You hear Michael Buffer’s voice blaring on the TV in the patient’s room, “Let’s get ready to rumble!” You are thinking how apropos as your charge nurse comes up to you.
“We have 6 traumas coming our way, Doc. ETA is 15 minutes. We’ve mobilized backup. The ultrasound machines are in the rooms, and the residents are gowned and ready to roll. Is there anything else you need help preparing?” You give your favorite charge nurse a thankful smile and start preparing yourself for the organized chaos that is about to ensue.
Thirty minutes and 6 secondary surveys later, you can’t help but marvel at the coordinated efforts of your EM and Trauma teams. The two most critical patients’ from the MVC have been taken up to the OR already, and your crew is carefully resuscitating and reassessing those waiting for CT scans. As your residents are performing their eFAST exams, one comes up to you to verify some of their findings.
“Bed 4 was the front seat passenger in the 2nd car. He is currently hemodynamically stable, and his lung images look fine. But, there is free fluid in his abdomen. He has no other reason to have free fluid other than trauma. I also think I see a liver laceration and a splenic laceration. I know we aren’t supposed to use bedside ultrasound to diagnose solid organ injury, but can you tell me what you think?” Your superstar resident can scan with the best of them, so you’re certain you’re about to see some interesting images saved to the machine.
You begin reviewing the images he has saved.
Left Upper Quad
Based on these images, do you agree that the patient has free fluid in their abdomen? Does the patient have a liver or splenic laceration?
Conclusion on next page.
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
Pearls & Pitfalls for The eFAST Exam
1. Use a 3-5 MHz curvilinear or phased array transducer to obtain images of the abdomen during the eFAST exam.
2. Remember that the eFAST is a focused, limited, bedside ultrasound application used to answer a select set of questions.
3. The eFAST can help practitioners diagnose a pneumothorax, determine if the patient has pleural fluid present above the diaphragm, visualize a pericardial effusion and detect intra-abdominal free fluid in the right upper quadrant, left upper quadrant, and pelvis.
4. Although its ability to diagnose solid organ injuries has not been well studied yet, it is important to know what solid organ injuries may look like on bedside ultrasound in case you come across them during your scan.
5. Train your eyes to know what a normal liver and spleen look like. Lacerations will often appear as irregularly shaped anechoic stripes within the organ parenchyma.
6. To determine if the anechoic area is a vessel or a laceration, apply color Doppler over the area of interest. Note that very large and actively bleeding lacerations may demonstrate a small amount of color flow, but the appearance of the color flow will be markedly different than that seen over normal adjacent veins and arteries.
7. A positive FAST provides very useful information that can help with management and imaging decisions when resources are limited or when a patient is hemodynamically unstable.
8. The FAST has a high specificity for detecting hemoperitoneum (89%-99%) but also carries a low sensitivity (73%-97%). If your patient has a normal FAST, remember the limitations of the scan, and consider obtaining a CT scan if there is a moderate to high suspicion for intra-abdominal, retroperitoneal or pelvic trauma.
9. Remember that Practice Makes Proficient. With bedside ultrasound there is no substitute for experience.
Teresa Wu is the EM Ultrasound Director and Co-Director for Simulation Based Training for the Maricopa Emergency Medicine Program in Phoenix, Arizona.
Brady Pregerson manages a free online EM Ultrasound Image Library and is the editor of the Emergency Medicine Pocketbook series. For more information visit ERPocketBooks.com