Sonographic assessment of traumatic injury. Future developments.

Sonographic technology in trauma care is increasing. Sonography is used for the initial assessment of injured patients, peripheral arterial and venous imaging, evaluation of cardiac function, and imaging of the thoracic aorta. The incorporation of the FAST (focused assessment with sonography for trauma) technique into the initial assessment of trauma victims in North America is a primary example of how sonography now is used in everyday trauma care. An accurate assessment of patients with potential thoracoabdominal injury should include a safe and reliable method to determine the need for operative intervention. Because physical examination alone has a low sensitivity for the detection of hemoperitoneum, particularly in patients with blunt multisystem trauma, clinicians have relied on tests such as diagnostic peritoneal lavage (DPL) and CT. Based on many evaluations,* *References 12,16,18,20,25,40,57,61 and 76 . these tests have gained general acceptance by surgeons, but they have some drawbacks. For instance, DPL is an invasive procedure that is highly sensitive and may result in too many nontherapeutic celiotomies with associated morbidity. 58 CT is costly and time consuming; requires oral and intravenous contrast agents; and, at present, mandates patient transport to the radiology suite, making it unsuitable for hemodynamically unstable patients. Developed for the evaluation of injured patients, the FAST technique is a rapid diagnostic test for assessing patients with potential truncal injuries. Historically, its development is rooted in several fundamental studies that demonstrated the high sensitivity of sonography for the detection of small amounts of intraperitoneal fluid, 24 splenic injury, 2 and hemoperitoneum in the hepatorenal space and pelvis. 13,64 With improved technology, sonography has been demonstrated to be an important investigative tool in the evaluation of trauma patients in Europe and Asia.* *References 3,29,31,34,37,41,43,71,79 and 80 . German surgeons, for example, routinely perform sonography on their patients and have incorporated sonography training into their surgical residency programs. In 1988, the German Association of Surgery included mastery of sonography in its guidelines for surgical resident education, and today, only candidates experienced in diagnostic sonography are eligible to sit for their national board examinations. Furthermore, the Germans have expanded their use of sonography to include prehospital trauma evaluation and follow-up of patients in the ICU and clinic. Such emphasis on sonography is encouraged because of technologic advances and cost-containment initiatives. With the advent of real-time sonography, scanners have become user friendly and do not require advanced technical knowledge to operate. In addition, the development of high-quality, portable scanners at a realistic price has increased the availability of the instrument to almost all departments. In the current era of cost containment in health care, increasing demand by patients, clinicians, and third-party payers for rapid and cost-effective diagnostic tools exists. Trauma patients should be triaged rapidly, their diagnoses confirmed, and their treatments instituted with the smallest possible expenditure of time and resources. Such reasoning, coupled with the accumulation of data that support sonography as a rapid, reliable, cost-effective diagnostic modality for the evaluation of injured patients, has enhanced the interest. When these factors are considered together with the factors that differentiate trauma from other surgical diseases, the use of sonography by surgeons is a necessary and logical element in the continuum of care.