By Katherine WD Dolbec, MD, FACEP, CAQSM|2022-12-28T09:09:42-08:00Dec 28, 2022|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
SplintER Series: Hip, Hip, Hooray!
A 67-year-old male with a history of bilateral total hip arthroplasties (THA) several years ago presents with left hip pain after a fall. He was walking downstairs and slipped, twisting his leg internally and with adduction and flexion of the hip to catch himself. He denies falling but felt an immediate pop in his left hip and could no longer bear weight. AP and lateral radiographs of the pelvis and left hip were obtained and are shown above (Image 1. Case courtesy of Dr Andrew Taylor, Radiopaedia.org, rID: 67457). (more…)SplintER Series: The Hidden Post
A 23-year-old male presents to the emergency department with right ankle pain after he rolled his ankle while walking down the stairs. An ankle exam reveals ecchymosis over the posterior ankle and tenderness of the distal tibia. His neurovascular exam is intact. The radiograph above was obtained (Image 1. X-ray right ankle. Original image provided by Justine Ko, MD).
Trick of the Trade: Managing Epistaxis with Merocel Nasal Packing and an Angiocatheter
There are many ways to manage epistaxis. Once nasal clamping and cauterization fail, the next step is to consider using tranexamic acid (TXA) and performing nasal packing. Inflatable packing devices such as a Rhinorocket are painful to insert and do not conform well to the shape of the naris. The expandable Merocel nasal packing, a compressed, dehydrated sponge, provides a softer, alternative option, although the insertion process can be painful given its initial rigid, edged structure. We propose 2 strategic tricks to optimize your nasal packing technique using the Merocel sponge.
Trick of the Trade: Strategic expansion of the Merocel sponge
The common approach for Merocel packing involves inserting the unexpanded sponge into the nose, tilting the patient’s head back, and dripping in TXA solution to expand the sponge to tamponade the bleeding.
Trick #1: Wet the tip of the Merocel’s sharp edge to allow for a softer cushion to slide the packing more comfortably and deeper into the naris.
Trick #2: Use an angiocatheter to deliver the TXA solution directly onto the mid-portion of the packing. Commonly, the TXA solution is dripped onto the outer end, which may cause an uneven and inadequate expansion at the site where the bleeding may be occurring. Because blood also can react with the packing, it is likely the blood will expand the packing before TXA reaches the center by osmosis. Another benefit of Merocel expansion starting at the center is that it will help anchor the sponge in place. In contrast, TXA administration at the outer tip first may pull the sponge out of the naris a few millimeters.
Equipment
- 20g or 22g angiocatheter (closed IV catheter system)
- Tranexamic acid solution
- A syringe
- Merocel nasal dressing
Technique
1. Insert the angiocatheter needle into the Merocel packing about ⅓ the distance from the external end of the packing. Remove the needle, leaving the plastic angiocatheter in place.
2. Soak the insertion tip of the nasal packing with a drop of TXA to soften it. Or apply a light coat of an antibiotic ointment or petroleum jelly to the insertion tip for lubrication. This will make it easier to advance the packing and also less painful for patients. Advance the Merocel into the affected naris just as you would a nasogastric tube. Some additional tips are in the ALiEM article about nasogastric and nasopharyngeal tube insertion.
3. Once the nasal packing is fully inserted, expand the sponge by administering TXA via the attached angiocatheter. The mid-portion of the sponge should expand first, thus preventing outward slippage of packing. Also TXA more quickly reaches the area of bleeding rather than from a more gradual osmotic effect when dripped in from the external tip.
SplintER: Pop, Lock & Drop It
A 38-year-old female presents to the ED with right shoulder pain after a fall directly onto that shoulder. She noticed immediate pain and difficulty moving the arm associated with mild tingling in her right fingers. The radiographs above were obtained in the ED (Image 1. AP and lateral radiographs of the right shoulder, author’s own images).
SplintER Series: Let the Feet Drop
A 20-year-old male distance runner who was jogging and happened to be running past the emergency department presented with severe bilateral leg pain, foot pain, and foot numbness that had resolved by the time he was evaluated in the ED. The x-ray above was obtained (Image 1. X-ray of the leg. Case courtesy of Andrew Murphy, Radiopaedia.org, rID: 41408).PEM POCUS Series: Pediatric Focused Assessment with Sonography for Trauma (FAST)
Read this tutorial on the use of point of care ultrasonography (POCUS) for Pediatric Focused Assessment with Sonography for Trauma. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.
Module Goals
- Summarize the indications and role of the FAST in the evaluation of injured children
- Describe the technique for performing the pediatric FAST
- Identify anatomical views and landmarks necessary for a complete pediatric FAST
- Accurately interpret each pediatric FAST anatomic view and corresponding landmarks
- Describe the literature on the pediatric FAST
Case Introduction
You receive an emergency medical services (EMS) notification that they are 2 minutes out from your ED with a 3-year-old boy who fell down a flight of 10 concrete stairs. He is awake and breathing spontaneously but irritable and crying with an obvious deformity to his right arm. EMS placed him in a cervical-collar and are bringing him to your ED.
| Vital Sign | Finding |
|---|---|
| Temperature | 37.5oC |
| Heart Rate | 158 bpm |
| Blood Pressure | 86/48 |
| Respiratory Rate | 32 |
| Oxygen Saturation | 98% room air |
You conduct your primary assessment:
| Trauma Algorithm | Assessment |
|---|---|
| Airway | Patent: Audibly crying; cervical collar in place |
| Breathing | Bilateral breath sounds heard |
| Circulation | Symmetric radial pulses palpable bilaterally; capillary refill 2-3 seconds |
| Disability | His eyes are open, but he is irritable and withdraws to touch (GCS= 13) |
| Exposure | Diffuse superficial abrasions to face and extremities; tenderness and swelling to right forearm; abdomen soft without distension although difficult to appreciate tenderness as patient is crying |
You call a trauma consult, connect the patient to the monitor, establish IV access, and reach for your ultrasound probe to perform a FAST.
Trauma remains the leading cause of childhood death and disability in children >1 year of age [1]. While head and thoracic trauma account for most death and disability in children, missed abdominal injuries are a common cause of mortality [2]. Particularly in polytrauma scenarios, it can be difficult for children to locate the exact area of pain and assessing for abdominal injury can be difficult.
FAST is a rapid ultrasound examination of 4 locations (Figure 1) with the primary objective of detecting free fluid within the abdomen, pleural space, and pericardial sac. In injured adults, FAST is useful in rapidly triaging hemodynamically unstable patients to expedite operative management [3]. Free fluid in any one view deems the FAST positive. However, for a FAST to be determined as negative, each of the landmarks in each individual view must be interrogated and evaluated for the presence of free fluid. The role of FAST in the hemodynamically stable child after blunt abdominal trauma is nuanced.
Figure 1. Location of the 4 FAST views: Right upper quadrant (A), left upper quadrant (B), pelvic (C), subxiphoid (D). Illustration by Dr. Maytal Firnberg.
FAST Technique
The FAST can be performed in parallel with the rest of the trauma evaluation. Serial FAST exams can be repeated as needed throughout the child’s ED stay, particularly if the child has an unexplained change in clinical status. For a complete FAST, each of the views needs to be assessed and every landmark in each view must be visualized. In addition to intra-abdominal hemorrhage and pericardial effusion, point-of-care ultrasound can be used to evaluate the thorax for hemothorax and pneumothorax. When included together, this exam is referred to as the extended FAST (E-FAST).
In general, the child should be positioned supine as free fluid will pool in dependent areas (Figure 2). In children, the recto-vesicular or recto-uterine pouch is the most common place for fluid to collect depending on the patient’s sex [4]. Fluid in the abdomen can move freely up the right pericolic gutter into the right upper quadrant. The left pericolic gutter is higher and the phrenicocolic ligament blocks the flow; consequently, fluid tends to flow to the right pericolic area over the left, regardless of injury type.
Some controversy exists about how much free fluid can be detected by the FAST, and most studies focused on adults. For pediatric patients, we are using 100 mL as it was the median quantity of fluid needed for ultrasound detection of the pelvic view [5].
Figure 2. Free fluid accumulates in dependent areas. In a supine patient, this is the hepato-renal pouch (right upper quadrant view), the spleno-renal pouch (left upper quadrant view), and recto-vesicular or recto-uterine pouch (pelvic view). Illustration by Dr. Maytal Firnberg.
Use a low frequency ultrasound probe: phased array probe (Figure 3) or curvilinear probe (Figure 4).
- Phased array probes can generally achieve adequate penetration particularly for smaller pediatric patients and have a smaller footprint allowing for easier intercostal views.
- Curvilinear probes allow for further penetration and greater depth of abdominal views and may be useful in larger children.
In order to obtain each landmark in the views discussed below, the ultrasound probe will often need to be manipulated in a number of orientations.
Figure 3 (left): Phased array ultrasound probe; Figure 4 (right): Curvilinear ultrasound probe
For the 4 scanning areas, each view must be interrogated completely, and the clinician should identify all key landmarks. The red dot on the probe correlates with the probe marker.
| Right Upper Quadrant (RUQ) View | |
|---|---|
| Probe Placement |  Figure 5. Place the probe in the right mid axillary line (around ribs 8-10) with the probe marker towards the head. Fan anterior and posterior and slide up or down a rib space to view the key landmarks. |
| Normal View and Landmarks |  Figure 6. Normal RUQ ultrasound view with labeled landmarks
|
| Normal Ultrasound Video | Video 1. Normal RUQ ultrasound view |
| Left Upper Quadrant (LUQ) View | |
|---|---|
| Probe Placement |  Figure 7. Place the probe in the left mid or posterior axillary line (around ribs 7-9) with the probe maker towards the head. Fan anterior and posterior and slide up or down a rib space to view the landmarks. In infants and smaller children, the midaxillary line generally provides the best view. |
| Normal View and Landmarks |  Figure 8. Normal LUQ ultrasound view with labeled landmarks
|
| Normal Ultrasound Video | Video 2. Normal LUQ ultrasound view |
| Pelvic View | |
|---|---|
| Probe Placement |  Figure 9. Place the probe in the midline below the umbilicus and fan or rock the probe down towards the feet until the bladder comes into view. Fan through the entire bladder in both transverse and sagittal orientations. For the transverse and sagittal views, the probe marker should be towards the patient’s right and head, respectively. |
| Normal View and Landmarks |  Figure 10. Normal sagittal (left) and transverse (right) views of the pelvic ultrasound with labeled bladder
|
| Normal Ultrasound Video | Video 3. Normal pelvic ultrasound view (sagittal)Video 4. Normal pelvic ultrasound view (transverse) |
| Pericardial View | |
|---|---|
| Probe Placement |  Figure 11. Place the probe under the sternum for a subxiphoid view. Point the probe towards the left shoulder and the probe marker towards the right shoulder. This view requires gentle downward pressure as you drop the angle of the probe down towards the patient. If unable to obtain this subxiphoid view, look parasternally. |
| Normal View and Landmarks |  Figure 12. Normal pericardial subxiphoid ultrasound view with labeled landmarks
|
| Normal Ultrasound Video | Video 5. Normal pericardial ultrasound view (no pericardial effusion and normal contractility) |
Free fluid will appear anechoic (black) and will pool in dependent, unobstructed areas. On the right side, fluid in the abdomen can move freely up the pericolic gutter into the right upper quadrant. On the left, the pericolic gutter is higher and the phrenicocolic ligament may impede its flow. The RUQ view is the most sensitive view in adults while the pelvic view is the most sensitive view in children [4]. The following are examples of free fluid identified within the various views of the FAST scan.
Figure 13. RUQ ultrasound view demonstrating free fluid in Morrison’s pouch in an unlabelled (A) and labelled (B) image
Abnormal RUQ Views
Figures 14 (left) and 15 (right). Abnormal RUQ ultrasound views with free fluid. Note that the right image demonstrates free fluid both above and below the diaphragm, meaning fluid that is in the peritoneal and pleural cavities, respectively.
Video 6. Abnormal RUQ ultrasound view with free fluid in the pleural space and Morison’s pouch
Abnormal LUQ Views
Tip: In the LUQ view, the free fluid tends to collect just under the diaphragm. Be sure to look at the diaphragm-spleen interface.
Figure 16. Abnormal LUQ view with free fluid below the diaphragm and above the spleen
Video 7. Abnormal LUQ ultrasound view with free fluid under the diaphragm
Abnormal Pelvic Views
Tip: Free fluid can collect between the bladder and colon in male patients. In female patients, fluid can collect between the bladder and uterus or between the uterus and colon.
Figure 17. Abnormal pelvic view showing free fluid between the bladder and colon
Video 8. Abnormal pelvic ultrasound on sagittal view showing free fluid
Abnormal Pericardial Views
Figure 18. Abnormal pericardial view showing pericardial free fluid
Video 9. Abnormal pericardial ultrasound view showing free fluid
| Artifact | Ultrasound Image |
|---|---|
| Mirror Artifact These artifacts are cast above the diaphragm in the RUQ and LUQ views. |  Figure 19. The RUQ view shows liver parenchyma architecture cephalad of the diaphragm as a mirror artifact. |
| Spine Sign The spine is not typically seen cephalad to the diaphragm by ultrasound due to air artifact. If the spine is visualized above the diaphragm, this indicates the lungs are no longer filled with air, which normally causes the refraction/reflection of ultrasound waves. This occurs in instances where air is replaced by fluid, such as a pleural effusion or hemothorax, or by a dense consolidation or contusion. |  Figure 20. A – The spine is not visualized cephalad to the diaphragm in a normal RUQ ultrasound view. B – A pleural effusion results in a “spine sign” where the spine can be seen extended beyond the diaphragm. |
| Posterior Acoustic Enhancement Since the bladder is a fluid filled structure which transmits ultrasound waves well, the waves illuminate the posterior wall of the bladder in a phenomenon called posterior acoustic enhancement. This brightness can hide free fluid settled in the pelvis. Thus, decrease the far field gain (brightness) behind the bladder to avoid missing obscured free fluid. |  Figure 21. Bladder view with posterior acoustic enhancement artifact |
| Old Blood As blood pools, the ultrasound appearance of clotted blood may have similar echotexture to surrounding soft tissue or organs rather than appear anechoic (black) as typical free fluid. |  Figure 22. Bladder view showing hypoechoic clotted blood that may be confused as soft tissue |
| Edge Artifact Due to ultrasound physics and sound wave transmission between structures of different densities, edge artifacts are seen as a dark thin line tracing off the edge of this interface extending to the bottom of the screen. It can be misinterpreted as free fluid. |  Figure 23. RUQ view with an edge artifact |
| Stomach Sabotage A full stomach will appear as a rounded collection of fluid and air anterior to the spleen. It may mimic a free fluid collection. Fan posterior of the stomach to visualize the spleen and perisplenic spaces. |  Figure 24. The stomach obscures the LUQ view. Note the mix of bright (air) and dark (other gastric contents) inside the stomach. |
| Seminal Vesicles Seminal vesicles can appear as hypoechoic, contained, symmetric structures posterior to the bladder in the transverse view and can be mistaken for free fluid. |  Figure 25. Bladder view showing hypoechoic seminal vesicles posterior to the bladder |
- The FAST evaluates for the presence free fluid only [6].
- In trauma, the assumption is that free fluid is due to hemorrhage; however, the FAST cannot adequately distinguish between blood and other types of free fluid, such as ascites or physiologic free fluid.
- It does not directly evaluate for injury to solid organs, bowel, diaphragm, or retroperitoneum.
- In isolation, the FAST cannot rule out intra-abdominal injury [7].
- The FAST can not detect tiny amounts of hemorrhage.
- The scan may appear initially negative with a free fluid volume under a threshold of about 100 mL [5].
- Repeat FAST scans may help detect an accumulation of fluid over time throughout a child’s evaluation.
- Trace pelvic free fluid may be physiologic in children, thus limiting specificity [8].
For adults, the FAST is integral in the diagnostic evaluation after blunt and penetrating trauma [9]. It improves outcomesby decreasing the time to surgical intervention, patient length of stay, surgical complications, CT scan, and diagnostic peritoneal lavage rates [3].
For children, however, the literature is less clear cut. Pediatric injury patterns commonly result in solid organ lacerations without hemoperitoneum, making the FAST a less sensitive means for detecting important intra-abdominal injury [7]. Further, the test characteristics of the FAST have variable reliability and accuracy in children [7,10,11]. This variation contributes to uncertainty of how to use results of the FAST and decreases its impact on potentially important clinical outcomes such as rates of CT scans and ED length of stay [12]. However…
- The FAST is able to identify injuries that the physical exam can miss. When combined with the physical exam, the FAST scan has been found to have better test characteristics than the physical exam alone [13].
- The improvement in POCUS technology, widespread pediatric-specific POCUS expertise, and a focus on clinically relevant outcomes have allowed clinicians to integrate the FAST into novel diagnostic strategies for children after blunt torso trauma [14].
- The pediatric FAST may be used in combination with signs, symptoms, and other diagnostic testing as a screening algorithm to decrease unnecessary CTs. Investigators will need to conduct larger validation trials to confirm and clarify the algorithm.
Studies that have shaped the pediatric FAST literature landscape:
| Study | Study Type, Location (Time Frame) | N, Ages | Notes |
|---|---|---|---|
| Menaker et al., J Trauma Acute Care Surg 2014 [7] | Secondary Analysis of a Prospective Observational Study Multicenter (May 2007 to January 2010) | 6,468 Median age, 11.8 yrs; interquartile range (IQR) 6.3-15.5 yrs |
|
| Holmes et al., JAMA 2017 [12] | Randomized Clinical Trial University of California, Davis Medical Center (April 2012-May 2015) | 925 Mean 9.7 yrs; SD 5.3 yrs |
|
| Kornblith et al., Acad Emerg Med 2020 [13] | Retrospective Review University of California, Benioff Children’s Hospital Oakland (November 2013 to July 2015) | 354 Median age 8 yr; IQR 4-12 yr |
|
| Liang et al., Pediatr. Emerg Care 2021 [11] | Systematic Review and Meta-Analysis Multicenter (January 1966- March 2018) | 2,135 Study dependent |
|
| Kornblith et al., JAMA 2022 [15] | Expert, consensus–based Modified Delphi International multicenter (May 2021 to June 2021) | n/a |
|
Future Directions
The use of FAST in pediatric trauma is an evolving area of active research. A clear consensus on the way the FAST fits into pediatric trauma protocols is yet to be determined. Studies will need to be performed to examine the benefits of serial FAST, patient factors that may influence its test characteristics, and effect on patient centered outcomes.
There are a number of strategies to incorporate the above studies into clinical care, and one example is illustrated in the algorithm below. Keep in mind that FAST should be used in conjunction with other signs and symptoms of intra-abdominal injury (vomiting, decrease breath sounds, abdominal pain, thoracic wall trauma). Also consider laboratory testing such as liver function tests and urinalysis, depending on the clinical context and consulting your surgical colleagues.
Sample Algorithm for Pediatric Blunt Torso Trauma
Zuckerberg San Francisco General Pediatric Blunt Torso Trauma Algorithm (shared with permission)
Case Resolution
The primary survey is completed with airway, breathing, and circulation noted to be intact. As someone starts the secondary survey, you grab a phased array probe and perform a FAST . You observe the following:
| RUQ View | LUQ View |
| Pelvis View, Sagittal | Pelvis View, Transverse |
| Pericardial View |
You call out ‘FAST negative’ to the documenting nurse and team leader.
ED Course
The patient has radiographs performed of his chest, pelvis, neck, and right forearm. He is diagnosed with a type 3 supracondylar humeral fracture but the other radiographs are negative for fracture and pneumothorax. The rest of his evaluation is reassuring. Orthopedics is consulted and they admit him for surgery. He is discharged home the next day with pediatrician follow up.
Pediatrician Clinic Follow-Up
At her pediatrician clinic visit 1 week later, he is playful and active with his arm in a cast. He has been eating and drinking normally without any complaints of abdominal pain. He has orthopedics follow up scheduled for the following week.
Learn More…
References
- Leading Causes of Death by Age Group United States 2018. Centers for Disease Control and Prevention. Accessed September 28, 2022
- Kenefake ME, Swarm M, Walthall J. Nuances in Pediatric Trauma. Emerg Med Clin North Am. 2013;31(3):627-652. doi:10.1016/j.emc.2013.04.004
- Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235. doi:10.1016/j.annemergmed.2006.01.008
- Brenkert TE, Adams C, Vieira RL, Rempell RG. Peritoneal fluid localization on FAST examination in the pediatric trauma patient. Am J Emerg Med. 2017;35(10):1497-1499. doi:10.1016/j.ajem.2017.04.025
- Jehle DVK, Stiller G, Wagner D. Sensitivity in Detecting Free Intraperitoneal Fluid With the Pelvic Views of the FAST Exam.
- Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM. 2019;21(6):727-738. doi:10.1017/cem.2019.381
- Menaker J, Blumberg S, Wisner DH, et al. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. J Trauma Acute Care Surg. 2014;77(3):427-432. doi:10.1097/TA.0000000000000296
- Berona K, Kang T, Rose E. Pelvic Free Fluid in Asymptomatic Pediatric Blunt Abdominal Trauma Patients: A Case Series and Review of the Literature. J Emerg Med. 2016;50(5):753-758. doi:10.1016/j.jemermed.2016.01.003
- Bloom BA, Gibbons RC. Focused Assessment with Sonography for Trauma. In: StatPearls. StatPearls Publishing; 2021. Accessed November 14, 2021.
- Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg. 2007;42(9):1588-1594. doi:10.1016/j.jpedsurg.2007.04.023
- Liang T, Roseman E, Gao M, Sinert R. The Utility of the Focused Assessment With Sonography in Trauma Examination in Pediatric Blunt Abdominal Trauma: A Systematic Review and Meta-Analysis. Pediatr Emerg Care. 2021;37(2):108-118. doi:10.1097/PEC.0000000000001755
- Holmes JF, Kelley KM, Wootton-Gorges SL, et al. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial. JAMA. 2017;317(22):2290-2296. doi:10.1001/jama.2017.6322
- Kornblith AE, Graf J, Addo N, et al. The Utility of Focused Assessment With Sonography for Trauma Enhanced Physical Examination in Children With Blunt Torso Trauma. Acad Emerg Med Off J Soc Acad Emerg Med. 2020;27(9):866-875. doi:10.1111/acem.13959
- Riera A, Hayward H, Torres Silva C, Chen L. Reevaluation of FAST Sensitivity in Pediatric Blunt Abdominal Trauma Patients: Should We Redefine the Qualitative Threshold for Significant Hemoperitoneum? Pediatr Emerg Care. 2021;37(12):e1012. doi:10.1097/PEC.0000000000001877
- Kornblith AE, Addo N, Plasencia M, et al. Development of a Consensus-Based Definition of Focused Assessment With Sonography for Trauma in Children. JAMA Netw Open. 2022;5(3):e222922. Published 2022 Mar 1. doi:10.1001/jamanetworkopen.2022.2922