<p begin="00:00:18.008" end="00:00:20.720" style="s2">- Hello, my name is Phil<br />Perera and I'm the emergency</p>
<p begin="00:00:20.720" end="00:00:23.219" style="s2">ultrasound coordinator at the<br />New York Presbyterian Hospital</p>
<p begin="00:00:23.219" end="00:00:27.918" style="s2">in New York City, and<br />welcome to SoundBytes Cases.</p>
<p begin="00:00:27.918" end="00:00:30.365" style="s2">In this module we're<br />going to focus entirely on</p>
<p begin="00:00:30.365" end="00:00:32.585" style="s2">the trauma fast exam.</p>
<p begin="00:00:32.585" end="00:00:34.852" style="s2">Specifically, we're going<br />to look further into the</p>
<p begin="00:00:34.852" end="00:00:37.038" style="s2">right upper quadrant view, also known as</p>
<p begin="00:00:37.038" end="00:00:39.032" style="s2">the hepatorenal view.</p>
<p begin="00:00:39.032" end="00:00:40.906" style="s2">Now, we're going to cover<br />the two other views of</p>
<p begin="00:00:40.906" end="00:00:44.365" style="s2">the trauma fast exam in<br />upcoming modules of SoundBytes.</p>
<p begin="00:00:44.365" end="00:00:46.697" style="s2">The left upper quadrant<br />view, also known as</p>
<p begin="00:00:46.697" end="00:00:49.387" style="s2">the splenorenal or perisplenic view,</p>
<p begin="00:00:49.387" end="00:00:53.297" style="s2">and the suprarpubic view, also<br />known as the bladder view.</p>
<p begin="00:00:53.297" end="00:00:55.717" style="s2">There's a tremendous amount<br />of information we can gain by</p>
<p begin="00:00:55.717" end="00:00:58.141" style="s2">looking closely into the<br />right upper quadrant area</p>
<p begin="00:00:58.141" end="00:00:59.548" style="s2">in our trauma patient.</p>
<p begin="00:00:59.548" end="00:01:02.289" style="s2">Traditionally it's been emphasized<br />that the hepatorenal area</p>
<p begin="00:01:02.289" end="00:01:05.283" style="s2">or Morison's pouch view, is<br />the primary target for the</p>
<p begin="00:01:05.283" end="00:01:09.001" style="s2">right upper quadrant, but it<br />can take up to 600 ccs of fluid</p>
<p begin="00:01:09.001" end="00:01:12.922" style="s2">to make a positive exam if<br />only looking into that area.</p>
<p begin="00:01:12.922" end="00:01:15.370" style="s2">So I'll show some alternative<br />views in this module that can</p>
<p begin="00:01:15.370" end="00:01:18.974" style="s2">help us to possibly<br />improve on that number.</p>
<p begin="00:01:18.974" end="00:01:21.149" style="s2">Now let's take a look at a<br />slide showing us how to perform</p>
<p begin="00:01:21.149" end="00:01:24.407" style="s2">the right upper quadrant<br />view of the trauma fast exam.</p>
<p begin="00:01:24.407" end="00:01:27.318" style="s2">We'll want to place the probe<br />at about the anterior axillary</p>
<p begin="00:01:27.318" end="00:01:30.431" style="s2">line and using the liver as<br />an acoustic window aiming</p>
<p begin="00:01:30.431" end="00:01:33.697" style="s2">the probe down towards the<br />bedside retroperitoneally to get</p>
<p begin="00:01:33.697" end="00:01:36.441" style="s2">a good view of these<br />anatomical structures.</p>
<p begin="00:01:36.441" end="00:01:38.683" style="s2">It's best to have a small<br />footprint probe that can easily</p>
<p begin="00:01:38.683" end="00:01:41.934" style="s2">sit between the ribs giving<br />a good view on to this area.</p>
<p begin="00:01:41.934" end="00:01:44.471" style="s2">Notice that this is a long<br />axis view with a probe marker</p>
<p begin="00:01:44.471" end="00:01:46.261" style="s2">position superiorly.</p>
<p begin="00:01:46.261" end="00:01:48.855" style="s2">Now our first view from this<br />right upper quadrant area</p>
<p begin="00:01:48.855" end="00:01:52.006" style="s2">will be position one as shown here in the</p>
<p begin="00:01:52.006" end="00:01:55.219" style="s2">infra-diaphragmatic space<br />just below the diaphragm</p>
<p begin="00:01:55.219" end="00:01:56.707" style="s2">and above the liver.</p>
<p begin="00:01:56.707" end="00:01:59.563" style="s2">Second, we'll move the probe<br />slightly inferiorly to look in</p>
<p begin="00:01:59.563" end="00:02:03.092" style="s2">to the traditional Morison's<br />pouch or hepatorenal interface,</p>
<p begin="00:02:03.092" end="00:02:05.958" style="s2">and the last view is the caudal<br />tip of the liver shown here</p>
<p begin="00:02:05.958" end="00:02:07.713" style="s2">in position three.</p>
<p begin="00:02:07.713" end="00:02:09.916" style="s2">It's very important to look at<br />the caudal tip of the liver,</p>
<p begin="00:02:09.916" end="00:02:12.356" style="s2">as this represents the<br />beginning of the right paracolic</p>
<p begin="00:02:12.356" end="00:02:15.214" style="s2">gutter and small amounts of<br />fluid will pool here before</p>
<p begin="00:02:15.214" end="00:02:17.832" style="s2">moving into Morison's pouch.</p>
<p begin="00:02:17.832" end="00:02:19.746" style="s2">Now that we know how to perform<br />the right upper quadrant</p>
<p begin="00:02:19.746" end="00:02:23.008" style="s2">view of the trauma fast exam,<br />let's take a look at a normal</p>
<p begin="00:02:23.008" end="00:02:24.974" style="s2">image that you might obtain.</p>
<p begin="00:02:24.974" end="00:02:26.988" style="s2">Remembering that this is a long axis view,</p>
<p begin="00:02:26.988" end="00:02:28.701" style="s2">I have the probe marker<br />here positioned towards</p>
<p begin="00:02:28.701" end="00:02:29.859" style="s2">the patient's head.</p>
<p begin="00:02:29.859" end="00:02:31.715" style="s2">So towards the left of the clip here is</p>
<p begin="00:02:31.715" end="00:02:34.075" style="s2">superior chest cavity<br />and towards the right is</p>
<p begin="00:02:34.075" end="00:02:36.349" style="s2">inferior or abdominal cavity.</p>
<p begin="00:02:36.349" end="00:02:38.918" style="s2">Notice the first large<br />structure that comes into view</p>
<p begin="00:02:38.918" end="00:02:41.651" style="s2">in the middle of the image is<br />the liver and to the right,</p>
<p begin="00:02:41.651" end="00:02:45.386" style="s2">or inferior to the liver we<br />see the football shaped kidney.</p>
<p begin="00:02:45.386" end="00:02:47.811" style="s2">Now it's that interface between<br />the liver and kidney that</p>
<p begin="00:02:47.811" end="00:02:50.821" style="s2">represents a potential space<br />known as Morison's pouch</p>
<p begin="00:02:50.821" end="00:02:54.384" style="s2">where we're be looking for dark,<br />anechoic fluid collections.</p>
<p begin="00:02:54.384" end="00:02:57.853" style="s2">Note here, we see a thin, white<br />line making up a normal exam</p>
<p begin="00:02:57.853" end="00:03:00.193" style="s2">and representing the<br />fat within the capsule</p>
<p begin="00:03:00.193" end="00:03:01.443" style="s2">around the kidney.</p>
<p begin="00:03:01.443" end="00:03:04.321" style="s2">Notice to the left of the liver<br />we see the white diaphragm</p>
<p begin="00:03:04.321" end="00:03:06.633" style="s2">that represents the<br />interface between chest</p>
<p begin="00:03:06.633" end="00:03:08.803" style="s2">and abdominal cavities.</p>
<p begin="00:03:08.803" end="00:03:10.312" style="s2">Let's take a look at another normal</p>
<p begin="00:03:10.312" end="00:03:11.979" style="s2">right upper quadrant examination.</p>
<p begin="00:03:11.979" end="00:03:14.509" style="s2">Again the probe marker is<br />towards the patient's head.</p>
<p begin="00:03:14.509" end="00:03:16.622" style="s2">This is the superior chest<br />cavity towards the left.</p>
<p begin="00:03:16.622" end="00:03:19.290" style="s2">Inferior abdominal<br />cavity towards the right.</p>
<p begin="00:03:19.290" end="00:03:21.066" style="s2">We see the liver in the<br />middle of the image,</p>
<p begin="00:03:21.066" end="00:03:24.420" style="s2">and notice the diaphragm above<br />the liver moving up and down</p>
<p begin="00:03:24.420" end="00:03:26.220" style="s2">as the patient breathes.</p>
<p begin="00:03:26.220" end="00:03:29.127" style="s2">We see the kidney inferior<br />to the liver, and notice</p>
<p begin="00:03:29.127" end="00:03:31.606" style="s2">the potential space in between<br />the liver and the kidney</p>
<p begin="00:03:31.606" end="00:03:35.565" style="s2">that makes up the hepatorenal<br />fossa or pouch of Morison.</p>
<p begin="00:03:35.565" end="00:03:38.443" style="s2">Notice in this video clip<br />all we see is a white line</p>
<p begin="00:03:38.443" end="00:03:41.675" style="s2">representing the fat within<br />the capsule around the kidney</p>
<p begin="00:03:41.675" end="00:03:43.342" style="s2">or Gerota's capsule.</p>
<p begin="00:03:44.189" end="00:03:47.119" style="s2">If there was fluid, we would<br />see a dark or anechoic fluid</p>
<p begin="00:03:47.119" end="00:03:49.361" style="s2">collection in this potential space.</p>
<p begin="00:03:49.361" end="00:03:52.630" style="s2">Let's now look at the diaphragm<br />which we see above the liver</p>
<p begin="00:03:52.630" end="00:03:54.990" style="s2">and if we look above the<br />diaphragm this is where we would</p>
<p begin="00:03:54.990" end="00:03:57.881" style="s2">look for fluid within the<br />chest cavity or hemothorax</p>
<p begin="00:03:57.881" end="00:03:59.188" style="s2">in the trauma patient.</p>
<p begin="00:03:59.188" end="00:04:01.756" style="s2">We may have to move the probe<br />several intercostal spaces</p>
<p begin="00:04:01.756" end="00:04:03.673" style="s2">on the patient's side to fully investigate</p>
<p begin="00:04:03.673" end="00:04:05.310" style="s2">the right upper quadrant for fluid.</p>
<p begin="00:04:05.310" end="00:04:07.712" style="s2">Here's a swing view where I'm<br />starting relatively superior</p>
<p begin="00:04:07.712" end="00:04:10.059" style="s2">right there looking in the<br />area between the diaphragm</p>
<p begin="00:04:10.059" end="00:04:13.222" style="s2">and the liver, going through<br />Morison's pouch, as I'll show</p>
<p begin="00:04:13.222" end="00:04:16.271" style="s2">coming up right here the<br />area between the liver</p>
<p begin="00:04:16.271" end="00:04:18.938" style="s2">and the kidney and<br />terminating at the inferior</p>
<p begin="00:04:18.938" end="00:04:20.270" style="s2">tip of the liver.</p>
<p begin="00:04:20.270" end="00:04:22.886" style="s2">Notice here we notice the caudal<br />tip of the liver extending</p>
<p begin="00:04:22.886" end="00:04:25.891" style="s2">almost all the way inferiorly<br />down past the inferior pole</p>
<p begin="00:04:25.891" end="00:04:28.408" style="s2">of the kidney, and it's<br />important to look at that caudal</p>
<p begin="00:04:28.408" end="00:04:30.370" style="s2">tip of the liver, as it<br />represents the beginning</p>
<p begin="00:04:30.370" end="00:04:32.649" style="s2">of the right paracolic gutter.</p>
<p begin="00:04:32.649" end="00:04:34.912" style="s2">So in conclusion, I'm glad I<br />could share with you part one</p>
<p begin="00:04:34.912" end="00:04:38.553" style="s2">of the right upper quadrant<br />view of the trauma fast exam.</p>
<p begin="00:04:38.553" end="00:04:41.635" style="s2">Now we know how to recognize<br />a normal examination</p>
<p begin="00:04:41.635" end="00:04:44.321" style="s2">looking all the way from<br />the area below the diaphragm</p>
<p begin="00:04:44.321" end="00:04:47.172" style="s2">through Morison's pouch and<br />terminating at a view of</p>
<p begin="00:04:47.172" end="00:04:48.666" style="s2">the caudal tip of the liver.</p>
<p begin="00:04:48.666" end="00:04:51.621" style="s2">So I hope to see you back<br />as SoundBytes continues,</p>
<p begin="00:04:51.621" end="00:04:54.619" style="s2">and we look at part two of<br />the right upper quadrant view</p>
<p begin="00:04:54.619" end="00:04:57.452" style="s2">focusing on positive examinations.</p>