Академический Документы
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Essential
US for Trauma:
E-FAST
Mauro Zago
Editor
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
diagnostics.
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
vii
viii Foreword
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
expected.
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
ix
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.
xi
Basic Ultrasound Physics,
Instrumentation, and Knobology 1
Fikri M. Abu-Zidan
1.1 Introduction
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
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.
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
GB
IVC
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
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
U D
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
R L
R
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.
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
situation.
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
Freeze
Depth
Mode
B
Caliper
M
Gain Measure
Fig. 1.8 Basic buttons of a portable ultrasound machine that a beginner user of point-of-care
ultrasound should know
Gain
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
Pitfalls
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
fluid.
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.
Shadows
Liver
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
Liver
GB
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
Urinary
bladder
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
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
Remember!
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
coronal)
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
93:84110
Introduction and Focused Questions
2
Mauro Zago
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
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
Remember!
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
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
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.
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.
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
lesions.
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
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
ventilation.
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.
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
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
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).
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
examination.
30 F. Ferreira et al.
Fig. 3.16 Normal pelvic transverse view colored for better identification
3 Abdominal Views: Technique, Anatomy, Abnormal Images, Scanning Tips, and Tricks 31
Fig. 3.18 Sagittal pelvic view. Colored structures for better visualization
32 F. Ferreira et al.
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.
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
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.
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
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
quadrant.
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.
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
65:632637
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
Images
4.1 Introduction
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
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
Pleural line
Fig. 4.9 Two ribs with their shadows and amidst them the pleural line: the so-called bat sign
No bat, no exam!
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
quicker.
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.
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
Warning!
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. 4.19, 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
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
Sliding lung?
(B-mode or M-mode)
YES NO
Vertical
NO PTX YES
artifacts?
NO
Moderate PTX NO
Remember
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
sliding!)
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
12:844849
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
133:204211
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
abdomen.
You also know that the sequential steps for a decision-making process helped by
US could be summarized as follows:
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
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
settings.
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
trauma.
For its focused nature, EFAST sonography has some limits which must be
known.
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
instance).
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
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.
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
ago.
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
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
advisable
5 Including EFAST in Trauma Algorithms: When? What Now? 61
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
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
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
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
patient.
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
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
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.
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.
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.
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
intubation
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
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
______________________
BUT imagine having decided to perform EFAST during the primary survey.
Look at the relevant US findings:
Fig. 6.2 RUQ view
6.7.2 Case 2a
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
a b
Question 4
Interpret US images:
(Go at the end of the Chapter for solutions, and come back quickly)
78 M. Zago and D. Mariani
6.7.3 Case 2b
a b
Question 5
Interpret US images:
Now, you can decide. I dont think you take the same decisions as in the previous
situation
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
If no,
EFAST where is fluid?
ABCDE-US other quick info on anatomy&physiology?
Summary
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
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:
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
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
Table 7.1 Sensitivity, specificity, and accuracy of ultrasound in blunt abdominal trauma
Diagnostic
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,
laparotomy,
autopsy
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
department
7.3 Training
Pitfalls
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
Remember
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.
References
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
48:453460
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?
8
Massimo Valentino, Libero Barozzi, and Cristina Rossi
8.1 Introduction
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.
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.
Liver
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
portions.
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.
Spleen
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)
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
(arrowhead)
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.
Kidney
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.
Pitfalls
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
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.
Remember
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.
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