This time let’s get straight to the point! No need to keep repeating what SOFsono JSOM cases are all about!
During a Partner Nation Force (PNF) field training exercise (FTX), you are called to a scene of a motor vehicle accident (MVA). Two all-terrain vehicles (ATV’s), carrying a total of 5 US and PNF service members, crashed into each other. As you TRiAGE the victims, you realize that all 5 potentially need further medical care. The closest hospital is 90 minutes away, and your local ambulance service is capable of transporting only two patients at a time.
- Patient 1: 35-year-old man, heart rate (HR) 95 beats/minute (bpm), blood pressure (BP) 105/65mmHg, respiratory rate (RR) 16/min, Spo2 98% on room air, temperature (T) 36.6C (97.8F); reporting deep right flank pain; has a large right flank contusion and tenderness;
- Patient 2: 40-year-old man, HR 98 bpm, BP 100/55mmHg, RR 19/min, Spo2 98% on room air, T 36.5C (97.7F); reporting generalized abdominal pain; has multiple abdominal wall abrasions and diffuse abdominal tenderness;
- Patient 3: 21-year-old man, HR 101 bpm, BP 105/75mmHg, RR 12/min, Spo2 100% on room air, T 36.7C (98.oF); reporting pain in his abdomen and left forearm; has diffuse abdominal tenderness and left distal forearm swelling with intact neurovascular examination;
- Patient 4: 32-year-old man, HR 85 bpm, BP 100/60mmHg, RR 20/min, Spo2 99% on room air, T 36.0C (96.8F), Glasgow Coma Scale (GCS) score 15; complains of a frontal headache centered around a 4-cm forehead laceration;
- Patient 5: 25-year-old man, HR 104 bpm, BP 99/50mmHg, RR 25/min, Spo2 97% on room air, T 36.2C (97.oF); reporting right-sided pain in his ribs, it “hurts to breath.” He has notable shallow respirations and a moderate-size chest wall contusion without crepitus.
To get a more precise idea about the extent of your patients’ injuries and to establish the priority of transfer, you perform focused ultrasound studies on patients 1, 2, 3, and 5. Their most pertinent findings are as follows:
1. What are their respective ultrasound findings?
2. How would your prioritize transfer BEFORE and AFTER the ultrasound evaluations?
CLiNiCAL CONSiDERATiONS
Who is the sickest? Who goes first? These two questions are pretty obvious, yet the answers not so much! Being able to send only 2 guys at a time, you have to make the right pick! Based on the clinical picture alone it might be a hard nut to crack:
- Patient 1: ABDOMINAL TRAUMA?
- Patient 2: ABDOMINAL TRAUMA?
- Patient 3: ABDOMINAL TRAUMA? LEFT FOREARM FRACTURE?
- Patient 4: JUST A HEAD LAC? INTRACRANIAL INJURY?
- Patient 5: CHEST TRAUMA?
While we would all possibly agree that patient #4 can wait, and patient #5 should likely leave right away, we want more than just an “educated guess” when deciding which aching belly truly means trouble!
Of course, observation and trending of vitals would provide us with some additional answers. However, in the setting of a multi-casualty incident, we are unlikely to have that luxury prior to assigning the evacuation priorities to our patients.
OPERATiONAL CONSiDERATiONS
In this particular scenario, it was “merely” an FTX. Yet in reality you would want to keep the guy who is still capable of fighting the good fight, while shipping off the sickest, and at same time, the weakest link in your chain of command.
SONOGRAPHiC MiSSiON SUPPORT
At SOFsono.org it never comes as a surprise that ultrasound is THE TOOL that can help you solve a few clinical mysteries and operational dilemmas. (A complete sonographic study has been performed on all patients, and only the most pertinent images are being presented).
Patient 1: 35 yo M with clinical concern for an ABDOMiNAL iNJURY, but a negative eFAST study. Here the red arrow is pointing towards the so called “double line sign”. That hypoechoic or anechoic wedge-shaped area in the Morison’s pouch, located between the two bright lines, one on each side, is most consistent with perinephric fat. It looks like free fluid, and is frequently mistaken for it. Not that you’d see it a lot when scanning your buddies, but if you see it, just call it the “missed workout sign” ;-).
Patient 2: 40 yo M with clinical concern for TRAUMA TO THE ABDOMEN and free fluid in the pelvis on the ultrasound exam (red arrow). In the setting of trauma this is most likely blood from intraabdominal hemorrhage, rather than urine from intraperitoneal bladder rutpure. His eFAST is positive!
Patient 3: 21 yo M with clinical concern for ABDOMiNAL TRAUMA, and a negative eFAST study. It turns out that his distal forearm swelling corresponds with an underlying fracture. 
The red arrow is pointing towards a cortical defect. (We talked about ultrasound for fractures in SOFsono JSOM case #2).
Patient 4: 32 yo M with HEAD iNJURY, and a normal GCS of 15. With pain focused just around his forehead laceration, it likely represents his only injury.
Patient 5: 25 yo M with CHEST TRAUMA, and ultrasound findings of thoracic “barcode sign” on the right side of his chest, consistent with pneumothorax (image in M-mode). He also has free fluid in the right pleural cavity (red arrow on RUQ view). In the setting of trauma this most likely represents hemothorax. His eFAST ultrasound is positive.
Now the decision is pretty simple: patients #2 and #5 go first! Was that your sono-guided decision as well?
In the setting of a mass-casualty incident (MCI) it can be very challenging to triage the injured. The resources are generally quite limited and the relief network can easily become overwhelmed. Yet one must strive to triage the patients quickly and efficiently. Therefore portable ultrasound systems are particularly well-suited to support the MCI triage process.It has proven useful during major natural disasters such as Haiti (1) disaster or Wenchuan (2) earthquake. Thanks to the objective and reproducible information acquired during ultrasound imaging, one can improve the accuracy of disaster triage (3), and avoid both under- and overtriage of the victims!
- Shorter M, Macias DJ. Portable handheld ultrasound in austere environments: use in the Haiti disaster. Crit Care Med. 2007;35(5 Suppl):S275-9.
- Zhou J, Huang J, Wu H et al. Screening ultrasonography of 2,204 patients with blunt abdominal trauma in the Wenchuan earthquake. J Trauma Acute Care Surg. 2012;73:890-4.
- Wydo SM, Seamon MJ, Melanson SW et al. Portable ultrasound in disaster triage: a focused review.Eur J Trauma Emerg Surg. 2016;42:151-9.
If you have any questions, concerns or educational needs, don’t hesitate to get in touch with our team!
