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Ultrasound in Emergency Medicine

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. Two large-bore IVs were established with 2 L of normal saline (NS) infused during extrication and transport. She is confused, amnestic to the event, and complains of pain in her left forearm and abdomen. Her vital signs upon arrival to ED are blood pressure (BP) 80/65 mm Hg, heart rate (HR) 140 beats/minute, respiratory rate (RR) 35 breaths/minute, temperature 97.9°F, and oxygen saturation 100% on a nonrebreather (NRB) mask. She is diaphoretic. 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 but no other extremities injuries are noted. She is neurovascularly intact. A third liter of NS is started, type O–negative blood is ordered, and the type and crossmatch 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?

 

image

(Reproduced with permission from 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 midaxillary line

The answer is d. The 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 and the inferior liver tip are the most dependent portions of the peritoneal cavity making it the most sensitive region to find free fluid, even if the injury is not to a structure in the RUQ. When fluid is seen in the LUQ, it is most often seen between the spleen and left kidney, but is variably found along any area of the spleen (eg, near diaphragm or at inferior spleen ...

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