Ultrasound in the Emergency Department
A 35-year-old woman presents to the emergency department (ED) via emergency medical services (EMS) after being involved in an automobile collision. She was the restrained front seat passenger in a car struck on the front passenger door with significant cabin intrusion. She required prolonged extraction from the vehicle. Pre-hospital vitals include blood pressure (BP) 105/80 mm Hg, heart rate (HR) 115 beats/minute, respiratory rate (RR) 22 breaths/minute, and oxygen saturation 100% on a nonrebreather (NRB) mask. Two large-bore IVs were established with 2 L of normal saline (NS) infused during extrication and transport. She is amnestic to the event and complains of pain in her left forearm and abdomen. Her vital signs are BP 90/65 mm Hg, HR 140 beats/minute, RR 35 breaths/minute, temperature 98.9°F, and oxygen saturation 100% on a NRB mask. She is diaphoretic, able to answer questions, but is confused. Her abdomen is nondistended, soft, and tender to palpation along the left upper and lower quadrants. She has a 4-cm laceration to her left forearm with active oozing of blood. She is neurovascularly intact and no deformities are noted. A third liter of NS is started, type O–negative blood is ordered, and the type and cross match is sent to the laboratory. Chest and pelvis radiographs are negative for acute injury. You obtain a focused assessment by sonography for trauma (FAST) examination, shown in the following figure. What is the next best step in the management of the patient?
(Courtesy of Mark Favot, MD, RDMS, RDCS)
a. Continue intravenous (IV) fluids and obtain a computed tomographic (CT) scan of her head
b. Continue IV fluids and obtain a CT scan of her abdomen and pelvis
c. Wait for the hemoglobin result and, if low, administer two units of packed red blood cells (PRBCs)
d. Transport the patient to the operating room (OR) for emergent therapeutic laparotomy
e. Perform a tube thoracostomy on the left hemithorax by placing a 36 F chest tube in the fifth intercostal space in the mid-axillary line
The answer is d. The left upper quadrant (LUQ) view of this FAST examination shows an anechoic fluid collection in the perisplenic space representing free fluid in the peritoneal cavity. In the setting of trauma, free peritoneal fluid is presumed to be blood. In the supine position the hepatorenal (Morrison) space is the most dependent portion of the peritoneal cavity making it the most sensitive region to find free fluid. When fluid is seen in the LUQ, it is most often seen surrounding the spleen inferior to the diaphragm rather than in the potential space between the spleen and the left ...