Images Tina Cullen, text Genevieve Carbonatto
It is 10.00 pm and you get a BAT call. There has been a fight at the local pub and the ambulance are bringing in a 34 year old who has been stabbed in the chest. He is tachycardic and hypotensive, GCS 14. They will arrive in 10 minutes. The trauma team gets activated, the cardiothoracic surgeons and cardiac anaesthetists are called down. Intubation equipment is set up as is the chest tube trolley, the cannulation trolley and of course the ultrasound machine is set up. What does that mean? The machine gets plugged in and turned on and placed stategically to the right of the bed the patient will be brought into without interfering with access to the patient. The probes are covered for infection control as you expect blood to be around. All probes are covered. Mentally you have prepared yourself. You will be looking for a pneumothorax, then a haemothorax then pericardial tamponade.
The patient get wheeled in. He is conscious, tachycardic 113/min and hypotensive – 86/40. He has a stab wound to the anterior chest at the level of the 4th intercostal space in the midclavicular line. At the scene he has had a needle decompression for presumed left pneumothorax and the needle is still in situ in the 2nd intercostal space of his left chest anteriorly. Six minutes after his arrival, you put the linear probe on his left anterior chest wall in the longitudinal plane and this is what you see
Lung sliding no pneumothorax . Then the probe is placed on his right chest wall anteriorly. This is what you see
Lung sliding, no pneumothorax. Then you change to an abdominal probe to see whether he has a pneumothorax. This is his left costophrenic angle
He has a left sided haemothorax.
You switch to a cardiac probe and look at his heart – a semi PLAX view with a downward tilt to see the pericardium. This is what you see
He has a haemopericardium.
It has taken exactly 4 minutes. It could have taken half the time if you hadn’t changed your probe. You could have used a cardiac probe or an abdominal probe for everything. In this case using the different probes provided excellent information, giving you the best opportunity to get it right the first time.
The decision is to take him straight to theatre. He leaves your department within the next 6 minutes. He has spent in total 16 minutes before going to theatre. Thanks to the cardiothoracic team he survives his injuries.
This scenario before the use of ultrasound would have been played out very differently with very different consequences for the patient. In a place where these sort of injuries are common this man might go straight to theatre bypassing the Emergency Department altogether. In most places however he would get a chest tube inserted and an Xray where the haemothorax would be identified but not the haemopericardium. The trauma team would spend precious minutes discussing how fast he should go to theatre and hypothesising on his most likely injuries. Ultrasound has taken the guesswork away. It takes 4 minutes to obtain the diagnosis with certainty.