplStats

Department of Surgery, Faculty of Medicine and Health Sciences,
UAE University, 17666, Al-Ain, United Arab Emirates
e-mail: fabuzidan@uaeu.ac.ae

M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons, 1
DOI 10.1007/978-88-470-5274-1_1, Springer-Verlag Italia 2014
2 F.M. Abu-Zidan

Fig. 1.1 The denser the material is, the more it reflects the sonographic waves. Fluid [like bile in
the gallbladder (GB)] transmits sound waves and has minimum waves reflected back. This yields
a black anechogenic image. Stones (S) yield white images with a shadow behind them. Soft tis-
sues, like the liver (L), yield different gray color scales. Fibrous tissue like the diaphragm will be
white without a shadow (D)

yields a black anechogenic or anechoic image. Other tissues have varying lev-
els of echogenicity. Stones, bones, and calcifications yield the brightest white
images and a shadow behind them. Between these two extremes, other tissues can
be outlined and identified within the gray scale (Fig. 1.2). Fibrous tissue like the
diaphragm or capsule of the kidney will be white without a shadow. Air is a strong
ultrasound beam reflector. It scatters the ultrasonic waves and prevents transmission
to deeper structures. That is why it is difficult to see behind subcutaneous emphy-
sema in a trauma patient.

1.3 Ultrasound Transducers

Transducers contain piezoelectric crystals that emit ultrasound. There are different
factors that can control the way these ultrasound waves are sent:
1. Continuity: Emission of ultrasound waves can be either interrupted or continu-
ous. Emission of ultrasound waves as pulses will have two periods: a period in
which the pulse is sent and another period in which reflected waves are received
to generate brightness (B) mode images. Continuous emission of ultrasound
waves is used for the Doppler mode.
2. Frequency: By modifying the frequency in which waves are sent, it is possible to
have different applications controlling mainly the depth and resolution of the
images. Frequency and resolution have an inverse relationship. The lower
1 Basic Ultrasound Physics, Instrumentation, and Knobology 3



Fig. 1.2 Ultrasound of the right upper quadrant in a patient complaining of right upper quadrant
pain to demonstrate acoustic impedance. The gallbladder (GB) and IVC contain fluid which is
black. The liver (L) is a soft tissue and is gray in color. The diaphragm (D) is a fibrous tissue which
is white without a shadow, and a gallstone which is a solid structure (arrow head) is white with a
posterior acoustic shadow (small arrows)

frequency is, the poorer the image resolution, but the greater the depth of wave
penetration. Higher frequency probes have less depth penetration but have the
advantage of higher resolution.
The transducer frequencies commonly used for abdominal exam are between
2.5 and 5 MHz. This implies that for obese patients and deep structures, probes
of low frequencies should be used. In contrast, probes of high frequency
(1012 MHz) should be used for superficial structures.
3. Shape of the surface of the probe: Ultrasound waves are sent vertical to the sur-
face of the probe. By curving the surface, it is possible to widen the area of the
studied field. It is understandable that the lateral resolution in the deeper struc-
tures will be less when using this type of probes. Lateral resolution is the ability
of ultrasound to differentiate between two objects located perpendicular to the
ultrasound beam. These probes are called convex array probes (Fig. 1.3). When
the surface is kept flat, the waves will be parallel with each other, and the lateral
resolution will be much better. These are called linear array probes. These probes
usually have high frequencies of 1012 MHZ indicating that their penetration is
less than others, but they have excellent resolution. That is why the shape of the
4 F.M. Abu-Zidan

Convex array Linear array Phased array

Fig. 1.3 Changing the shape of the surface of the probe and its size has resulted in different types
for different applications

image of the linear array probe is rectangular compared with the convex array
probe images which will be wider in the area located away from the probe.
4. Surface area of the probe: It is important to have no barrier between the studied
structures and the ultrasound waves. For example, the ribs will not permit ultra-
sound waves to pass through them when imaging intrathoracic structures through
the thoracic wall and will have a shadow behind them. The phased array probe
has a small surface that will enable the examiner to visualize the heart between
the ribs (Fig. 1.3).
5. Orientation of the probe: Each piezoelectric crystal in the probe is represented
on specific points on the screen. Each probe will have a marker to identify a
specific side of the probe. The operator should know the probe side before start-
ing any diagnostic or interventional procedure. This side should be confirmed
practically by putting gel on the surface and moving the index finger on it to see
which side it represents. It is advisable as agreed standard to have the marker that
represents the right side of the screen upward toward the head of the patient in
the sagittal or coronal sections (Fig. 1.4) and to the right side of the patient in
transverse sections (Fig. 1.5). This will save time as emergency physicians will
do both abdominal and thoracic images in emergency conditions and there is no
time to change the setting. The rule of thumb is that the right side of the patient
should be on the right side of the screen.
1 Basic Ultrasound Physics, Instrumentation, and Knobology 5

Sagital section


Fig. 1.4 Sagittal section of the abdominal examination. The probe marker (arrow) should point
upward. The upper part of the abdomen (U) should be to the right side of the screen. U upward or
proximal, D down or distal

Transverse section L


Fig. 1.5 Transverse section of the abdominal examination. The probe marker (arrow) should point
to the right. The right part of the body (R) should be to the right side of the screen. R right, L left
6 F.M. Abu-Zidan

Fig. 1.6 A schematic diagram demonstrating different sonographic images produced when the
body is sliced by ultrasound at different planes

6. Slicing the body to get images: It is important to appreciate that the B mode is a two-
dimensional (2D) section that depends on the anatomical site of the slice. The body
can be sliced at different planes depending on the position of the probe. Sections can
be sagittal, coronal, transverse, or oblique. These thin slices are of less than 1 mm
each. This implies that we are visualizing only a thin section of the body. Figure 1.6
demonstrates this principle. If the gallbladder shown in this image is sectioned verti-
cally, then it will appear as a single cavity. If it is transected transversely on the plane
shown in Fig. 1.6, then it will appear as two cavities and possibly misinterpreted as
an intraperitoneal collection. If the transverse planes are moved to be more proxi-
mal, then it will be appreciated that this is a continuous cavity.
The fan-shaped movement is a very useful technique to obtain images by
using different angles to slice the body while keeping the probe at the same point.
This movement can be horizontal as shown in Fig. 1.7 or vertical.

Tips and Tricks

1. Choose the proper transducer depending on the indication and patients
age and built.
2. Use plenty of ultrasound gel to have proper contact between the transducer
and skin.
3. Check the orientation and side of the transducer.
4. Optimize the gain and depth of the image.
5. Use the fan-shaped movement gently.
1 Basic Ultrasound Physics, Instrumentation, and Knobology 7

Fan shaped movement

Fig. 1.7 Horizontal fan-shaped movement used to obtain sonographic images by changing the
angles in which the body is sliced while keeping the probe at the same point

1.4 Knobology

There are basic buttons that a beginner user of point-of-care ultrasound should know
(Fig. 1.8). These include:
1. On/off button: Ultrasound machines with rapid boot-up are more desirable
because the machine should be moved quickly between patients especially in
mass casualty situations. Long boot-up time may become problematic in this
2. The gain setting: The gain is the amplification of the received ultrasound signal.
When the overall gain knob is turned to the right side, the received signal is mag-
nified and more received signals are allowed to be processed. The ultrasound
image will become brighter and vice versa (Fig. 1.9). Time gain compensation
(TGC) will change the gain factor so that equally reflective structures will be
displayed with the same brightness regardless of their depth. Try to overuse/
underuse gain and TGC at different depths to easily understand the meaning of a
right regulation.
3. The image depth: It is always advised to have a deeper depth than needed and
then gradually reduce it to cover the area of interest. One of the pitfalls is to use
a shallow depth missing deeper important sonographic findings.
4. The mode buttons: These buttons will select the mode of ultrasound waves.
Brightness mode (B mode) is the basic mode that is usually used. The B mode
gives a two-dimensional (2D) black and white image. Imaging one line over time
is called the moving mode (M mode).
8 F.M. Abu-Zidan

TGC On/off





Gain Measure

Fig. 1.8 Basic buttons of a portable ultrasound machine that a beginner user of point-of-care
ultrasound should know


Fig. 1.9 The ultrasound image will become brighter when the gain is increased

5. The freeze button: This freezes the image so that certain structures can be mea-
sured, saved, or printed. When turned off, the real-time continuous display of
images is turned on.
6. The caliper and measurement buttons: These buttons will generate point markers
on the frozen image to define distances of interest that can be measured.
1 Basic Ultrasound Physics, Instrumentation, and Knobology 9

1. Having a wrong orientation of the transducer especially when performing
interventional ultrasound.
2. Using high gain when looking for pelvic fluid in Douglas pouch.
3. Starting with superficial limited depth when looking for deep intraperitoneal
4. Judging quickly that a B mode study is negative. B mode is only a
two-dimensional image of less than 1 mm thick. You should have a three-
dimensional orientation.

1.5 Ultrasound Artifacts

The operator should be especially knowledgeable of the sonographic artifacts that

can mislead him/her. Nevertheless, some artifacts are useful for diagnosing different
conditions. The most common artifacts seen are as follows.
Shadow artifact and posterior enhancement: Ultrasound will not be able to
image what is behind a solid structure (like the ribs) causing a shadow artifact
(Fig. 1.10). The shadow artifact is occasionally useful, for example, in detecting



Fig. 1.10 Ultrasound will not be able to image what is behind a solid structure like the rib. This
will cause a shadow artifact (S) behind the ribs
10 F.M. Abu-Zidan

Posterior enhancement



Fig. 1.11 Gallstones within the gallbladder (GB) causing shadow artifact behind them. The posterior
enhancement is shown on both sides of the shadow artifact

Edge artifact


Fig. 1.12 Edge artifact caused by refraction of the ultrasound at the edge of the urinary bladder

gallstones (Fig. 1.11). The posterior enhancement may occur when imaging fluid-
filled structures. More ultrasound waves will penetrate fluid-filled structures, like
the gallbladder and urinary bladder, and a white enhancement area will appear
behind them compared with adjacent tissues. Small amount of pelvic fluid can be
missed in Douglas Pouch if the gain was high. It is important to use the proper gain
once looking for pelvic fluid, otherwise it can be missed.
Edge artifact: The edge artifact occurs when a beam of ultrasound refracts at the
edge of a rounded structure like the urinary bladder and kidney (Fig. 1.12). This
1 Basic Ultrasound Physics, Instrumentation, and Knobology 11

Mirror plane

Urinary Mirror
bladder artifact

Fig. 1.13 Sagittal section of the pelvis showing a mirror artifact of the urinary bladder mimicking
a fluid collection

should not be misinterpreted as intraperitoneal fluid. This artifact will change by

changing the angle of the probe.
Mirror artifact: High acoustic impedance tissues like the diaphragm or the pelvic
floor work like a mirror reflecting sonographic waves by an angle. Similar to a real
mirror, the mirror artifact will show as a virtual object (Fig. 1.13). The mirror effect
is a normal artifact in RUQ view: it disappears in case of pleural effusion. Ultrasound
artifacts are useful in diagnosing gall stones (Fig. 1.2) and in showing the normal
sonographic lung characteristics (Fig. 1.14).
Reverberation artifact: Reverberation artifact occurs when ultrasound bounces
between two interfaces, especially with high acoustic impedance like the pleura.
The waves will move forward and backward between these interfaces. The machine
will recognize these waves as parallel lines with equal distances between them and
decreased density for the deeper lines, because the reflected waves become gradually
less (Fig. 1.14).
1. You should be careful not to interpret the mirror artifact of the urinary bladder as
a pelvic fluid.
2. You should be careful not to interpret a rib shadow or edge artifact as intraperi-
toneal fluid.
In summary the operator should be familiar with basic physics of ultrasound and
know their ultrasound machine, the type of probes used, how to control its outcome,
and, more importantly, how to correlate sonographic findings with clinical findings
so as to maximize ultrasound benefit.
12 F.M. Abu-Zidan

Fig. 1.14 Reverberation artifact of the lung occurs as ultrasound waves bounce between the trans-
ducer and the pleura (head arrow). The reverberation lines (arrows) are called A lines, represent-
ing repetition of the pleural line. The distances between these lines are equal

The right side of the patient on the right side of the screen (transversal)
The upper part of the patient on the right side of the screen (sagittal or
The key buttons of an US machine are (fill yourself look at pages 7 and
8 of this chapter)
1. _______________________________
2. ___________& TGC _____________
3. ______________________________
4. __B-________/ -mode____________
5. ____________________________
6. ______________________________
Artifacts are not always enemies
1 Basic Ultrasound Physics, Instrumentation, and Knobology 13

Suggested Reading
1. Feldman MK, Katyal S, Blackwood MS (2009) US artifacts. Radiographics 29:11791189
2. Hangiandreou NJ (2003) AAPM/RSNA physics tutorial for residents. Topics in US: B-mode
US: basic concepts and new technology. Radiographics 23:10191033
3. Lichtenstein DA (2010) Basic notions in critical ultrasound. In: Lichtenstein DA (ed) Whole
body ultrasonography in the critically ill. Springer, New York, pp 310
4. Muglia V, Cooperberg PL (1998) Artifacts. In: McGahan JP, Goldberg BB (eds) Diagnostic
ultrasound, a logical approach. Lippincott-Raven Publishers, Philadelphia, pp 2137
5. Rose JS (1997) Ultrasound physics and knobology. In: Simon BC, Snoey ER (eds) Ultrasound
in emergency and ambulatory medicine. Mosby-Year book Inc., St Louis, pp 1038
6. Rose JS, Bair AE (2006) Fundamentals of ultrasound. In: Cosby KS, Kendall JL (eds) Practical
guide to emergency ultrasound. Lippincott Williams and Wilkins, Philadelphia, pp 2741
7. Schuler A (2008) Image artifacts and pitfalls. In: Mathis G (ed) Chest sonography, 2nd edn.
Springer, New York, pp 175182
8. Wells PNT (1998) Physics and bioeffects. In: McGahan JP, Goldberg BB (eds) Diagnostic
ultrasound, a logical approach. Lippincott-Raven Publishers, Philadelphia, pp 119
9. Whittingham TA (2007) Medical diagnostic applications and sources. Prog Biophys Mol Biol
Introduction and Focused Questions
Mauro Zago

EFAST (extended focused assessment by sonography for trauma) represents the

basic US approach to trauma patient. Its role in trauma management algorithm is
evolving over the years and depends from many factors:
Standardized and agreed institutional (not those found in literature) protocols
including focused US
Trained surgeons/physicians in the team available and able 24/7 to perform US
Local resources
Different settings (prehospital, in-hospital, austere environment, etc.)
Local political constraints and resistance to the use of US by non-radiologists
If you are reading this book, you are certainly convinced of US being an invalu-
able tool for you in a context of quick decision-making. You want to know how to do
it and how to use the findings you get on the screen, in both major and minor trauma.
Before going through technical points, learning how to perform and to better include
this exam in the management of your patients, remember you should ask EFAST for
a few focused questions in order to benefit from a technologic third hand.
The first questions are not specifically about US.

How is the physiology of my patient? And anatomy?

Does my patient require US?
Could I better understand/anticipate physiologic derangements in this
patient by EFAST?

M. Zago, MD
General Surgery Department, Minimally Invasive Surgery Unit,
Policlinico San Pietro, Bergamo, Italy
e-mail: maurozago.md@gmail.com

M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons, 15
DOI 10.1007/978-88-470-5274-1_2, Springer-Verlag Italia 2014
16 M. Zago

Doubting the appropriateness of US might be surprising in a US manual, but

indeed in major trauma patients even a few minutes are lifesaving, and all proce-
dures that are not strictly necessary should be avoided, unless they could really
change the clinical decision.
Any flow chart should start from the patient physiology and not from the US
The immediate identification of the so-called hemodynamic instability is a clini-
cal prerequisite.
It is an information you can get in a few seconds (RTS score, on the scene hypo-
tension, vital parameters on road and at arrival, etc.), and anticipates the following
steps if damage control resuscitation is required. We recommend you to be exces-
sively careful in starting by this key point. Sort the US probe from your pocket
immediately after.
Finally, you have the probe in your hands.
Your aim is to identify free fluid and air and to correlate the US findings with the
patient status.
You must first discover signs of two main killers: hemorrhage and pneumothorax.

Is there free fluid in the abdomen? Yes No

Is there free fluid in the thorax? Yes No
Is there free air in the chest? Yes No

Simple questions, simple binary answers!

Wherever and whenever during the primary and secondary survey, the EFAST
exam is for answering only these questions.
Every other adjunctive finding observed on the screen (for instance, dishomoge-
neous spleen suspected for rupture) could be for sure taken into account, but we
cannot forget to remain simple in the reasoning.
This is the only way to be adherent to the master law: clinical decision before
definitive diagnosis.
The three EFAST key questions depicted in the box above help you in answering
the basic clinical questions: becomes.
Is there

A hemoperitoneum?
A hemothorax?
A pericardial effusion? Is it a cardiac tamponade?
A pneumothorax?
Do the US findings correlate with the patient status?

In other words, you need to understand, for example, if the amount of blood you
found in the abdomen justifies the shock in your patient. You might assess it using
simple scores.
2 Introduction and Focused Questions 17

Or you would like to quickly answer to the following questions:

Hemorrhagic? Where?
Nonhemorrhagic? Where is the cause of shock?
EFAST is an effective tool for ruling in/ruling out some of the hemorrhagic/
nonhemorrhagic causes of shock: hemoperitoneum, hemothorax, tension pneumo-
thorax (if not already clinically detected and treated), and cardiac tamponade.
Imagine a less emergent situation: a young female sustained a blunt abdominal
trauma, she is hemodynamically normal and stable, and you found a little amount of
fluid in the abdomen.
There is a slight abdominal pain in the RLQ on physical examination.
CT (when available) showed no solid organ injuries and minimal amount of fluid
in right iliac fossa.
Might it may be a hollow viscus lesion or not? Operation? Observation?
Literature allows both options.
Could US help you?
Maybe yes, with a US-guided diagnostic peritoneal aspiration (DPA):
Bile Operation
Blood It depends!
Clear fluid Physiologic peritoneal fluid in childbearing age females
In other chapters (Algorithms), you will find some examples of US-driven sug-
gested management of trauma cases and test yourself.
EFAST has certainly some limits and pitfalls, and it really not always solves the
problem: be aware about that, go ahead with your clinical reasoning like as you
dont have US, and ask your team and if needed for a help!
Having clear questions in mind is mandatory for getting the best clinical result
from EFAST.
Your US performance is important, but more important is to take the right clini-
cal decision: that is why you have decided to read this book! Frequently, unsatis-
factory or doubtful exams can help your decision-making process.
Even in more advanced application of US in trauma patients (ABCDE-FAST,
interventional maneuvers, monitoring of shock, CEUS-FAST, etc.), surgeon should
always ask himself/herself if and what US can add to decision-making process: Can
US help me? Can US shorten the time to definitive treatment? Can US change my
diagnostic algorithm?

Assess physiology and anatomy first
Basic US questions (liquid? air?)
Clear clinical questions (according to the patient status)
Link EFAST findings to your clinical reasoning
Abdominal Views: Technique,
Anatomy, Abnormal Images, 3
Scanning Tips, and Tricks

Fernando Ferreira, Eva T. Barbosa, and Antnio R. Silva

3.1 Introduction

Trauma care has evolved all over the world with more efficient integrated emer-
gency medical systems. Many of these systems are achieving lower mortality rates
comparatively to the past because of expeditious trauma management that starts
immediately on scene all the way to the trauma resuscitation bay often extending
into the operating room.
The approach to these patients requires dedicated surgeons that must determine
the extent of injuries in minutes with E-FAST (extended focused assessment with
sonography for trauma) and decide if a patient is bleeding and from which body com-
partment. This may diminish time to definitive care (operating/angiography suite)
with possible improvements in length of stay, lower cost of hospitalization, morbidity,
and mortality if definitive surgical trauma care (DSTC) is accordingly executed.
E-FAST is most useful in the emergency room for the patient who is too hemo-
dynamically unstable to perform a CT exam. This modality has proven to decrease
the number of nontherapeutic laparotomies because it decreases the need for a

F. Ferreira, MD (*)
Emergency and Trauma Surgery, Upper Gastrointestinal Surgery Unit,
Department of Surgery, U.L.S. Matosinhos, E.P.E., Pedro Hispano Hospital,
Rua Dr. Eduardo Torres, Senhora da Hora 4464-513, Portugal
The Faculty of Medicine, University of Oporto, Porto, Portugal
e-mail: med1873@gmail.com
E.T. Barbosa, MD, MSc A.R. Silva, MD
Emergency and Trauma Surgery, Colorectal Surgery Unit, Department of Surgery,
U.L.S. Matosinhos, E.P.E., Pedro Hispano Hospital,
Rua Dr. Eduardo Torres, Senhora da Hora 4464-513, Portugal
The Faculty of Medicine, University of Oporto, Porto, Portugal
e-mail: evatamar@gmail.com; rs31785@gmail.com

M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons, 19
DOI 10.1007/978-88-470-5274-1_3, Springer-Verlag Italia 2014
20 F. Ferreira et al.

diagnostic peritoneal lavage and its false positives. It is the modality of choice in
shock evaluation in Advanced Trauma Life Support (ATLS) and DSTC proto-
cols for trauma management. One should never forget to repeat an E-FAST exam
after a few minutes placing the patient in reverse Trendelenburg for the pericardial
view and regular Trendelenburg to scan the abdomen if the patient shows any sign
of shock despite resuscitation. You must also repeat the primary assessment and
exclude all other types of shock. It is important for the surgeon to integrate E-FAST
into the evaluation protocol to help determine any indication for a trauma lapa-
rotomy and/or thoracotomy.
This chapter will aid the surgeon in understanding E-FAST as a powerful diag-
nostic modality by reviewing the following aspects:
Scanning technique
How to scan
Normal anatomy
Basic abnormal findings (what to search) and the clinical meaning
Scanning tips and tricks

3.2 Scanning Technique

3.2.1 How to Scan

The main objective of performing focused ultrasound is to detect blood in areas

where it should not exist. E-FAST views involve thoracic views discussed previ-
ously and the abdominal views of the 4 Ps (pericardial, perihepatic, perisplenic,
and pelvic) (Fig. 3.1).
Recent bleeding is represented by an anechoic dark line in these spaces, yet
older blood may have a heterogeneous echogenicity owing to clots.
Attaining E-FAST views requires basic knowledge of ultrasound physics and
knobology of ultrasound machines. We prefer the use of curved probes with a fre-
quency between 3 and 5 MHz. Optimal depth settings will depend on patient body
habitus, but a setting of 815 cm is usually sufficient. Adjust gain settings in a way
that blood vessels are black and the surrounding tissues are not too bright. Hold the
probe like you hold a pen or a pencil. Grasp it with the first three fingers of the
dominant hand, and use the remaining fingers to stabilize the probe touching the
patient if needed avoiding inadequate pressure. Do not forget the basic transducer
movements known as ART (alignment for sliding movements, rotation, and
The patient must be in a supine position, and the operator should stand to the
According to international ultrasound consensus, the transverse view of our
patients is a perspective from the feet (Fig. 3.2). Therefore, the images on the right
of the patient should show on the left of the monitor. The sagittal and coronal views
also corresponds to an image on the left of the monitor which corresponds to the
cranial direction (Fig. 3.3). The scanning probe has a marker on the probe which
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks 21

Fig. 3.1 The four scanning windows of the E-FAST abdominal examination

helps keep the proper orientation as referred. One can also assure this by pressing
on the surface of the probes marker just to guarantee its correct position by viewing
movement on the left side of the monitor. All obtained ultrasound images should be
correlated with the clinical situation. Please remember that this type of ultrasound
is more focused on a clinical basis rather than the traditional anatomically oriented
ultrasound that is performed in the radiology unit.

3.2.2 Normal Anatomy

The order of the E-FAST views is not standardized although many surgeons argue
that in cases of thoracic trauma, one should begin with a pericardial view. The peri-
hepatic view may first be performed in abdominal trauma since it is where blood
primarily deposits in the peritoneum.
22 F. Ferreira et al.

Fig. 3.2 The ultrasound transverse caudal to cranial view

Pericardial View
The subcostal view is also known as subxiphoid; this permits the visualization of the
heart as well as part of the liver and diaphragm. Usually, a very small amount of
physiological fluid exists between the parietal and visceral pericardium that is non-
circumferential and that is rarely seen. The probe should be placed with the pointer
directed toward the patients right. The convex surface of ultrasound probe should
be placed in the midline, angled slightly upward toward the left shoulder, and insin-
uated under the ribcage to minimize thoracic ribcage shadow, until a view of the
heart and left lobe of the liver is obtained (Fig. 3.4). Normal pericardium is seen as
a hyperechoic (white) line surrounding the heart below the left lobe of the liver
(Figs. 3.5 and 3.6). To enhance imaging ask the patient to bend his knees and hold
his breath or make an end-inspiratory pause if on mechanical ventilation. The inter-
costal or parasternal view is also a valid option if the subcostal view is not adequate
owing to obesity, protuberant abdomen, abdominal tenderness, and gas or epigastric
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks 23

Fig. 3.3 Green marker pointing toward the patients head in coronal view

Fig. 3.4 Position for pericardial subxiphoid view

24 F. Ferreira et al.

Figs. 3.5 and 3.6 Normal subcostal echocardiographic view

3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks 25

Fig. 3.7 Position for perihepatic E-FAST view

Perihepatic View
The perihepatic or right upper quadrant view permits the surgeon to acquire a
partial image of the liver, the right kidney, the subphrenic space, and the right
pleural space. The right subcostal technique is obtained with the probe at the
right infracostal margin, just lateral to the midclavicular line (Fig. 3.7). Angle
the probe until the hepatorenal space (Morisons pouch) is seen. In a normal view,
the liver and kidney are closely aligned separated by a brightly echogenic surface
(Gerotas fascia) (Figs. 3.8 and 3.9). To better visualize the subphrenic space, one
should gradually move the probe in a more cranial direction and laterally closer
to the posterior clavicular line allowing for a more coronal perspective. Right
intercostal oblique or transverse views can be obtained rotating the probe counter-
clockwise (Fig. 3.10). This allows a better visualization of the right pleural space,
Morisons pouch, and right paracolic gutter. As mentioned, to enhance imaging,
have the patient hold his breath or make an end-inspiratory pause if on mechanical

Perisplenic View
The perisplenic or left upper quadrant view may be considered more challeng-
ing since the spleen is smaller and located more posteriorly than the liver. This
approach requires that the placement of the probe be intercostal and as close to the
posterior axillary line as possible between the 10th and 11th ribs angled to achieve
26 F. Ferreira et al.

Figs. 3.8 and 3.9 Normal view of hepatorenal interface

a view of the spleen, the left kidney, the subphrenic space, and the left pleural space
(Figs. 3.11, 3.12, and 3.13). The spleen has a homogeneous cortex that is more
echogenic than the left kidney cortex. To better visualize the subphrenic space, one
should position the probe marker upward pointing toward the left posterior axilla
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks 27

Fig. 3.10 Probe rotation for intercostal view

Fig. 3.11 Position for perisplenic view

and gradually move the probe in a more cranial direction laterally closer to the
posterior clavicular line allowing for a more coronal perspective.
One should enhance the view of the left diaphragm and spleen by having the
patient hold his breath or making an end-inspiratory pause if on mechanical ventila-
tion. This will cause the diaphragm to move into the necessary plane. For a better
view of the spleen and lower pole of the kidney, have the patient exhale or make an
end-expiratory pause if on mechanical ventilation, thus minimizing interference
from the stomach.
28 F. Ferreira et al.

Fig. 3.12 Normal anatomy of splenorenal space with colored spleen and kidney

Fig. 3.13 Anatomy and view of splenorenal space

3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks 29

Fig. 3.14 Position for pelvic transverse view

Pelvic View
The pelvic view should be evaluated in both transverse and sagittal planes. The
probe must be placed transversely in the abdominal midline 24 cm superior to the
symphysis pubis with the probe marker pointing to the patients right, angled down
until the prostate or vaginal stripe is identified (Fig. 3.14). The probe is then rotated
90 placing the probe marker in a cranial direction and slightly tilting the probe, to
avoid interference from the pubic rami, providing a sagittal view of pelvic struc-
tures (Fig. 3.15). A full bladder is essential for an adequate scan. The best oppor-
tunity to acquire a good sonographic view is before the placement of a urinary
Foley. If it has already been placed, one may inject saline into the bladder in a ret-
rograde manner or wait until it fills normally not forgetting to clamp the tube. The
pelvic view permits the visualization of the bladder that serves as an acoustic win-
dow. In the female it allows for visualization of uterus and the rectouterine pouch
and in the male the seminal vesicles, prostate, and rectovesical recess (Figs. 3.16,
3.17, 3.18, and 3.19).

3.2.3 Basic Abnormal Findings (What to Search)

and the Clinical Meaning

In the same order as previously presented, we shall review the abnormal findings
and the clinical meaning that one should keep in mind when performing an E-FAST
30 F. Ferreira et al.

Fig. 3.15 Position for pelvic sagittal view

Fig. 3.16 Normal pelvic transverse view colored for better identification
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks 31

Fig. 3.17 Normal pelvic view as seen in display monitor

Fig. 3.18 Sagittal pelvic view. Colored structures for better visualization
32 F. Ferreira et al.

Fig. 3.19 Normal anatomy of sagittal pelvic view

Heplful Tips
Never forget the basics of ultrasonography such as the use of sufficient amount
of gel to facilitate good ultrasound wave transmission and the proper inclina-
tion of the probe to avoid interference from any bone structures.

Pericardial View: Subcostal and Parasternal

In the E-FAST view, the subcostal window may permit a full four-chamber perspec-
tive of the heart. The pericardium is more hyperechoic than the heart muscle. If fluid
is present between the parietal and visceral pericardium, this should be identified
with high sensitivity as a black line representing an acute bleed; however, in some
healthy patients, a small amount of fluid can also be seen in the dependent aspect of
the heart, so clinical correlation is always mandatory. A partial pericardial anterior
anechoic line may correspond to a pericardial fat strip yet if circumferential will in
fact represent pericardial fluid (Fig. 3.20).

Helpful Tips
Be careful with subcutaneous emphysema which can obscure a proper ultra-
sound view. The transducer should be very angled approximately 510 or be
flat to the skin.
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks 33

Fig. 3.20 Positive pericardial E-FAST

Pericardial fluid may be obscured by a large hemothorax. It is advisable to

repeat your scan after chest tube placement. If the subxifoid window is not
available try the left parasternal window at 4th or 5th intercostal space.

Perihepatic View
The perihepatic or right upper quadrant view allows for a partial view of the liver and
right kidney. This permits good visualization of fluid in Morisons pouch, the right
pleural space, and the subphrenic space. If a hemoperitoneum exists, it will appear
as an anechoic area in Morisons pouch and/or the subphrenic space (Fig. 3.21).
This free fluid tends to triangulate as it follows the path of least resistance differing
from visceral edema, which has a more cylindrical appearance. Morisons pouch
represents a dependent location for blood accumulation. Be aware that the internal
fluid in the viscera such as the duodenum, colon, gallbladder, and even the vena
cava can be mistaken for free peritoneal fluid.

Helpful Tips
Placing the patient in a Trendenlenburg position will facilitate fluid accumula-
tion at Morisons pouch.
34 F. Ferreira et al.

Fig. 3.21 Positive perihepatic E-FAST

Be aware that perinephric fat can mimic a hematoma. Perinephric fat is

usually symmetric with the opposite kidney.
Ascites has an identical appearance and can be mistaken for hemoperito-
neum. Liver disease and right heart failure should be considered.

Perisplenic View
The perisplenic or left upper quadrant view allows for different perspectives of the
spleen, left kidney, and left pleural space. Hemoperitoneum will translate as an
anechoic area in the subphrenic space or in the splenorenal recess (Fig. 3.22). The
path of least resistance for the peritoneal fluid will most likely extend to the sub-
phrenic space, with overflow going into the splenorenal fossa and eventually across
to Morisons pouch. Pleural fluid, in a trauma context, is most likely a hemothorax
being located in the left pleural space and accurately detected on this limited view
as an anechoic region above the left hemidiaphragm.
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks 35

Fig. 3.22 Positive perisplenic E-FAST

Helpful Tips
Due to gastric distension secondary to opioid medication and hyperventila-
tion, a NG tube placement will permit a better view of the upper left
Placing a towel under the spine board will allow for a better view of the
spleen from a more posterior angle.
Stay posteriorly for a better visualization.

Pelvic View: Transversal and Sagittal

In a female patient, free fluid appears in the rectouterine pouch with greater amounts
of fluid extending around the uterus (Figs. 3.23 and 3.24). In a male patient, this
fluid appears in the rectovesical pouch or cephalad to the bladder. In both cases, a
significant amount of perivesical fluid, most likely blood in trauma cases, will pro-
duce an anechoic medium that accentuates bowel loop underwater undulation.
36 F. Ferreira et al.

Fig. 3.23 Positive pelvic view (transverse)

Fig. 3.24 Positive pelvic view (sagittal)

3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks 37

Helpful Tips
Fluid within a collapsed bladder may appear as free peritoneal fluid. A full
bladder is essential.
Seminal vesicles may be incorrectly identified as free fluid in a transverse
view. Use a sagittal view and sweep slightly lateral to differentiate.
Premenopausal females may normally have a small amount of free fluid in
the Pouch of Douglas.

Suggested Reading
1. American College of Surgeons Committee on Trauma (2008) ATLS student course manual,
8th edn. American College of Surgeons, Chicago
2. Boffard KD (2007) Manual of definitive surgical trauma care, 2nd edn. Edward Arnold
Publishers Ltd., London
3. Boulanger BR, Brenneman FD, McLellan BA et al (1999) Prospective evidence of the superi-
ority of a sonography-based algorithm in the assessment of blunt abdominal injury. J Trauma
4. Ihnatsenka B, Boezaart AP (2010) Ultrasound: basic understanding and learning the language.
Int J Shoulder Surg 4:5562
5. Melniker L, Liebner E, McKinney M et al (2006) Randomized clinical trial of point-of-care,
limited ultrasonography for trauma in the emergency department: Sonography Outcomes
Assessment Program (SOAP) -1 trial. Ann Emerg Med 48:227235
6. Rozycki GS, Ochsner MG, Feliciano DV et al (1998) Early detection of hemoperitoneum by
ultrasound examination of the right upper quadrant: a multicenter study. J Trauma 45:878880
Thoracic Views: Anatomy, Techniques,
Scanning Tips and Tricks, Abnormal 4

Andrea A. Casamassima and Mauro Zago

4.1 Introduction

The idea behind chest ultrasound is not a recent one.

The first published paper on the diagnosis of pneumothorax dates back to the
1986 (Rantanen).
In the last 15 years, several papers showed the efficacy of chest ultrasound in
detecting both pneumothorax (PTX) and hemothorax.
Some authors say that US is faster than the fastest of X-rays, and indeed, it can
buy you some time just when time is of the essence.
In this chapter, youll learn how to perform a correct chest ultrasound examina-
tion to detect two life-threatening conditions, such as pneumothorax and
You will learn to recognize the normal sonographic anatomy of the chest wall as
well as normal and pathological US patterns.
At the end of this chapter, youll be able to answer the same old question (Is
there free fluid?) and a new one (Is there free air?).

Chest US is useful in prehospital and in emergency room but also in intensive

care units, to detect PTX and hemothorax earlier than using X-ray and with-
out moving the patient!

A.A. Casamassima, MD (*)

Emergency Department, Istituto Clinico Citt Studi, Milano, Italy
e-mail: casamax@gmail.com
M. Zago, MD
General Surgery Department, Minimally Invasive Surgery Unit,
Policlinico San Pietro, Bergamo, Italy
e-mail: maurozago.md@gmail.com

M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons, 39
DOI 10.1007/978-88-470-5274-1_4, Springer-Verlag Italia 2014
40 A.A. Casamassima and M. Zago

4.2 Scanning Technique and Semeiotics

As we said before, there are two main severe conditions possibly affecting a chest
trauma patient that can be detected with US: hemothorax and pneumothorax.
Lets talk about hemothorax first as the technique is a natural extension of the
abdominal views.
You have learned to explore the abdomen in the previous chapter and you
may recall the upper right and left quadrant views. Starting from those views, you
simply have to pan the probe headward a few inches, along midaxillary/posterior
axillary line. That way you will switch from the abdominal to the chest cavity. On
the monitor you will see the liver, a bright curved line which is the diaphragm and
on the left side of the screen you will have the chest cavity.
What you see depends on the condition of the patient.
A bright curtain moving synchronously with the breathing cycle stands for a
normal finding (Fig. 4.1). The white artifact is the lung (see below): so, if the lung
is detectable on mid-/posterior axillary line without any black strip interposition,
there is no clinically relevant fluid in the thorax!
Another normal finding is the mirror effect, an US artifact. Due to the curved
surface of the diaphragm, you will happen to see the same texture of the liver above
(i.e., on the left side) the diaphragm bright line (Fig. 4.2).

Fig. 4.1 Normal right upper quadrant view. On the left side of the figure, there is the white
curtain of the lung, descending to cover the texture of the liver
4 Thoracic Views: Anatomy, Techniques, Scanning Tips and Tricks, Abnormal Images 41

Fig. 4.2 Mirror effect. On both sides of the diaphragm, you can see the same texture. That indi-
rectly rules out pleural effusion

On left side of the patient, the technique will be the same: upper left abdominal
quadrant view, pan headward 1 or 2 in. You will see the spleen, a bright white line
(the diaphragm), and the white curtain moving in and out of the screen with the
patients breathing.
In patients affected by hemothorax, you will see the liver or the spleen, according
to the side youre probing, the bright line of the diaphragm and on the left side of the
screen, there will be a sort of black triangle or black strip, which is fluid (Figs. 4.3,
4.4, 4.5, and 4.6).
As you may recall from the abdominal views, fluid is (almost) always black on
the screen.
That simple.
Since these views can be considered an extension of the abdominal examination,
you will use the curved array.
Now we can explore the chest to detect PTX.
In order to obtain a correct chest exam, we need to set our US machine to let us
see artifacts (i.e., you have to switch off any artifact reduction algorithm that US
machine manufacturers are proud of).
You may explore the chest using almost any kind of probe, but its advisable to
use the linear array, because higher resolution helps to tell the very artifacts were
looking for. When you will become skilled, you will use phased array or curved
probes too.
42 A.A. Casamassima and M. Zago

Figs. 4.3, 4.4, 4.5, and 4.6 Hemothorax. On the right of the figure, there is the texture of the solid
organ (spleen or liver). You may notice the bright, curved line of the diaphragm, and on the left
side (above the diaphragm) there is the fluid. Note the collapsed lung appears solid with some
white spots (trapped air bubbles)
4 Thoracic Views: Anatomy, Techniques, Scanning Tips and Tricks, Abnormal Images 43

Figs. 4.3, 4.4, 4.5, and 4.6 (continued)

44 A.A. Casamassima and M. Zago

Fig. 4.7 Position of the

probe on the chest when
scanning for PTX

Fig. 4.8 Scheme of a classic

US chest view for PTX: two Key landmarks
ribs with their shadows and
amidst them the pleural line Rib shadow Rib shadow

Pleural line

The probe will be applied longitudinally, on the midclavicular line, on the

uppermost area of the chest (your patient is in supine position) (Fig. 4.7).
You have to recall the anatomy of the chest wall. Think of it in layers: skin and
subcutaneous tissue, muscles, ribs, and pleura (Fig. 4.8).
When you apply the probe on the chest of the patient, the first image you have to
look for is the bat sign (Fig. 4.9), an original way to describe normal US anatomy.
The bat sign is characterized by two ribs and their shadows and the pleural line.
As you can see in Fig. 4.9, with a bit of imagination, you can see the wings of the
bat (the ribs with their acoustic shadow) and the back of the bat (the bright pleural
line), flying toward you.
This particular static sign allows us to know if our ultrasound exam will be con-
ducted properly: in fact if youre not able to see the bold white line between the rib
shadows (pleural line), you cannot tell if there is a PTX.
(NB: properly, pleural line defines the visceral pleural interface sliding up and
down, so it is obviously not detectable if there is PTX, but to help you in familiar-
izing with chest US, lets call pleural line the white line 1 cm below and between the
two rib shadows.)
4 Thoracic Views: Anatomy, Techniques, Scanning Tips and Tricks, Abnormal Images 45

Fig. 4.9 Two ribs with their shadows and amidst them the pleural line: the so-called bat sign

No bat, no exam!

In trauma patient, we have to pay particular attention to subcutaneous emphy-

sema, since high acoustic impedance of the air in subcutaneous tissue will deflect
the ultrasonic beam, preventing us to detect the bat sign and thus to perform the
Once we clearly see the pleural line, we can start the exam looking for a dynamic
sign called sliding lung or gliding sign.
The sliding lung can be described as a rhythmic sparkle of the pleural line,
moving synchronously with the breathing cycle of the patient.
Its generated by the comet tail artifacts of the air in the outer alveoli, just beneath
the visceral pleura sliding on the parietal pleura (Fig. 4.10).
If you can detect the sliding lung, you can be sure there is no PTX.
In order to identify the sliding lung properly in difficult environment (i.e., bright
lights in ER reflecting on the US machine screen), you can switch on the M-mode
(motion mode), and youll have a second useful dynamic sign: the seashore sign.
M-mode measures the intensity of each single point along the scanning line. If a
structure remains still, it will produce horizontal lines (since in M-mode our Y-axis
on the screen is depth and X-axis is time). If a structure moves, it will produce a
granular pattern (Fig. 4.11).
46 A.A. Casamassima and M. Zago

Fig. 4.10 Close-up of the pleural line. Notice the small vertical comet tail artifacts departing from
the bright line

Fig. 4.11 Seashore sign. You may notice the different patterns in M-mode: above the pleural line,
the linear pattern, and the granular pattern below it
4 Thoracic Views: Anatomy, Techniques, Scanning Tips and Tricks, Abnormal Images 47

Fig. 4.12 Stratosphere sign. No granular pattern can be identified. The very small intermittent
granular pattern columns are related to the movement transmitted to the lung by the beating heart
(lung pulse)

As you can see in Fig. 4.11, the chest wall stands still (i.e., makes lines), while
from below the pleural line (the bright line), all we have is granular pattern. With
a bit of imagination, you can describe this image as waves (lines) crashing on the
beach (granular pattern).
Seashore sign (M-mode) is a good method for ruling in/ruling out PTX when you
are a beginner or you are in doubt, because it makes often the diagnosis simpler and
When our patient is affected by a PTX, no granular pattern could be detected,
and the seashore becomes the stratosphere sign (all horizontal lines; Figs. 4.12 and
4.13). Nothing is moving; horizontal lines are everywhere on the screen.

Sliding Lung: Tips and Tricks

Amplitude of sliding lung increases from lung apex to basis progressively
Dyspnea makes the diagnosis difficult, even in M-mode, because our
patient is using even his accessory muscles, making our image shake with
every breath
48 A.A. Casamassima and M. Zago

Pleural line is interrupted by rib shadows. If youre in trouble, put the

probe on cartilages, next to the sternum: cartilage does not completely
block ultrasound!
Sliding lung has to be seen in spontaneous and assisted ventilation. Its
useful to diagnose a wrong endotracheal intubation!
Apnea cancels the sliding lung (but not small vertical artifacts at the pleural
line comet tails)

Fig. 4.13 A PTX, in both B- and M-modes

Another important dynamic sign, pathognomonic of PTX, is the lung point. It

is pathognomonic for PTX. You can imagine the lung point to be the point in which
the collapsed lung touches the chest wall during breathing cycle. On your US
machine screen, the lung point will appear as an alternation between the presence
and absence of sliding lung (Figs. 4.14 and 4.15).
Lung point allows you to define the extent of PTX; from medial to lateral, you
can assess where the lung point is (parasternal, on midclavicular, on anterior axil-
lary, on midaxillary, etc.), precisely evaluating the entity of PTX and relating it to
patient status. Complete PTX has no lung point!
4 Thoracic Views: Anatomy, Techniques, Scanning Tips and Tricks, Abnormal Images 49

Fig. 4.14 Lung point

Fig. 4.15 Lung point (M-mode): alternation between stratosphere and seashore signs

Lung point is better observed with the probe along the axis of the intercostal
space, eliminating the rib shadows.
50 A.A. Casamassima and M. Zago

Dont lose time with US if a tension PTX is suspected (patient is in shock)
Priority is to decompress the thorax
If needed, use the probe for a few seconds: rule out hemothorax, confirm
PTX (parasternal), and insert the needle and drainage

Several other static signs were described and cataloged (Lichtenstein) using
alphabet letters. From our practical perspective, just three of them are the most
significant for clinical approach:
1. A-lines
2. B-lines
3. E-lines
A-lines are horizontal reverberation artifacts, repeating themselves below the
pleural line at regular intervals, roughly equal to the distance between the skin and
the pleural line (Figs. 4.16, 4.17, and 4.18).

Figs. 4.16, 4.17, and 4.18 A-lines. Notice the bright horizontal lines underneath the pleural line,
at regular intervals
4 Thoracic Views: Anatomy, Techniques, Scanning Tips and Tricks, Abnormal Images 51

Figs. 4.16, 4.17, and 4.18 (continued)

52 A.A. Casamassima and M. Zago

Their number has no clinical relevance, while their presence does.

Be aware: A-lines are not moving; they are normal pattern in both PTX and
normal lung! You can find similar artifacts even looking at it in the bowel.
B-lines are vertical, laser-like artifacts, departing from the pleural line and
descending to the lower edge of the screen, increasing in thickness as they go down
(Figs. 4.19 and 4.20). They move synchronously with the sliding lung. They can be
as few as one or multiple. Plenty of B-lines (till a so-called white lung) means a wet
lung (lung contusion, pulmonary edema, ARDS) (Figs. 4.21). Fine US lung semiol-
ogy is out of the scope of this book.
B-lines are better visualized with convex or phased array probe.
The last artifact of interest is called E-line (Fig. 4.22).
Generated by the air in the subcutaneous tissue, this particular artifact appears as
long or short vertical lines, masking the bat sign. It is very important to identify the
bat sign BEFORE starting to classify artifacts for diagnosis, because if you have
subcutaneous emphysema, you cannot see the pleural line and thus you cannot tell
a PTX.

Figs. 4.19, 4.20, and 4.21 B-lines and the so-called lung rocket. The laser-like vertical lines go
down to the edge of the screen
4 Thoracic Views: Anatomy, Techniques, Scanning Tips and Tricks, Abnormal Images 53

Figs. 4.19, 4.20, and 4.21 (continued)

54 A.A. Casamassima and M. Zago

Fig. 4.22 E-lines. They look

almost like the B-lines, but
no bat sign can be detected.
There is subcutaneous
emphysema: Lung US not

4.3 Clinical Meaning: Diagnosis of Pneumothorax

Lets get to the core: how can I diagnose a PTX with US?
When you suspect a PTX, you should apply the probe on the anterior chest wall
and check for the sliding lung.
If you can detect it, your patient has no PTX.
Move the probe toward the feet, till you see the liver (on the right side) or heart
(on the left). Small PTX are located parasternal, over the diaphragm (right), and
over the heart (left), not at the apex, as your patient is in supine position.
If you cannot tell the sliding lung and you can see the A-lines, you should check
for a lung point. If lung point can be seen, thats your evidence of PTX. With lung
point detection, you also have a crude idea of the extension of the PTX. If in dif-
ferent positions over the chest you cannot detect the lung point (and sliding lung
neither), you should think of a massive PTX and act accordingly.

Key Points
Sliding lung no PTX
Sliding? No comet tails? Yes apneic patient or wrong intubation
Sliding + lung point PTX
No Sliding + no lung point complete PTX
4 Thoracic Views: Anatomy, Techniques, Scanning Tips and Tricks, Abnormal Images 55

Here is a small flow chart (Fig. 4.23):

In the very spirit of think binary, with this chart in mind, we can exclude or
diagnose a PTX (and have a rough idea of its extension as well) in less than 2 min.

Sliding lung?
(B-mode or M-mode)




YES Lung point?


Moderate PTX NO

Severe Complete PTX

Fig. 4.23 Pneumothorax diagnosis flow chart

56 A.A. Casamassima and M. Zago

Check for hemothorax at the same moment you scan abdominal RUQ and
LUQ with the convex probe
Dont lose time: missed small hemothorax are not clinically relevant; you
are treating a trauma patient!
Detection of PTX is simpler than free fluid in the abdomen
Start with linear probe for PTX if you are not an expert
Dont move the probe checking for PTX (you are finding for lung
Small PTX are caudal, not at the apex

Suggested Reading
1. Blaivas M, Lyon M, Duggal S (2005) A prospective comparison of supine chest radiography
and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med
2. Lichtenstein DA, Menu Y (1995) A bedside ultrasound sign ruling out pneumothorax in the
critically ill. Lung sliding. Chest 108:13451348
3. Lichtenstein D, Meziere G, Biderman P, Gepner A (1999) The comet-tail artifact: an ultra-
sound sign ruling out pneumothorax. Intensive Care Med 25:383388
4. Lichtenstein D, Meziere G, Biderman P, Gepner A (2000) The lung point: an ultrasound sign
specific to pneumothorax. Intensive Care Med 26:14341440
5. Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Silveri NG (2008) Occult traumatic pneu-
mothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest
6. Zhang M, Liu ZH, Yang JX, Gan JX, Xu SW, You XD, Jiang GY (2006) Rapid detection of
pneumothorax by ultrasonography in patients with multiple trauma. Crit Care 10:R112
Including EFAST in Trauma Algorithms:
When? What Now? 5
Diego Mariani and Mauro Zago

5.1 Introduction

You have learned to recognize fluids: liquid effusions (in abdominal or pericardial
or pleural cavity) or free air in the thorax. In other words, you know how to quickly
detect hemothorax, pneumothorax, pericardial effusion, and free fluid in the
You also know that the sequential steps for a decision-making process helped by
US could be summarized as follows:

Is my patient in a life-threatening condition?

Should I overcome EFAST?

If no,
EFAST  where is fluid/air?


my decision is

life-saving maneuver or immediate DCS or further work-up

D. Mariani, MD (*)
General Surgery Department, AO Ospedale Civile di Legnano,
Via Papa Giovanni Paolo II, Legnano, Milano 20025, Italy
e-mail: diemar@me.com
M. Zago, MD
General Surgery Department, Minimally Invasive Surgery Unit,
Policlinico San Pietro, Bergamo, Italy
e-mail: maurozago.md@gmail.com

M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons, 57
DOI 10.1007/978-88-470-5274-1_5, Springer-Verlag Italia 2014
58 D. Mariani and M. Zago

Neither detection of injured organs nor a precise diagnosis is required for

The key point on which to apply EFAST findings is patient
All lesions not producing free fluid will not be in the range of EFAST: if
you suspect them, go ahead with your further step

5.2 The Common Role of US Exam in Trauma

The golden hour paradigm is not a strictly clock-related concept but means an
evidence increasing of morbidity and mortality if care is delayed beyond the first
hour after injury.
So a quick examination like focused sonography found a kind of a natural place
in the primary evaluation of traumatized patient, both in hospital and in prehospital
The first aim of EFAST is to assist in assessing the undifferentiated hypotensive
status secondary to a blunt trauma.
It could be also selectively applied in the evaluation of penetrating torso
For its focused nature, EFAST sonography has some limits which must be
Specificity is high. So, if my EFAST is positive, I could be sure there is an effu-
sion (abdominal, pericardial, or thoracic), and these results must be related with the
clinical condition of the patient.
Sensitivity depends on my skills, the patient, and time from trauma. So, if my
EFAST is negative, it is very important to be very sure about my images and inter-
pret them cautiously in both blunt and penetrating traumas, because the presence of
an underlying lesion in abdominal trauma is not always related with free fluid, espe-
cially in the early period.
Some lesions dont produce free fluid (retroperitoneal bleeding, intraparenchy-
mal lesions); others sometimes require time to develop effusion (bowel injuries, for
When we performed a focused sonography examination in trauma setting, we do
a particular sonography with a particular point of view.
5 Including EFAST in Trauma Algorithms: When? What Now? 59

EFAST applies to thoracic and abdominal trauma

The choice of the sequence of scans is mostly dependent on the patients
trauma status and mechanism
EFAST should be performed
During the primary survey in physiologically unstable patients
At the end of primary survey in normal and stable patients
During the secondary survey and whenever needed by changes in
patient clinical status
EFAST refers to B and C steps of the primary survey

Taking in mind the basic ATLS method of assessing a trauma patient, which is
valid for both major and minor traumas, it will be not so difficult to realize and agree
what is depicted in the box above.

5.3 Common Algorithms

Simple algorithms including EFAST and its meaning for clinical decision in blunt
and penetrating trauma are shown below. Brief comments are given for each one in
order to explain some points of the flow chart.
Before taking a look at them, please consider that:
There is a great debate in the last few years about the concept of hemodynamic
instability. For this reason, in order to do not be confusing, we prefer to talk
about normal or not normal hemodynamics and physiology. Always remem-
ber that the first treatment of bleeding is to stop the bleeding and misdiagnosed
latent shock should be carefully anticipated (with EFAST too).
For didactical purposes, flow charts are presented for different anatomic
areas (thoracic, abdominal). In order for you to merge them, you could imag-
ine to apply them to some complex trauma patients you mananged a few days
These flow charts are not fully comprehensive trauma algorithms. They highlight
the place and the decisional role of US.
Finally, local resources can significantly change the clinical path. For that reason,
sometimes a list of option is shown.
60 D. Mariani and M. Zago

5.3.1 Blunt Abdominal Trauma

Fig. 5.1 Proposed algorithm

for blunt abdominal trauma

Here following a Flow chart on Blunt Abdominal Trauma (Fig. 5.1) to which some
additional considerations are to be made:
1. *Other sources of shock: hemorrhage elsewhere (thorax, pelvis, bones, retroperito-
neum), tension PTX, cardiac tamponade, neurogenic shock, cardiac pump failure.
Consider you could rule in/rule out some of them with US in a few seconds!
2. Peritonitis in trauma is a mandatory indication for surgery. Further workup and/or
laparoscopy could be used in selected cases
3. The list of possible indications for CT after a negative or slightly positive abdom-
inal EFAST views is based on literature proposals. Having your own protocol is
5 Including EFAST in Trauma Algorithms: When? What Now? 61

5.3.2 Pelvic Trauma

Fig. 5.2 US driven protocol

for Pelvic Trauma

This flow chart is for a patient with clinically or more often radiologically docu-
mented pelvic fracture at high risk of bleeding (in the vast majority of cases, Tile
B/C fractures).
US has a pivotal role for orienting the definitive treatment.
Comments to the Pelvic Trauma Flow Chart
1. Possible options for treatment are listed; choice depends on skills, resources,
training, etc., and is out of the goal of this chapter.
2. Physiology (hemodynamics, coagulation, core temperature, pH, etc.) and pelvis
X-ray features (type of fracture relates to the mechanism of injury) are the main
criteria for choosing the best treatment. FAST is the best tool for assessing priori-
ties and deciding for the need of full laparotomy, extraperitoneal packing, or
external fixation +/ angioembolization.
3. Dont forget the KISS (keep it simple and stupid): close the pelvic ring immedi-
ately before any further diagnostic and therapeutic maneuver, if needed.
4. In up to 18 % of patients with pelvic fracture, free abdominal fluid is urine (blad-
der rupture): if in doubt and clinical and US findings do not fit with patient status,
use again US and perform a diagnostic peritoneal aspiration (DPA). In 20 s, with-
out risks, you solve your problem: immediate or maybe delayed surgery for
repairing a ruptured bladder.
5. In stabilized patient, you have time for CT and eventually angioembolization.
6. If patient hemodynamics is normal, algorithm is that of blunt abdominal trauma
(see Fig. 5.1).
62 D. Mariani and M. Zago

5.3.3 Penetrating Abdominal and Thoracoabdominal Trauma

Fig. 5.3 EFAST driven

protocol in penetrating
thoraco-abdominal injury

The main recognized role of EFAST in penetrating abdominal trauma is to ruling in/
out intraperitoneal injuries in physiologically normal patients.
It has a high positive predictive value.
Comments to Penetrating Abdominal Trauma Flow Chart
1. Blood or enteric fluid? A US-guided DPA is sometimes crucial and can change
your decision.
If the patient is hemodynamically normal, with a few amount of fluid in the
abdomen, but you retrieve blood with DPA, you can probably observe this patient.
If the patient is hemodynamically normal, with a few amount of fluid in the
abdomen, but you retrieve bile/enteric with DPA, go straight to OR (laparoscopy
or laparotomy).
2. US can help you in prioritizing the surgical approach (chest first vs. abdomen
first) in thoracoabdominal penetrating trauma.
5 Including EFAST in Trauma Algorithms: When? What Now? 63

5.3.4 Penetrating Thoracic Trauma (Cardiac Box)

Fig. 5.4 Flow chart for

Penetrating Thoracic Injury
in the cardiac box

Comments to Penetrating Thoracic Trauma Flow Chart

1. Pericardial window is a diagnostic procedure. A reliable US makes it unuseful.
2. Pericardial windows require to be ready for an immediate thoracotomy, if
3. Pericardiocentesis in trauma setting is nowadays only a bridge emergency
procedure on the way for OR. If you need this, US is a marvelous tool for guiding
the maneuver (not explained in this book).
The Role of EFAST in a Comprehensive
US Trauma Management (ABCDE-US): 6
Facing with Clinical Scenarios

Mauro Zago and Diego Mariani

Before reading this chapter, be aware of the objectives:

An overview of extended applications of US in trauma.

The ABCDE-US concept (clinically integrated US).
Try to manage simulated cases with and without US.

6.1 Beyond EFAST

EFAST protocol remains the cornerstone for quickly answering a lot of key ques-
tions arising during the assessment of a trauma patient. Its value in speeding the
decisions for definitive treatment is demonstrated (Melniker). But from airway man-
agement to the detection of fractures, from venous cannulation to pulmonary contu-
sion assessment, and from monitoring volume replacement to NOM follow-up, US
revealed extremely useful in many steps of trauma patient evaluation and treatment.
An US probe could be ideally put everywhere on the body for answering focused
clinical questions.
The awareness about that is at the basis of the so-called ABCDE-US concept
(Neri), for which the US probe can help in the decision process in every step of the
primary, secondary, and tertiary survey in trauma patient. This does not mean you
should mandatorily use US for each A-B-C-D-E step, but you have to know you can

M. Zago, MD (*)
General Surgery Department, Minimally Invasive Surgery Unit,
Policlinico San Pietro, Bergamo, Italy
e-mail: maurozago.md@gmail.com
D. Mariani, MD
General Surgery Department, AO Ospedale Civile di Legnano,
Via Papa Giovanni Paolo II, Legnano, Milano 20025, Italy

M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons, 65
DOI 10.1007/978-88-470-5274-1_6, Springer-Verlag Italia 2014
66 M. Zago and D. Mariani

Table 6.1 Questions possibly answered by US in trauma patient

Primary survey
Assessment and possible problems Key questions
A Definitive airway control Is tracheal tube in the right position?
B ptx hemothorax lung contusion Why the pt is dyspnoeic? Should I drain the thorax
now? Is there an occult ptx requiring drainage in
my intubated patient? Why does he desaturate if
there is no ptx or hemothorax?
C Hemothorax hemoperitoneum Is there free fluid? How much? Does it justify
hemopericardium cardiac motility hemodynamic instability? Where is the major
venous and artery cannulation hemorrhage? Is there a PEA? Or cardiac
-volume replacement IVC tamponade? Should I resuscitate this pt? Should I
assessment take the pt to OR before any other diagnostic test?
How about preload? How is IVC? How can obtain
a quicker and safer vascular access?
D Optical nerve caliper (to be validated) Can I confirm intracranial hypertension?
E Long bone fractures Is there a femur fracture under this enlarged thigh?
Should this explain hemodynamics?
Secondary survey Key questions
B ptx hemothorax lung contusion
C Hemothorax hemoperitoneum Is abdominal fluid really blood? Is
hemopericardium venous and artery cannulation there a hollow viscus perforation? Is
volume replacement bile (DPA) there a solid organ injury? Should I
pneumoperitoneum solid organ injuries (CEUS?) perform abdominal CT even in this
low energy trauma? Why the physical
exam is worsing after observation?
E Long bone fractures, sternal fractures, rib fractures Why does the pt complain pain if
x-rays are negatives?

rely on US every time you need it, according to the ATLS protocol, provided you
know the focused clinical question you have to solve (your clinical mind!) and how
to get the proper image (your skills!).
Table 6.1 shows a sample of questions you might answer in a critically ill trauma
ABCDE-US is a fully clinically integrated US!
The power and usefulness of real-time sonographic information for the critical
clinical decision-making process remains largely operator dependent, but several
experiences have shown that when appropriate training is provided, results are
highly accurate and reliable.
Surprisingly, you will realize that some applications for this innovative way to use
US are not difficult technical skills (for instance, assessment of tracheal tube position-
ing needs the same skills needed for PTX evaluation); what is amazing and difficult is
to change our mind, leaving considered gold standards beside, good as second tools.
Coming back to the example above, the quickest way to assess the proper positioning
of the endotracheal tube is not by chest x-ray but by US: you check, you move if
needed, you check again, and you secure, for only a few seconds.
Comprehensive US-helped trauma management is flexible: the recent emphasis on
C-ABCDE approach (find and stop the bleeding as soon as possible!) can be
6 The Role of EFAST in a Comprehensive US Trauma Management 67

strongly supported by US. EFAST can rule in/out torso free fluid. US can confirm that
the patient is empty (looking at the heart chambers and heartbeat from the subxi-
phoid view and using IVC calipers), and if a pelvic fracture is present, FAST can give
you criteria to decide a strategy (such as laparotomy if there is significant free fluid,
but extraperitoneal packing/external fixation/angioembolization if it is not).
Comprehensive US-helped trauma management is flexible: its role can change
according to your available resources. So, train yourself daily to be able to profit in
emergency situations.

Brain leads hands: your brain asks for; your hands + US answer
No answers? No skills? Go ahead without US
US can help you many times until the patient is discharged (not only FAST!)
US is a flexible tool: use whenever you need it

Some specific aspects of US applications in trauma are depicted before going

through clinical scenarios.

6.2 Assessment of Free Abdominal Fluid: The Scores

Many experimental and clinical studies explored the minimal amount of fluid
detectable with US. From the clinical and practical point of view, this is only rela-
tively relevant. We know there are plenty of lesions without free peritoneal fluid, at
least at the beginning. US cannot overcome suspicion index, based on trauma mech-
anism, physiology, clinical evaluation, and associated lesions. A negative FAST
gives us more time to reasoning or observe, but is not enough.
On the other side, we know the amount of fluid itself is often not enough to
impose a laparotomy. Consider physiology first for decision in a hemodynamically
unstable patient, assess with other imaging techniques before NOM.
So, is there any sense to estimate the amount of free abdominal fluid
(hemoperitoneum)? How can we do that? Is it reliable?
Three similar score systems are available; none is largely validated (Tables 6.2, 6.3,
and 6.4).
Whatever score systems you use, it is really easy to get a score (the simplest are
Huang and McKenney).
Is there a utility? What is the meaning of the scores?
In Huang series, score 3 was associated with more than 1,000 ml of blood in
84 % of operated patients; Huang scores <3 corresponded to less than 1,000 ml and
only 38 % of therapeutic laparotomies.
Similarly, McKenney score 3 correlated with 87 % of therapeutic laparotomies,
a score <3 with only 15 %.
A positive FAST revealed a more effective prognostic factor for the need for
laparotomy than a base deficit 5 (Melniker).
68 M. Zago and D. Mariani

Table 6.2 Huang score US view Assessment Score

Morison Minimal (<2 mm) 1
Moderate (>2 mm) 2
Douglas Minimal (<2 mm) 1
Moderate (>2 mm) 2
Perisplenic + 1
Floating bowel loops + 2
Paracolic gutters + 1
It is easy at a glance to recognize more or less than 2 mm
of fluid

Table 6.3 McKenney score US view Assessment Scorea

Morison + 1
Perisplenic + 1
Douglas + 1
Measure the thickness of fluid (in cm) where is the high-
est one. Add 1 point for each other positive view
Example: positive (4 cm) in Douglas, positive in
Morison, negative in perisplenic. Score: 4 + 1 + 0 = 5

Table 6.4 Sirlin score US view Assessment Score

Morison + 1
Perisplenic + 1
Douglasa + 1
Paracolic right + 1
Paracolic left + 1
Perirenal right (retroperitoneal) + 1
Perirenal left (retroperitoneal) + 1
Not considered positive if small amount of fluid in this
space only in young female

For Sirlin and coworkers, scores >3 (three spaces or more) were related to
therapeutic laparotomy in 63 % of cases and 4 in 81 % of patients.

Scores for estimating the amount of hemoperitoneum are easily applicable

in a few seconds.
High scores strongly suggest/indicate early definitive hemostasis.
Scoring hemoperitoneum immediately gives you an additional warning
and helps you to plan further actions.
REMEMBER: the amount of hemoperitoneum is not the unique criterium
for choosing the right treatment.
6 The Role of EFAST in a Comprehensive US Trauma Management 69

6.3 Repeated US

The concept to repeat US exam a few hours (16) after trauma in stable patients is
not new.
Early studies in hemodynamically normal patients confirmed the increasing rate
of detection of fluid for the secondary exam. This datum is often overcome by per-
forming a CT.
Notwithstanding, in low-resource situations this option could be kept in mind.
Low resources refer not only to scarce resource hospitals but also to a hospital
without immediate CT availability during the night, facing with a presumed minor
trauma. For those patients, observation in the ED with repetition of EFAST could be
very effective, from both clinical and medicolegal issues.
The sensitivity of ultrasound exam significantly increased in an average of 20 %
from primary to secondary exam in detecting the intraperitoneal fluid. Examining
the space between small bowel loops with a linear probe (not properly a standard
FAST view) significantly verificare bibliografia improved the sensitivity of ultraso-
nography in both primary and secondary FAST.
So, performing a secondary ultrasound exam in stable blunt abdominal trauma
patients and adding the interloop space scan to the routine FAST exam are good
tricks, which should not be forgotten, to use in special settings.

6.4 Minor Trauma and US

Would you like to be able to profit from using US probe in polytrauma patients? Be
paranoid over-careful and apply US protocols in minor/stable trauma patients too.
You will standardize your technique, you will have time to improve your skills in dif-
ficult patients, you will discover some unexpected findings, and you will have the oppor-
tunity to check yourself with a CT or another colleague more skilled in US than you.
It is beyond the purpose of this book, but US can also help you in minor doubtful
skeletal trauma, like for detection of sternal and rib fractures.

6.5 US and Airway Management

US probe is a very effective and quick tool for confirming the right position of an
endotracheal tube and for promptly reassessing the endotracheal tube after reposi-
tioning. Notwithstanding, unfortunately it is not a widespread standard.
Imagine you need:
To check in real time the transit of the endotracheal tube during a difficult
To perform a tracheostomy in a neck with a large lateral hematoma (Fig. 6.1)
To decide for a cricothyroidotomy in an obese patient with a large neck, where
tactile landmarks are missing
70 M. Zago and D. Mariani

Fig. 6.1 Tracheal axis

detected by the linear probe
(arrow) is displaced to the
right by a large neck
hematoma. Right incision for
tracheostomy is far away
from the midline (dotted line)

With an US probe, you can!

Follow us in the next volume, after having improved your skills in basic trauma US.

6.6 US and Hemodynamics Assessment and Monitoring

There is a so-called quartet singing different and very sensitive hemodynamic

ultrasound songs: heart, lung, IVC, and abdomen.
In a critically ill traumatized patient, your (expert) probe can help you explore
and get many important findings you are asking for:
HEART: beating rate, right and left chambers filling, pericardial fluid, and myo-
cardial contraction (all at glance!)
LUNG: wet or dry, pulmonary contusion (new or evolving), pleural effusion,
PTX evolution, and ARDS monitoring
IVC: empty or full, how is changing after volume replacement
ABDOMEN: the FAST findings!
US findings combined with the clinical status can offer you the right solution for
deciding the best for your patient, both in ED and in ICU or in the ward.
In order to not shaking your current knowledges now, we dont put normal and
pathological US pictures of these topics.
It is another step of your performance, coming soon in another book....

6.7 Clinical Scenarios

Read, try to solve, and test yourself.

You have to manage the first case with (or without) the EFAST protocol. Others
are presented to push you in a more extended use of US.
6 The Role of EFAST in a Comprehensive US Trauma Management 71

For didactical purposes, US is not included in pre-hospital phase, but you can
imagine it being applied and reasoning about management impact.

6.7.1 Case 1

The same case, with and without US

A 25-year-old athletic male injured after a vehicle crash, unrestrained and

with blunt thoracic and abdominal trauma. On scene and at admission in ED,
vital signs are as follows: BP 90/60, HR 115 bpm, and GSC 14.
After the primary survey and infusion of 500 ml of crystalloids, hemo-
dynamics is normal (BP 105/85, HR 95 bpm, SatHbO2 96 %)

Chest x-ray and pelvis x-ray are negative.

The patient is immediately transferred to CT suite. US is considered unuseful,
time-consuming, and irrelevant.
Immediately after the head scan, patient shows sudden hypotension and signs of
shock: BP 80/40, HR 125 bpm, and SatHbO2 90 %.
!! Third class shock !!
What do you do?
Which action will you take?
Probably, something like this:
Exclude tension PTX --> excluded.
Ask for blood and frozen plasma.
Go quickly ahead with CT completion for ruling in/out hemoperitoneum.
Alert OR.
OK. There is a huge hemoperitoneum with splenic injury OIS 4.
Next step is emergency laparotomy.
It is good if you are in OR 50 min after arrival.
Crash laparotomy, aspiration of 4 l of blood, and splenectomy were performed.
Blood is oozing from a lacerated mesentery and from any other rough surface.
You ask the anesthesiologist, how is the pH and core temperature?
pH 7.12; core T 34.2 C
Need to bail out.
The following were performed: temporary abdominal closure, ICU rewarming
and resuscitation, and transfusion of 7 FFP, 10 RBC, and 1 PLT units.
Thirty-six hours later, a planned relaparotomy is performed. You find a seg-
mental small bowel ischemia due to mesenteric laceration. Bowel resection is
required, definitive abdominal closure performed.
The patient is discharged on day 10.
In summary: good choices, Damage Control Surgery correctly applied.
72 M. Zago and D. Mariani

BUT imagine having decided to perform EFAST during the primary survey.
Look at the relevant US findings:
Fig. 6.2 RUQ view

Fig. 6.3 LUQ view

Fig. 6.4 Pelvic view, sagittal

6 The Role of EFAST in a Comprehensive US Trauma Management 73

What do you think?

Question 1


Pelvic view is NORMAL ____ ABNORMAL ____

Do you change strategy?

CT scan again?
Or immediately OR?
If OR is your choice, you probably agree this could be the story:
Laparotomy in 20 min after arrival
Aspiration of 1.5 l of blood, splenectomy, and repair of minor laceration of the
No transfusions
Discharge on day 7

6.7.2 Case 2a

This scenario should be managed with a comprehensive US protocol. Answer and

check step by step at the end of the chapter.

A 32-year-old woman had been involved in a one-car collision. She was a

passenger in the front seat and restrained. Her car rolled over. She was trapped
for 15 min. The windshield was smashed.
She was conscious, and the vital signs are as follows: BP 120/70 dropped
to 90/75, HR 90/min, RR 32, and SaO2 90 % with O2 supplementation.
Torso and pelvis seem injured. Five hundred milliliters of crystalloids was
infused during transport to ED.

Primary Survey in ED
A: Maintained
B: Decreased breath sounds on the right lung
SaO2: 83 %
C: BP 75/50, HR 110/min, clinically unstable pelvic fracture
D: GCS 14, confused
E: Temp 35.7 C
Infusion of crystalloids, 750 ml
74 M. Zago and D. Mariani

Question 1
Which critical questions and decisions you need a quick answer for? (Write
below with a pencil and then compare with suggestions at the end of the chapter)
Question 2
Do you think EFAST could help you?
YES ____ NO ____
Question 3
If NO, If you have chosen NO, you prefer to follow a surgical path that is not US
driven and might miss some opportunities. Please read what would happen with US
for your information: may be you become surprised!
If YES, list the finding you could rule in/out in a few seconds with US, waiting
for pelvis x-ray:
(Write below with a pencil, solutions at the end of the chapter)
This was the pelvis x-ray of the female patient

Fig. 6.5 Clearly an open

book fracture!
6 The Role of EFAST in a Comprehensive US Trauma Management 75

Fig. 6.6 Clearly an open

book fracture!

And these are the US relevant findings:

(No PTX on both sides)

Fig. 6.7 Right hemithorax

76 M. Zago and D. Mariani

Fig. 6.8 Left hemithorax


Fig. 6.9 RUQ

Fig. 6.10 LUQ

6 The Role of EFAST in a Comprehensive US Trauma Management 77

Fig. 6.11 Pelvic view

a b

Fig. 6.12 IVC view. (a) Expiration. (b) Inspiration phase

Question 4
Interpret US images:

1. Right hemithorax NORMAL ____ ABNORMAL____

2. Left hemithorax NORMAL ____ ABNORMAL____
5. Pelvis NORMAL ____ ABNORMAL____
6. IVC view (insp.) FULL ____ EMPTY____

(Go at the end of the Chapter for solutions, and come back quickly)
78 M. Zago and D. Mariani

Now, you know that:

A. Your patient is in shock.
B. There is blood in the thorax: YES_____ NO _____
C. There is blood in the belly: YES_____ NO _____
D. There is an open book fracture (type B1). You know these kinds of fractures are
generally associated with venous and only rarely arterial bleeding.
Now, you can decide:
If not yet done, put a sling around the pelvic ring and intrarotate the legs.
Look at hemodynamics evolution.
(It should rapidly improve
Yes, it improves! BP 100/65, HR 90/min, GCS 15)
Depending on your resources (your hospital, your team, your trauma system, etc.):
CT scan (first option, if possible) --> excluded other visceral lesions, further
decisions for pelvic fracture (angiography if arterial blush or indirect signs of
arterial injury, immediate ORIF, external fixation and delayed ORIF)
External fixation and close resuscitation/observation
Immediate transfer to a referral center
Different situations could be depicted for a similar case scenario, with identical
conditions on the scene and after primary survey in ED.

6.7.3 Case 2b

Same patient, same mechanism of trauma, and same clinical findings.

You perform now the US on this unlucky female with the same pelvic fracture
shown on Fig. 6.5. Look at the US findings (No PTX on both sides):

Fig. 6.13 Right hemithorax

6 The Role of EFAST in a Comprehensive US Trauma Management 79

Fig. 6.14 Left hemithorax


Fig. 6.15 RUQ

80 M. Zago and D. Mariani

Fig. 6.16 LUQ

Fig. 6.17 Pelvic view

a b

Fig. 6.18 IVC view. (a) Expiration. (b) Inspiration phase

6 The Role of EFAST in a Comprehensive US Trauma Management 81

Question 5
Interpret US images:

1. Right hemithorax NORMAL ____ ABNORMAL ____

2. Left hemithorax NORMAL ____ ABNORMAL ____
5. Pelvis NORMAL ____ ABNORMAL ____
6. IVC view (insp.) FULL ____ EMPTY ____

(Solutions at the end of the Chapter)

Question 6
Now, you know that:
A. Your patient is in shock.
B. There is blood in the thorax: YES_____ NO _____
C. There is blood in the belly: YES_____ NO _____
D. Grossly, Huang score is __; McKenney score is __; Sirlin score is __.
E. The probability of surgical intraperitoneal bleeding is
HIGH ____ LOW ____
F. There is an open book fracture (type B1). You know these kinds of fractures are
generally associated with venous and only rarely arterial bleeding.
(Look at right answer before turning the page.)
82 M. Zago and D. Mariani

Now, you can decide. I dont think you take the same decisions as in the previous
If not yet done, put a sling around the pelvic ring and intrarotate the legs.
CT? No, please!
Massive transfusion protocol activation (if not yet done).
Damage Control strategy and resuscitation, wherever you are and whatever are
the skills of your team:
Straight to OR.
Stop the bleeding (damage control surgery).
Possible pelvic packing.
External fixation or pelvic binder.
ICU for stabilization.

So :
Different clinical decisions
In similar settings
Thanks to US findings
Obtained in a few seconds
REMEMBER: ABCDE-US helps you to quickly see and assess the
anatomy and physiology for decision making

Here is an already printed algorithm, with a slight modification

Is my patient in a life-threatening condition?

Should I overcome EFAST?

If no,
EFAST where is fluid?
ABCDE-US other quick info on anatomy&physiology?


my decision is

life-saving maneuver or immediate DCS or further work-up

US can help you in assessing faster BOTH anatomy AND physiology
A comprehensive US-driven trauma management allows you to explore the
potential of US probe in your hands
6 The Role of EFAST in a Comprehensive US Trauma Management 83

Clinical Scenario Answers

Case 1
Question 1


Pelvic view is NORMAL ____ ABNORMAL __X__

Case 2
Question 1
Which critical questions and decisions you need a quick answer for?
Below are some possible answers:
Right PTX or hemothorax?
Is there blood in the belly?
Which is the priority for managing shock? Thorax, abdomen, or pelvis?
Straight to OR or time for further investigations? (It depends on resources too.)
If to OR, which problem is to fix first?
Is she pregnant?
Question 2
Do you think EFAST could help you?
YES, of course!
Question 3
List the finding you could rule in/out with US:
Hemoperitoneum (yes/no)
Assessment of the amount of hemoperitoneum (Is it a shock from pelvis fracture
only and/or intra-abdominal injury?)
Hemothorax (yes/no)
Pneumothorax (yes/no)
IVC diameter: is my patient completely empty?
Question 4
Interpret US images:
All US EFAST views are normal.
Your patient is empty.
No pregnancy.
No fluid detectable everywhere.
Your patient is probably bleeding only from the pelvic fracture!
Question 5
Interpret US images:

1. Right hemithorax NORMAL

2. Left hemithorax NORMAL
3. RUQ ABNORMAL_free fluid ++__
4. LUQ ABNORMAL_free fluid ++__
5. Pelvis ABNORMAL_free fluid ++, floating loops
6. IVC view (insp.) EMPTY
84 M. Zago and D. Mariani

Question 6
Now, you know that:
A. Your patient is in shock.
B. There is NO blood in the thorax.
C. There is blood in the belly.
D. Grossly, Huang score is >3 (at least 5: Morison 2 + Douglas 2 + Perisplenic 1);
McKenney score is >3 (8 [cm in Douglas pouch, at least] + Morison 1 + Perisplenic
1); Sirlin score is at least 3 (Douglas 1, Morison 1, Perisplenic 1).
E. The probability of surgical intraperitoneal bleeding is very HIGH.

Suggested Reading
1. Mayse ML (2005) Real-time ultrasonography. Should this be available to every critical care
physician? Crit Care Med 33:12311238
2. Melniker LA (2006) Randomized controlled clinical trial of p-o-c limited US for trauma in the
ED: the first SOAP trial. Ann Emerg Med 48:227235
3. Neri L, Storti E, Lichtenstein D (2007) Toward an ultrasound curriculum for critical care medi-
cine. Crit Care Med 35(Suppl):S290S304
4. Zago M (2009) Time for a comprehensive US-enhanced trauma management. Eur J Trauma
Emerg Surgery 35:339-40
Prehospital Ultrasound in Trauma:
Role and Tips 7
Miriam Ruesseler

7.1 Introduction

Abdominal trauma in combination with pelvic injuries is a major cause of death in

patients with multiple injuries in the first 24 h after trauma. In blunt abdominal
trauma (BAT), determining which patients should be triaged to laparotomy is impor-
tant, even more, when these patients are unstable. A rapid, accurate triage and initia-
tion of resuscitation and specific therapy are crucial as delayed treatment is
associated with increased morbidity and mortality.
The ultrasound examination (FAST) is the gold standard as early screening
method in the emergency department (ED) and provides a quick, standardized over-
view of the intraperitoneal cavity searching for the typical sites of free fluid accu-
mulation as already described in detail in previous chapters. Meanwhile, it is part of
the Advanced Trauma Life Support algorithm. The presence of free abdominal
fluid in the ED in combination with hemodynamically unstable patients indicates
the necessity of urgent laparotomy without any further diagnostics [13].
At the trauma scene however, clinical parameters and physical examination are
the only prehospital measures to detect intra-abdominal bleeding in spite of its low
accuracy and reliability. In patients with undiagnosed intra-abdominal bleeding,
crucial time may be lost. The determination of a source of hemorrhage at the trauma
scene might expedite transport and disposition and may result in more timely and
effective definite therapy.
Through a joint civilian-military initiative, the first portable handheld ultrasound
devices were developed suitable for the battlefield or a mass casualty situation. The
modern handheld devices are small and lightweight with adequate battery life and
have increasing technical features with relative simplicity to use and an excellent
quality of image scans. These handheld devices add one more dimension to FAST

M. Ruesseler, MD
Department of Trauma Surgery, University Hospital of the Goethe-University,
Theodor-Stern-Kai 7, Frankfurt 60590, Germany
e-mail: miriam.ruesseler@kgu.de

M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons, 85
DOI 10.1007/978-88-470-5274-1_7, Springer-Verlag Italia 2014
86 M. Ruesseler

as they make prehospital FAST (p-FAST) a possibility to detect life-threatening

injuries within the golden hour and appropriately triage the patients as demon-
strated in several studies.

7.2 Feasibility of p-FAST

Several studies confirmed the feasibility of p-FAST in prehospital trauma care

[4 9]. These studies were able to demonstrate that p-FAST could be performed in
both ground-based and air rescue with a sensitivity, specificity, and accuracy com-
parable to FAST under inhospital conditions (Table 7.1). In 95 % of the investigated
patients (219/239) by Walcher et al. [9], the time frame was sufficient to integrate
and complete p-FAST into prehospital trauma care algorithm. The investigation
time of p-FAST is comparable to inhospital times in the ED (p-FAST with negative
findings: 2.4 0.8 min [9]; FAST with negative findings: 2.3 to 2.6 + 0.25 to 1.2 min
[1, 3]).
p-FAST can lead to relevant changes in prehospital trauma therapy and manage-
ment with the aim to shorten the time to surgical therapy (Table 7.2). The patients
receive p-FAST on average 35 13 min prior to inhospital FAST or CT scan [9].
Early diagnosis is precious as it can contribute to accelerate and optimize patient
care and orientation.
Detection of hemoperitoneum at the trauma scene means that the receiving hos-
pital can be notified in advance and the inhospital trauma team can modify their
preparations by expanding their team to include a surgeon and prepare theater for
urgent laparotomy for hemorrhage control. Based on the p-FAST results, the admit-
ting trauma center might be changed toward the closest appropriate hospital, espe-
cially in rural settings, where mean response times and mean transport times can be
much longer.

Table 7.1 Sensitivity, specificity, and accuracy of ultrasound in blunt abdominal trauma
First author and reference
reference no. Year Modality n Sensitivity Specificity Accuracy standard
Boulanger [1] 1996 FAST 400 81 97 94 DPL, CT
Brown [10] 2001 FAST 2,693 84 96 96 DPL, CT,
Kirkpatrick [6] 2005 HHFAST 313 68.6 96.9 91.6 CT, laparotomy
Walcher [9] 2006 p-FAST 202 93 99 99 CT, laparotomy
Busch [11] 2006 PHASE 38 90 96 FAST, CT
Modified from Ruesseler et al. [12]
FAST focused abdominal sonography in trauma, HHFAST handheld FAST, p-FAST prehospital
FAST, CT computed tomography, DPL diagnostic peritoneal lavage, PHASE prehospital applica-
tion of sonography in emergencies
7 Prehospital Ultrasound in Trauma: Role and Tips 87

Table 7.2 Consequences Modification in therapy (21 %) and management on scene (30 %)
of p-FAST results [9] Changes in selection of trauma center (22 %)
Information transfer about prehospital findings to trauma team
(52 %)
Changes in trauma team preparation and management (92 %)
Ultrasound on scene 35 min prior to FAST in the emergency

7.3 Training

US is the first and foremost an operator-dependant examination. Thus, experience

plays an important role, and sensitivity drops with little experience. A standardized
training with both theoretical and hands-on modules is mandatory to gain the
required skills to conduct FAST or p-FAST sufficiently. This training should include
subjects with positive findings.
Emergency physicians/paramedics treating patients at the scene of an accident face
several challenges such as time pressure. This has important implications for the train-
ing program. Thus, the training program should include real-time simulation training
and different patient positions (e.g., ventral position), where the learner has to find
the appropriate time frame to integrate p-FAST into the prehospital trauma care algo-
rithm, adopt the transducers position, and furthermore face the time pressure. After
a 1-day course with hands-on training as described above, p-FAST can be performed
by both paramedics and physicians who were not familiar with the technique before
attending the course with a high sensitivity, specificity, and accuracy [13]. However,
to maintain this skill at the required competence level, regular practice is necessary.

7.4 Tips and Pitfalls

p-FAST should be performed on all traumatized patients with suspected BAT. As

intra-abdominal bleeding is a dynamic situation, p-FAST should be repeated every
15 min during the prehospital period as well as in the emergency department if sus-
picious physical findings with negative or slight positive initial p-FAST result occur
as hemorrhage may not yet have been apparent [2]. Thus, p-FAST can be used to
monitor the patient.
p-FAST can be performed within the first several minutes, while other team
members are carrying out simultaneous diagnostic and therapeutic maneuvers.
However, the appropriate time frame has to be considered, as p-FAST should not
delay the trauma algorithm, constrain other necessary procedures, or even delay the
prehospital transport to the hospital and thus the definitive treatment.
Reasons for an incomplete p-FAST can be bright sunlight (technical failure),
gross obesity, thoracic skin emphysema due to lack of penetration of sonographic
88 M. Ruesseler

waves or reverberation artifacts. Duration of examination has to be kept short; thus,

if the examination cannot be performed properly, it should be stopped and repeated
under optimized conditions (e.g. different patient position).
p-FAST should be used as screening method to identify patients at risk. It is not
indicated for a definitive diagnosis as the only question that can be answered with
high accuracy is the presence or absence of free fluid. Thus, no time should be
wasted on trying to identify organ lesions, but the patient should be moved to CT or
operating room as quickly as possible. p-FAST must not be performed if its result
would not have any influence on further prehospital therapy, management, or choice
of hospital.

Tips and Tricks

US is a highly user-dependant examination; thus, an adequate training and
regular practice are obligatory

Tips and Tricks

FAST and p-FAST training should include mainly hands-on training, sub-
jects with positive findings, real-time scenario training, and different subject

Tips and Tricks

Repeat p-FAST every 15 min to monitor the patient

Tips and Tricks

Perform p-FAST while other team members simultaneously perform proce-
dures of the trauma algorithm

Time is wasted on trying to identify organ lesions
p-FAST should only identify the presence or absence of free fluid
7 Prehospital Ultrasound in Trauma: Role and Tips 89

p-FAST can significantly increase diagnostic performance and diagnostic
accuracy. However, it should never delay the prehospital trauma algorithm nor
patients transport to definitive therapy. US is highly user-dependant; thus,
training and regular practice are obligatory.

1. Boulanger BR, Mclellan BA, Brenneman FD et al (1996) Emergent abdominal sonography as
a screening test in a new diagnostic algorithm for blunt trauma. J Trauma 40:867874
2. Rozycki GS, Ballard RB, Feliciano DV et al (1998) Surgeon-performed ultrasound for the
assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg 228:557567
3. Wherrett LJ, Boulanger BR, Mclellan BA et al (1996) Hypotension after blunt abdominal
trauma: the role of emergent abdominal sonography in surgical triage. J Trauma 41:815820
4. Brooks AJ, Price V, Simms M (2005) FAST on operational military deployment. Emerg Med
J 22:263265
5. Heegaard W, Plummer D, Dries D et al (2004) Ultrasound for the air medical clinician. Air
Med J 23:2023
6. Kirkpatrick AW, Sirois M, Laupland KB et al (2005) Prospective evaluation of hand-held
focused abdominal sonography for trauma (FAST) in blunt abdominal trauma. Can J Surg
7. Lapostolle F, Petrovic T, Lenoir G et al (2006) Usefulness of hand-held ultrasound devices in
out-of-hospital diagnosis performed by emergency physicians. Am J Emerg Med 24:237242
8. Walcher F, Kortum S, Kirschning T et al (2002) Optimized management of polytraumatized
patients by prehospital ultrasound. Unfallchirurg 105:986994
9. Walcher F, Weinlich M, Conrad G et al (2006) Prehospital ultrasound imaging improves man-
agement of abdominal trauma. Br J Surg 93:238242
10. Brown MA, Casola G, Sirlin CB et al (2001) Blunt abdominal trauma: screening us in 2,693
patients. Radiology 218:352358
11. Busch M (2006) Portable ultrasound in pre-hospital emergencies: a feasibility study. Acta
Anaesthesiol Scand 50:754758
12. Ruesseler M, Kirschning T, Breitkreutz R et al (2009) Prehospital and emergency department
ultrasound in blunt abdominal trauma. Eur J Trauma Emerg Surg 35:341346
13. Walcher F, Kirschning T, Muller MP et al (2010) Accuracy of prehospital focused abdominal
sonography for trauma after a 1-day hands-on training course. Emerg Med J 27:345349
CEUS: What Is It?
Massimo Valentino, Libero Barozzi, and Cristina Rossi

8.1 Introduction

Contrast-enhanced ultrasound (CEUS) is a new tool for investigating blunt abdomi-

nal trauma. Ultrasound contrast agents (UCAs) are exogenous nontoxic substances
smaller than red blood cells. In combination with nonlinear imaging methods, they
offer the possibility of detecting abnormal parenchymal tissue, accurately recogniz-
ing or excluding abdominal solid organ injuries and assessing their size and compli-
cations. The technique is capable of showing the extent of the lesions to the capsule
and the presence of active bleeding, overcoming the limits of baseline sonography
in studying traumatic parenchymal injuries.

8.2 Scanning Technique

8.2.1 How to Scan

UCAs are microbubbles with a diameter from 2 to 6 m composed of a shell of

biocompatible materials, including proteins, lipids, or biopolymers. These agents

M. Valentino (*)
Department of Diagnostic ImagingRadiology Unit,
Hospital of Tolmezzo, Via Morgagni 18, Tolmezzo 33028, Italy
e-mail: mvm.valentino@gmail.com
L. Barozzi
Department of Diagnostic ImagingRadiology Unit,
Maggiore Hospital, Largo Bartolo Nigrisoli, 2, Bologna 40100, Italy
e-mail: libero.barozzi@alice.it
C. Rossi
Department of Diagnostic ImagingEmergency Radiology Unit,
University Hospital of Parma, Via Gramsci 14, Parma 43100, Italy
e-mail: crrossi@ao.pr.it

M. Zago (ed.), Essential US for Trauma: E-FAST, Ultrasound for Acute Care Surgeons, 91
DOI 10.1007/978-88-470-5274-1_8, Springer-Verlag Italia 2014
92 M. Valentino et al.

are blood pool agents that remain in the intravascular compartment and do not leak
into the organ tissue. UCAs are injected IV as a bolus, increasing the signal of the
vascularized parenchyma: therefore, in the case of trauma, the areas of laceration
appear as defects of perfusion (black).
CEUS requires contrast-specific software, nowadays available in many portable
machines, with the suppression of the static signal of the tissues and highlighting
the signal from microbubbles circulating in the bloodstream.
The dose of UCA depends on the technical equipment, ranging from 1.2 to 2.4 mL
per dose. After IV injection, the microbubbles persist in the bloodstream for 810 min
and can cross the pulmonary and systemic capillary circulation without trapping. Their
long life allows the sonographer to investigate all the abdominal organs in real time.
UCAs differ from computed tomography contrast media because they lack inter-
stitial spread, consequently functioning as perfect traces of organ vascularization.
They are well tolerated, and serious reactions are rarely reported. Nevertheless,
adverse reaction toward UCA constituents must always be considered. Due to the absence
of renal excretion, UCAs can be safely employed also in patients with renal failure.
For trauma protocol, UCA is administered in two doses for visualization of the
right and the left upper quadrant organs, separately. This procedure is needed to
study the single organs during all the vascular phases (early and late phases). The
study is interpreted simultaneously during the investigation, and the record of the
investigation as a video clip allows reviewing for minor lesions, while the acquisi-
tion of static images is useful for measuring the lesions.
Trauma study begins with FAST protocol, and CEUS follows immediately after-
ward. During FAST, the optimal patient positions and the accessibility of the organs
are assessed for planning CEUS.

8.2.2 Normal Anatomy (Fig. 8.1ad)

In CEUS, the normal parenchyma appears homogeneously hyperechoic with the

vessels having the maximum of echogenicity. The enhancement starts 1015 s after
the UCA injection, the time of delay depending on the specific vascular physiology
of the investigated organ.
The kidneys show rapid, intense, and transient enhancement due to the absence
of glomerular filtration after IV UCA injection. The arterial phase of CEUS starts
1015 s after intravenous injection and lasts up to about 40 s, when the venous
phase becomes prevalent. The venous and late phase lasts from 3 to 6 min. In the
arterial phase, the cortex shows the most intense enhancement, whereas in the late
phase the whole kidney appears homogeneously perfused.
In the liver, UCAs are firstly visualized in the hepatic artery, followed by those
in the portal vein. Hence, the CEUS process is always divided into the arterial phase
(<30 s from the injection of UCA), portal phase (31121 s), and late phase (>120 s). In
the portal phase, the liver appears homogeneously perfused, with slightly hyperechoic
vessels and anechoic gallbladder. The delayed phase is particularly useful for char-
acterization of focal liver lesions since almost all malignant lesions are hypoechoic
in this phase. Also traumatic lesions are well visible in the portal and delayed phase.
8 CEUS: What Is It? 93

a b

c d

Fig. 8.1 (a) CEUS of normal kidney. In the arterial phase, the cortex shows the most intense
enhancement. Note the absence of enhancement in the renal pelvis. (b) CEUS of normal liver in
the venous phase. In this phase, the liver appears homogeneously perfused, with the vessels and
border clearly defined. (c) CEUS of normal spleen in venous phase. In this phase, the parenchyma
appears homogeneous with a persistent enhancement for up to 57 min. (d) CEUS of normal pan-
creas. In the venous phase, pancreas has a darkened appearance (arrows) in contrast to the adjacent
liver, but the vessels (asterisk) allow to identify it

Splenic parenchyma starts about 1215 s after UCA injection. In this phase, we
can observe an inhomogeneous enhancement of the spleen, resembling the well-
known zebra-striped pattern seen on dynamic CT. The phase can give the false
impression of a scattered spleen, confusing the sonographer: we suggest studying
first the left kidney and then moving to the spleen in the venous phase. Approximately
50 s after the injection, the venous phase starts, and the splenic parenchyma becomes
homogeneous, showing dense persistent enhancement for up to 57 min. In this
phase, the injured parenchyma is well detectable as a hypoenhanced area.
In the pancreas, uptake of contrast medium during CEUS is very rapid; at
approximately 2540 s, it produces a transient, bright homogeneous enhancement
that is due to the high vascularization of the organ. Accumulation in the capil-
laries is negligible; thus, the washout also occurs rapidly after the arterial phase,
giving the pancreas a darkened appearance in contrast to the adjacent liver after
2 min. Consequently, CEUS may be difficult at delineating masses, but it allows an
excellent delineation of traumatic lesions.
94 M. Valentino et al.

Tip and Tricks

A double injection of UCA is needed for studying all the organs in all the
In the arterial phase, attention must be focused on the vessels in order to
highlight vascular injuries and UCA extravasation!
UCAs are not eliminated from the kidney and cannot visualize lesions of
the pelvis and ureter

8.2.3 Traumatic Lesions (What We Have to Search for)

Liver injuries include contusion (subtle and inhomogeneous area without vessel
displacement), laceration (clear band-like lesion, linear or branched), and parenchy-
mal or subcapsular hematoma (fluid collection of variable attenuation and echo-
genicity within liver parenchyma or below the liver capsule).
On CEUS, liver lesions appear as markedly hypoechoic lines or bands and are
more evident than on baseline sonographic scans, also showing sharper borders
(Fig. 8.2). Injury conspicuity increases progressively while passing from arterial
phase scans (2050 s from injection) to portal-sinusoidal scans (50240 s), owing to
a progressive increase in parenchymal echogenicity. On early-phase images, subtle
hyperechogenicity (hypervascularity) can sometimes be noted around the injury,
suggesting perilesional hyperemia. In lacerative-contusive areas, CEUS allows opti-
mal depiction of defined lacerations, but in comparison with CT, CEUS less effec-
tively depicts the subtle contusive inhomogeneity. In a series of 87 patients, CEUS
was more sensitive than unenhanced sonography in directly showing hepatic lesions
(87 % vs. 65 %, 100 % specificity) and correlated better with CT for injury size and
capsule involvement.
Hepatic lesions lack or have very little enhancement, appearing as hypoechoic
areas at CEUS. Although they may be visible in all three vascular phases, injuries
appear more evident during the venous phase. In the later phase, the images deterio-
rate very quickly, and the abnormalities become indistinguishable. The venous
phase is thus undoubtedly the most efficient for liver injury detection and has been
called the homogeneous phase.
Some injuries, mainly in the liver, may appear quite large on CECT and smaller
on CEUS, as reported by McGahan and colleagues. Although surgical correlation is
lacking due to the conservative treatment, it is plausible that the hypoechoic area
seen with CEUS is related to the parenchymal laceration and the larger area seen
with CECT is the sum of the edema and the laceration. If this hypothesis is correct,
this is not a pitfall but an added value of CEUS, capable of distinguishing the true
lesion (laceration) from the surrounding edema. Minor lesions not seen with CEUS
may be areas of edema visible only with CECT but without clinical implication.
In liver injuries, CEUS can have some drawbacks. Because of the use of low-
emission-frequency harmonics, there is loss in spatial resolution and overall image
8 CEUS: What Is It? 95

a b

c d


Fig. 8.2 A 19-year-old male admitted to hospital after a motor vehicle accident. (a) Sagittal
oblique sonogram shows a large nonhomogeneous hyperechoic area in the right lobe of the liver
(arrows). (b) Color Doppler US shows the absence of vascularization. (c) CEUS scan in the same
position illustrates a large parenchymal laceration (arrows). The hepatic vessels (asterisks) are in
the area of the lesion, but there is no blushing. (d) MDCT confirms the lesion (arrowheads) and the
absence of bleeding

quality. The poor signal arising from the most deeply located lesions may give them
partially or completely unrecognized, resulting in a false-negative study. Moreover,
hepatic steatosis or fibrosis increases attenuation of the US beam reducing CEUS
capability and newly resulting in a false-negative study when exploring deep liver
Subcapsular or intraparenchymal hematoma appears as a hypoechoic area sur-
rounding or central to the organ, respectively (Fig. 8.3). Active hemorrhage is identi-
fiable during the first phase as an extravasation of microbubbles into the hematoma.

The spleen enhances very brightly, and UCAs accumulate in the parenchyma,
allowing lengthy examination. The superficial position and the small volume permit
optimal study.
Splenic injuries show a decreased or absent enhancement and are clearly seen
as opacification defects, better evident during the late phase of enhancement.
A contusion appears as ill-defined, slightly hypoechoic areas, whereas a laceration
96 M. Valentino et al.

a b

Fig. 8.3 A 62-year-old man admitted to hospital after a motor vehicle crash. (a) CEUS of the liver
reveals a fracture in the right lobe (arrow) with a large subcapsular hematoma (calipers). (b) MDCT
confirms the lesions (arrowhead and asterisk)

Fig. 8.4 Laceration of the lower

pole of the spleen. CEUS shows a
clearly hypoechoic linear band,
perpendicular to the spleen surface

is seen as a clearly hypoechoic band, linear or branched, that is usually perpendicu-

lar to the spleen surface (Fig. 8.4). Contrast extravasation, indicating active bleed-
ing, is frequently seen in spleen fracture. On CEUS, it is detected as an early-phase
hyperechoic pool or jet within the splenic parenchyma or perisplenic hematomas
(Fig. 8.5). Differential diagnosis includes calcifications (already visible on baseline
images), normal vessels (different appearance and disposition), pseudoaneurysms
(limited practical value of differentiation), and uninjured parenchymal areas within
large lesions caused by contusions and lacerations (there is a different appearance
with lower echogenicity). Decreased splenic parenchymal enhancement (partial or
total) is a finding of traumatic infarction in vascular pedicle avulsion. According
to our previous report, the sensitivity of CEUS in detection of splenic injuries
approaches 100%.
8 CEUS: What Is It? 97

a b

Fig. 8.5 A 21-year-old male admitted to hospital after a motor vehicle trauma. (a) CEUS scan
shows a linear laceration in the lower pole of the spleen (arrow). (b) In the late phase, a focal
extravasation of UCA demonstrated an active bleeding (arrow). (c) MDCT confirmed the lesion

The technique allows the exact evaluation of the number and the extension of the
lesions. Complex traumatic lesions can be easily recognized.
One disturbing factor that is not correlated to the vascular phases of the spleen is
a common, quite rapid decrease of the enhancement in the parenchymal splenic
veins. About 23 min following the injection, the veins become anechoic. This is
probably due to the effective filtration of microbubbles from the circulation on the
part of the spleen. At first, this phenomenon is somewhat confusing, as the veins can
be mistaken for lacerations, but with awareness of the problem, it can be resolved.
If in doubt, a reinjection of a small amount of UCA is an efficient solution.

Renal injuries present as defects of vascularization in a well-perfused parenchyma.
Contusions appear as focal alterations of enhancement; interruption of the renal
profile is consistent with a laceration (Fig. 8.6). Renal artery tear or thrombosis
presents with the absence of parenchymal perfusion. Focal UCA extravasation sug-
gests active hemorrhage.
98 M. Valentino et al.

a b

Fig. 8.6 (a) CEUS shows a laceration of the left kidney with interruption of the posterior profile
(arrows). (b) MDCT confirms the lesion (arrowheads) (multiplanar sagittal reconstruction)

The homogeneous phase is still the most effective phase for the detection of trau-
matic injuries. Until today, little specific attention has been paid to the role of emergency
sonography in evaluating acute renal trauma. In our experience with traumatic lesions,
at CEUS a subcapsular hematoma appears as an inhomogeneous collection surrounding
the kidney while a laceration is a clear hypoechoic band, possibly associated with a
subcapsular hematoma. It is beneficial to use a small dose of UCA for visualizing the
traumatic lesions of the kidney, since too much contrast may cause a glare that covers
very thin lacerations. If the phenomenon occurs, it can be corrected by performing a
new examination using a low dosage immediately after the bubble destruction.
Although injection of UCAs improves the sensitivity of US for identification of
renal injuries, the role of this technique in clinical practice is debatable. Injury to the
renal collecting system may be overlooked at CEUS because of a lack of micro-
bubbles in urinary excretion. Small renal injuries may be unidentified, especially
when perirenal hematoma is small or absent.

Splenic arterial phase can mimic a scattered spleen. Lesions are visualized
in a late phase
Peri-traumatic lesions (extracapsular hematomas) are not visible on CEUS
as on CT, because parenchyma remains well vascularized
Contrast extravasation at CEUS imaging is detected immediately after ves-
sel opacification, spreading to the hemorrhage site, and it appears as a
round/oval spot of variable sizes or as a fountain-like or serpentine-like
hyperechoic jet
Pseudoaneurysm has an appearance very similar to contrast extravasation
but is a round or oval mass continuous with the vessel; both occurrences,
active bleeding and posttraumatic pseudoaneurysm, require a surgical
decision (surgery or embolization)
8 CEUS: What Is It? 99

8.2.4 Nonoperative Management

Nonoperative management is today the preferred treatment for the solid organ inju-
ries of grades 13 according to AAST grading. All nonsurgical patients are usually
staged by abdominal CT scanning and are closely monitored in an intensive care
unit setting. Although delayed bleeding seems extremely rare, delayed rupture of
the spleen remains a major concept; therefore, patients undergo repeated imaging
procedures before discharge. Currently, CT plays an important role in the follow-
up, improving the success rate of nonsurgical management.
CEUS is ideally suited for the follow-up of abdominal solid organ lesions man-
aged conservatively, especially in young patients, because it reduces the number of
CT scans.
CEUS can be proposed for serial imaging of conservatively treated solid organ
injuries. It can be performed at the bedside safely and without radiation exposure
until the lesions are completely healed.

The use of contrast agents in ultrasound significantly improves detection of
solid organ injury and is an area still under investigation
While contrast-enhanced ultrasound may evaluate solid organ injuries,
bowel and mesenteric injuries remain best assessed by CT scan
US is less panoramic than CT, and CEUS cannot replace CT in the initial
assessment of trauma
CEUS has the potential to replace CT in follow-up when nonoperative
treatment is realized, in an effort to minimize diagnostic radiation, espe-
cially in younger patients

Suggested Reading
1. Bertolotto M, Catalano O (2009) Contrast-enhanced ultrasound: past, present, and future.
Ultrasound Clin 4:339367
2. Catalano O, Lobianco R, Raso MM, Siani A (2005) Blunt hepatic trauma: evaluation with
contrast-enhanced sonography: sonographic findings and clinical application. J Ultrasound
Med 24:299310
3. Catalano O, Sandomenico F, Raso MM, Siani A (2005) Real-time, contrast enhanced sonogra-
phy: a new tool for detecting active bleeding. J Trauma 59:933939
4. McGahan JP, Horton S, Gerscovich EO et al (2006) Appearance of solid organ injury with
contrast-enhanced sonography in blunt abdominal trauma: preliminary experience. AJR Am
J Roentgenol 187:658666
5. Piscaglia F, Bolondi L (2006) The safety of SonoVue in abdominal applications: retrospective
analysis of 23188 investigations. Ultrasound Med Biol 32(9):13691375
6. Thorelius L (2007) Emergency real-time contrast-enhanced ultrasonography for detection of
solid organ injuries. Eur Radiol 17(Suppl 6):F107F112
7. Valentino M, Serra C, Pavlica P, Barozzi L (2007) Contrast-enhanced ultrasound for blunt
abdominal trauma. Semin Ultrasound CT MR 28:130140
100 M. Valentino et al.

8. Valentino M, Serra C, Pavlica P et al (2008) Blunt abdominal trauma: diagnostic performance

of contrast-enhanced US in children-initial experience. Radiology 246:903909
9. Valentino M, Serra C, Zironi G et al (2006) Blunt abdominal trauma: emergency contrast-
enhanced sonography for detection of solid organ injuries. AJR Am J Roentgenol 186:
10. Xu HX (2009) Contrast-enhanced ultrasound: the evolving applications. World J Radiol

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