Interesting Case #1
An elderly female presents to your ED with shock & altered cognition. She is tachycardic and hypotensive (refractory to fluids), but afebrile. Her only complaint is abdominal pain.
A CXR demonstrates bilateral pleural effusions (which have been present on previous imaging) and her blood gas reveals a metabolic acidosis with a markedly elevated lactate.
You consider the possible diagnoses and decide to perform a RUSH exam but focus on the abdomen first, given her pain.
She has an unremarkable AAA scan and her Morrison’s pouch view is normal.[showhide type=”pressrelease” more_text=”As you look at her LUQ you obtain this view….” less_text=”As you look at her LUQ you obtain this view….” hidden=”yes”] [/showhide] [showhide type=”pressrelease3″ more_text=”So what does it show ?” less_text=”So what does it show ?” hidden=”yes”]
- Free fluid on the diaphragmatic surface of the spleen.
- Moderate left pleural effusion
Given her abdominal pain, hypotension and free peritoneal fluid, she was taken for an urgent abdominal CT.
- CT demonstrated features consistent with a perforated peptic ulcer (with gastric stranding) with free fluid. Her mesenteric angiogram demonstrated normal visceral perfusion.
With a diagnosis of sepsis secondary to peritonitis her resuscitation was altered with addition of broad-spectrum antibiotics to her haemodynamic support (vasopressors). She ultimately went to the theatre for washout + surgical repair of her perforation and had a protracted ICU stay.
- Arguably, her positive FAST exam narrowed the differential diagnoses and changed her clinical course.
[showhide type=”pressrelease1″ more_text=”The TAKE HOME message:” less_text=”The TAKE HOME message:” hidden=”yes”]
- The LUQ view is often the most difficult view to obtain
- Free fluid is rarely seen between the spleen & kidney, rather surrounding all other parts of the spleen or between the spleen and diaphragm. Therefore, make a conscious effort to exam the diaphragmatic surface on the spleen during your LUQ view of the FAST exam.
- Free fluid typically accumulates on the diaphragmatic surface of the spleen first, therefore this may be the only ‘positive’ view of your examination in patients with small amounts of fluid.
- O’Brien, K., Stolz, U., Stolz, L., & Adhikari, S. (2014). LUQ view and the FAST exam: helpful or a hindrance in the adult trauma patient? Critical Ultrasound Journal, 6(Suppl 1), A3. doi:10.1097/00005373-199508000-00032
- Perera, P., Mailhot, T., Riley, D., & Mandavia, D. (2010). The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emergency medicine clinics of North America, 28(1), 29–56, vii. doi:10.1016/j.emc.2009.09.010
- SonoGuide – The FAST exam
- SonoTutorial (via SonoSpot);
- EMCRIT.org – The RUSH Exam