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.

Case 11. 18 yr old obese male found down on street, diaphoretic, no evidence of external trauma, nonsense words upon attempting to answer questions. abdomen soft. Unable to examine tenderness with mental status. HR 124 RR20 BP 90/62 O2 sat 91%RA

Part missing: above diaphragm, paracolic gutter

Improve image: increasing width of fanning (but that is a mute point since we see the fluid already)

Interpretation: intraperitoneal free fluid seen around liver and the superior and inferior pole of kidney.

Actual dx: right rib fracture with moderate sized right hemothorax (not seen above as did not evaluate that region), liver laceration, bowel contusion, renal contusion

Case 12. 68 yr old (on Coumadin) restrained front seat passenger in motor vehicle collision (rear-ended) at 30mph c/o abdominal pain. abdomen soft and mild tenderness in lower abdomen. HR 72 RR16 BP 152/92 O2 sat 99%RA

Part missing: paracolic gutter

Improve image: increasing width of fanning and stay in intercostal space to avoid rib shadow coming into your view

Interpretation: no intrathoracic fluid as has mirror image above diaphragm; no intraperitoneal free fluid seen around liver and the superior pole of kidney. Paracolic gutter (where free fluid develops first in the RUQ is not visualized)

Actual dx: no intra-thoracic or intra-abdominal injury; large contusion of abdominal wall

Case 13. 24 yr old assault victim beaten by fists and baton in abdomen c/o abdominal pain. abdomen soft, but tender in epigastric region without distension. HR 118 RR20 BP 100/78 O2 sat 99%RA

Part missing: paracolic gutter, full evaluation of region

Improve image: avoid sliding up and down rib spaces while you are fanning. Stay in one rib space and slowly fan anterior to posterior to look for free fluid (anechoic – black – stripe); increasing width of fanning to completely evaluate the region

Interpretation: no intrathoracic fluid as has mirror image above diaphragm; no intraperitoneal free fluid seen around liver and the superior pole of kidney but incompletely evaluated. Paracolic gutter (where free fluid develops first in the RUQ is not visualized)

Actual dx: Grd3 splenic laceration (FAST was positive in the paracolic gutter view and with complete fanning of the above section)

Case 14. 67 yr old with history alcohol abuse c/o abdominal pain and confusion. abdomen without distension and tender diffusely. HR 80 RR16 BP 92/60 O2 sat 98%RA

Part missing: paracolic gutter

Improve image: great fanning through region for this section of the RUQ

Interpretation:  intraperitoneal free fluid seen around liver and the superior pole of kidney  Paracolic gutter (where free fluid develops first in the RUQ is not visualized) is seen in the corner of the screen with more free fluid than any other space

Actual dx: new onset ascites with bacterial peritonitis and hepatic encepahlopathy. As you can see, ascites is also anechoic (black) and will look just like new (nonclotted) blood. This will make it difficult to differentiate the two if this patient came in as a trauma patient.

Case 15. 60 yr old hit by car at low speed c/o left side and left hip pain with shortened and rotated left leg. Abdomen is nontender and soft. HR 94 RR22 BP 110/70 O2 sat 95%RA

Part missing: above diaphragm, paracolic gutter

Improve image: great fanning through region for this section of the RUQ

Interpretation:  intraperitoneal free fluid seen around liver and the superior and inferior pole of kidney. Paracolic gutter (where free fluid develops first in the RUQ) is seen in the corner of the screen with more free fluid than any other space. You can see that with fanning the space for free fluid between the liver and kidney changes and can be quite small in certain sections (and can be missed), whereas the left liver edge and paracolic gutter has more space and more free fluid and will not be missed.

Actual dx: left rib fractures, grd2 splenic laceration, left femoral neck fracture (a distracting injury can limit your abdominal exam! – and this patient also was on a beta blocker with h/o HTN so those “normal” vitals actually weren’t normal for him)

Case 16. 45 yr old fall from 3rd story balcony onto grass c/o back pain and right side pain.  abdomen tender to palpation in upper quadrants, HR 98 RR20 BP 100/72 O2 sat 99%RA

Part missing: paracolic gutter; full region of this section not evaluated – just one slice

Improve image: needs to slowly fan through the entire region as just one slice of this section of the RUQ is not enough, nor is it complete.

Interpretation:  no intrathoracic free fluid seen as has great mirror image artifact above diaphragm although no fanning occurred to truly evaluate the space. The image above has no evidence of free intraperitoneal fluid but there is no fanning and the paracolic gutter (where free fluid can develop first in the RUQ) is not visualized.

Actual dx: grade 2 liver laceration, splenic laceration, renal contusion, multiple posterior rib fractures, vertebral fracture (there was tons of free fluid on the CT scan and when the patient came back, the FAST was repeated and still showed the above image, but with fanning the large amount of free fluid was visualized – dont forget to FAN!)

Case 17. 68 yr old c/o gradual shortness of breath, chest pain. HR 82 RR24 BP 90/60 O2 sat 90%RA

Part missing: around inferior pole of kidney, paracolic gutter; complete evaluation of above section of RUQ

Improve image: decrease depth to have the area of interest centered on the screen, slowly fan through the region of interest.

Interpretation:  intrathoracic free fluid seen above diaphragm as an anechoic region without the mirror imaging confirmed by the spine shadows travelling past the diaphragm. Intraperitoneal space poorly evaluated and cannot make interpretation.

Actual dx: fluid overload from CHF – pleural effusion, mild ascites (not seen on above image due to poor fanning)

Case 18. 24 yr old bicycle accident flying over handlebars and into ditch. c/o chest pain and difficulty breathing. abdomen soft and nontender. chest rib cage with tenderness right side HR 116 RR 24 BP 100/72 O2 sat 94%RA

Part missing: around inferior pole of kidney, paracolic gutter

Improve image: great fanning through region for this section of the RUQ and although depth could have been decreased (to 16cm instead of 19cm) you can still see the pathology

Interpretation:  no intrathoracic fluid. positive intraperitoneal free fluid seen as a sliver of anechoic fluid above diaphragm between it and liver. Paracolic gutter (where free fluid can develop first in the RUQ) is not visualized. You can see that with fanning the free fluid changes and can be quite small or absent in certain sections (and can be missed).

Actual dx: multiple rib fractures, liver laceration, pulmonary contusion (the paracolic gutter section was evaluated as well and showed 1cm of free fluid in that area! – dont forget to evaluate that region!)

Case 19. 24 yr old female with lower abdominal pain and positive pregnancy test, no vaginal bleeding. abdomen soft and mildly tender in suprapubic area. HR 90 RR 18 BP 92/64 O2 sat 100%RA

Part missing: paracolic gutter

Improve image: great slow fanning through region for this section of the RUQ; if the area of interest around the diaphragm, then the depth is perfect; if the area od interest is around the kidney, then the depth could be adjusted to be more shallow.

Interpretation:  positive intraperitoneal free fluid around liver and superior pole of kidney

Actual dx: ruptured ectopic pregnancy

Case 20. 80 yr old fall from standing onto rail on left side of body. c/o left side pain. tender abdomen in left upper quadrant. HR 72 RR20 BP 116/80 O2 sat 99%RA

Part missing: above diaphragm, paracolic gutter

Improve image: great slow fanning through region for this section of the RUQ;

Interpretation:  positive intraperitoneal free fluid around liver and superior pole of kidney (only found with complete fanning through this region as when the classic morrison’s pouch view is seen, there is no free fluid visualized)

Actual dx: rib fractures, splenic laceration