A Handlebar to the Gut

Case: 

23 year-old male presented to the ED following an electric bicycle accident. He struck the left upper aspect of the abdomen on the handle bar and had immediate emesis and left upper quadrant (LUQ) pain, followed by worsening pain and development of left shoulder pain. The patient had normal vital signs. On exam, his abdomen was soft but notable for tenderness in the LUQ. The left shoulder had full range of motion and no bony tenderness. A FAST exam was performed and found the following.

Case conclusion: 

The FAST exam was concerning for a supcapsular splenic hematoma and a small amount of free fluid at the tip of the spleen, but did not show free fluid elsewhere. The patient underwent a contrasted CT of the abdomen and pelvis that confirmed the presence of a grade 2 splenic laceration with subcapsular hematoma, and additionally identified pelvic hemoperitoneum. The patient was upgraded to a trauma. No additional injuries were identified. He was admitted for serial hemoglobins assessments and discharged two days later. 

FAST Exam Pearls: 

  • The FAST exam is highly specific tool for detecting free intraperitoneal fluid, but lacks sensitivity in hemodynamically stable patients (1)

  • A complete FAST exam should fully visualize not only Morison's pouch on the right and the spleno-renal recess on the left, but should also include evaluation of the hepato-diaphragmatic/splenic-diaphragmatic areas, the caudal liver edge, and the left paracolic gutter

  • The RUQ view is the most frequently positive view on a FAST, with the caudal liver edge being the most common site of fluid visualization (2)

  • The LUQ may be the only positive view in a small percentage of FAST exams and the paracolic gutter is most likely site to find fluid in theses cases (3). In this particular case, had care not been taken to evaluate the entirety of the spleen, the small supcapsular hematoma would have been missed, as would the very small pocket of free fluid at the tip of the spleen

-Allison Zanaboni, MD, Emergency Medicine Ultrasound Fellow

References

1) Miller, M. T., M. D. Pasquale, W. J. Bromberg, T. E. Wasser, and J. Cox. "Not so FAST." J Trauma 54.1 (2003): 52-59.

2) Lobo V, et al. "Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam." Western Journal of Emergency Medicine 18.2 (2017): 270-80.

3) O'Brien, K., U. Stolz, L. Stolz, and S. Adhikari. "LUQ View and the FAST Exam: Helpful or a Hindrance in the Adult Trauma Patient?" Critical Ultrasound Journal 6.Suppl 1 (2014)