Fluid Collection

Case: FAST Exam - LUQ Exam

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The left upper quadrant (LUQ) ultrasound exam can help clinicians more accurately diagnose intra-abdominal injuries. Topics: infra-diaphragmatic and splenorenal spaces, & how to identify free fluid caused by a trauma.

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- Hello, my name is Phil Perera,
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases.
In this module, we'll continue our journey,
looking at the views of the Trauma FAST exam.
Hopefully you've had a chance to join me prior
for the views of the right upper quadrant,
and in this module,
we're going to look specifically
at the left upper quadrant views of the Trauma FAST exam,
known traditionally by two terms,
the splenorenal, or the perisplenic views.
In an upcoming module,
we'll look specifically at the suprapubic view,
or bladder view, of the Trauma FAST exam.
There's a lot of information we can gain
by looking at the left upper quadrant
in our trauma patients,
and we'll need to know that it's not a mirror image
of the right upper quadrant,
that the spleen offers less of an acoustic window
onto the left upper quadrant than the liver does
on the other side.
Here's a slide reviewing how to perform
the left upper quadrant view of the Trauma FAST exam.
As the spleen offers less of an acoustic window
on the left upper quadrant,
we need to bring the probe in
from a more posterior position.
Thus, the mantra, knuckles to stretcher.
Optimally, we're using a smaller footprint probe
that can get in between the ribs
and get a good view into the left upper quadrant area.
Position the probe in the long axis view
with the probe marker towards the patient's head,
at about the midaxillary line, or posterior axillary line,
with your knuckles almost touching down to the bedside.
We'll concentrate on two areas, most importantly,
the area above the spleen and below the diaphragm,
where fluid will preferentially accumulate,
but rounding out our exam,
we'll look inferior at that spleno-renal space.
Now that we know how to perform
the left upper quadrant view of the Trauma FAST exam,
let's take a look at a normal ultrasound image.
I have the probe oriented towards the patient's head,
so superior chest cavity is towards the left,
inferior abdominal cavity towards the right.
Notice the spleen,
the large organ in the middle of the image here,
and the kidney, the football shaped organ,
as seen inferior and posterior to the spleen.
Notice the curving white line just above the spleen,
which is the diaphragm.
Recall that in the left upper quadrant,
that fluid will accumulate preferentially
in between the spleen and the diaphragm
and will be a dark or anechoic stripe positioned there.
Here's another normal video clip
taken from the left upper quadrant.
In this case, I'm swinging the probe from inferior,
looking at the spleno-renal interface,
to superior, looking at that infra-diaphragmatic space.
And here, as I freeze the image,
we see the spleen right in the middle of the image,
the curving white line making up the diaphragm,
and notice the thoracic cavity
as seen just left, or superior, to the diaphragm.
If the patient had a significant hemothorax,
or fluid collection in the thoracic cavity,
that would be represented by
a dark or anechoic fluid collection
just above the diaphragm in the thoracic cavity.
Now that we've had a chance
to examine several normal video clips
as taken from the left upper quadrant,
let's look at a pictorial here,
showing a positive left upper quadrant FAST exam.
Here we see superior located to the left,
inferior to the right.
We see the spleen in the middle of the image,
the kidney inferiorly to the right.
The thoracic cavity with the diaphragm
to the left of the spleen, or superior.
We see the area of fresh fluid
as demarcated by the orange color,
and notice that it layers out
predominantly below the diaphragm
and above the spleen,
and this is the area where fluid
will preferentially deposit in the left upper quadrant.
There are ligaments that sling
from the diaphragm all the way to the colon
that prevent the flow of fluid
into that area between the spleen and the kidney
until the fluid is relatively large
within the left upper quadrant.
So, now let's take a look at a positive exam
from a trauma patient,
and we see here the spleen in the middle of the image,
the kidney inferiorly located to the spleen,
and notice the large amount of fresh fluid,
that dark or anechoic fluid collection
that layers out above the spleen
in the infra-diaphragmatic location,
and anterior to the spleen.
This indicates a large amount of fresh blood
in the left upper quadrant,
and we also see a blood clot,
that echogenic material waving around
anteriorly to the spleen.
So a positive exam in a trauma patient.
Here's another positive left upper quadrant view.
Notice here, there's a larger amount
of fresh fluid present on this examination.
We see the spleen in the middle of the image,
the kidney inferiorly there to the right,
and all the dark, fresh fluid,
as indicated by the dark, or anechoic, fluid collection,
as seen infra-diaphragmatic and above the spleen.
Notice again that the fluid is not
preferentially layering out in between
the spleen and the kidney, reinforcing the point that
this is not a mirror image of the right upper quadrant.
Here's another positive examination
in a patient who comes in hypotensive
after being hit by a car.
Notice I'm swinging the probe
between the kidney, up superiorly,
to look at the spleen.
Notice the absence of fluid in between the spleen
and the kidney,
but the presence of free fluid
right above the spleen and below the diaphragm
as indicated by that dark stripe.
Here's an interesting video clip from a trauma patient.
Again, we're looking at the left upper quadrant,
and we delineate the spleen and kidney.
Notice the presence here of fresh fluid,
the dark or anechoic fluid stripe
as seen layering out superior, or in anterior,
to the spleen there,
but let's look above the diaphragm here,
which we see as the curving white line
moving up and down as the patient breathes,
and what we notice here is the presence
of a dark fluid collection within the thoracic compartment.
So we're able to diagnose in this patient
an associated hemothorax
in addition to the hemoperitoneum.
So the left upper quadrant view
also helpful for looking into the thoracic compartment
as well as diagnosing interabdominal injury.
One maneuver that can help you
uncover fresh fluid within the left upper quadrant
is to have the patient take a deep breath
and analyze that infra-diaphragmatic space
as the diaphragm moves upward, off of the spleen.
Notice here that we uncovered the amount
of fresh fluid that's present right above the spleen
and below the diaphragm as the patient
takes a deep breath,
and that diaphragm moves superiorly.
So, in conclusion, I'm glad I could share with you
this SoundBytes module, going over the trauma FAST exam,
specifically the left upper quadrant, or perisplenic view.
There's a great deal of information that we can gain
by looking into the left upper quadrant
in our trauma patients,
and it's important to realize that
the left upper quadrant is not a mirror view
of the right upper quadrant,
and that fluid will preferentially layer out
in the area above the spleen and below the diaphragm,
in contrast to the hepatorenal space
on the right upper quadrant.
So, I hope to see you back as SoundBytes continues
and we move on to look at the suprapubic,
or bladder view, of the Trauma FAST exam.

Brightcove ID

5726805223001

https://youtube.com/watch?v=VBHCmw8iHCc

Case: FAST RUQ Exam - Hemorrhage

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This video (part 2 of 2) focuses on positive findings found during right upper quadrant (RUQ) ultrasound examinations; it also includes instructions for performing the trauma FAST RUQ-hepatorenal ultrasound exams

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- Hello, my name is Phil Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City
and welcome to SoundBytes Cases.
In this module entitled,
Part Two of the Right Upper Quadrant View
of the Trauma Fast Exam,
we're going to focus entirely on positive findings
from this view.
Hopefully you've had a chance to join me prior
for Part One of the Right Upper Quadrant View
of the Trauma Fast Exam where we focused entirely
on normal findings from the right upper quadrant.
And hopefully have a chance to join me back
as we go through the left upper quadrant
and suprapubic views of the Trauma Fast Exam.
So let's begin this module by going through a
review of how to perform
the right upper quadrant view of the Trauma Fast Exam.
Remember that the probe is positioned in the
long axis configuration with the marker dot superiorally
and that we're going to place the probe in between the ribs
at about the anterior axillary line.
Here we'll want to focus on the three areas
as I emphasized in Part One of this module.
Number one, the infra-diaphragmatic space
looking at that region just below the diaphragm
and above the liver,
and actually looking into the chest cavity for a hemothorax.
Position two, which is the traditional Morison's Pouch
or hepatorenal interface.
And position three, to round out the exam
looking at the caudal liver tip representing the
beginning of the right paracolic gutter.
Here's a nice illustration showing a positive examination
from the right upper quadrant view of the Trauma Fast Exam.
We see the liver smack in the middle of the image
and the kidney slightly posterior and inferior to the liver.
Let's look at the preferential deposition of fluid
as shown here in the orange color,
and we see that it layers out predominantly around
the caudal tip of the liver as shown towards the
inferior edge of the image here.
Notice that it flows from the caudal tip of the liver
into that potential space which is Morison's Pouch
in between the liver and the kidney.
Now this is very important to emphasize as many times,
fresh fluid can only be seen around that
caudal tip of the liver,
and then it would move into that hepatorenal interface
or Morison's Pouch.
Here's a positive ultrasound examination from a patient
who was hit by a car while crossing the street
and we see here the liver
smack in the middle of the image here.
Notice the kidney located inferior and posterior
to the liver.
And in between the liver and the kidney in that
potential space known as Morison's Pouch,
we see a dark or anechoic fluid collection.
Not insignificant,
actually a pretty large stripe in this patient.
This represents the positive examination,
or the presence of fresh fluid,
in this case blood within Morison's Pouch.
And notice that it layers out in between
that liver and kidney.
To emphasize the point that a complete right upper quadrant
view includes looking at the caudal tip of the liver,
let's examine this video clip from another trauma patient.
If we look at the hepatorenal interface there,
we fail to see the presence of any fluid,
but as we move the probe inferiorially,
we see that the caudal tip of the liver as shown right there
is well outlined by fluid.
And here we see the inferior pole of the kidney,
the caudal tip of the liver extending above the kidney,
and notice all the fresh fluid
both anterior and posterior to the caudal tip of the liver.
Making the point that this is a very important area
to look for in the right upper quadrant exam.
Here's a video clip from a patient who was stabbed
with a really big knife to the epigastric region.
And as we look at the right upper quadrant,
we can actually see a linear liver laceration
extending through the medial aspect of the liver.
We also appreciate the presence of a large
amount of fresh fluid.
That dark or anechoic fluid collection
layering out posteriorally there to the liver
and extending into Morison's Pouch,
the hepatorenal interface.
So as this patent had unstable hemodynamics,
the next move was to package for the operating room.
And here we can actually see the caudal tip of the liver
waving around in all the fresh fluid,
in this case blood.
And I obtained this view by moving the probe
one intercostal space inferior from the last view
to well delineate the caudal tip of liver
which we can see here moving around in all the fresh fluid.
In the last few video clips the appearance of fresh fluid
on bedside sonography was darker, anechoic.
However as blood clots it can take on a more echogenic
or lighter appearance.
In this video clip a patient was stabbed
and had a significant down time before being
brought to the Emergency Department.
As we look at the hepatorenal interface,
we see a large amount of clotted blood there
made up by that echogenic
or lighter appearance of the blood there.
Notice that the large amount of blood extends into
the right paracolic gutter as we scan inferiorially.
And here we can see the liver,
the kidney,
and the clotted blood,
that more echogenic or lighter blood in Morison's Pouch.
So in conclusion,
I'm glad I could share with you this Part Two Module
on the Right Upper Quadrant View of the Trauma Fast Exam.
I hope now you have a better understanding
on how to perform a complete exam
looking into the three areas as we discussed.
Infradiaphragmatic,
Morison's Pouch,
and inferior tip of the liver.
And hopefully now you'll be able to discern
the presence of fresh blood versus clotted blood
on bedside sonography.
So I hope to see you back as Sono access continues
and as we move further through the other views of the
Trauma Fast Exam.

Brightcove ID

5508109915001

https://youtube.com/watch?v=Gj5IioG7SyM