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En pacientes con trauma mayor, la ecografa es el estudio por imagen inicial. Es un mtodo fcilmente disponible y no requiere preparacin. Es efectiva en demostrar colecciones intraperitoneales, signo indirecto de lesin de rganos solidos que requieren de una inmediata ciruga. Sin embargo, el mtodo ecogrfico a veces tiene baja sensibilidad para demostrar lesiones de rganos solidos, por lo que es seguido de estudios de mayor complejidad (TAC).
DESVENTAJAS No evidencia sitio de sangrado No detecta fluido <250cc Limitado en lesiones intestinales Obesidad
ECO-FAST CONDUCTA:
FAST + PACIENTE INESTABLE CIRUGIA FAST + PACIENTE ESTABLE TAC
Causas extraabdominales
OBSERVACION
TRAUMATISMO HEPATICO
El traumatismo de hgado es el segundo rgano abdominal mas frecuentemente implicado, luego del bazo. Causa ms comn de muerte. 25% de lesiones hepticas pueden ser detectadas si se realiza TAC en forma inicial. Este mtodo es de eleccin en casos de traumatismo cerrado. En ecografa las lesiones van desde hipoecoicas hasta hiperecoicas.
GRADO
DESCRIPCION
Hematoma: subcapsular, <10% de superficie Laceracin: desgarro capsular, <1 cm de profundidad Hematoma: subcapsular, 10%-50% de superficie; intaparenquimatosa, <10 cm de dimetro Laceracin: 1-3 cm de profundidad; <10 cm de longitud Hematoma: subcapsular, >50% de superficie o expansin o ruptura de hematoma subcapsular con sangrado activo; intraparenquimatoso, >10 cm o expansin o ruptura Laceracin: >3 cm de profundidad Hematoma: ruptura de hematoma intraparenquimatoso con sangrado activo. Laceracin: disrupcin parenquimatosa que involucra el 25-75% de un lbulo heptico, Laceracin: disrupcin del parnquima que involucra ms del 75% de un lbulo heptico. Vascular: lesin venosa yuxta heptica Vascular: avulsin heptica.
I II
III
IV V VI
Flecha verde: rea hipodensa ovalada consistente con hematoma Flecha amarilla:. rea hipodensa en forma lineal consistente con laceracin que cruza la vena porta izquierda Flecha azul: rea hipodensa mal definida que corresponde a contusin. Lquido alrededor del hgado.
Grade I hepatic injury. Contrast-enhanced CT scan shows a focal capsular tear in the posterior right hepatic lobe (arrow). An associated small perihepatic hemorrhage is also seen (arrowheads).
Grade II hepatic injury. (14) Contrast-enhanced CT scan demonstrates a hepatic laceration less than 3 cm in depth in the posterior right hepatic lobe (arrow). Note also the small fluid collection in the hepatorenal fossa (arrowheads). (15) Contrast-enhanced CT scan shows a lentiform, low-attenuation fluid collection (arrows) between the liver capsule (arrowheads) and enhancing liver parenchyma, a finding that suggests subcapsular hematoma. Note also the rib fracture.
Grade III hepatic injury. (16) Contrast-enhanced CT scan shows a subcapsular hematoma in the right hepatic lobe (arrows). Note the high-attenuation foci within the hematoma (arrowhead), findings that indicate active contrast material extravasation. (17) Contrast-enhanced CT scan shows hepatic lacerations greater than 3 cm in parenchymal depth, with a focus of active hemorrhage (arrowhead).
Grade IV hepatic injury. (18) Contrast-enhanced CT scan shows a ruptured intraparenchymal hematoma with active bleeding in the right hepatic lobe. Note also the associated large hemoperitoneum. (19) Contrastenhanced CT scan shows multiple hepatic lacerations in the right hepatic lobe, resulting in parenchymal disruption of about 50% of the lobe.
Grade V hepatic injury. (20) Contrast-enhanced CT scan shows a large intraparenchymal hematoma and lacerations that involve the entire right hepatic lobe and the medial segment of the left hepatic lobe. (21) Contrast-enhanced CT scan shows a deep hepatic laceration that extends into the major hepatic veins. Note the discontinuity of the left hepatic vein (arrowhead), a finding that indicates laceration. This finding was confirmed at surgery.
Avulsin heptica
Images from a 24-year-old woman who was struck by a car while riding a bicycle. (a) Transverse US view of the subxiphoid region, obtained at an initial FAST examination, shows an area of slight hyperechogenicity in the left lobe of the liver (arrow), a finding suggestive of a laceration. A small collection of free fluid also was visible in the pouch of Douglas. GB gallbladder, RLL right lobe of liver. (b) Abdominal CT image shows an area of decreased attenuation (arrow) in the liver, a finding that helped confirm the diagnosis of liver laceration.
Bare area hepatic injury. Contrast-enhanced CT scan shows multiple lacerations (arrowheads) and a parenchymal hematoma that extend into the bare area of the liver, resulting in retroperitoneal hematoma. Note the hemorrhagic fluid surrounding the IVC and the associated hematoma in the right adrenal gland (arrow).
TRAUMATISMO ESPLENICO
En el traumatismo abdominal cerrado, el bazo es el rgano ms frecuentemente lesionado. Los hallazgos tpicos son el hematoma subcapsular y la laceracin. No hay evidencias de que la ecografa como nico mtodo sea suficiente para estadificar el grado de lesin y planear un tratamiento. Sospecha clnica: dolor en HI y flanco izquierdo. A veces asintomtico hasta la ruptura de la cpsula: hemoperitoneo.
GRADO
DESCRIPCION
Hematoma: subcapsular, <10% de la superficie del rgano. Laceracin: <1 cm de profundidad Hematoma: subcapsular, 50% de la superficie; intraparenquimatosa <5 cm Laceracin: 1-3 cm de profundidad Hematoma: subcapsular >50% de superficie; ruptura capsular; parenquimatoso de 5 cm o ms Laceracin: 3-10 cm de profundidad Laceracin: compromiso segmentario vascular produciendo desvascularizacin >25%
I II
III
IV V
Contusiones
Extravasacin de contraste
TRAUMATISMO RENAL
GRADO I:
c) Laceracin
d) Laceracin
GRADO V:
g) Estallido renal h) Avulsin ureteropilica i) Avulsin de arteria renal j) Trombosis de arteria renal
GRADO I
GRADO II
GRADO III
GRADO IV
GRADO V
BIBLIOGRAFIA
Markus Korner, MD; et. al ; Current Role of Emergency US in Patients with Major Trauma; RadioGraphics 2008; 28:225244.
Woong Yoon, MD; et. al.; CT in Blunt Liver Trauma; RadioGraphics 2005; 25:87104.
Raquel Cano Alonso, MD; et. al.; Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma; RadioGraphics 2009; 29:20332053. Radiology assistant; Stephen Ledbetter and Robin Smithuis; Acute Abdomen - Role of CT in Trauma;