Hemorrhage

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 Exam - Suprapubic Views

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This video details how using long-axis and short-axis suprapubic views during a trauma FAST ultrasound examination enables clinicians to identify fluid in a trauma patient's pelvic cavity.

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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 Soundbytes module we'll continue
our journey looking at the Trauma Fast Exam.
I hope you've had a chance to join me prior
for modules looking at the right upper quadrant
and left upper quadrant views of the Trauma Fast Exam.
In this module we will specifically look at
the Suprapubic view, also known as the bladder or pelvic
view of the Trauma Fast Exam.
There is a lot of information we can gain
from looking at the Suprapubic view,
as we can potentially detect a smaller amount of fluid
than is required to make a positive right
upper quadrant or left upper quadrant view.
Literature suggests that only about
100 to 200 ccs of fluid can be detected
accurately on the Suprapubic view.
Here's a slide reviewing how to perform
the Suprapubic view of the Trauma Fast Exam.
In contrast to the upper quadrant views,
where we looked only in the long axis configuration,
the Suprapubic view is made up of two planes.
We want to look in both long and short axis configurations.
We'll begin at long axis with the marker dot
oriented toward the patient's head
and complete our exam by moving the probe
into short axis with the marker dot
toward the patients right side.
This way we can fully scan through the pelvis
and not miss any small amounts of fluid there.
It's optimal to perform the examination
with a full bladder as an optimal
acoustic window, so perform the
exam prior to having the patient
void or placing a foley catheter.
Here's an illustration showing the anatomy
that we'll need to know to perform
the Suprapubic view of the Trauma Fast Exam.
We see the pattern of fluid flow in a female,
to the left here, and a male, to the right.
Let's look closer at the female pelvis,
to the left, and what we see is that fluid will
preferentially develop in the pelvic
Cul de Sac, located behind the uterus.
Now, small amounts of fluid will only be
located in the pelvic Cul de Sac,
but as the amount of fluid enlarges
it will come out and increase so
that it will layer out on top of
the uterus and on top of the dome of the bladder.
But small amounts of fluid will only be found in
that pelvic Cul de Sac posterior to the uterus.
Now let's take a look at the male
pelvis to the right and we see
small amounts of fluid that will only be found
in the Retrovesical Space behind the bladder.
As the amount of fluid enlarges it
will come anterior to settle out
over the top of the dome of the bladder.
But as we emphasized in the female,
small amounts of fluid will only be
found in one place and in the male
it will be in that Retrovesical Space
immediately posterior to the bladder.
Let's begin by looking at some normal
video from the Suprapubic View.
In this case, a long axis view in a female,
superior to the left, inferior to the right.
The first structure we identify is
the bladder, the dark area, anteriorly
and posterior to the bladder we see the uterus.
Now if we look into the potential space,
the Pelvic Cul de Sac, posterior to the
uterus for any dark fluid collections, we see an
absence of any fluid on this normal video clip.
Now let's inspect a video clip from a male.
In this case a short axis view.
We see a large bladder there, anteriorly
and behind the bladder we see two
tubular structures making up the
Seminal Vesicles, a normal finding in a male.
Now if we're looking for free fluid
behind the bladder, we'd be looking
for dark or anechoic fluid collection
layering out behind the bladder.
Notice this is a normal examination.
Here's a positive examination
in a female trauma patient.
We're looking in the long axis view,
superior to the left, inferior to the right.
The first structure we identify is
the bladder, as seen inferior here.
And notice the uterus, the solid organ,
as seen superior to the bladder.
We note the parts of the uterus, the fundus
anteriorly, and the cervix more posteriorly.
Now let's look into the Pelvic Cul de Sac
immediately posterior to the uterus,
and what we see here is the presence of a
dark or anechoic fluid collection just posterior
to the cervix within the pelvic Cul de Sac.
So in the female trauma patient,
this does denote a positive examination
and can be a sign of ongoing bleeding
within the abdominal pelvic cavity.
So let's contrast this clip in which
we see a small amount of fresh
fluid within the pelvic Cul de Sac.
With this one, in which we have a female
trauma patient with a large amount
of bleeding within the pelvic cavity.
We see here, again, a long axis scan superior
to the left, inferior to the right, the bladder
we see as the dark structure inferiorly
and the uterus superior to the bladder.
Notice the fresh fluid as seen posterior
to the uterus within the Cul de Sac,
but note that the amount of fluid
comes anterior to the uterus,
as seen here between the uterus and the bladder.
So this denotes a large amount of blood within
the pelvic cavity in this female trauma patient.
If we now orient the probe to the patient's right side,
we obtain a short axis view of the same patient.
And what we see here is the uterus in the
middle of the image and notice the large amount
of fresh fluid as seen both to the top, or anterior,
to the uterus and posterior to the uterus.
Notice in this case we can see the
broad ligaments of the uterus well outlined
by all the fresh fluid within the pelvis.
So a large amount of fresh fluid, or blood,
in this case, within this female trauma patient.
Here's a positive examination
Suprapubic View, short axis in a male.
Probe is oriented towards the patient's right and
anteriorly we see a large, fluid filled bladder.
Posterior to the bladder, in the retrovesical
space we appreciate the presence of free fluid,
as shown by that dark or anechoic
fluid collection there.
Now this gives a finding known as
the double wall sign, and we see
the wall of the bladder, outlined by
the urine inside the bladder, and the
blood, in this case, outside the bladder
in the area of the retrovesical space.
To further confirm that the last patient
had a positive exam and that we're
not mistaking areas of fluid as seminal vesicles,
we'll re-scan the patient in the long axis plane,
superior to the left, inferior to the right.
We see the large circular bladder,
as seen anteriorly and superior
and posterior to the bladder in the
retrovesical space, we can see
free fluid layering out there.
This confirms that indeed the patient
has a positive exam, with blood
layering out behind the bladder.
And, again, we see the double wall sign,
urine outlining the inner wall of the
bladder, and blood, in this case,
outlining the outer wall of the bladder.
Here we're scanning a male trauma patient with
a long axis configuration and we see a large
amount of free fluid within the pelvis.
We note the bladder inferiorly,
and note all the free fluid layering
out both posterior to the bladder
in the retrovesical space and coming
anteriorly onto the dome of the
bladder as seen to the left here.
So a large amount of free fluid in this male trauma patient.
In conclusion, I'm glad I could
share with you the Soundbytes Module
covering the Suprapubic View of the Trauma Fast Exam.
This view is a very important
one to add onto the exam of your
trauma patient as we can potentially
detect a smaller amount of fluid here,
within the pelvis, than it takes to
make a positive right upper quadrant
or left upper quadrant view.
Remember that this is a two-step exam,
we'll be looking in both short
and long axis configurations to
verify fluid, and also remember
the differences between the female, where we're
looking into the pelvic Cul de Sac for fluid,
and the male, where we're looking into
the retrovesical space for fluid.
So I hope to see you back in the
future as Soundbytes continues.

Brightcove ID

5508114789001

https://youtube.com/watch?v=Pa3z9zWNfB8

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

LUQ Spleen/L Kidney

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Knee: Baker's Cyst Dual Image

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Knee: Baker's Cyst

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3D How To: Baker's Cyst Aspiration

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3D animation demonstrating an ultrasound guided aspiration of a Baker's Cyst.

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Orthopedics

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- [Voiceover] A linear array transducer
with a musculoskeletal exam type
is used to perform an ultrasound guided aspiration
of a Baker's cyst.
The patient is in a supine position.
The transducer is placed transversely
over the popliteal fossa,
with the orientation marker directed to the patient's right.
The most common location for a Baker's cyst
is at the crossing of the semimembranosus muscle
and the medial head
of the gastrocnemius muscle above the femoral condyle.
The femoral condyle is seen as a
bright hyperechoic structure on the left of the screen.
The speckled pattern of the tendon
of the semimembranosus muscle,
and the starry night appearance of the medial head
of the gastrocnemius can be seen as the transducer
is moved more distally.
A Baker's cyst appears as a
C-shaped, darker hypoechoic or anechoic cystic structure,
with a superficial and deep component.
The transducer is rotated 90-degrees clockwise,
with the orientation marker
directed toward the patient's head.
The extent and depth of the Baker's cyst
should be confirmed by scanning
the cyst proximally and distally.
The needle is inserted in the skin
just proximal to the transducer.
The needle is slowly advanced to lie in plane
to the transducer beam,
and is seen as a bright, hyperechoic linear structure.
The needle is slowly advanced
under direct ultrasound visualization,
until the tip is seen to lie
within the Baker's cyst,
where an aspiration can be done.
After the procedure is finished,
the area should be scanned
to ensure that there is no evidence of bleeding
in this area.

Brightcove ID

5969016454001

https://youtube.com/watch?v=MDkPZRFUM-U

3D How To: eFAST Pelvis

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3D animation demonstrating the pelvis view while performing an eFAST exam.

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- [Voiceover] A phased array transducer
with an abdomen exam type
is used to perform the pelvis view of the fast exam.
Place the transducer in a transverse position
with the orientation marker to the right
at the level of the symphysis pubis.
The pelvis is evaluated in two planes.
It is easier to perform this exam
when the bladder is filled.
The bladder is used as an acoustic window
to view the cul de sac
or retrovesicular space for free fluid.
To visualize the bladder,
angle the transducer inferiorly into the pelvis.
If it is difficult to visualize the bladder,
slide to the left or right of the symphysis pubis
to bring the bladder into view.
To evaluate the pelvis for free fluid,
sweep the transducer from an inferior to superior position.
Fluid will appear hyperechoic or anechoic
and accumulate posterior to the bladder,
posterior to the uterus, and between loops of bowel.
To obtain a long access view,
rotate the transducer 90 degrees
with the orientation marker
pointed toward the patient's head.
Sweep the transducer across the pelvis from left to right
to evaluate the pelvis for free fluid.

Brightcove ID

5508134284001

https://youtube.com/watch?v=pFtpx-yZfe0

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3D animation demonstrating the pelvis view while performing an eFAST exam.

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Case: FAST Exam - LUQ Exam

Case: FAST Exam - LUQ Exam

Case: FAST Exam - Suprapubic Views

Case: FAST Exam - Suprapubic Views

Case: FAST RUQ Exam - Hemorrhage

Case: FAST RUQ Exam - Hemorrhage

LUQ Spleen/L Kidney

LUQ Spleen/L Kidney

Knee: Baker's Cyst Dual Image

Knee: Baker's Cyst Dual Image

Knee: Baker's Cyst

Knee: Baker's Cyst

3D How To: Baker's Cyst Aspiration

3D How To: Baker's Cyst Aspiration

3D How To: eFAST Pelvis

3D How To: eFAST Pelvis

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