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SAEM Clinical Images Series: A Rash You Don’t Want to Miss

rash

A 54-year-old female with a past medical history of diabetes presented to the Emergency Department (ED) for evaluation of unresponsiveness. The patient was found unresponsive by her spouse, who notes she had missed several doses of insulin over the past few days. EMS notes the glucometer read ‘HIGH’ on fingerstick. The patient remains unresponsive on presentation and is unable to contribute further history.

Vital Signs: BP 148/105; HR 120; RR 24; Pulse Oximetry 98% on room air; Temperature 97.7°F

Constitutional: Patient is morbidly obese, unresponsive, and toxic-appearing.

Cardiovascular: Regular rhythm with tachycardia. No murmur.

Pulmonary: Pulmonary effort is normal. Lungs clear to auscultation bilaterally.

Abdomen: Abdomen is soft and non-distended. Unable to assess for tenderness given unresponsiveness.

Skin: Cool, pale, mottled. Large gangrenous, draining, foul-smelling wound on proximal left thigh. There is necrotic, malodorous, black skin noted over the left lower abdomen and left upper thigh.

Neurological: Unresponsive. GCS 3.

White blood cell (WBC) count: 20.5

Comprehensive metabolic panel (CMP): K 5.8; Cr 2.06; BUN 86; Glucose >600

Venous blood gas (VBG): pH<7; lactate 3.4; bicarbonate 7

These photographs show advanced Fournier’s Gangrene, a form of necrotizing fasciitis located in the genitals, perineum, or perianal region. Rapid involvement of our surgical colleagues is crucial, as these patients will not recover without the debridement of affected tissues. Aggressive fluid resuscitation and broad-spectrum antibiotics can be initiated after a surgical consult is made.

This patient presented with impressive visual evidence of advanced disease including severe ecchymosis, but our clinical suspicion must be high as Fournier’s is rapidly progressing and carries a high mortality rate (may be upwards of 30%). Earlier symptoms are genital or perineal pain which may be associated with itching, lethargy, or fever. The biggest exam finding to keep in mind is ‘pain out of proportion to the exam’ as up to 40% of these patients may present without localized symptoms. Advanced disease, as seen in this patient, can present with crepitus and severe ecchymosis of tissue involved. This patient was also found to be in DKA, as evidenced by her laboratory findings. This case should serve as a reminder that it is vital to perform a proper skin examination in patients presenting with hyperglycemia. Ultimately in this case, the patient was intubated for airway protection and started on vasopressors for cardiovascular support in the setting of septic shock. She went into VTach arrest and was successfully defibrillated before further decompensating and becoming asystolic.

Take-Home Points

  • The first task after suspected diagnosis of Fournier’s Gangrene is a page to your surgery service for evaluation and emergent debridement in the OR (depending on your institution this may be general surgery, urology, or both). After your patient is on the path to definitive management, you can begin aggressive fluid administration and broad-spectrum antibiotics (gram-positive, gram-negative, and anaerobic coverage needed).
  • Fournier’s Gangrene is a clinical diagnosis. Imaging may assist in atypical or borderline cases, but should never result in delay of surgical evaluation and treatment. Crepitus and ecchymotic tissue are very late findings; have high clinical suspicion inpatients with signs of swelling, erythema, and pain.

  • Shyam DC, Rapsang AG. Fournier’s gangrene. Surgeon. 2013 Aug;11(4):222-32. doi: 10.1016/j.surge.2013.02.001. Epub 2013 Apr 8. PMID: 23578806.
  • Ustin JS, Malangoni MA. Necrotizing soft-tissue infections. Crit Care Med. 2011 Sep;39(9):2156-62. doi: 10.1097/CCM.0b013e31821cb246. Erratum in: Crit Care Med. 2011 Nov;39(11):2592. Dosage error in article text. PMID: 21532474.
  • Harbrecht BG, Nash NA. Necrotizing Soft Tissue Infections: A Review. Surg Infect (Larchmt). 2016 Oct;17(5):503-9. doi: 10.1089/sur.2016.049. Epub 2016 Aug 2. PMID: 27483003.
  • Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier’s gangrene. A clinical review. Arch Ital Urol Androl. 2016 Oct 5;88(3):157-164. doi: 10.4081/aiua.2016.3.157. PMID: 27711086.
  • Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88. doi: 10.1016/j.jamcollsurg.2008.10.032. Epub 2008 Dec 12. PMID: 19228540.
  • Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. p.592- 593.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2022-11-06T10:25:45-08:00Nov 28, 2022|Dermatology, Infectious Disease, SAEM Clinical Images|
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SAEM Clinical Images Series: ‘Tis Not the Season to be Wheezing

wheezing

A 2-year-old male with a history of solitary kidney presented with greater than one month of daily coughing, wheezing, and decreased appetite. The patient was previously seen by his primary care physician after three weeks of symptoms where he was prescribed albuterol as needed for viral bronchospasm. The patient’s wheezing did not improve after two weeks of albuterol treatment so a chest x-ray was ordered. The patient’s mother denied any fevers, vomiting, diarrhea, weight changes, or night sweats.

Vitals: BP 131/60; Pulse 148; Temp 36.7 °C (98.1 °F) (Axillary); Resp 28; Wt 15.7 kg (34 lb 9.8 oz); SpO2 95%

General: Alert; well appearing

HEENT: Pupils equally reactive to light; moist mucous membranes; nares with normal mucosa without discharge

Cardiovascular: Regular rate; regular rhythm; normal S1, S2; no murmur noted; distal pulses 2+

Pulmonary: Good aeration throughout all lung fields; clear breath sounds bilaterally; prolonged expiratory phase; stridor with agitation

Abdomen: Soft; non-tender; non-distended

White blood cell (WBC) count: 56.1/uL (Blasts 58%)

Platelets: 288/uL

Uric acid: 8.3 mg/dL

LDH: 2231 iU/LD

D-Dimer: 3.22 ug/mL

Fibrinogen: 463 mg/dL

Bronchospasm, bronchiolitis, viral infection, pneumonia, foreign body aspiration, space-occupying lesion, vocal cord dysfunction, cardiac dysfunction, and acute chest in patients with sickle cell disease.

The radiograph shown demonstrates a mediastinal mass. This patient was ultimately diagnosed with T-cell acute lymphoblastic leukemia. T-ALL can present with fatigue, fevers, weight loss, easy bleeding/bruising, paleness, or a mediastinal mass. Mediastinal masses found on chest x-ray require further evaluation to determine the diagnosis, location, and treatment. If malignancy is suspected, an oncology referral and bone marrow sample will be necessary.

Take-Home Points

  • In patients with first-time wheezing that does not improve with bronchodilator therapy, consider alternative diagnoses and further evaluation.
  • A mediastinal mass is found at the time of diagnosis in 10% to 15% of children with acute lymphoblastic leukemia.

  • Steuber, P (2021). Overview of common presenting signs and symptoms of childhood cancer.UpToDate. Retrieved January 2, 2021.2.
  • Juanpere, S., Cañete, N., Ortuño, P., Martínez, S., Sanchez, G., & Bernado, L. (2013). A diagnostic approach to the mediastinal masses. Insights into imaging, 4(1), 29–52.https://doi.org/10.1007/s13244-012-0201-0

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2022-11-06T10:12:53-08:00Nov 21, 2022|Heme-Oncology, Pediatrics, Pulmonary, SAEM Clinical Images|
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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

merocel sponge nasal packing trick setup

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.

merocel tip moisten txa trick

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.

By |2022-11-07T20:42:31-08:00Nov 11, 2022|ENT, Expert Peer Reviewed (Clinical), Tricks of the Trade|
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SplintER: Pop, Lock & Drop It

Shoulder

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).

 

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By |2022-11-08T17:53:57-08:00Nov 9, 2022|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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SAEM Clinical Images Series: An Enlarging Scalp Mass

scalp mass

A 27-day-old female infant born at 34 weeks 4 days with a prenatal history of maternal syphilis treated with penicillin presented with an enlarging scalp mass since birth. Since birth, the patient has had a 1 cm erythematous and flat lesion on her scalp. Since that time, the lesion has continued to grow and develop scales. On the day of presentation, the lesion was noted to be 7-8cm in diameter with multiple surrounding smaller lesions. There is some clear to bloody drainage coming from the main lesion. The patient has otherwise been growing and developing normally. No fevers or other sick symptoms. Feeding well. Mom has no concerns with bowel movements or voiding habits.

General: She is active. She is not in acute distress. She is well-developed.

HEENT: No congestion or rhinorrhea. Mucous membranes are moist. No posterior oropharyngeal erythema.

Cardiovascular: Normal rate and regular rhythm. Normal pulses. No murmur heard.

Pulmonary: Respiratory effort is normal. No retractions. Normal breath sounds. No wheezing.

Skin: Skin is warm. Capillary refill takes less than 2 seconds. On the left side of the scalp, there is a large raised keratinized plaque with a stuck-on appearance. Some red blood is noted when tapped with a white sheet. The plaque is firm and non-tender. On the rest of the scalp, there are several peeling flat lesions with hair attached, and intermittent alopecia.

Neurological: No focal deficit present. She is alert. Suck is normal.

Scalp ultrasound: Posteriorly exophytic left parietal lesion is peripherally echogenic, possibly representing a calcified lesion or cephalohematoma. CT or MRI may be useful for further evaluation, as clinically indicated.

a. Seborrheic Dermatitis: A common, self-limiting eruption consisting of erythematous plaques with greasy, yellow-colored scales that distribute to the areas of the body with sebaceous glands.

b. Atopic Dermatitis: Erythematous, scaly, crusted lesions that are poorly demarcated. It is pruritic and commonly involves the cheeks, scalp, and extensor surfaces.

c. Psoriasis: Uncommon in infants, but can mimic seborrheic dermatitis with sharply demarcated, shiny, erythematous plaques with fine silvery scales in non-intertriginous regions.

d. Tinea Capitis: While rare, tinea can present with a scaly scalp rash in infants. There may be a mild to moderate inflammatory reaction associated as well as hair loss.

e. Langerhans Cell Histiocytosis (LCH): LCH can present as refractory seborrheic dermatitis. There may also be papules or reddish-brown nodules that appear with the rash.

Pityriasis Amiantacea secondary to Seborrheic Dermatitis with a significant build-up of crust and scale. Pityriasis amiantacea is an exaggerated inflammatory response to regional dermatitis, most often seborrheic dermatitis. Treatment consists of a keratinolytic and antibacterial ointment. In this patient, 1:4 part vinegar and water soaks were recommended twice daily, followed by mupirocin ointment until the resolution of the lesions.

Take-Home Points

  • Seborrheic dermatitis is a commonly presenting rash in infancy.
  • When rashes are refractory to conservative management, additional diagnoses and sequelae need to be considered.

  • Amorim GM, Fernandes NC. Pityriasis amiantacea: a study of seven cases. An Bras Dermatol. 2016 Sep-Oct;91(5):694-696. doi: 10.1590/abd1806-4841.20164951. PMID: 27828657; PMCID: PMC5087242.
  • Olanrewaju O. Falusi; Seborrhea. Pediatr Rev February 2019; 40 (2): 93–95. https://doi.org/10.1542/pir.2017-0215. PMID: 30709979.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2023-03-22T12:13:28-07:00Nov 7, 2022|Dermatology, Pediatrics, SAEM Clinical Images|
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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).

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By |2022-10-28T16:35:45-07:00Nov 2, 2022|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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PEM POCUS Series: Pediatric Focused Assessment with Sonography for Trauma (FAST)

PEM POCUS fascia iliaca block

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

  1. Summarize the indications and role of the FAST in the evaluation of injured children
  2. Describe the technique for performing the pediatric FAST
  3. Identify anatomical views and landmarks necessary for a complete pediatric FAST
  4. Accurately interpret each pediatric FAST anatomic view and corresponding landmarks
  5. 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 SignFinding
Temperature37.5oC
Heart Rate158 bpm
Blood Pressure86/48
Respiratory Rate32
Oxygen Saturation98% room air

You conduct your primary assessment:

Trauma AlgorithmAssessment
AirwayPatent: Audibly crying; cervical collar in place
BreathingBilateral breath sounds heard
CirculationSymmetric radial pulses palpable bilaterally; capillary refill 2-3 seconds
DisabilityHis eyes are open, but he is irritable and withdraws to touch (GCS= 13)
ExposureDiffuse 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.

FAST ultrasound probe locations surface anatomy

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].

Free fluid collection areas FAST

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.

probe types

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
RUQ 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
RUQ normal ultrasound view

Figure 6. Normal RUQ ultrasound view with labeled landmarks

  • Diaphragm (including the subdiaphragmatic intraperitoneal space and supradiaphragmatic intrathoracic space)
  • Liver (including the caudal tip of the liver)
  • Kidney (including superior and inferior poles)
  • Hepatorenal Recess (Morison’s Pouch) – A potential space between the liver and kidney where free fluid can collect
Normal Ultrasound Video

Video 1. Normal RUQ ultrasound view
Left ​​Upper Quadrant (LUQ) View
Probe Placement
LUQ 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
Normal LUQ ultrasound view

Figure 8. Normal LUQ ultrasound view with labeled landmarks

  • Diaphragm (including the sub- and supradiaphragmatic areas)
  • Spleen (including splenic tip)
  • Kidney (including superior and inferior poles)
  • Splenorenal Recess – a potential space between the spleen and kidney where free fluid can collect
Normal Ultrasound Video

Video 2. Normal LUQ ultrasound view
Pelvic View
Probe Placement
pelvic 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
Normal pelvic ultrasound views

Figure 10. Normal sagittal (left) and transverse (right) views of the pelvic ultrasound with labeled bladder

  • Bladder (including anterior and posterior walls)
    • In patients with uteruses, make sure to visualize the uterus and the recto-uterine space as fluid can collect between the bladder and uterus and also behind the uterus.
Normal Ultrasound Video

Video 3. Normal pelvic ultrasound view (sagittal)

Video 4. Normal pelvic ultrasound view (transverse)
Pericardial View
Probe Placement
pericardial ultrasound probe

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
Normal pericardial ultrasound view

Figure 12. Normal pericardial subxiphoid ultrasound view with labeled landmarks

  • Hepatic-pericardial interface
  • Left and right ventricles (atria may also be visible)
  • Pericardial space
Normal Ultrasound Video

Video 5. Normal pericardial ultrasound view (no pericardial effusion and normal contractility)

Overarching Goal

The aim of the FAST is to identify free fluid in the abdomen, pelvis, pleural, and pericardial spaces.

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.

free fluid ultrasound labelled

Figure 13. RUQ ultrasound view demonstrating free fluid in Morrison’s pouch in an unlabelled (A) and labelled (B) image

Abnormal RUQ Views

RUQ Free Fluid ultrasound

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.

LUQ free fluid ultrasound

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.

pelvic free fluid ultrasound

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

abnormal pericardial FF ultrasound

Figure 18. Abnormal pericardial view showing pericardial free fluid

Video 9. Abnormal pericardial ultrasound view showing free fluid

ArtifactUltrasound Image
Mirror Artifact

These artifacts are cast above the diaphragm in the RUQ and LUQ views.

ultrasound spine sign artifact

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.

posterior acoustic enhancement

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.

clotted blood artifact

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.

edge artifact ultrasound

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.

Stomach sabotage artifact

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.

Seminal vesicle artifact

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:

StudyStudy Type, Location (Time Frame)N, AgesNotes
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

  • Evaluated the variability of clinician-performed FAST examinations and the use of abdominal CT following FAST examination in children with blunt trauma
  • 373 (5.8%) were diagnosed with intra-abdominal injury
  • 3,015 (46.6%) underwent abdominal CT scanning. Only 887 (13.7%) underwent FAST examination before CT scan.
  • Use of the FAST increased as clinician suspicion for intra-abdominal injury increased. When clinicians had a lower suspicion, they were significantly less likely to order a CT scan, if a FAST examination was performed.
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

  • Studied the impact of the FAST scan on on multiple patient centered outcomes
  • Hemodynamically stable patients with blunt torso trauma were randomized a FAST or no FAST scan.
  • 50 had intra-abdominal injury, including 40 patients (80%) with intraperitoneal fluid and 9 patients underwent laparotomy.
  • No difference in the proportion obtaining CT, missed intra-abdominal injuries, length of stay, or cost.
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

  • Query of trauma database for children who met institutional trauma activation criteria and who also had a FAST performed.
  • 50 (14%) patients were found to have an intra-abdominal injury with 13 (4%) requiring intervention.
  • Positive FAST and positive physical exam were found to be independent predictors of intra-abdominal injury, both with a 74% sensitivity.
  • When combined, FAST and physical exam (FAST-enhanced physical exam) improved sensitivity to 88% (NPV 97.3%).
Liang et al., Pediatr. Emerg Care 2021 [11]

Systematic Review and Meta-Analysis

Multicenter (January 1966- March 2018)

2,135

Study dependent

  • Based on 8 studies, the FAST had a pooled sensitivity of 35% and specificity 96% for intra-abdomianal injury.
  • All 8 studies were prospective; 1 of the 8 was the 2017 Holmes paper mentioned above [12].
  • Conclusion: For a positive FAST, the post-test probability of an intra-abdominal injury was 63% meaning that those patients should get a CT to characterize injury. If the FAST is negative, you may still need a CT, because the post-test probability of intra-abdominal injury was still relatively high at 9%.
  • None of the studies had low enough negative likelihood ratios to obviate the need for CT.
  • Although a negative FAST alone does not exclude an intra-abdominal injury, it can identify low-risk patients with a reassuring physical exam and GCS 14-15.
Kornblith et al., JAMA 2022 [15]

Expert, consensus–based Modified Delphi

International multicenter (May 2021 to June 2021)

n/a
  • Generated definitions for complete pediatric FAST and E-FAST studies in the context of blunt trauma

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

  1. Leading Causes of Death by Age Group United States 2018. Centers for Disease Control and Prevention. Accessed September 28, 2022
  2. 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
  3. 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
  4. 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
  5. Jehle DVK, Stiller G, Wagner D. Sensitivity in Detecting Free Intraperitoneal Fluid With the Pelvic Views of the FAST Exam.
  6. 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
  7. 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
  8. 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
  9. Bloom BA, Gibbons RC. Focused Assessment with Sonography for Trauma. In: StatPearls. StatPearls Publishing; 2021. Accessed November 14, 2021.
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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

By |2022-10-12T10:48:28-07:00Oct 7, 2022|Expert Peer Reviewed (Clinical), Pediatrics, PEM POCUS, Radiology, Ultrasound|
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