Training Day: 3 areas to use ultrasound in trauma assessment
Tim Nowak // April 6, 2020
Handheld ultrasound technology can greatly enhance your assessment skills and scope of practice when it comes to secondary trauma assessment and vascular access
POCUS in the EMS setting can provide important internal clarity for assessing the heart, lungs and abdomen in trauma cases, as well as opportunities for vascular assessment and access. (image/Getty: 7activestudio)
Looking for a "hot belly" or "ants marching" might almost sound like you’re ordering an artisan sandwich at a local deli, but when it comes to performing a trauma assessment, these findings might be the difference between facility diversion or procedure avoidance.
Prehospital point of care ultrasound, aka POCUS, is both a technological advancement and an advanced scope skillset that is gradually increasing in popularity among EMS agencies. What was once reserved for hospitals and medical facilities – often due to its cost and unit size – is now a feasible technology that can fit into the palm of your hand and can be included into even the most meager of budgets. It all comes down to what you want to assess and what you’re going to do about your findings.
In the realm of trauma assessment and care, ultrasound technology can greatly enhance both your assessment skills and your scope of practice. Once spinal motion restriction is considered, bones are splinted, bleeding is managed, and your patient is loaded into your ambulance, it’s now time for you to work on secondary trauma assessment:
While your partner works on gaining IV access, you pull out your ultrasound device, often a single probe connected via USB adapter into your smartphone or tablet. Apply gel to the patient, and you’re off to assessing three primary anatomical areas: the heart, lungs and abdomen.
Start with the Heart
Subxiphoid and parasternal views can allow you to view not only chamber and ventricular wall movement, but also pericardial sac integrity. Most importantly, you can assess whether you’ve got an effusion present that is resulting in a cardiac tamponade.
For those EMS agencies that allow “blind” insertion of a needle toward the pericardium, you’re truly allowing this emergent skill in the dark. Incorporating ultrasound, however, will allow you to perform this skill in black-and-white (at a minimum) – literally watching the needle poke into the pericardium (and not directly into the ventricle).
Assessing the Lungs
Which is better – a "bar code" or "ants marching?" While no one wants ants marching into their house, seeing this sign present on an ultrasound screen truly is a good sign. Much like the waves crashing up against the shore, this indicates pleural wall movement and a lack of air trapping between the lungs and pleural lining.
Bar codes, however, indicate pneumothorax. Coupled with absent or diminished lung sounds and perhaps some jugular vein distention, now you’ve got a build-up of tension, which needs to be released.
Once again, poke your needle above the third rib in the mid-clavicular line and hope you don’t insert too far, all the while watching for air bubbles in your fluid syringe or the hissing sound of trapped air being released. Or, gently guide your needle into the patient’s chest and watch it puncture the pleural lining and see the "ants" return (or the "waves" begin to crash).
Ultrasound and the Abdomen
When we think of a "hot belly," we may associate this with some sort of infection. After all, when else would something on your body be hot or even "angry?" When it comes to ultrasound, this term takes on its own meaning, indicating the presence of fluid (even blood). Scanning around the liver, spleen, kidneys and even the bladder can all alarm us to fluid leaking out of its container. This means your patient needs surgery (and not necessarily liters of fluid). Diverting transport from one hospital toward another may be the best course of action in some of these situations.
Beyond the top three
Think about your last trauma patient that was involved in a motor vehicle collision. Perhaps they were ejected from the vehicle. Their mentation is wavering, you don’t see any obvious bleeding or deformities, but you do notice their blood pressure appears normal. Is this necessarily a good thing?
They have no response to pain (due to unresponsiveness) and still have spontaneous respirations present. You suspect they’ve suffered internal injuries, but you don’t have any external proof. Where should you transport this patient? Can you justify a longer transport in order to activate more specialized teams for your patient’s care?
POCUS in the EMS setting can provide your crews with some of the internal clarity they’ve longed to see. Even beyond the three anatomical areas explored above, there are opportunities for vascular assessment and access as well. Is the aorta ruptured? Where is the big vein you’re seeking to cannulate? Wouldn’t it be nice if you had a way to actually see all of this? Ultrasound can provide that visibility.