SonoTutorial: The FAST Part 2a: Left Upper Quadrant – Images that could fool you…

Get ready for some cases!!! The images and clips below will be a great review to see how much of the information from the prior post on how to perform a complete left upper quadrant view of the FAST scan you recall, while keeping FAST limitations in mind. Remember, in order to be complete and thorough you must evaluate above the diaphragm, below the diaphragm, around the spleen and superior pole of the kidney, and around the spleen and inferior pole of the kidney, and along the left paracolic gutter –  through slow, deliberate, and full fanning between multiple rib spaces, and adjusting your depth as needed.

The images will appear with a clinical correlation first which may give you a certain level of suspicion. Think about what part of the LUQ scan is missing (as there is very few times when you can get all of the above areas in just one clip or in just one rib space), how would you improve the evaluation (changing position of probe, fan more widely or slowly, depth or gain (brightness) adjustment, etc), and what your interpretation of that image would be (positive or negative for free fluid – or is the image just too technically limited to make a statement on it?)- all while thinking of your level of suspicion of injury given the clinical correlate.

These are all real cases:

Case 1: 36 yr old male c/o falling down 12 steps, found unconscious and now awake c/o severe headache with extensive scalp laceration, left side pain over rib cage. Tenderness over lower posterior rib cage, abdomen nontender. HR 124 RR 18  BP 110/78  O2 sat 96%RA

Part missing: around inferior pole of kidney and left paracolic gutter

Improve image: slow down the fanning, only evaluate one rib space at a time (stop, stay and slowly fan when at a rib space) then slide down a rib space to complete the evaluation

Interpretation: trace free fluid around superior pole of kidney – are you surprised? Take another look, it’s there, but it was actually missed upon initial read. no intrathoracic free fluid as has mirror image artifact – but not adequately evaluated with fanning.

Actual diagnosis: multiple rib fractures, left Grade 3 splenic laceration. Large scalp laceration without intracranial findings. The RUQ view of this full study was positive.

Case 2: 86 yr old female c/o seatbelted passenger in high speed MVC c/o back pain, abdomen with SB sign and soft mildly tender suprapubic. HR 80 RR16 BP 116/80 O2 sat 99%RA

Part missing: around inferior pole of kidney and left paracolic gutter

Improve image: needs to increase and widen the fanning as a true evaluation of the region is not being evaluated. The stomach is also in the way but they adequately adjust their probe to oblique the view (indicator to gurney to get in plane wit the ribs) to get the stomach out of view, but needs more fanning and less sliding.

Interpretation: no evidence of free fluid on this image, but the scan is limited.

Actual diagnosis: bladder rupture, bowel perforation causing moderate free fluid in pelvis. Repeat FAST scan after results known and with good slow and dedicated within the rib space fanning – positive in LUQ/RUQ/suprapubic.

Case 3: 55 yr old male c/o assault by bats and metal bars to chest, abdomen and back c/o pain in all places and tender to light palpation diffusely, multiple contusions. HR 78  RR 20  BP 146/90 O2 sat 99%RA

Part missing: around inferior pole of kidney and left paracolic gutter

Improve image: need to adjust probe position: either get into midaxillary line and angle posteriorly to get away form the anterior stomach or oblique the probe rotating it so the indicator is toward the gurney, then fan more completely.

Interpretation:no intrathoracic free fluid, no intraperitoneal free fluid but unable to visualize the region due to stomach sabotage

Actual diagnosis: no intrathoracic or intra-abdominal injuries. CT scan done, although a discussion was done prior to that to instead perform serial exams and serial FAST scans, given stable vitals.

Case 4: 6 yr old fall from second story building onto concrete c/o left sided pain, tender in left lateral rib cage and mild tenderness in abdomen. HR 100 RR 26 BP 100/62 O2 sat 92%RA

Part missing: around inferior pole of kidney and paracolic gutter

Improve image: the depth is adjusted given the small size of the patient, increased width of slow fanning.

Interpretation: obvious splenic laceration (seen as the spleen seeming to be cut in half) and free fluid, positive intrathoracic free fluid

Actual diagnosis: multiple rib fractures, hemothorax, pulmonary contusion, splenic laceration

Case 5: 45 yr old homeless man found down on side of street, poorly responsive, smells of alcohol, and appears intoxicated, moans with exam and therefore limited, no external signs of trauma, HR 110 RR 18 BP 90/62 O2 sat 95%RA

Part missing: around inferior pole of kidney and paracolic gutter

Improve image: this is the perfect depth to visualize above and below diaphragm as you can see the spine sign (spine shadow traversing past the diaphragm into thoracic space on screen, indicating intrathoracic free fluid). no visualization of kidney so will need to lower a rib space, but since you see the fluid, who cares!

Interpretation: intraperitoneal and intrathoracic free fluid

Actual diagnosis:high grade liver laceration, bowel perforation, IVC injury, hemothorax, rib fractures – thought to be probable hit and run victim.

Case 6: 88 yr old c/o shortness of breath, chest pain and abdominal pain, gradual onset over 2 weeks. lungs with rales, abd nontender and soft, mild bilateral lower extremity peripheral edema: HR 80 RR 22 BP 82/60 O2 sat 94%RA 

Part missing: around superior and inferior pole of kidney, left paracolic gutter

Improve image: slow fanning needs to happen, but I think the sonographer was really diggin’ the dipahragm movement.

Interpretation: intrathoracic fluid, intraperitoneal fluid seen above and below the diaphragm.

Actual diagnosis: the is part of a RUSH exam and the patient ended up having a subacute MI with severe CHF

Case 7: 62 yr old unresponsive, lungs clear, abdomen soft nondistended. HR 82 RR 14 BP 80/58 O2 sat 96%RA

Part missing: around inferior pole and left paracolic gutter

Improve image: decrease the depth, increase width of fanning as the true region in this rib space is not evaluated. Stomach is successfully avoided using the posterior angling of the probe.

Interpretation: kidney cyst, mirror image past diaphragm and the spine shadow stops at diaphragm and therefore no intrathoracic fluid. no intraperitoneal fluid seen but poor study due to no fanning and will need to complete the study around the inferior pole.

Actual diagnosis: AAA rupture

Case 8: 70 yr old c/o chest pain radiating to left shoulder x 2 days. h/o HTN. lungs clear to auscultation (of course!) and heart with regular rate and mild systolic murmur. abdomen is soft and nontender. HR 100 RR 18 BP 80/58 O2 sat 96%RA

Part missing: around inferior pole of kidney  and left paracolic gutter (yup, again!)

Improve image: decrease depth, increased slow and widely fanning

Interpretation: was negative by the sonographer, but upon closer review, there is a left sided effusion – which is significant in the case ( a RUSH exam) Why? – see below

Actual diagnosis: descending thoracic aortic dissection – which will leak into the left thoracic cavity and can result in left sided effusion. This should always be thought about if an ultrasound is done for chest pain and a previously normal thoracic cavity is now abnormal.

Tune in for the next post that will show more images with clinical cases, and we may even explore around the inferior pole… 🙂 As you can see with the above clinical correlates, the FAST scan is used in trauma, in unexplained shock, or abdominal pain of unknown etiology – do it, and do it right!