Emergency Ultrasound in Critical Patients: The “Bedside Ultrasonography” as the “Third Hand” of Emergency Surgeon

Giuseppe Frazzetta*¹, Faraci Cristofaro¹, Mancuso Salvatore Igor¹, Fragati Giuseppe¹, Di Giovanni Silvia², Costanzo Luigi¹

¹U.O.C. General Surgery and Emergency Hospital "M. Chiello" of Piazza Armerina, Italy

²U.O. Medicine Acceptance and Emergency Hospital "Umberto I" Enna, Italy

*Corresponding author: Giuseppe Frazzetta, U.O.C. General Surgery and Emergency Hospital "M.Chiello" of Piazza Armerina, Italy

Received: May 05, 2015; Accepted: June 22, 2015; Published: June 24, 2015

Abstract

Introduction: Ultrasound (US) is a safe and useful diagnostic tool for the detection and the study of several organs. Absence of radiations and collateral effects make it be a repeatable test with low costs, feasible and quickly. Ultrasound scan can be performed to patient's bedside avoiding losing precious time for diagnostic and therapeutic decision making in transferring him in radiologic room or department.

Aim: To illustrate and support the precious aid of emergency ultrasound in emergency surgeon's hands.

Materials and Methods: we selected 45 patients admitted to our department of general and emergency surgery for abdominal and thoracic acute problems. A retrospective cohort study was made on a period of six month.

Conclusion: Bedside ultrasonography in critical patients is safe and feasible; it could be the “third hand” of emergency surgeon integrating the bounds of clinical examination.

We stand that all emergency surgeon or physician should be trained in bedside emergency ultrasound.

Keywords: Ultrasound; Critical; Ultrasonography; Surgeon; Bedside

Introduction

Ultrasound is a safe and useful diagnostic tool used for the detection and the study of several organs and their diseases. Because of absence of radiations and collateral effects it is a repeatable test with low costs, feasible and quickly. One of the great advantages of the ultrasound scan is the possibility to perform the exam to patient's bedside avoiding transferring him in radiologic room or department and losing precious time for diagnostic and therapeutic decision making [1]. In recent time not only radiologist appreciate the potentiality of ultrasound, but overall emergency physicians and surgeons start to perform ultrasonography scans both as Focused Assessment Sonography for Trauma (FAST) and monitoring hemodynamic conditions specially in critically ill patients. Increasingly, the ultrasound scans integrates the clinical examination giving precious dates on areas closed to physical exploration [2]. Ultrasound power makes the “bedside ultrasonography” often the first diagnostic instrumental approach to several both abdominal and lung pathologies and not only but also in the neurological evaluation because of the advances in technology that allow to penetrate the skull [3-4]. Often the bedside ultrasound is the “third hand” of the emergency physician or surgeon. In this cases series we report our daily experience in a small centre illustrating the precious aid of this fantastic diagnostic tool [5].

Materials and Methods

For this retrospective cohort study, we collect the data, from October 2014 to April 2015 from the emergency department of general and emergency surgery of “M. Chiello” hospital in Piazza Armerina. In a period of six month we selected 45 patients, as heterogeneous population, admitted to our department for abdominal and thoracic acute problems. They were divided in four groups: Abdominal acute problems (Group 1), Blunt trauma (Group 2), Post-operative complication (Group 3), and Thoracic acute problems (Group 4). The main age was 63 years old with a range between 8 and 92 years old. 7 patients were admitted for thoracic pain and evolving dyspnea: 3 had pleural effusion. 2 patients developed pneumothorax, one had spontaneous pathogenesis and one iatrogenic due to central vein catheterization; 2 patients developed pulmonary edema and lung disease. 11 patients, suffered from upper abdominal pain, vomiting and fever, had biliary colic pain; 17 patients were admitted for lower right or left abdominal-pelvic pain, sub-continuous fever and vomiting, 2 of these had missed evacuation of gasses or feces, dehydrations and other occlusive clinical signs. 2 patients were admitted for left colic pain with associated resistance to abdominal palpatory examination. 6 patients were recovered for jaundice; 2 had blunt abdominal trauma and 2 were reported for postoperative surgical complications. All these patients underwent first of all to ultrasonography evaluation (Table 1). In our experience all these patients were primary valued in emergency rooms and often underwent to a summary radiologic evaluation in emergency setting; often the primary examination was superficial and too fast so all the patients admitted to our department were be retested to ultrasound evaluations. Only expert surgeon with advanced echographyc technique skills carried out all the exams. Where use always the same echographyc instrument. All the exams were carried out using Convex probe 3-5 MHz and linear probe 7-9 MHz for both abdomen and thorax. Patient's position was chosen in agreement with general clinical conditions, patient's degrees of collaborations, previous surgical procedures if present and however to patient's bedside. Few times patients were prepared the day before with fasting diet and medicine to reduce abdominal meteorism; according to the age and the collaboration of the patients, we use standard scansions to detect abdomen and thorax; in some cases, patients were studied in sitting or prone position. In all cases, we do not use contrast enhancement. Median time elapsed between admission and echographyc evaluation was about 1.3 ± 8.5 hours. Mean operative time was 10 ± 30 min. Mean ASA (American Society of Anaesthesiologists) score was III.

Table 1: Summary of ecographyc findings driving decision making.




  
    Indications to admission
    N° pz
    Ecographyc findings
    Diagnosis
    Decision making 
  
  
    Group 1 
      Abdominal acute problems
      Upper pain, fever, vomiting, biliary colic    pain
    11
    -Gallbladder distension and wall thickening    > 6 mm
      -pericholecystic fluid and peri-intrahepatic free gasses
      -stagnant or purulent gallbladder contents
    Acute lithyasic cholecystitis
      - associated pericholecystic abscesses
      -gangrenous cholecystic perforation
    -Cholecystectomy
      -Perihepatic drainage
  
  
    Lower right or left abdominal-pelvic pain,    fever, vomiting, missed evacuation dehydrations
    17
    -Free intrabdominal fluid
      -pelvic abscesses
      -thickening appendicular wall
      -intestinal dilatations and bowel immobility
      -Colonic wall thickening
      -per colic free fluid
      -“Pseudo kidney” images
    -Acute appendicitis
      -Ovarian rotation and pelvic diseases
      -Intestinal occlusion
      -Acute diverticulitis
      -Per colicabscesses
    -Appendectomy pelvic lavage and drainage
      -Gynaecologic counselling and transfer
      -Intestinal resection
      -Bowel viability monitoring and discharging
      -Colic resection 
  
  
    Jaundice
    6
    -Biliary tree dilatations
      -Obstructive iperechogenic images
      -intrahepatic masses
    -Choledocholithyasis
      -Liver tumours
    ERCP 
  
  
    Group 2 
      Blunt trauma 
    2
    -Non homogenous spleen aspect
      -per splenic free fluid
      -Psoas disomogeneus aspect
    -Evolving spleen rupture
      -Psoas hematoma
    -Splenectomy
      - Monitoring 
  
  
    Group 3 
      Post-operative complications 
    2
    -Disomogeneus wall collection
    -Hematoma of rectum muscle
      -Seroma mesh related
    Non Operative Management 
  
  
    Group 4 
      Thoracic acute problems 
      Chest pain,
      dyspnea, blunt chest trauma
    7 
    -Lung point
      -A Lines
      -B Lines
      -Pleural free fluid
    -Pneumothorax (2)
      -Pleural effusion (3)
      -Lung diseases (2)
    -Thoracentesis (3)
      -Chest drainage (2)
      -Medical management (2)
  
  
    Total 
    45



Table 1:  Summary of ecographyc findings driving decision making.

Results

In 11 patient of Group 1 were found gallbladder enlargement, with wall thickening and free fluid or perihepatic collection and in all cases was made diagnosis of acute cholecystitis, associated in two cases to hepatic abscesses and gangrenous cholecystic perforation in other two patients (Figure 1-2). In all these patients were performed cholecystectomy and perihepatic lavage and drainage [6]. In 17 patients, admitted for lower abdominal pain, the echographyc findings were: intra abdominal fluid, pelvic collection, thickening small bowel or colonic wall or distention and was made diagnosis of acute appendicitis in 11 cases whom underwent to appendectomy (Figure 3); ovarian torsion and pelvic pathologies were found in two cases whom underwent to gynaecologic evaluation avoiding useless surgical procedures (Figure 2). In two patients were demonstrated echographyc signs of mechanical occlusion and in one cases was necessary the surgery but in one due to adhesion we preferred Non Operative Management and echographyc monitoring of bowel viability [7-8] (Figure 3). One of two patients with colonic wall thickening developed the “pseudo-kidney” signs after few days as expression of paracolic abscesses and was performed a colonic resection after TAC evaluation. 6 patients had jaundice and were studied to detect the obstructive cause, that in 5 cases was a biliary stones, but in one case was an intrahepatic mass: all these underwent to Endoscopic-Retrograde-Cholangiopancreatography [9-11] (Figure 4).

Figure 1: Acute cholecystitis.

    
    
    Figure 1:  Acute cholecystitis.

Figure 2: Hepatic abscesses.

    
    
    Figure 2:  Hepatic abscesses.

Figure 3: Acute appendicitis.

    
    
    Figure 3:  Acute appendicitis.

Figure 4: Pelvic disease.

    
    
    Figure 4: Pelvic disease.

In Group 2 one patients with finding of free increasing perisplenic fluid, anaemia and haemodynamic instability, after blunt abdominal trauma underwent to splenectomy; the other one to Non Operative management and monitoring of psoas muscle hematoma [12]. In Group 3 two patients developed post-operative complication and echographyc detection showed dishomogeneous wall collection due to hematoma of rectum muscle and seroma mesh related, no surgical procedure were carried out (Figure 5). In Group 4 were collected patients with chest pain, dyspnea or chest blunt trauma; in these cases we performed ultrasounds evaluation finding pleural effusion, treated by thoracentesis, “lung point” as expression of pneumothorax treated by chest drainage [13-15].

Figure 5: Bowel obstruction.

    
    
    Figure 5:  Bowel obstruction.

The only echographyc evaluation has been sufficient to establish that in 30 cases (66.7%) was necessary immediate surgery, in 9 cases (20%) was sufficient monitoring and non-operative management or transfer the patient to other specialists' care and in 6 cases (13.3%) endoscopic management was required (Table 2).

Decision Making	Procedures	Cases	%
Surgical Management	Cholecystectomy and peritoneal drainage Appendectomy Splenectomy Bowel resections Thoracentesis Chest drainage	11 11 1 2 3 2	66.7
Endoscopic Management (ERCP)	Biliary stent Common bile duct “toilette”	1 5	13.3
Non Operative Management (NOM)	Monitoring (hematoma-seroma-bowel motility) Medical menagement Transfer to other specialists	5 2 2	20
Total		45	100

Emergency Ultrasound in Critical Patients: The “Bedside Ultrasonography” as the “Third Hand” of Emergency Surgeon

Abstract

Introduction

Materials and Methods

Results

Discussion

Conclusion

References