<p begin="00:00:18.274" end="00:00:19.681" style="s2">- Hello, my name is Phil Perera</p>
<p begin="00:00:19.681" end="00:00:21.698" style="s2">and I'm the Emergency<br />Ultrasound Coordinator</p>
<p begin="00:00:21.698" end="00:00:24.668" style="s2">at the New York Presbyterian<br />Hospital in New York City</p>
<p begin="00:00:24.668" end="00:00:27.335" style="s2">and welcome to SoundBytes Cases.</p>
<p begin="00:00:28.292" end="00:00:29.381" style="s2">In this module entitled,</p>
<p begin="00:00:29.381" end="00:00:31.324" style="s2">Part Two of the Right Upper Quadrant View</p>
<p begin="00:00:31.324" end="00:00:33.018" style="s2">of the Trauma Fast Exam,</p>
<p begin="00:00:33.018" end="00:00:35.829" style="s2">we're going to focus<br />entirely on positive findings</p>
<p begin="00:00:35.829" end="00:00:37.117" style="s2">from this view.</p>
<p begin="00:00:37.117" end="00:00:38.549" style="s2">Hopefully you've had a<br />chance to join me prior</p>
<p begin="00:00:38.549" end="00:00:40.975" style="s2">for Part One of the<br />Right Upper Quadrant View</p>
<p begin="00:00:40.975" end="00:00:43.605" style="s2">of the Trauma Fast Exam<br />where we focused entirely</p>
<p begin="00:00:43.605" end="00:00:46.967" style="s2">on normal findings from<br />the right upper quadrant.</p>
<p begin="00:00:46.967" end="00:00:48.796" style="s2">And hopefully have a<br />chance to join me back</p>
<p begin="00:00:48.796" end="00:00:50.346" style="s2">as we go through the left upper quadrant</p>
<p begin="00:00:50.346" end="00:00:53.836" style="s2">and suprapubic views of<br />the Trauma Fast Exam.</p>
<p begin="00:00:53.836" end="00:00:56.135" style="s2">So let's begin this<br />module by going through a</p>
<p begin="00:00:56.135" end="00:00:57.736" style="s2">review of how to perform</p>
<p begin="00:00:57.736" end="00:01:01.200" style="s2">the right upper quadrant<br />view of the Trauma Fast Exam.</p>
<p begin="00:01:01.200" end="00:01:02.853" style="s2">Remember that the probe<br />is positioned in the</p>
<p begin="00:01:02.853" end="00:01:05.887" style="s2">long axis configuration with<br />the marker dot superiorally</p>
<p begin="00:01:05.887" end="00:01:08.204" style="s2">and that we're going to place<br />the probe in between the ribs</p>
<p begin="00:01:08.204" end="00:01:10.836" style="s2">at about the anterior axillary line.</p>
<p begin="00:01:10.836" end="00:01:12.922" style="s2">Here we'll want to<br />focus on the three areas</p>
<p begin="00:01:12.922" end="00:01:15.338" style="s2">as I emphasized in Part<br />One of this module.</p>
<p begin="00:01:15.338" end="00:01:17.987" style="s2">Number one, the infra-diaphragmatic space</p>
<p begin="00:01:17.987" end="00:01:19.388" style="s2">looking at that region<br />just below the diaphragm</p>
<p begin="00:01:19.388" end="00:01:21.619" style="s2">and above the liver,</p>
<p begin="00:01:21.619" end="00:01:25.422" style="s2">and actually looking into the<br />chest cavity for a hemothorax.</p>
<p begin="00:01:25.422" end="00:01:28.084" style="s2">Position two, which is the<br />traditional Morison's Pouch</p>
<p begin="00:01:28.084" end="00:01:29.756" style="s2">or hepatorenal interface.</p>
<p begin="00:01:29.756" end="00:01:31.793" style="s2">And position three, to round out the exam</p>
<p begin="00:01:31.793" end="00:01:34.033" style="s2">looking at the caudal<br />liver tip representing the</p>
<p begin="00:01:34.033" end="00:01:37.306" style="s2">beginning of the right paracolic gutter.</p>
<p begin="00:01:37.306" end="00:01:39.680" style="s2">Here's a nice illustration<br />showing a positive examination</p>
<p begin="00:01:39.680" end="00:01:43.088" style="s2">from the right upper quadrant<br />view of the Trauma Fast Exam.</p>
<p begin="00:01:43.088" end="00:01:45.365" style="s2">We see the liver smack in<br />the middle of the image</p>
<p begin="00:01:45.365" end="00:01:48.981" style="s2">and the kidney slightly posterior<br />and inferior to the liver.</p>
<p begin="00:01:48.981" end="00:01:51.533" style="s2">Let's look at the preferential<br />deposition of fluid</p>
<p begin="00:01:51.533" end="00:01:53.081" style="s2">as shown here in the orange color,</p>
<p begin="00:01:53.081" end="00:01:55.156" style="s2">and we see that it layers<br />out predominantly around</p>
<p begin="00:01:55.156" end="00:01:57.231" style="s2">the caudal tip of the<br />liver as shown towards the</p>
<p begin="00:01:57.231" end="00:01:59.674" style="s2">inferior edge of the image here.</p>
<p begin="00:01:59.674" end="00:02:02.437" style="s2">Notice that it flows from<br />the caudal tip of the liver</p>
<p begin="00:02:02.437" end="00:02:05.439" style="s2">into that potential space<br />which is Morison's Pouch</p>
<p begin="00:02:05.439" end="00:02:07.817" style="s2">in between the liver and the kidney.</p>
<p begin="00:02:07.817" end="00:02:10.397" style="s2">Now this is very important<br />to emphasize as many times,</p>
<p begin="00:02:10.397" end="00:02:12.487" style="s2">fresh fluid can only be seen around that</p>
<p begin="00:02:12.487" end="00:02:13.823" style="s2">caudal tip of the liver,</p>
<p begin="00:02:13.823" end="00:02:16.881" style="s2">and then it would move into<br />that hepatorenal interface</p>
<p begin="00:02:16.881" end="00:02:18.752" style="s2">or Morison's Pouch.</p>
<p begin="00:02:18.752" end="00:02:21.083" style="s2">Here's a positive ultrasound<br />examination from a patient</p>
<p begin="00:02:21.083" end="00:02:23.553" style="s2">who was hit by a car<br />while crossing the street</p>
<p begin="00:02:23.553" end="00:02:24.947" style="s2">and we see here the liver</p>
<p begin="00:02:24.947" end="00:02:26.823" style="s2">smack in the middle of the image here.</p>
<p begin="00:02:26.823" end="00:02:29.772" style="s2">Notice the kidney located<br />inferior and posterior</p>
<p begin="00:02:29.772" end="00:02:30.794" style="s2">to the liver.</p>
<p begin="00:02:30.794" end="00:02:32.597" style="s2">And in between the liver<br />and the kidney in that</p>
<p begin="00:02:32.597" end="00:02:34.966" style="s2">potential space known as Morison's Pouch,</p>
<p begin="00:02:34.966" end="00:02:37.712" style="s2">we see a dark or anechoic<br />fluid collection.</p>
<p begin="00:02:37.712" end="00:02:38.904" style="s2">Not insignificant,</p>
<p begin="00:02:38.904" end="00:02:41.351" style="s2">actually a pretty large<br />stripe in this patient.</p>
<p begin="00:02:41.351" end="00:02:44.143" style="s2">This represents the positive examination,</p>
<p begin="00:02:44.143" end="00:02:45.618" style="s2">or the presence of fresh fluid,</p>
<p begin="00:02:45.618" end="00:02:48.786" style="s2">in this case blood within Morison's Pouch.</p>
<p begin="00:02:48.786" end="00:02:50.717" style="s2">And notice that it layers out in between</p>
<p begin="00:02:50.717" end="00:02:52.851" style="s2">that liver and kidney.</p>
<p begin="00:02:52.851" end="00:02:55.158" style="s2">To emphasize the point that a<br />complete right upper quadrant</p>
<p begin="00:02:55.158" end="00:02:57.687" style="s2">view includes looking at<br />the caudal tip of the liver,</p>
<p begin="00:02:57.687" end="00:03:00.905" style="s2">let's examine this video clip<br />from another trauma patient.</p>
<p begin="00:03:00.905" end="00:03:02.994" style="s2">If we look at the<br />hepatorenal interface there,</p>
<p begin="00:03:02.994" end="00:03:05.333" style="s2">we fail to see the presence of any fluid,</p>
<p begin="00:03:05.333" end="00:03:07.439" style="s2">but as we move the probe inferiorially,</p>
<p begin="00:03:07.439" end="00:03:10.530" style="s2">we see that the caudal tip of<br />the liver as shown right there</p>
<p begin="00:03:10.530" end="00:03:12.643" style="s2">is well outlined by fluid.</p>
<p begin="00:03:12.643" end="00:03:15.267" style="s2">And here we see the<br />inferior pole of the kidney,</p>
<p begin="00:03:15.267" end="00:03:18.300" style="s2">the caudal tip of the liver<br />extending above the kidney,</p>
<p begin="00:03:18.300" end="00:03:19.688" style="s2">and notice all the fresh fluid</p>
<p begin="00:03:19.688" end="00:03:23.230" style="s2">both anterior and posterior to<br />the caudal tip of the liver.</p>
<p begin="00:03:23.230" end="00:03:25.335" style="s2">Making the point that this<br />is a very important area</p>
<p begin="00:03:25.335" end="00:03:28.583" style="s2">to look for in the right<br />upper quadrant exam.</p>
<p begin="00:03:28.583" end="00:03:30.565" style="s2">Here's a video clip from<br />a patient who was stabbed</p>
<p begin="00:03:30.565" end="00:03:33.680" style="s2">with a really big knife<br />to the epigastric region.</p>
<p begin="00:03:33.680" end="00:03:35.362" style="s2">And as we look at the<br />right upper quadrant,</p>
<p begin="00:03:35.362" end="00:03:38.070" style="s2">we can actually see a<br />linear liver laceration</p>
<p begin="00:03:38.070" end="00:03:41.307" style="s2">extending through the<br />medial aspect of the liver.</p>
<p begin="00:03:41.307" end="00:03:43.222" style="s2">We also appreciate the presence of a large</p>
<p begin="00:03:43.222" end="00:03:44.441" style="s2">amount of fresh fluid.</p>
<p begin="00:03:44.441" end="00:03:46.764" style="s2">That dark or anechoic fluid collection</p>
<p begin="00:03:46.764" end="00:03:48.893" style="s2">layering out posteriorally<br />there to the liver</p>
<p begin="00:03:48.893" end="00:03:51.027" style="s2">and extending into Morison's Pouch,</p>
<p begin="00:03:51.027" end="00:03:53.194" style="s2">the hepatorenal interface.</p>
<p begin="00:03:54.048" end="00:03:56.660" style="s2">So as this patent had<br />unstable hemodynamics,</p>
<p begin="00:03:56.660" end="00:03:59.865" style="s2">the next move was to package<br />for the operating room.</p>
<p begin="00:03:59.865" end="00:04:02.804" style="s2">And here we can actually see<br />the caudal tip of the liver</p>
<p begin="00:04:02.804" end="00:04:04.937" style="s2">waving around in all the fresh fluid,</p>
<p begin="00:04:04.937" end="00:04:06.466" style="s2">in this case blood.</p>
<p begin="00:04:06.466" end="00:04:08.332" style="s2">And I obtained this<br />view by moving the probe</p>
<p begin="00:04:08.332" end="00:04:11.699" style="s2">one intercostal space<br />inferior from the last view</p>
<p begin="00:04:11.699" end="00:04:14.210" style="s2">to well delineate the caudal tip of liver</p>
<p begin="00:04:14.210" end="00:04:17.735" style="s2">which we can see here moving<br />around in all the fresh fluid.</p>
<p begin="00:04:17.735" end="00:04:20.328" style="s2">In the last few video clips<br />the appearance of fresh fluid</p>
<p begin="00:04:20.328" end="00:04:23.161" style="s2">on bedside sonography<br />was darker, anechoic.</p>
<p begin="00:04:23.161" end="00:04:26.028" style="s2">However as blood clots it<br />can take on a more echogenic</p>
<p begin="00:04:26.028" end="00:04:27.586" style="s2">or lighter appearance.</p>
<p begin="00:04:27.586" end="00:04:29.431" style="s2">In this video clip a patient was stabbed</p>
<p begin="00:04:29.431" end="00:04:31.383" style="s2">and had a significant<br />down time before being</p>
<p begin="00:04:31.383" end="00:04:33.156" style="s2">brought to the Emergency Department.</p>
<p begin="00:04:33.156" end="00:04:35.099" style="s2">As we look at the hepatorenal interface,</p>
<p begin="00:04:35.099" end="00:04:38.357" style="s2">we see a large amount<br />of clotted blood there</p>
<p begin="00:04:38.357" end="00:04:39.651" style="s2">made up by that echogenic</p>
<p begin="00:04:39.651" end="00:04:41.668" style="s2">or lighter appearance of the blood there.</p>
<p begin="00:04:41.668" end="00:04:44.129" style="s2">Notice that the large<br />amount of blood extends into</p>
<p begin="00:04:44.129" end="00:04:47.615" style="s2">the right paracolic gutter<br />as we scan inferiorially.</p>
<p begin="00:04:47.615" end="00:04:48.950" style="s2">And here we can see the liver,</p>
<p begin="00:04:48.950" end="00:04:49.946" style="s2">the kidney,</p>
<p begin="00:04:49.946" end="00:04:51.079" style="s2">and the clotted blood,</p>
<p begin="00:04:51.079" end="00:04:54.524" style="s2">that more echogenic or lighter<br />blood in Morison's Pouch.</p>
<p begin="00:04:54.524" end="00:04:55.421" style="s2">So in conclusion,</p>
<p begin="00:04:55.421" end="00:04:57.889" style="s2">I'm glad I could share with<br />you this Part Two Module</p>
<p begin="00:04:57.889" end="00:05:01.202" style="s2">on the Right Upper Quadrant<br />View of the Trauma Fast Exam.</p>
<p begin="00:05:01.202" end="00:05:02.767" style="s2">I hope now you have a better understanding</p>
<p begin="00:05:02.767" end="00:05:04.762" style="s2">on how to perform a complete exam</p>
<p begin="00:05:04.762" end="00:05:07.234" style="s2">looking into the three<br />areas as we discussed.</p>
<p begin="00:05:07.234" end="00:05:08.530" style="s2">Infradiaphragmatic,</p>
<p begin="00:05:08.530" end="00:05:09.651" style="s2">Morison's Pouch,</p>
<p begin="00:05:09.651" end="00:05:12.246" style="s2">and inferior tip of the liver.</p>
<p begin="00:05:12.246" end="00:05:13.986" style="s2">And hopefully now you'll<br />be able to discern</p>
<p begin="00:05:13.986" end="00:05:16.560" style="s2">the presence of fresh<br />blood versus clotted blood</p>
<p begin="00:05:16.560" end="00:05:18.445" style="s2">on bedside sonography.</p>
<p begin="00:05:18.445" end="00:05:21.397" style="s2">So I hope to see you back<br />as Sono access continues</p>
<p begin="00:05:21.397" end="00:05:24.553" style="s2">and as we move further<br />through the other views of the</p>
<p begin="00:05:24.553" end="00:05:25.970" style="s2">Trauma Fast Exam.</p>