Tag Archives: Jennifer Cotton

eFAST – The Quick Hit

Everything you need to know about the eFAST in 60 seconds or less (120 seconds if you count the one minute ultrasound video).

Who Needs an eFAST Ultrasound:

  • Blunt and penetrating abdominal trauma
  • Blunt and penetrating chest trauma
  • Ectopic pregnancies
  • Any patient you suspect has abdominal or thoracic free fluid or bleeding

The Technique: 5 scans in 1 exam

Heart

  • Probe position: subxyphoid
  • Image: four chambers of the heart and pericardium
  • Evaluation for: pericardial effusion and cardiac tamponade

Right Upper Quadrant (Perihepatic)

  • Probe position: RUQ
  • The image: Morrison’s Pouch (liver and kidney), diaphragm, and some chest
  • Evaluation for: intra-abdominal bleeding or fluid and hemothorax

 Left Upper Quadrant (Perisplenic)

  • Probe position: LUQ
  • The image: Spleen, kidney, diaphragm, and some chest
  • Evaluation for: intra-abdominal bleeding or fluid and hemothorax

Pelvis

  • Probe position: above the bladder
  • The image: in men- bladder and rectum, in women- bladder, uterus, and rectum
  • Evaluation for: intra-abdominal bleeding or fluid

Lungs

  • Probe position: anterior chest at the 3rd and 4th intercostal space
  • The image: ribs, pleura, and lung
  • Evaluation for: pneumothorax

eFAST 1 minute ultrasound

Submitter: Jennifer Cotton

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Life in the eFAST Lane: extended Focused Assessment with Sonography for Trauma (Part 2)

 We’re back! Last time we reviewed eFAST basics and part of the eFAST technique. Hopefully you’ve been practicing the heart, RUQ, and LUQ scans like my friend below. So without further adieu…. I give you eFAST Part Deux!
Figure 1 - An eFAST Rockstar in Training

Figure 1 – An eFAST Rockstar in Training

How to Do I Do an eFAST? (Continued from Part 1)
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Life in the eFAST Lane: Extended Focused Assessment with Sonography for Trauma (Part 1)

The Case: There are just too many eFAST cases to choose from. Which one to tell you…? Should I tell you about my first eFAST patient, the supposed-to-be-simple-but-really-wasn’t, on-coumadin guy who laid out his motorcycle? What about the lady from the rollover down a twenty foot embankment? Or the teenager from a horseback riding accident? Should I tell you about the night I hung out in resuscitation and did an eFAST on every patient that came through? A night in December I like to think of as Ultrasound Christmas. A night when a trauma alert rolled in and before I knew what was happening, the resident put the ultrasound probe in my hand and said “Go for it!” Needless to say it was AWESOME! Like do-a-secret-happy-dance-in-the-hallway-afterwards kind of awesome. I’m definitely still lovin’ the ultrasound elective, especially since I’ve become competent at eFASTs.

So what’s an eFAST you ask? It’s simple, really. It’s a systematic ultrasound scan to check for pneumothorax and free fluid (usually blood) in the abdomen and chest. It’s quick, easy, and incredibly useful. You don’t have to be a genius for this stuff. And it’s an ultrasound scan, so it means fewer patients being radiated by CT scans. Remember? Radiation bad. No radiation good. If you’re going to spend time in the ED, you should learn the eFAST. End of story. Plus if trauma’s your scene, you’ll get close to some wicked traumas. So now that you’re convinced… just how do you do an eFAST?

What’s eFAST All About?

The eFAST is a fast (pun intended) and easy way to check for blood in the chest and abdomen. eFAST is an acronym for extended Focused Abdominal Scan for Trauma. It’s an ultrasound exam designed for trauma patients that can be used at the bedside without interrupting ongoing care. Unstable patients with positive eFAST scans can then receive definitive care (get a chest tube, go to surgery, etc.) without the delay of waiting for a CT. The exam is a set of scans that quickly visualize free fluid (like blood) in the anatomical sites it most commonly collects, so the trick to quickly interpreting an eFAST exam is learning just where free fluid tends to collect. An eFAST looks at the right upper quadrant (RUQ), left upper quadrant (LUQ), pelvis, heart, and lungs. (Lungs are the extended part of the exam. Without the lung component it’s just called a FAST exam.) So that’s five ultrasound views, six if you’re picky about the whole 2 lungs thing, and you’ve completed an eFAST exam. It takes less than 5 minutes to complete, but more like 2 minutes as you approach ultrasound rock star status. Plus it’s more sensitive than x-ray for conditions like pneumo or hemothorax. Basically, eFASTs are a great ultrasound scan for rapidly identifying bleeding and other common injuries in the trauma patient.

The Patient: Who Gets an eFAST? 

  • Blunt and penetrating abdominal trauma
  • Blunt and penetrating chest trauma
  • Ectopic Pregnancies
  • Suspected abdominal or thoracic free fluid or active bleeding

How Do I perform an eFAST?

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Beating a Dead Horse: Why Ocular Ultrasound Beats Papilledema for Detecting Increased Intracranial Pressure

Our earlier article on ocular ultrasound for measuring intracranial pressure was met with a common question. Primarily, why not just use papilledema as your initial assessment for intracranial pressure? This is what we are taught in medical school. Optic nerve disc swelling equals increased intracranial pressure (ICP). End of Story. Right? Not exactly…  While optic disc swelling can indicate increased ICP, it is an inferior measure of acutely elevated ICP. And here is why…

  • It’s an indirect measure.
  • It’s a late sign of increased ICP.
  • It’s more subjective.
  • It’s not a dynamic measurement.
  • It’s not always practical.

pap vs oc us 1

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Keeping an Eye on Intracranial Pressure: Measuring ICP Using Ocular Ultrasound

Measuring Intracranial Pressure Using Ocular Ultrasound

Measuring ICP

  • There is a caliper function on ultrasound machines that gives you precise measurements of selected structures.
  • Take your optic nerve sheath diameter (ONSD) measurement 3 mm posterior to the globe.
    • This area has the greatest contrast with surrounding tissue (more contrast = more accurate measurements).
    • Use the calipers to determine 3 mm.
  • Measure across the optic nerve sheath (not just the optic nerve).
  • Measure ONSD for both eyes and average the two measurements.

Interpreting Your Results:

  • Increased ONSD correlates with increased ICP
  • Upper limit of normal ONSD vary with age…
    • Adults: < 5 mm
    • Children > 1 yo: < 4.5 mm
    • Children < 1 yo: < 4 mm
  • ONSD 5 – 5.7 mm: may indicate ICP > 20 mmHg, especially if symptomatic
    • > 5 mm is 100% sensitive for elevated ICP
    • All patients with elevated ICP have ONSD > 5mm
  • ONSD > 5.7 mm: indicates ICP > 20 mmHg
    • > 5.7 mm is 100% specific for elevated ICP
    • Only patients with elevated ICP have ONSD > 5.7 mm
  • ONSD measurements increase with increasing ICP.
  • ONSD measurements plateau around 7.5 mm even with significantly increased ICP.
  • In severe cases, an echoluscent circle called a crescent sign may be present.
    • Crescent sign is formed by the separation of the optic nerve sheath from the optic nerve by high ICP.

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CT Imaging in Minor Head Injury

For minor head injury patients (GCS 13-15) apply the CCHR or NOC decision making tools to help you decide if a head CT is required.

Canadian CT Head Rule:

Head CT is only required in minor head injury patients with any one of the following:

High Risk Factors (for neurological intervention)

  •  GCS score <15 at 2 h after injury
  • Suspected open or depressed skull fracture
  • Any sign of basal skull fracture (haemotympanum, ‘racoon’ eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, or Battle’s sign)
  • Vomiting ( > two episodes)
  • Age 65 years

Medium Risk Factors (for brain injury on CT)

  • Amnesia before impact >30 min
  • Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or five stairs)

But the Rules Don’t Apply If:

  • GCS < 13
  •  Patient taking coumadin or had a bleeding disorder
  • Obvious open skull fracture
  • Age < 16 yo
  • Non-traumatic

MDCalc: Canadian CT Head Rule Tool

New Orleans Criteria: 

Presence of one or more of the following seven findings requires a head CT:

  • Headache
  • Vomitting
  • Age > 60 yo
  • Drug or alcohol intoxication
  • Deficits in short-term memory
  • Physical evidence of trauma above the clavicles
  • Seizure

MDCalc: New Orleans Criteria Tool

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