Test Yourself

Case 1

HISTORY

Blunt abdominal trauma, left upper quadrant pain, sustained a knee in his left upper quadrant playing Aussie Rules Football.

Presented mildly tachycardic, had one brief episode of hypotension but this settled en route to hospital.

An EFAST scan is requested.

ULTRASOUND FINDINGS

This is a positive FAST scan.

Free fluid is demonstrated in the RUQ, in the paracolic gutter (not a routine view of the FAST examination) and in the pelvis.

The left upper quadrant view shows the spleen is no longer homogenously echogenic, but is heterogenous (with dark bits and bright bits) and poorly defined. This is characteristic of acute blood clot and confirms splenic rupture.

DISCUSSION

The aim of the FAST scan is to determine (or exclude) the presence of free intra abdominal fluid. Sometimes however it can tell more.

The RUQ view clearly demonstrates free fluid in Morrisons pouch and around the inferior tip of the liver.

The LUQ view demonstrates a very heterogenous spleen and this is the characteristic appearance fo splenic rupture with bloot clot formation.

The paracolic gutter view shows free fluid around a loop of bowel. remember free fluid "has corners" - it outlines abdominal structures.

The bladder view shows a little free fluid just cranial to the bladder (although this could be fluid within bowel - it is hard to tell on a single still image!

IMPROVING THE IMAGES

These images achieve the purpose - they show free fluid - but they could be improved.

RUQ view - depth should be increased so the back of the kidney and the full extent of Morison's pouch seen. The posterior costophranic recess above the diaphragm can also be imaged in this view if depth is increased  to assess for haemothorax.

LUQ View - again depth should be increased. In the second view a rib shadow is thrown over the area of interest, angling the probe so its long axis lies between the ribs stops this.

Pelvic view - depth should be increased and gain reduced. Free fluid generally gathers behind and superiorly to the bladder. One needs to image the posterior part of the bladder to adequately visualise free fluid particularly if it is to be excluded.

Other views - a subcostal view of the heart and views of the lungs to assess for pneumothorax and haemothorax would compelte the study. If a patient is particularly painful over a specific area of rib a fracture will be evident as a step in the cortex.

SUBMITTED BY:

James Rippey