QA of the Month: September 2013

Syncope

Congratulations Dr. Yoshi Mitarai!

Case

77 year-old female with h/o HTN presenting with syncope, found by EMS on the floor of her home in a pool of dark stool. Seen by PCP 2 days prior for dark stool and decreased hematocrit (22% down from baseline of 38%). Patient on Prilosec, Celebrex, and iron sulfate. 

Vitals

HR 102 RR 18 BP 60/40 SpO2 98% RA T 98

Physical Exam

Physical exam was pertinent for mild diffuse abdominal tenderness and guaiac positive black stool. 

Bedside US was performed due to shock state and abdominal pain - and FAST exam in RUQ, suprapubic, and subxiphoid views were normal. However, the LUQ view showed the following:

That’s right, free fluid between the spleen and the diaphragm and travelling in the splenic –renal recess. This FAST scan caused Dr. Mitarai to order a CT A/P, showing a perforated duodenal bulb ulcer. In addition to resuscitation of the hypotensive GI bleeder (massive transfusion, IV PPI, central line, arterial line, endoscopy), patient also received prophylactic antibiotics and received a coil embolization of the gastroduodenal artery. Patient was discharged several days later in stable condition. NICE JOB YOSHI! 

Important tips to remember in the FAST LUQ view

  1. Free fluid in the LUQ most commonly first develops between the spleen and the diaphragm, NOT between the spleen and the kidney, as seen here with Dr. Mitarai’s patient (contrary to the RUQ, where fluid most commonly is first seen in the para-colic gutter and then Morison’s pouch).
  2. Several reasons make free fluid harder to visualize in the LUQ compared to the RUQ:
    • Spleen is smaller than the liver, so there is a smaller acoustic window to visualize the LUQ view
    • The stomach can also obstruct the LUQ view, especially if it is distended or full of air. We call that “stomach sabotage”. The anechoic contents inside the stomach can easily be mistaken for intra-thoracic free fluid. To differentiate between the two, look for the spine shadow: if it stops at the diaphragm, there is no intra-thoracic free fluid; if the shadow continues, then intra-thoracic free fluid is present.
  3. For completeness, don’t forget to scan above the diaphragm and to include both the superior and inferior pole of the L kidney
  4. To improve your view, try the following:
    • “Oblique” your probe to avoid the rib shadows and stomach (turn probe marker towards the bed instead of having it point up to patient’s head)
    • Start scanning at the posterior axillary line first, not the mid-axillary line as we typically do with the RUQ view. Remember, “knuckles on the gurney”!

Once again, nice work Dr. Mitarai! 

-Josh Ennis, Mansour Jammal, and Laleh Gharahbaghian