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:

SonoTutorial: The FAST Part 2: Left Upper Quadrant – being right with the left…

No, this isnt a talk about partisan politics (thankfully!), but something that is even more important that you should know and learn well, that could not only change everyone’s life [like politics thinks it does] (by way of how they manage their patients) but also saves a life (by how quickly you help your diagnoses be made). That’s right fellow blogosphere friends. Listen up!

Our SonoTutorial on The FAST: Right Upper Quadrant (RUQ) week was just the beginning of this review on the FAST scan- the most common application done at the bedside at many institutions, and for good reason. It’s used (as a screening study for intraperitoneal free fluid) for any blunt or penetrating chest/abdomen/back trauma as well as the unexplained hypotensive patient (the RUSH exam). The RUQ is the best area to evaluate for free intraperitoneal fluid of all the FAST views, but don’t think you can just do that view and stop there! It is not 100%, and there are enough times for me to see free fluid in the left upper quadrant (LUQ) that was difficult to see in the RUQ that makes it evident that completing the FAST scan is key! The LUQ is, essentially, the not-so-ugly sister to the RUQ.

SonoTutorial: The FAST Part 1b: The Right 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 right 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 right upper quadrant view:  read the clinical correlate, see the image, and think about what section of the right upper quadrant view is missing (above the diaphragm, below the diaphragm, between the liver and superior pole of kidney, between the left heptaic edge and inferior pole of kidney at 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  it’s indications and…. Don’t forget the FAST limitations.

SonoTutorial: The FAST Part 1a: The Right Upper Quadrant: Images That Could Fool You

Now the fun starts! The images and clips below will be a great test to see how much of the information from the prior post on how to perform a complete right upper quadrant view of the FAST scan you recall, while keeping it’s limitations in mind. Remember, to be complete and thorough, you must evaluate above the diaphragm, below the diaphragm, around the liver and superior pole of the kidney, and around the left liver edge and inferior pole of the kidney (along the right paracolic gutter) through slow and deliberate full fanning between multiple rib spaces, and adjusting your depth as needed.

SonoTutorial: The FAST Part 1: The right upper quadrant – the right way to do it

The FAST scan (focused assessment with sonography for trauma) is probably the most frequent application of bedside ultrasound with a moderate sensitivity and very high specificity. It is done as part of our trauma evaluation for blunt or penetrating chest/abdomen/back/pelvic trauma as well as in the evaluation of the unexplained hypotensive patient as part of the RUSH protocol and the patient with a possible ruptured ectopic pregnancy.

SonoApp & Study: Cellulitis vs Abscess; US more sensitive than CT for soft tissue abscess

A patient comes into your emergency department or outpatient clinic that has a painful red area on their skin:

 -from Medicineo blog

…and you wonder whether its a superficial cellulitis, or if it’s a pus-filled abscess – and if it is an abscess, then how deep is it? how long is it? how loculated is it?

SonoApp/News: “The window to the soul!” Intracranial Pressure by Ocular Ultrasound

One day, years ago, I went to my ophthalmologist who looked in my eye through their ‘whatchamacallit’-scope and then sat back in his chair and asked me (with a straight face): “Are you having any diarrhea?” Of course, this immediately confused me as I wondered whether my years of medical training lacked the concept that my eye could assess diarrhea. I answered with a chuckling, “no” and he concluded with, “ok, then Im sure it’s fine.” I decided to just forget that odd encounter until I started to perform ocular ultrasounds several years ago, excited about how I now dont have to rely on my horrible fundoscopic technique as it gives tons of information not only about the eye, but also the brain!

SonoInterview by Medscape: A Radiologist’s perspective of Appendix US…replacing CT? Yes!

This comes in great timing as a prior SonoSpot post describing recent studies evaluating CT findings in appendicitis rule-outs show that the majority ( 80-90% ) are negative…. US, clinical judgement, and a possible observation period can go a long way in radiation reduction.

Expert Interview: Stephanie Wilson, MD, on the Value of Ultrasonography for Imaging Appendicitis

SonoReview: US-guided Interscalene nerve blocks

Hope you had a Happy 4th! To all those who received patients with an upper extremity that has been burned, fractured, or blown away from all the “legal” fireworks foreplay……

Pain control. Two words. Patient satisfaction. Two more words. Physician satisfaction. Two MORE words. Nerve blocks are the new procedural sedation for many painful procedures we do in the ED. Takes much less resources and time, and provides immediate pain control for however long your anesthetic will work without concern for respiratory distress, hypotension, hypoxia, and… well… death. So why dont we do it more? Well, in a prior post, we have discussed the ins & outs for performing US guided nerve blocks with the help of some of my colleagues, some of whom are mentioned below.

SonoApp: Lung Ultrasound… Be fine with B lines!

So you get a patient with shortness of breath, and you have no idea what the reason is…. but they can’t lie flat and the Xray tech is busy with the trauma. Lung US can help you – but that’s weird, right? Air is supposed to be the enemy of ultrasound with gas scatter artifact making what you want to see very hard. Well, believe it or not, with the lung, ultrasound will turn into your go-to tool for quick evaluation. There has been a study that has described a methodical approach to this, the RADIUS study, and one of the key elements of this is evaluating artifact. Yup, that’s right, ARTIFACT….