SonoTutorial: The FAST Part 2b: Left Upper Quadrant – More images that could fool you…

Get ready for some more real cases and, just like the prior post, with images of various sections of the left upper quadrant (as you cannot really have all sections in only one 6 second clip). Just like before, think of what is needed to complete the left upper quadrant view:  read the clinical correlate, see the image, and think about what section of the left upper quadrant view is missing (above the diaphragm, below the diaphragm, between the spleen and superior pole of kidney, between the spleen and inferior pole of kidney, or the paracolic gutter), how the image could be improved, and what the interpretation would be. All are stated below the image as well as the actual diagnosis of that particular patient. And, in case any of the below cases stump you as to why the FAST is negative or why it was done in the first place, recall its indications and…. Don’t forget the FAST limitations.

Case 9. 24 yr old high speed MVC, restrained driver, c/o chest pain and severe lower back pain, chest tender in left upper chest anterior wall, abdomen nontender and soft, low back tender to palpation L1-4 midline. HR 104  RR 18  BP 100/78  O2 sat 99%RA

Part missing: well, lets see – I would say we are missing all of it! There is no evaluation of any specific region, just sliding back and forth with a huge stomach in the view

Improve image: Stop, Stay and Slowly fan at each rib space. Do not slide and fan at the same time. Get the stomach out of view by angling the probe posteriorly or do an oblique view by rotating your probe so that the indicator is toward the gurney, in plane with the ribs.

Interpretation: unable to assess but no obvious fluid seen

Actual diagnosis: grade 2 liver laceration, splenic rupture, kidney contusion, left 2nd rib fracture, L1 spinous process fracture, L2-3 vertebral body fractures, no hemothorax. (So that means it’s a missed FAST – entirely due to technique – the RUQ view was done the same way without fanning and without inferior pole and paracolic gutter views, and thus seemed negative…..but wasnt on repeat by attending physician)

Case 10. 65 yr old female, history COPD and lung cancer, not on home O2, with altered mental status, fatigue, and gradual increased work of breathing over 2 days. HR 100    RR 20    BP 88/66    O2 sat 94%RA

Part missing: inferior pole and left paracolic gutter

Improve image: in order to get a better view above the diaphragm, an increase in depth can be done, but the very bottom of the screen shows the spine traversing above the diaphragm, indicative of effusion in the thoracic cavity. The stomach gets in view when the sonographer angles the probe anteriorly to fan through the region, and putting the probe in oblique view may help.

Interpretation: left pleural effusion; unable to assess for intraperitoneal fluid

Actual dx:  bilateral pleural effusions with pericardial effusion, thought to be due to lung cancer – done as part of RUSH

Case 11. 55 yr old male motorcycle accident, found unconscious with deformity to left femur and swelling and large cephalohematoma. Abdomen soft and nondistended, lungs clear bilaterally without chest wall crepitance. HR 112   RR 16   BP 140/92 O2 sat  97%RA

Part missing: Above the diaphragm (which I’d like to know), inferior pole and left gutter (but who cares after seeing the image above)

Improve image: this is a great view with adequate depth of the splenorenal space and subdipahragmatic area (note how the fluid is seen below the diaphragm but not that much in the splenorenal space – this is key and a common finding of where free fluid pools in the LUQ first)

Interpretation: intraperitoneal free fluid (…and with a soft/nondistended abdomen too); unable to assess intrathoracic cavity with this image alone.

Actual dx: skull fracture, Subdural hematoma, subarachnoid hematoma, grade 2 liver laceration, high grade splenic laceration, multiple left sided posterior rib fractures, femur fracture –

Case 12. 34 yr old male fall from 2nd story onto feet and back c/o severe mid back pain, with distal motor function intact but unable to range at hip due to back pain. abdomen soft/nontender/nondistended. lungs clear bilaterally. HR 124  RR 22   BP 168/98   O2 sat 95%RA

Part missing: below diaphragm, inferior pole and left paracolic gutter

Improve image: the stomach is in the view here – oblique the probe (indicator toward gurney and angle posteriorly) and fan more thoroughly

Interpretation: was negative – but was it?….

Other things to know about the image: there is a small sliver of intraperitoneal free fluid between the spleen and superior pole of the kidney – look at it again and you’ll see it now that you know (if you saw it from the beginning – right on!)

Actual dx: left posterior lower rib fracture, splenic laceration, renal contusion, lumbar fractures

Case 13. 25 yr old female with abdominal pain, suprapubic, mild. abdomen tender in suprapubic and right lower quadrant. no dysuria/hematuria. Got 2 L normal saline bolus for filling bladder awaiting pelvic ultrasound. HR 90  RR 18  BP 98/60   O2 sat 99%RA

Part missing: above and below diaphragm, splenorenal space

Improve image: decrease gain as it is a bit too bright

Interpretation: positive for free fluid at inferior pole and splenic edge – trustme its there, look again.

Actual dx: ruptured ectopic pregnancy

Case 14. 60 yr old male found on carpeted floor in home, altered. abdomen slight tender to palpation. HR 120  RR 20  BP 82/58  O2 sat 99%RA

Part missing: inferior pole of kidney and left paracolic gutter

Improve image: stomach is in view – rotate probe toward gurney to be in plane with ribs and then slowly fan in order explore area without stomach in view

Interpretation: negative for intraperitoneal free fluid

Actual dx: ruptured abdominal aortic aneurysm

Case 15. 55 yr old female restrained driver, high speed MVC c/o moderate chest pain and mild abdominal pain. abdomen slight tender to palpation in epigastrium. HR 110  RR 26  BP 100/76   O2 sat 92%RA

Part missing: inferior pole and paracolic gutter; poor visualization above diaphragm due to stomach

Improve image: oblique the probe as described above. fan more slowly

Interpretation: negative for intraperitoneal fluid

Other things to know about the image: even though it looks like there is a black area above the diaphragm suggestive of pleural effusion, you can see the spine shadow does not continue past the diaphragm. This occurs when the stomach gets in the view and quite commonly has a false positive finding in LUQ

Actual dx: multiple rib fractures, pneumothorax. no abdominal injury

Case 16. 28 yr old male, intoxicated, found down and poorly responsive, smells of alcohol. lungs clear to asucultation, abdomen soft and nondistended (unable to assess tenderness). HR 90  RR 16   BP 110/82   O2 sat 99%RA

Part missing: inferior pole of kidney and paracolic gutter. poor fanning in region (cannot visualize kidney)

Improve image: decrease depth, and slowly fan through region

Interpretation: positive for free fluid between spleen and where superior pole of kidney would be (its a tiny sliver and if you fan too quickly, you’d miss it!)

Actual dx: splenic laceration