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Medicina

创伤超声重点评估 （FAST） 检查：图像采集

Published: September 22, 2023
doi:
10.3791/65066
, , , , ,
1Trauma, Acute, and Critical Care Surgery,Duke University Hospital, 2Mount Sinai Medical Center, 3Department of Anesthesiology,Massachusetts General Hospital, 4Acute Care Surgery,Atrium Health, 5Department of Surgery,Duke University School of Medicine, 6Department of Anesthesiology, Duke University School of Medicine,Duke University Health System, Durham Veterans Health Administration

Summary

创伤超声重点评估 （FAST） 检查是一种诊断性床旁超声检查，用于筛查心包和腹膜中是否存在游离液体。本文将讨论该手术的适应症、技术和缺陷。

Abstract

在过去的二十年中，创伤超声重点评估 （FAST） 检查改变了对创伤（钝性或穿透性）和低血压患者的护理。在这些血流动力学不稳定的创伤患者中，FAST 检查允许快速、无创地筛查游离心包或腹膜液，后者表明腹腔内损伤可能是导致低血压的原因，因此需要紧急腹部手术探查。 此外，FAST 检查的腹部部分也可用于创伤环境之外，以筛查在任何情况下血流动力学不稳定的患者的游离腹膜液，包括在可能无意中损伤腹部器官的手术后。这些血流动力学不稳定的“非创伤”情况通常由不熟悉 FAST 检查的急诊医学或创伤外科以外的专业提供者进行分类。 因此，有必要向所有照顾危重病人的临床医生宣传有关FAST检查的知识。 为此，本文介绍了 FAST 检查图像采集：患者定位、换能器选择、图像优化和检查限制。 由于游离液体可能存在于特定的解剖位置，这些位置对于每个典型的 FAST 检查视图都是唯一的，因此这项工作集中在每个窗口的独特图像采集注意事项上：肋下、右上腹、左上腹和骨盆。

Introduction

创伤超声重点评估 （FAST） 检查是一种躯干诊断性床旁超声 （POCUS） 检查，旨在快速评估创伤患者可能危及生命的出血1。FAST 考试是最早被广泛采用的 POCUS 技术之一：它于 1980 年代在欧洲首次开发，并于 1990 年代初传播到美国。随着 POCUS 在创伤患者评估中的应用越来越普遍，1997 年召开了一次共识会议，标准化了 FAST 检查的定义及其在创伤患者护理中的作用。随着时间的流逝，一些作者主张在传统的 FAST 检查中增加肺部的重点超声检查，并将这种多器官检查称为扩展的 FAST （e-FAST） 检查2。

经典 FAST 及其新版本 e-FAST 的主要作用是创伤患者的初始评估3。创伤性损伤患者的血流动力学不稳定通常由少数疾病引起，包括原发性出血、心包填塞和张力性气胸 3,4。作为高级创伤生命支持 （ATLS） 初步调查的 ACBDE 步骤的一部分，循环步骤旨在识别和治疗创伤患者血流动力学不稳定的危及生命的原因 3,5,6。此步骤包括排除心包填塞和胸膜腔和腹膜腔内出血，以及其他来源 6,7。FAST 检查允许显示心包和腹膜中的游离液体，并通过 e-FAST 视图显示双侧胸膜腔 3,6,7。在严重创伤后血流动力学不稳定的临床表现中，除非另有证明，否则推定这种液体是血液。

作为床旁超声检查，FAST/e-FAST检查具有多项优势。可以在患者床边使用小型便携式超声机进行检查，同时进行其他护理，而无需运送患者 3.使用 B 模式技术的有限视野意味着可以在几分钟内快速获得完整的检查，并且超声检查的无创性质意味着如果患者的临床表现发生变化，可以很容易地重复检查 3,8,9。

同时，FAST考试的简单性也有一些局限性。与任何超声检查一样，操作员依赖于实时获得适当的视图和图像的准确解释9。各种患者因素，包括肥胖和皮下肺气肿，可能会限制获得足够图像的能力。此外，FAST/e-FAST检查的简化视图不会寻找特定的器官损伤，而是筛查各个身体隔室中的游离液体。在适当选择的创伤患者中，这种游离液体可能代表持续出血产生的血液，但也可能代表来自创伤性或非创伤性医疗状况的其他液体。

鉴于 FAST/e-FAST 检查的优点和局限性，其主要适应症是评估遭受钝挫伤的血流动力学不稳定患者。对于这一患者群体，主要目标是确定血流动力学不稳定的创伤源，例如心包填塞和腔内出血，这些都需要立即进行手术干预。在这个角色中，它取代了诊断性腹膜灌洗 （DPL） 作为诊断腹膜内出血和体格检查的主要方式，并挑战了胸部 X 线检查诊断胸膜内出血和气胸1。凭借其快速和无创的性质，FAST/e-FAST检查已被用于其他创伤患者，包括血流动力学稳定的钝性创伤患者和稳定和不稳定的穿透性创伤患者。然而，这些检查的适应证和解释仍不太清楚。

在创伤环境之外，FAST 检查可能在几种不同的危机管理情况下具有价值，包括但不限于以下任何一种：对产科出血的严重程度进行分类10、寻找围手术期出血的位置、筛查围手术期膀胱破裂，以及作为计划进行择期手术的疑似但未经证实的腹水患者的术前评估的一部分11，12,13.在这些非创伤环境中，可用于执行 FAST 考试的提供者可能来自产科、麻醉学、内科和重症监护等专业，对他们来说，FAST 考试培训在住院医师/奖学金课程中差异很大13、14、15、16。正是这些非创伤专业构成了本综述的目标受众。其中一些非创伤专科往往要么具有肺部超声方面的现有专业知识（例如，重症监护医生17），要么有理由单独执行 FAST 检查的腹部视图（例如，麻醉师和产科医生）10。由于这些原因，并且由于e-FAST检查的肺部视图已经在单独的手稿18中进行了全面介绍，因此本综述将主要关注FAST检查腹部视图的图像采集。尽管如此，值得强调的是，在创伤环境中，在许多医院中，肺部超声检查被认为是 FAST 协议的核心部分（即，e-FAST 是一些创伤提供者首选的 FAST 检查形式）。

Protocol

在涉及人类受试者的研究中执行的所有程序均符合机构和/或国家研究委员会的伦理标准以及 1964 年《赫尔辛基宣言》及其后来的修正案或类似的伦理标准。患者提供了参与研究的书面知情同意书。患者纳入标准：任何有血流动力学不稳定或腹痛/腹胀的患者。患者排除标准：患者拒绝。 1. 换能器选型 选择低频线性换能器（1-5 MHz）（参见材料表</strong…

Representative Results

通常使用四个超声窗口来获得传统的 FAST 检查视图19。窗户是肋下 4 腔 （SC4C）、右上腹 （RUQ）、左上腹 （LUQ） 和耻骨上/盆腔。虽然可以按任何顺序对窗口进行成像，但检查通常按以下顺序进行：SC4C、RUQ、LUQ，然后是耻骨上/盆腔 1,19。这是因为心包填塞通常比腹腔出血更快地危及生命，并且因为无论损伤部位如何，右上腹视图都是?…

Discussion

创伤性损伤仍然是美国和全世界发病和死亡的主要原因。对创伤患者进行快速评估和识别损伤，包括大出血，是降低创伤发病率的关键组成部分。FAST 检查可快速、无创地筛查危及生命的出血的潜在来源。手术成功的关键步骤是通过四个主超声窗口获得所有视图，并在必要时使用备用胸骨旁窗口来完全可视化空间。

在创伤中成功使用 FAST 检查的关键仍然是识别和解释心包、腹…

Declarações

The authors have nothing to disclose.

Acknowledgements

作者感谢 Annie Y. Chen 博士和 Linda Salas Mesa 女士对摄影的帮助。

Materials

Affiniti  (including linear high-frequency, curvilinear, and sector array transducers) Philips n/a Used to obtain a subset of the Figures and Videos
Edge 1 ultrasound machine (including linear high-frequency, curvilinear, and sector array transducers) SonoSite n/a Used to obtain a subset of the Figures and Videos
M9 (including linear high-frequency, curvilinear, and sector array transducers) Mindray n/a Used to obtain a subset of the Figures and Videos
Vivid iq  (including linear high-frequency, curvilinear, and sector array transducers) GE n/a Used to obtain a subset of the Figures and Videos
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Keywords: FAST ExamTrauma ImagingFocused Assessment With SonographyHemopericardiumPneumothoraxHemothoraxFree Peritoneal FluidParasternal Long AxisLeft Upper QuadrantSagittal Pelvic ViewMorison’s PouchSpleno-renal InterfaceUltrasound TechniqueImage Acquisition
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Ritchie, J. D., Trujillo, C. N., Convissar, D. L., Lao, W. S., Montgomery, S., Bronshteyn, Y. S. Focused Assessment with Sonography for Trauma (FAST) Exam: Image Acquisition. J. Vis. Exp. (199), e65066, doi:10.3791/65066 (2023).
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