QA of the Month: May 2013

Blunt Flank Trauma

Congratulations Dr. Ayesha Khan!

Case

18 year old Lacrosse player presents to the Fast Track area with left shoulder and left side pain after being hit with the lacrosse ball in his left flank area. 

Vitals

HR 94 RR 20 BP 137/67 SpO2 99% RA T 36.8

Physical Exam

Soft abdomen, LUQ tenderness, L Flank circular contusion with tenderness. Otherwise unremarkable. 

Even though the patient was well appearing, young and healthy, Dr. Khan’s astute clinical skills did not lead her astray. She had the patient move to a bed, and laid him down supine for a few minutes. She brought the Ultrasound machine to Fast Track and proceeded to do a FAST exam: 

Dr.Khan, immediately recognized fee fluid in his abdomen, and transferred the patient to the main ED. The patient was activated as a trauma, and was immediately evaluated and had a repeat FAST in the main ED that confirmed the prior FAST: Note that free fluid is only at the lower liver edge in the RUQ view (not seen in Morison’s pouch) and between the spleen and diaphragm in the LUQ view as well as a large amount of fluid in the suprapubic view: 

At this time, patient’s abdomen now more rigid and tender. CT showed a Grade 4 Splenic laceration with pseudo aneurysms and active extravasation. This patient’s care was clearly expedited and diagnosed using the Ultrasound. 

Pearls

1. Patient must be supine to visualize free fluid in the best dependent areas (RUQ). 
2. The images show us free fluid in the RUQ inferior liver edge (paracolic gutter region), where free fluid develops first. Also, the LUQ free fluid is first seen between the diaphragm and the spleen. 
3. This case teaches us that we must always have a high suspicion for solid organ injury in any blunt trauma of the torso, and use bedside ultrasound to screen for injuries that cause free fluid and efficiently provide the best care. 
4. It is important to visualize the entire region of the RUQ and LUQ – (1) above and below the diaphragm, (2) around the entire kidney, (3) and at the lower edge of the liver and spleen – this requires multiple rib spaces and wide dedicated fanning in each rib space to detect fluid. 

Case follow up – Patient discharged from hospital 3 days later in stable condition. 

- Viveta Lobo and Laleh Gharahbaghian