Case 68: Erector Spinae Plane Block for Rib Fracture Pain

Anthony Galvez, Tommy Ngo, Akash Desai

A 62yo male with a history of HIV and hypothyroidism presents to the ED with left-sided chest pain and shortness of breath after a near-syncopal episode followed by a fall 3 days prior. The patient was carrying groceries when he suddenly felt lightheaded and fell to the ground. He denies loss of consciousness or head trauma and reports having not eaten or drinking anything all day. Since the fall, he has had progressively worsening left-sided chest pain and spasming.

Vitals: BP 157/87, HR 70, RR 18, T 98.3F, SpO2 98%

Exam:

The patient appeared uncomfortable, splinting with respirations, and was wearing a self-applied weightlifting brace over the left chest wall.
Chest wall examination revealed focal tenderness to palpation over the left lateral and posterior ribs without overlying ecchymosis, crepitus, or step-off deformity. There was no flail segment appreciated. Auscultation revealed clear and equal breath sounds bilaterally.
Cardiac exam was regular without murmurs.
The abdomen was soft and non-tender.
Neurologic exam was grossly intact with no focal deficits.

ED Course:

Syncope workup showed no significant electrolyte derangements or anemia.
Chest x-ray was obtained to evaluate for trauma which showed acute displaced left posterior 4^th-7^th rib fractures. No pleural effusion or pneumothorax was seen.
After administration of ibuprofen, acetaminophen, and oxycodone, the patient’s pain was still reported as 8-9/10. The patient was offered and consented to an erector spinae plane block for multimodal pain control.
The block was performed at bedside using ultrasound guidance (Figures 1-2). Half an hour after the block was performed, the patient’s pain had reduced to 4/10. The patient reported increased range of motion and subsequently was able to walk himself to the bathroom.
The patient was subsequently cleared by trauma surgery for discharge home with multimodal pain control and follow up with PCP.

Figure 1: With transducer dot caudally, the needle is inserted and aimed at the transverse process. A faint echogenic line represents the needle terminating on the transverse process (TP).

Figure 2: With the needle pressed against the transverse process, the anesthetic is injected just below the erector spinae muscle. An arrow depicts the injectate, which should be seen spreading across the underside of the erector spinae (ES) muscle.

Discussion
Effective pain control in patients with rib fractures is critical to prevent complications such as atelectasis, pneumonia, and respiratory failure.^1,2 Traditional management often relies on systemic opioids, which carry known risks including respiratory depression, cough suppression, and delirium.³ The erector spinae plane block (ESPB) is a regional anesthesia technique that provides effective analgesia for thoracic wall pain while reducing opioid requirements.^4,5,6 In this case, ESPB resulted in a clinically meaningful reduction in pain and improved range of motion after failure of multimodal oral analgesia and facilitated safe discharge from the emergency department. The ESPB is well suited for the emergency room setting as it can easily be done at bedside using ultrasound guidance and is performed away from the pleura and other critical structures.^5,6 Additionally, this technique is more technically straightforward in comparison to paravertebral or epidural blocks, which require greater technical expertise and carry higher risk.^7,8 By targeting the fascial plane at the level of the transverse process, there is consistent blockade of the dorsal rami, with variable anterior spread to the ventral rami and intercostal nerves, allowing the ESPB to effectively provide broad unilateral analgesia across multiple rib levels^4,5,9,10 (Figures 3-5).

**Figure 3**. Probe positions and corresponding ultrasound views at three lateral levels: spinous process (midline), transverse process (~3 cm lateral), and rib. The transverse process appears blunted and squared vs. the rounded rib shadow; pleura is visible deep to the rib but obscured behind the TP. (Source: Highland Ultrasound).

**Figure 4**. Posterior thoracic musculature with the right side partially reflected to expose the spine. The needle (center) is shown targeting the ESP at the level of the transverse process. Both superior and inferior approaches are demonstrated with the ultrasound transducer (blue) positioned in the parasagittal plane. Yellow nerves visible on the left demonstrate the multilevel coverage achieved by cephalocaudal LA spread. (Source: Regional Anesthesiology and Acute Pain Medicine).

**Figure 5**. Cross-section at T5 showing local anesthetic (dark blue) injected into the erector spinae plane (ESP), with anterior spread (light blue) toward the dorsal ramus (DR), ventral ramus (VR), and intercostal nerves (IC). Needle target is deep to the erector spinae (ES) and rhomboid (Rh), superficial to the transverse process (TP). (Source: Highland Ultrasound)

References:

Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth. 2017;118(3):474-475. doi:10.1093/bja/aex013
Luftig J, Mantuani D, Herring AA, Dixon B, Clattenburg E, Nagdev A. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med. 2018;36(8):1391-1396. doi:10.1016/j.ajem.2017.12.060
Peek J, Smeeing DPJ, Hietbrink F, Houwert RM, Marsman M, de Jong MB. Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2019;45(4):597-622. doi:10.1007/s00068-019-01116-w
Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621-627. doi:10.1097/AAP.0000000000000451
Kumar G, Kumar Bhoi S, Sinha TP, Paul S. Erector spinae plane block for multiple rib fracture done by an emergency physician: a case series. Australas J Ultrasound Med. 2021;24(3):167-172. doi:10.1002/ajum.12261
Jiang M, Peri V, Ou Yang B, Chang J, Hacking D. Erector spinae plane block as an analgesic intervention in acute rib fractures: a scoping review. Local Reg Anesth. 2023;16:81-90. doi:10.2147/LRA.S414056
Palachick BJ, Carver RA, Byars DV, Martyak MT, Collins JN. Erector spinae plane blocks for traumatic rib fractures performed by nonspecialized emergency physicians: a prospective, interventional study. Am Surg. 2022;88(9):2124-2126. doi:10.1177/00031348221078428
Elawamy A, Morsy MR, Ahmed MAY. Comparison of thoracic erector spinae plane block with thoracic paravertebral block for pain management in patients with unilateral multiple fractured ribs. Pain Physician. 2022;25(6):483-490.
Ivanusic J, Konishi Y, Barrington MJ. A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 2018;43(6):567-571. doi:10.1097/AAP.0000000000000789
Chin KJ, El-Boghdadly K. Mechanisms of action of the erector spinae plane (ESP) block: a narrative review. Can J Anaesth. 2021;68(3):387-408. doi:10.1007/s12630-020-01875-2

April 16, 2026April 16, 2026

Case 65: Knee Pain

Colleen Sweeney, Akash Desai

A 55-year-old female with no pertinent past medical or surgical history was brought in by ambulance after a bicycle accident with left knee pain. She was unhelmeted while riding a bicycle going 10mph when she collided into an e-bike. Her left knee was caught in her handlebars; she denied head trauma and had no LOC.

Vitals: BP 168/120, HR 70, T 96.0F, RR 22, SpO2 95% on RA, BMI 24.41

Physical Exam:
General/Neuro: alert, in acute distress, diaphoretic
HEENT: normocephalic, atraumatic, EOMI
CV: normal rate
Resp: tachypneic
Abdomen: flat, soft, no tenderness
MSK: RLE normal
L knee: +swelling, +deformity. Skin intact, small ecchymosis to left lateral knee. Knee diffusely tender to palpation. Sensation intact to light touch throughout. Palpable popliteal, PT, and DP pulses. Able to wiggle toes. Compartments compressible. Patient unable to tolerate any movement of L knee secondary to pain.
L lower leg: +swelling from knee distally, no lacerations
L ankle/foot: normal pulse, sensation intact to light touch throughout

Radiographs were indicated and initially attempted at bedside, however were unsuccessful as the patient was unable to tolerate the pain. Radiography was delayed until two hours due to pain management and census. In the interim, a POCUS was performed

Figure 1. Transverse view of infrapatellar lipohemarthrosis.

Figure 2. Longitudinal view of infrapatellar lipohemarthrosis.

Figure 3. Longitudinal view of tibia with cortical break (arrow).

Xray findings: "Acute, comminuted, displaced proximal tibial fracture extending to the lateral and central tibial plateau. Acute, mildly displaced and impacted fibular neck fracture. No fracture or malalignment of the left ankle. "

The patient was admitted to the trauma surgery service. The next day, she underwent a left knee spanning external fixator for stabilization of the tibial plateau fracture. One week later, she had an ORIF for long-term fixation of the fracture as well as a hamstring tendon repair.

Discussion

POCUS is increasingly utilized in acute musculoskeletal trauma. The patient’s gross knee deformity after a traumatic event led to POCUS utilization to provide rapid clinical guidance. In this patient, ultrasound was complete half an hour prior to the first attempt at radiographs and over 2 hours prior to their completion, thus proving useful in differentiating the severity of a patient’s injury during prolonged wait times and facilitating early orthopedic surgery consultation.

Ultrasound, though not a primary diagnostic modality for acute fractures, offers sensitivity of 87% and specificity of 70% for proximal tibial fractures specifically in cadaveric models [3]. In Figure 3, the cortical break visible on the left side of the image corresponds to the proximal tibial fracture seen on X-ray.

Figures 1 and 2 both demonstrate lipohemarthrosis. The presence of hemarthrosis, rather than a simple joint effusion, raises the suspicion for an intra-articular injury or fracture, with ultrasound demonstrating a sensitivity of 90% and specificity of 86% for this finding [2]. When lipohemarthrosis is identified—most clearly visualized in Figure 2 as hypoechoic fat “bubbles” originating from the bone marrow—it is even more indicative of an intra-articular fracture, carrying 97% sensitivity and 100% specificity for such fractures [4]. In its early stage, lipohemarthrosis appears as scattered fat globules, which later settle into the characteristic triple-layer pattern of fat, serum, and blood products [5]. Recognition of hemarthrosis or lipohemarthrosis on ultrasound may help risk-stratify patients for joint aspiration, potentially reducing unnecessary aspirations and associated infection risk.

The presence of lipohemarthrosis is highly suggestive of a distal femur or proximal tibial fracture. Recognizing these findings early allows clinicians to maintain a high index of suspicion for periarticular fracture prior to radiographic confirmation, enabling prompt immobilization, consultation, and fracture management. This early identification facilitates more efficient triage and throughput in the ED and underscores POCUS as a worthwhile adjunct in knee trauma in addition to traditional imaging such as X-ray, CT, and MRI [6].

References:

Stannard JP, Lopez R, Volgas D. Soft tissue injury of the knee after tibial plateau fractures. J Knee Surg. 2010;23(4):187-192. doi:10.1055/s-0030-1268694
Taljanovic MS, Chang EY, Ha AS, et al. ACR appropriateness criteria® acute trauma to the knee. Journal of the American College of Radiology. 2020;17(5). doi:10.1016/j.jacr.2020.01.041 
Demers G, Migliore S, Bennett DR, et al. Ultrasound evaluation of cranial and long bone fractures in a cadaver model. Mil Med. 2012;177(7):836-839. doi:10.7205/milmed-d-11-00407
Bonnefoy, O., Diris, B., Moinard, M. et al. Acute knee trauma: role of ultrasound. Eur Radiol 16, 2542–2548 (2006). Doi:10.1007/s00330-006-0319-x
Levrini G, Reggiani G, Vacondio R, Zompatori M, Nicoli F. Post-traumatic knee lipohemarthrosis: Temporal evolution with progressive separation of the three layers of the joint effusion by ultrasonography and computed tomography. European Journal of Radiology Extra. 2006;60(1):37-41. doi:10.1016/j.ejrex.2006.06.011 
De Maeseneer M, Marcelis S, Boulet C, et al. Ultrasound of the knee with emphasis on the detailed anatomy of anterior, medial, and lateral structures. Skeletal Radiol. 2014;43(8):1025-1039. doi:10.1007/s00256-014-1841-6

July 28, 2025July 28, 2025

Case 52: The Role of FAST in Penetrating Thoracoabdominal Injury

Brandon Woo, Elaine Yu

A 28 year old male with unknown past medical history presented to the emergency department with a single gunshot wound sustained to the anterior chest just prior to arrival. He was brought in by family members who reported a witnessed traumatic gunshot wound to the chest by an unreported individual. The patient complained of trouble breathing and was severely agitated in the setting of pain. He required 75 mg IV ketamine for moderate sedation while obtaining vital signs, ultrasound, and intravenous access. The team prepared for urgent intubation in the setting of possible respiratory decompensation and activated massive transfusion protocol.

On physical exam, the patient was in acute distress and diaphoretic, reporting trouble breathing but speaking in full sentences. He was alert and oriented to person, place, and event. Primary trauma assessment: patent airway, rapid shallow breathing, and capillary refill less than 2 seconds. Secondary survey revealed an approximately 1 cm open wound with active bleeding to the subxiphoid region. There were no step-offs or deformities to the spine and no other obvious signs of trauma externally. There were equal breath sounds, and 2+ pulses were present in the radial and posterior tibialis arteries. The remainder of the exam was unremarkable.

A FAST exam was performed to evaluate for free fluid, hemothorax, or pericardial effusion.

Figure 1: Subxiphoid view

Figure 2: RUQ view

Figure 3: LUQ view

Figure 4: Pelvic view (transverse).

Figure 5: Pelvic view (longitudinal).

Figure 6: Chest X-Ray

Discussion:

The extended Focused Assessment with Sonography for Trauma (eFAST) is a validated rapid, bedside trauma tool, classically validated in hemodynamically unstable patients with blunt trauma where delays in imaging may be fatal. However its use in penetrating trauma is situational. The sensitivity of ultrasound is significantly lower for bowel injury, retroperitoneal bleeding, and intra-abdominal bleeding [1]. This patient was hemodynamically stable, which typically decreases the urgency for bedside ultrasound. However the patient’s agitation, tachypnea, and uncertain injury trajectory of a subxiphoid entry wound made thoracic and abdominal evaluation critical.

The presence of pelvic free fluid (Figures 4,5) and tachycardia with hyperdynamic ventricles (Figure 1) raised concern for intra-abdominal injury and potential hemorrhage. The location of free fluid in a supine trauma patient is influenced by gravity, with the rectovesical or rectouterine pouch being common sites of accumulation [1]. This patient had been upright prior to arrival and was agitated and repositioned multiple times, raising the possibility that the visualized pelvic fluid was gravitational rather than an isolated pelvic organ injury.

Figure 7: Abdominal X-ray.

Free fluid was visualized only in the suprapubic view, which may be due to localized pelvic injury, supported by the bullet location on KUB (Figure 7), or redistributed by gravity from another source, given that the patient had been upright and repositioned prior to evaluation. The absence of fluid in the right or left upper quadrants does not exclude intra-abdominal hemorrhage, particularly in the setting of penetrating trauma, where eFAST sensitivity varies significantly by region and injury type [1,2]. Retroperitoneal bleeding or bowel injury are often missed with eFAST alone, both possibilities in this case.

A meta analysis of over 24,000 trauma patients demonstrated eFAST sensitivity and specificity, respectively, for intra-abdominal free fluid (74%, 98%), pericardial effusion (91%, 94%), pneumothorax (69%, 99%) [2]. In the suprapubic view, sensitivity ranges from 80 - 90%, with specificity ~ 99%, and detection thresholds as low as 100 - 150 mL [2]. The RUQ view, Morison’s pouch, has a sensitivity 85 - 96% and specificity 98%, but typically requires at least 200 mL of fluid for reliable detection [2]. The LUQ view, splenodiaphragmatic space, demonstrates sensitivity 70 - 85% with specificity 98 - 99% [2]. These ranges reflect variations in body habitus, fluid pooling, and operator dependency. These views are widely taught per guidance of the ACEP Sonoguide [5].

A randomized controlled trial found that while FAST did not reduce mortality, it significantly improved workflow and led to a faster time to diagnosis, fewer CT scans, shorter hospital stays, and lower costs [3]. Additional studies have shown that even when eFAST yields false negative results, outcomes are favorable as long as patient status is closely monitored and reassessed [4]. These statistics demonstrate eFAST’s strength in ruling in injuries when positive, but its limitations in ruling out injuries when negative, especially in penetrating trauma, where sensitivity can range from 28-100% depending on trajectory, organ involved, and injury severity [5].

In this case, eFAST was used as an adjunct to clinical decision making, not a replacement for formal imaging or serial exam. Its findings enabled structured handoff, avoiding unnecessary invasive interventions, and highlighted how point-of-care ultrasound can be safely integrated into trauma workflows even when patients fall outside classical indications. Additional data are needed to clarify how patient position prior to arrival, upright versus supine, affects the sensitivity and specificity of eFAST in trauma assessment, particularly in the evaluation of intra-abdominal free fluid.

References:

Tewari V, et al. The efficiency of focused assessment with sonography for trauma (FAST) vs. CT in penetrating torso trauma. J Emerg Trauma Shock. 2024;17(1):3–9.
Netherton S, Milne WK, Proctor C, et al. Diagnostic accuracy of eFAST in trauma: a systematic review and meta-analysis. Can J Emerg Med. 2019;21(6):727–738.
Stengel D, Bauwens K, Sehouli J, et al. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries: a randomized controlled trial. JAMA. 2017;317(11):1110–1119.
Sierzenski PR, et al. Clinical outcomes after false-negative FAST in hypotensive trauma patients. BMC Emerg Med. 2023;23:45.
American College of Emergency Physicians (ACEP). Trauma Ultrasound (eFAST). Sonoguide. Available at: https://www.acep.org/sonoguide/basic/fast
https://www.bcpocus.ca/organscans/efast/

November 21, 2024November 11, 2024

Case 37: Forearm Fracture

Teini Elisara

Case

An 82 year old female with a past medical history of anemia of chronic disease, breast cancer, diabetes mellitus, hypertension, osteoporosis, rectal adenocarcinoma, scleroderma with pulmonary involvement, and systemic lupus erythematosus presented to the emergency department after a mechanical fall the night prior. Patient reported that she was getting into bed when she tripped and fell on the left side of her body landing on her left arm and hit in the side of her head on the floor. Patient endorsed severe pain to her left wrist. She was able to move her fingers; however had severe pain doing so. In addition, unable to supinate due to severe pain. Sensation was intact throughout the hand and wrist.

On physical exam of the left wrist, there was significant swelling and overlying bruising. Wrist did not appear grossly displaced laterally or medially. Decreased range of motion secondary to pain; sensation intact and able to move digits. There were no open wounds.

A bedside ultrasound was performed on the patient’s distal forearm, the following images were obtained:

Figure 1: Left distal ulna

Figure 2: Left distal radius

Discussion

In this case, we identified fractures in both the distal radius and ulnar styloid of our patient. The joint capsule was visualized and negative for signs of effusion. We visualized the joint capsule by identifying Lister’s tubercle, the extensor carpi radialis brevis tendon and extensor carpi radialis longus. We then rotated the transducer into a longitudinal plane and looked for signs of anechoic fluid between the distal radius and scaphoid bone.

The right wrist also scanned for anatomy comparison. We were able to identify fractures quickly and with minimal discomfort to the patient. Left distal radius and ulnar styloid fractures were confirmed by two-plane x-ray.

Cortical fractures are a common presentation to the emergency department, with distal forearm fractures being amongst the most common in both adult and pediatric populations. Wrist fracture prevalence in the United States is 12% in adults over the age of 50, with significant increases over the last 20 years [1,2]. As x-ray is the gold standard for diagnosing fractures, ultrasound is not typically thought of as an option for identification. However, it is a possible alternative for fracture identification in the emergency department, with high specificity and sensitivity [3]. In addition, ultrasound can be used to assess the healing phases of fracture using grayscale and color doppler [4]. With increased prevalence and use of ultrasound, it is a reasonable alternative for patients where reduction of exposure to ionizing radiation is preferred, such as pediatrics or pregnant peoples. It also may provide benefit for those with significant pain, when further MSK or vasculature evaluation is needed, or when x-ray is not easily accessible.

References

Ye J, Li Q, Nie J. Prevalence, Characteristics, and Associated Risk Factors of Wrist Fractures in Americans Above 50: The Cross-Sectional NHANES Study. Front Endocrinol (Lausanne). 2022 Apr 25;13:800129. doi: 10.3389/fendo.2022.800129. PMID: 35547001; PMCID: PMC9082306.
Xu B, Radojčić MR, Anderson DB, Shi B, Yao L, Chen Y, Feng S, Lee JH, Chen L. Trends in prevalence of fractures among adults in the United States, 1999-2020: a population-based study. Int J Surg. 2024 Feb 1;110(2):721-732. doi: 10.1097/JS9.0000000000000883. PMID: 37921645; PMCID:PMC10871608.
Douma-den Hamer D, Blanker MH, Edens MA, Buijteweg LN, Boomsma MF, van Helden SH, Mauritz GJ. Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis. PLoS One. 2016 May 19;11(5):e0155659. doi: 10.1371/journal.pone.0155659. PMID: 27196439; PMCID: PMC4873261.
Cocco G, Ricci V, Villani M, Delli Pizzi A, Izzi J, Mastandrea M, Boccatonda A, Naňka O, Corvino A, Caulo M, Vecchiet J. Ultrasound imaging of bone fractures. Insights Imaging. 2022 Dec 13;13(1):189. doi: 10.1186/s13244-022-01335-z. PMID: 36512142; PMCID: PMC9748005.

July 29, 2020May 4, 2021

Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam

Background

The FAST exam is a useful tool in screening for the presence of intraperitoneal free fluid in the setting of trauma. The utilization of ultrasound provides rapid imaging in the trauma bay that can help guide clinical decision making and the necessity for surgical intervention. The FAST exam is comprised of subxiphoid, right upper quadrant, left upper quadrant, and suprapubic views by ultrasound. Previous research has indicated that the RUQ, specifically the hepato-renal space (Morrison’s pouch), is the preferred area for the detection of free fluid.1,2 However, scarce research into the sub-divisions of each view has been performed.

Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam

Clinical Question

The aim of this study was to determine what specific sub-divided areas of each FAST view were the most sensitive in the detection of intraperitoneal free fluid.

Methods & Study Design

• Design

This was a retrospective cohort analysis.

• Population

All patients who received a FAST exam at a single Level 1 trauma center over an 18-month period.

• Intervention

The RUQ, LUQ, and suprapubic views of the FAST were each subdivided into three additional sections for analysis. Specifically, the RUQ was divided into the hepato-diaphragmatic space (RUQ1), hepato-renal space (Morrison’s pouch) (RUQ2), and the caudal liver tip (RUQ3). The LUQ was divided into the spleno-diaphragmatic space (LUQ1), the spleno-renal space (LUQ2), and the inferior pole of the kidney (LUQ3). The suprapubic area was divided into the lateral sides of the bladder (SP1), posterior bladder and anterior pelvic organ space (SP2), and posterior uterus (in female subjects) (SP3). The subxiphoid view was excluded as the study was only interested in intraperitoneal free fluid.

• Outcomes

Each sub-quadrant of all positive FAST exams was analyzed for the presence of free fluid.

Results

Of the 1,008 FAST scans included in the study, 48 (4.8%) were positive for free fluid. These findings were either confirmed by CT or intraoperatively.
Of the positive FAST exams, 32 (66.7%) were positive in the RUQ, 17 (35.4%) were positive in the LUQ, and 23 (47.9%) were positive in the suprapubic region.
Of the positive RUQ scans, 30 (93.8%) were positive in RUQ3, 27 (84.4%) in RUQ2, and 5 (15.6%) in RUQ1.
Of LUQ scans, 11 (64.7%) were positive in LUQ1, 10 (58.8%) in LUQ2, and 4 (23.5%) in LUQ3.
In the SP view, 15 (64.7%) were positive in SP1, 9 (58.8%) in SP2, and 7/9 (77.7%) in SP3.
No correlation was found between quadrants.

Strength & Limitations

This was a simple, well done study that provides useful information on the FAST exam. The study featured a relatively small sample size of 48 positive FAST exams. There is a potential that in the time between a FAST exam and further intervention (CT or OR) further bleeding could have occurred, thus lowering the sensitivity of the FAST. The authors struggled to make conclusions regarding the suprapubic view between sexes due to a small sample size of positive SP views.

Authors Conclusion

The caudal tip of the liver (RUQ3) is the most sensitive area for the detection of free fluid on FAST exam.

Our Conclusion

The FAST exam can be an extremely useful tool at the bedside or in the setting of trauma. All areas of the FAST should be properly viewed, with particular emphasis on the caudal tip of the liver. It is important to note that many FAST exams only showed free fluid in one area of one quadrant while showing no free fluid elsewhere, therefore it is important to assess all three areas in every view to increase the sensitivity of the FAST exam.

The Bottom Line

Despite previous emphasis on Morrison’s pouch, the caudal liver tip is a more sensitive indicator of intraperitoneal free fluid and should be properly visualized on every FAST exam.

Authors

This post was written by Oliver Marigold, MS4 at UCSD School of Medicine, Charles Murchison MD and Amir Aminlari MD.

References

Von Kuenssberg Jehle, D., Stiller, G. & Wagner, D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. The American Journal of Emergency Medicine 21, 476–478 (2003).
AIUM Practice Guideline for the Performance of the Focused Assessment With Sonography for Trauma (FAST) Examination. Journal of Ultrasound in Medicine 33, 2047–2056 (2014).
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. WestJEM 18, 270–280 (2017).

February 9, 2018July 21, 2020

Case # 13: What Lies Beneath

A 30 year old male presents to the emergency department after blunt trauma to the face from an altercation. He notes he was punched several times in the face but did not pass out. His exam is notable for significant right periorbital ecchymosis and edema with inability to open his eye. You are unable to perform a direct eye exam given the significant periorbital swelling. A CT maxillofacial is performed which shows an isolated right inferior orbital wall fracture.

Vitals: T 98.6 HR 85 BP 142/81 RR 14 O2 98% on RA

Prior to ENT consultation, a bedside ultrasound of the orbits is performed. In spite of being unable to open the eye, what can you tell your consultant regarding your exam?

Answer and Learning Points

Answer

Using ultrasound as an adjunct to your exam, you are able to tell the consultant that there is a normal appearing, reactive pupil and that the extra-ocular movements of the eye are intact. The consultant is appreciative over the phone and is happy to come in and see the patient whom after evaluation is discharged home with close outpatient follow up.

Learning Points

It is often the case where a patient suffers such significant facial trauma that a complete physical exam of the orbit due to periorbital swelling is not possible. Ultrasound can be a critical tool in these cases to provide useful information to assess for multiple potential pathologies. Previous studies have shown the ability of ocular ultrasound in trauma to detect elevated intracranial pressure (via optic nerve sheath diameter), retinal detachment, vitreous hemorrhage, and retrobulbar hematoma. It can also be used for early detection of muscular entrapment in the case of an orbital wall fracture, as well as performed serially for pupillary response in patients with significant neurological injury at risk for deterioration and potential herniation.

To evaluate extraocular movements:
- Prepare the patient by laying the bed backwards and having their face parallel to the ceiling, supporting the patient's head and neck with a pillow or blanket.
- (Optional) Place a tegaderm over the eye. If you do, ensure there is no air between the tegaderm and the eyelid.
- Place a small amount of ultrasound gel on the closed eyelid and prepare the linear probe with the gain turned almost all the way up.
- Stabilize your hand on the patient's nasal bridge or zygoma, with the probe marker to your left, and place the probe transverse on the orbit with minimal pressure being applied directly to the eye. This is very important in trauma as the area is likely painful and theoretically the patient could have a ruptured globe.
- Adjust the depth to ensure the optic nerve is just visualized at the bottom of the screen. The anterior chamber and lens should be used as visual landmarks to ensure you are in proper location.
- Next, have the patient look left and right, then turn the probe to a sagittal orientation and have the patient look up and down. During these maneuvers you should be evaluating for symmetric movements of the orbit in each direction.
- If you do not appreciate symmetric movements of the orbit in all directions then you may have entrapment of an extraocular muscle.
To evaluate for pupillary response and shape:
- Be sure to dim the lights in the room prior to performing this exam to allow for an adequate pupillary response.
- Gently apply the linear probe with gel in a transverse plane just inferior to the eye, angling superiorly towards the patient's head (Depending on the location of the swelling around the eye, you can also place the probe superior to the eye, angling inferiorly towards the patient's feet).
- Keep flattening out your probe angle relative to the skin until you have a cross section of the pupil and iris in view.
- The pupil should be evaluated for symmetry as an asymmetric or oblong pupil could suggest globe rupture. You can then shine a light in the affected or non-affected eye (consensual light reflex) and observe the pupil for constriction.

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

1. Blaivas M. Bedside emergency department ultrasonography in the evaluation of ocular pathology. Acad Emerg Med 2000;7:947-50.
2. Blaivas M, Theodoro D, Sierzenski P. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med 2002;9(8):791-9.
3. Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 2008;15(2):201-4.
4. Tayal VS, Neulander M, Norton HJ, et al. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med 2007;49(4):508-14.
5. Harries A, et al. Ultrasound assessment of extraocular movements and pupillary light reflex in ocular trauma. Am J Emerg Med 2010 28(8):956-9.

July 28, 2017July 22, 2020

Comparison of Four Views to Single-View Ultrasound Protocols to Identify Clinically Significant Pneumothorax

Background

Ultrasound has become a key adjunct for the initial evaluation of trauma patients in the emergency department (ED), with the eFAST, or extended focused assessment with sonography in trauma examination, including lung evaluation for the presence of a pneumothorax (PTX) or hemothorax. While prior research has shown ultrasound (US) to be very effective at identifying a PTX [1], there is no standardized imaging protocol that has been shown be superior to others. The two most common approaches are a single view of each hemithorax and four views of each hemithorax [2] —this paper sets out to determine if the single view strategy is sufficient to identify a clinically significant PTX.

Comparison of Four Views to Single-view Ultrasound Protocols to Identify Clinically Significant Pneumothorax