How Ultrasound (really) improved my clinical practice

24 Ago

Beyond theories and protocols, here we are three (real) clinical prehospital scenarios  in which without ultrasound my own practice would have been different with (probably!!!) some (bad!!) consequence on patients final outcome.

Case #1

 

 

pic 2

Apparently 45 yrs old female found unconscious in a secondary street by people accidentally passing by. No witness of the event. No other information on the patient.

When the first medical team arrived, the patient was unconscious with some non coordinated vocal response (if stimulated) and no finalized movements of the extremities; she was spontaneously breathing with an apparent good respiratory drive a RR of 24 and O2 sat of 98% on room air.  Good breath sounds were (apparently) bilaterally transmitted (not easy to appreciate when you perform auscultation of the chest on the roadside).

She had a good palpable radial pulse (bilaterally), the HR was 72 and her BP 110 over 70. To a quick external exam multiple minor signs of trauma where present on her face, forehead and left anterior chest wall. No sign of major external bleeding was present.

When we arrived the above clinical scenario was confirmed. The cops, on the scene, were investigating about what happened, but at the moment no other new information was available.

As first thing I was concerned, cause of the low level of consciousness, about patient’s competence to maintain airway patency , so I decided to protect the airways with tracheal intubation. 

But first to proceed to RSI, during the preox period and despite the apparent hemodynamic stability I decided to perform an extended FAST ultrasound exam; it takes 2 min, is safe and free.  The EFAST revealed a pneumothorax on the left, no abdominal bleeding, no pericardial fluid effusion. At this point we decide to open the chest (finger bougie tecnique, Ketamin pre-medication) before intubating the patient in prevision  of the mechanical positive pressure ventilation, and air transport.

The patient arrived well compensated (from both respiratory and hemodynamic point of view) at the trauma  center where was discharged 3 weeks later without major clinical consequences.

But what without ultrasound???

We don’t have a clinical guidance (and practice) to open the chest simply ‘cause of the presence of external sign of chest trauma when the patient is in a well compensated respiratory status and had a good hemodynamic balance.

In this case the chance to find clear US signs of penumothorax, prevented a possible worsening of respiratory and hemodynamic status  after intubation.  Intubation itself, PPV and high altiutde transport, are all factors that can precipitate a prior stable pneumothorax.

Case #2

pic 1

28 yrs male victim in a car accident extricated after several minutes by the firefighters. At the arrival of the fire crew he was still breathing but when the first medical crew arrived found him in CA. Advanced life support started and was ongoing when we arrived.

The patient was intubated on the field, two thoracic tubes were bilaterally placed (emo-thorax on the right side no pneumo bilaterally)  and a bolus of 2 liters of fluids administered via two large bore venous accesses.

He had an organized cardiac electric activity and an EtCO2 value of 35 mmHg (without chest compressions in place). The US of the heart shown some weak wall motion (coordinated with electric activity), so we decided to rapidly transport the patient to the nearest trauma center where he was reanimated for more than 1 hour and then called  without any evidence of possible cause of death.

In this case the presence of wall motion at the US exam (well supported from EtCO2 values and and by an organized cardiac electric activity) strongly influenced the decision to transport the patient in TCA to the hospital for definitive care.

Ultrasound can be a further hint in the decision to carry on the resuscitative efforts in patients in CA with PEA and no evidence of reversible causes on the field. It can be also the decisive tool in deciding  to transport those patients to the hospital for second level diagnostic assessment and advanced care.

Case #3

pic 3

24 yrs old pedestrian male hit by a motorbike while crossing the road. He was found unconscious by first responders. When we arrived the patient was lying down on the spinal board wearing a cervical collar with eyes closed but responsive when called and able to execute simple commands with no apparent deficit of the limbs. He suffered a severe facial trauma  with  avulsion of several frontal teeth and a profound total tickness wound to the superior lip with presence of a lot of blood in the mouth and  the first part of the airways; his breathing was laborious and noisy. Anyway  the patient was able to maintain an ox sat of 93% on room air (that easily improved to 98% with 2 liters of oxygen administered via simple O2 mask). 

The radial pulse was present at a rate of 90/min and the BP was 100 over 70. The rest of external exam highlighted a profound wound at the internal part of the calf with exposition of muscular plan and some hemorrhage well controlled with external manual compression.

We provided (with not much success due to the unstoppable bleeding) to clear the airways from blood and secretions, but still the respiration was difficult and noisy even if the ox sat was on a satisfying 98% on O2 non rebreather mask . In the meanwhile two large bore venous accesses were placed and some fluids keep going.

The EFAST exam revealed no signs of pneumo but presence of blood in the right and left upper quadrant of the abdomen.

We decided to do not insist further on airways control because at this point the control of abdominal bleeding became the first priority. After a rapid transport in ED the total body CT (he was still hemodynamically compensated)  confirmed the presence of internal bleeding and the patient proceeded straight to OR.

Often the suspect of internal bleeding is not clear just by considering clinical signs, especially when we have to deal with young patients who have a large compensation range. POCUS can give us the chance to see the presence of blood in the abdomen and to prioritize our clinical pathway pondering these findings.

Take home points

#1

Performing a chest US before intubating a even stable chest trauma patient, prevents possible  (pre, intra and post) intubation hemodynamic disasters.

#2

Prehospital arrested trauma patients with an organized electric activity and good EtCO2  might have some cardiac activity even in absence of palpable carotid or femoral pulse. They deserve a strong effort on addressing reversible causes and a rapid transport to a  trauma center for advanced in hospital care.

#3

The presence of internal bleeding (revealed by US) can revolve clinical priorities enabling a fast track toward the OR. This virtuous path can start from the prehospital environment.

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