QA of the Month: January 2013

Traumatic Abdominal Injury

Congratulations Dr. Yvonne Bailey and Dr. Colin Bucks!

Case

30 year old male helmeted motorcyclist presents after collision with passing car at 40mph. +LOC, now complains of b/l knee pain and abdominal pain 

BP 105/62 | Pulse 70 | Temp 36.7 °C (98.1 °F) (Tympanic) | Resp 18 | SpO2 97% 

Primary Survey was Negative. Secondary Survey reveals abrasion over Right Maxilla, Right lower chest wall tenderness, Abdomen soft and non-tender. 

FAST exam: Subxiphoid, LUQ and Pelvic views were negative, but RUQ showed:

If you carefully notice, although the Morison's pouch view is negative for free fluid, there is a small amount of free fluid around the very tip of the left liver edge, peri-colic gutter space. This was an AWESOME catch on Dr.Bailey's part, and is very easily missed. Another great reminder of why the left liver edge/peri-colic gutter region (where the inferior pole of the right kidney usually lies) is of paramount importance. It is where free fluid will develop FIRST in the RUQ. From there it will trickle down into Morrison's pouch, and the sub-diaphragm region. 

Case Disposition: Patient to CT - Grade 3 Liver Laceration, and was taken to the OR. 

RUQ FAST Review

When evaluating the RUQ for a FAST there are 3 areas that need to be carefully visualized, and fully evaluated by adjusting your depth and slowly fanning through each region. This requires evaluation through multiple rib spaces - more than one clip. Start by using the phased array, P21 probe, indicator toward patient's head, and place over lower ribs, mid-axillary line in the RUQ. Start high and continue evaluation of lower rib spaces to see the below: 

Above and Below the diaphragm

This is a view of the diaphragm and Liver interface. You should notice a bright white echogenic line of the diaphragm around the liver - above which is the pleural space, and below is the Liver. You should appreciate a "mirror image" artifact of the liver above the diaphragm when there is no thoracic fluid. Pleural effusions (and hemothorax) will appear black above the diaphragm (without a mirror image artifact) and the spine shadows will also be seen extending beyond the diaphragm as fluid allows its visualization. Look between the diaphragm and the liver for any intraperitoneal free fluid as (although rare) fluid may only be located here depending on the location of the laceration. 

Morrison's Pouch

This is the interface between the Liver and the Kidney, and will appear as a bright white distinct line. Free intraperitoneal fluid will often trickle into this area from above, and appear as a black area between the liver and kidney. Make sure you slowly and widely fan through this entire region well, to not miss fluid at any part. Certain types of artifact, especially edge artifact can confound your evaluation, but an easy trick to differentiate the two is that artifact will likely extend beyond the liver edge, unlike free fluid. 

Left Liver edge/Peri-colic gutter/Inferior Kidney Pole

This is the most important region, as demonstrated in the above case, and where free intraperitoneal fluid will develop first. To obtain this view, you will often need to move the probe to a lower rib space, adjust your depth, and then carefully fan the region to view around the entire inferior kidney pole and left liver edge. You may see just a small amount of black fluid in a positive study sitting right at the liver edge. 

Another great case, great job Drs. Bailey & Bucks!

- Viveta Lobo and Laleh Gharahbaghian