Dx: Liver Lac, But a Normal Spleen
(click on images to enlarge)
You applaud your resident for obtaining excellent RUQ views and for detecting free fluid on his eFAST. You agree that the anechoic irregularly shaped stripe within the liver parenchyma appears abnormal. To ensure that you aren’t simply looking at an enlarged vascular structure, you apply color Doppler over the stripe and the surrounding vessels. Sure enough, there is no flow through that anechoic stripe, and the surrounding veins demonstrate normal, rumbling flow. You suspect your patient does indeed have a liver laceration.
Turning your attention to the LUQ views, you see that your resident has made a common diagnostic error. The irregularly shaped anechoic area seen in the left upper quadrant view is actually the air and fluid filled stomach overlying the spleen. It’s irregular border and anechoic center can often fool physicians into thinking that they’ve seen signs of splenic parenchmal injury.
You gently logroll the patient onto his right side and obtain another view of the splenorenal space, without the stomach in the way. You fan through the entire spleen and don’t see any obvious parenchymal injury, and there is no free fluid in the left upper quadrant. The surgical Chief Resident came down to the ED to check on the other trauma patients just as you were reviewing the ultrasound images on Bed 4. He agrees with your call and decides to take the patient directly up to the OR, thereby freeing up the CT scanner for the other 3 trauma patients. He gives kudos to you and your resident for a great pickup on ultrasound, and you can’t help but smile with pride as your see your resident run off to share with his colleagues his “cool ultrasound case.” You peel off your sweaty surgical gown, lead gown, gloves, booties and facemask, and breathe a sigh of relief for such a smooth set of traumas.
Normal Splenorenal View
Continue to next page for Pearl and Pitfalls for the eFAST exam