All right, good evening everyone. My name is Julie Creech and I will be your moderator for tonight's edition of the AMSSM National Fellows Online Education Committee Lecture Series. This evening we are going to learn about abdominal visceral trauma from Dr. Corey Hudson. But before we get started and before the introductions, let me go ahead and kind of lay out the ground rules as normal. So again, this tonight's lecture is presented by the National Fellows Online Lecture Series and sponsored by the AMSSM. The kind of goals for tonight would be to serve as an adjunct to your individual programs, educational programming, provide direct access to educational experiences with very experienced AMSSM members and expert guests who are going to be presenting and assist with your preparation for CAQ. Our rules of engagement, we ask that during tonight's lecture, you mute your microphone and turn off your video. If questions arise during the presentation, please feel free to share those in the chat function. And if you'd like to include your name and your program, you're welcome to do that. I'll then ask the questions to Dr. Hudson at the end of her presentation, at which time you can also live submit as well. And then after the program, please complete the evaluation so we can continue to improve these lectures. So now I'd like to have the opportunity to introduce Dr. Corey Hudson. She is an associate professor at Georgetown University and practices sports medicine and emergency medicine with MedStar Health in Washington, DC and in Northern Virginia. She is currently the program director of the MedStar Washington Hospital Center Georgetown Sports Medicine Fellowship Program. She received her undergraduate degree and medical degrees from the University of Virginia and remained at UVA for her residency training in emergency medicine before she went on to complete a fellowship in primary care sports medicine at Georgetown University and MedStar Washington Hospital Center. Dr. Hudson has been on faculty at MedStar Georgetown University Hospital since 2006. She has served as a team physician for Georgetown University Athletics since 2009 and is also a team physician for the Washington Wizards and a consulting physician for the Washington Capitals. Dr. Hudson also serves on the Big East Conference Health and Safety Committee and the NCAA Division One Concussion Safety Protocol Committee. She's actively involved in research and is currently conducting ongoing research on concussion, emergency action planning and response, and emergency response simulation and education. So it is without further ado that I will let Dr. Hudson take over and give us a wonderful lecture. Thank you so much. Here's always the drama part when we make sure that I can share the screen and we get to where we want to go. Does that work? You got it? It looks great. All right. So if you can see what I'm seeing. So hi, everybody. Nice to be here. Thank you all so much for having me. So we're going to talk a little bit about abdominal trauma and athletics today. And we'll start by saying, oh, there we go. I have no relevant financial conflicts. We always got to start there. I always say I'm looking for some if anybody has any to offer. So our playbook for today, we're going to talk about some relevant anatomy as it pertains. We'll talk about some common injuries, how we perform a rapid evaluation and examination as it pertains to our athletes. We're going to talk about the role for ultrasound and the assessment of these injuries, and then how we put it all together. And I'll throw in some pearls here about how I think this does pertain to the CAQ and where I think this comes in. I think there are a few kind of buzzwords in some places where you can get some good pearls here. When we talk about the anatomy here, remember, we talked about the abdominal wall, which we'll talk about first, the musculature and the structure of the abdominal wall, GU, which is really kind of a separate topic, the genital urinary system comes in later. There'll be a little bit on that here. Solid organs. We'll talk about the liver, the kidneys, the spleen, pancreas, which we really won't touch on much here. The retroperitoneal organs, including the kidney, the hollow organs, and Julius, I'm looking at this, I'm realizing I think we are in an old version of the talk. We're going to roll with it anyway. And then the hollow organs, including the small bowel and the large bowel. Abdominal wall. Oh, I'm wondering if I really do want to roll with this. I don't. We're going to have to go with a different version. I'm going to unshare for just a second, guys. Hold on. I uploaded two versions of this talk and I uploaded the wrong one. Hold on. You don't want this one. You want the new version. I'm so sorry. We ran with a little problem here where I had to switch from one computer to the other. And in doing so, I ended up with the wrong version of the talk. Hold on. I'm so, so sorry. Oh, Julie, do you have the version that you had? That may actually be better. I hate to do this, but. I do. Yeah. It may be better to do it from your version than from mine. Okay. I like that. That's no problem. Let me get it pulled up. Because I feel like the version that I'm doing is one version old and doesn't have a lot of changes that I think are actually pretty relevant here. How does that look? Good. Let's go with it. We're going to make it go. All right. All right. So we're going to get up to. There we go. Do this on the fly, guys. Thanks. All right. So we're going to go on to the next one here. We're going to start with the abdominal wall. So when we talk about abdominal wall injuries, we talk about contusions to the abdominal wall. We're going to talk about diaphragmatic injuries. We'll talk about some rectus sheath hematomas, muscular injuries, including things like hip pointers just a little bit, and then other soft tissue injuries. Julie, if you'll roll ahead. All right. So we're going to go on to the next one here. We're going to start with the abdominal wall. So when we talk about abdominal wall injuries, we talk about contusions to the abdominal wall. We're going to talk about diaphragmatic injuries. We'll talk about some rectus sheath hematomas, muscular injuries, including things like hip pointers just a little bit, and then other soft tissue injuries. Julie, if you'll roll ahead. So muscular contusions, our mechanism here is like a direct blow to the abdomen, a direct blow to the abdominal wall. We talked about intramuscular and subcutaneous bleeding. This is really just a bruise, right? Typical bruise presenting symptoms will be pain, swelling, tenderness at the site, a little echemosis that you can see under the skin. Maybe not immediately, but pretty quickly. Evaluation is pretty easy, right? This is going to be a physical exam. Imaging typically not required. If you have a bedside ultrasound and want to take a quick look, you can sort of see how far deep this goes. Make sure it's not into the deep layers. Make sure it doesn't go below the fascial layers. Treatment is really symptom-based, ice, analgesics. You can consider some additional padding and think about return to play. These really shouldn't affect the athlete in terms of having any peritoneal signs, right? If they have any peritoneal signs, if they're having any deep tenderness on palpation, you really need to think again of whether this is just in the muscular layers. Next sign. Diaphragmatic injury. I think we've all seen collisions like this. We see this sign. We know that at least two of those three guys are not getting up off the grass. There's going to be a little moment where everybody takes a deep breath, and we're going to kind of pause to see who's going to take a moment. Really everybody's getting the wind knocked out of them in this. That's that diaphragmatic muscle spasm or sort of a transient sense of doom. Everybody takes a deep gasp. No one's quite sure what's happening next. Really the evaluation here is focused on ruling out other serious injuries. We got to take a minute, make sure nothing else is hurt, shake off the cobwebs, make sure that nothing else more serious is going on. Usually there's usually no treatment required. Once you make sure that there's no significant trauma, make sure there's no ongoing tenderness, make sure everybody's getting up and walking around, the condition is self-limited. Return to play can be permitted as soon as the athlete is able. And really, again, they usually tell you that this is the case. They're breathing fine. They're not having any pain. They say, doc, I'm good to go. Get me back out there. This is just a temporary spasm of the diaphragm, that classic, I got the wind knocked out of me. Abdominal wall hematomas are something that can be a little bit more serious. You can get a rectus sheath hematoma that can be caused by a rupture of the epigastric artery or vein, or sometimes both. You can get lateral wall, which is much more rare, which can be either a slow venous bleed or sometimes a rapid or arterial bleed, usually coming from a deep circumflex artery branch. These sometimes can result in significant bleeding. These are usually a result of direct trauma. The more significant bleeds usually happen in people who are on anticoagulants, though I've seen this a time or two in athletes who obviously were not on anticoagulants, so we probably wouldn't have had them playing contact or collision sports, and can just be that odd hit that just happens in such a way that causes this big hematoma to collect. The key here is that they'll get a really obvious grapefruit-sized or large swelling. You can feel the hematoma. It feels deep to the muscular layers. They can still contract the muscle over top of the muscle layers, and you can feel that hematoma underneath. Again, if you've got bedside ultrasound, you can see that in the layers, but really the key here is CT with IV contrast. Sometimes if you do a CT or a CTA with IV contrast, you can see active extravasation from the bleeding vessel. Some sites will like MRA or MRI to actually rule out other injury. The key here is you want to make sure that this is extraperitoneal. You want to make sure that there's no intraabdominal injury, that all of the injury is in fact in the abdominal wall. If you advance that one, we can actually see one of these. This is a rectus sheath hematoma. Again, you can see that large sort of egg-shaped or lenticular blood collection in the abdominal wall there, but it's really all extraperitoneal. This is all in the abdominal wall itself. As we advance one more, we'll talk about the management here. Again, this is typically conservative management. The smaller hematomas, ice, analgesics, gradual return to play, consider padding the site. In some cases, if there's ongoing bleeding or oozing, we might consider angiography, which may go on or without embolization to stop the bleeding. In some cases, we might even think about surgical options to evacuate that hematoma because these surgeries don't need to go in through the peritoneal fascia. We can do this all extra-abdominally. That hematoma can be removed in a way that actually the recovery time is quite short. Just lift up the muscle layers, remove the hematoma, get the muscle layers back down. Again, it's not like a speedy, speedy recovery, but it's not like intraabdominal surgery six to eight weeks. The biggest complication there is a post-op seroma, and so you do have to keep some compression on those layers for some time. Again, there is some recovery time, but it's not like a major intraabdominal surgery in terms of recovery. Splenic injuries, I think we worry about splenic injuries a lot. They're not common, but I think if we think about all intraabdominal injuries together, there are at least a couple of large case series which show that about 10% of all significant intraabdominal injuries come from sporting injuries. Of those, most of those are injuries to the liver and the spleen. Blunt trauma to the left upper quadrant, to the left lower thorax is the most common mechanism. This certainly comes mostly from collision and contact sports. As we see more extreme sports, motocross, certainly the aerial sports are risky for this. I work with a group, we have a sports medicine group that takes care of the jockeys at one of our racetracks, and we certainly know that this is an injury that we could see in our jockeys as they get thrown from horses racing at speed as well. Certainly more common in athletes with a history of reship mono, and we'll talk about that a little bit in a minute, but the key here is to know that splenic lacerations can be life-threatening. Of all the things we talk about in sports, most of the injuries we discuss, we have a little bit of time to think about it. We have a little time to talk about it. We have a little bit of time to, quite frankly, get it wrong once or twice, to consult a friend, to look it up, to think about it a time or two. Splenic injuries are not one of those. These can be life-threatening if we get it wrong, if we second-guess ourselves. So we've got to get it right, we've got to get it right the first time. So if you see trauma to the left upper quadrant or an athlete who looks like they've had an injury to the left upper quadrant and you're concerned, pay attention to those hairs on the back of your neck and that sinking feeling. Next slide. So again, these presenting symptoms may be left upper quadrant pain, might be flank pain. Cursine is nonspecific, but it's that referred pain to the left shoulder that comes from diaphragmatic irritation from free intraperitoneal blood. It's sort of classic for a splenic rupture, but really that's intraperitoneal blood, usually described in a supine patient as that blood touches the diaphragm, that diaphragmatic irritation causes shoulder pain, but it's not necessarily specific for the spleen or specific for that left shoulder. Shown here on the slide are Cullen's sign, that peri-umbilical ecchymosis, or Gray-Turner sign, that flank ecchymosis, again, those are nonspecific signs for intraperitoneal blood. On exam, you're going to see left upper quadrant tenderness to palpation, hypotension and tachycardia, which are things that we'd like to think about as a splenic laceration or splenic rupture, are really late signs or may only be present to just a fraction of patients. Remember that a splenic laceration is often encapsulated. It's often really held inside the spleen for quite some time until that laceration is quite severe. And so the spleen can hold quite a bit of blood inside. It may take a while before we actually get to true hypotension. And many of our athletes, especially our adolescents, may maintain, they may compensate quite some time before they become tachycardic. So don't wait for them to become hypotensive or tachycardic. It may be way too late. Next slide. So without going way into ATLS, if you suspect a splenic injury, get them to the ER and get them to the ER fast, call an ambulance. Once they get to us in the ER, they're going to get two large-bore IVs and labs. They'll get imaging. If they're in a trauma center, they'll probably get that fast scan, which we'll talk about, that ultrasound in the ER, but they'll probably go pretty quickly for a CT with IV contrast. They may go directly to the OR based on a positive fast scan if they're in a trauma center. They'll get monitored with serial HNH, hemoglobin, and hematocrit. There's a grading system that we don't need to go into here, but just know that there's a grading system based on severity. And typically, if we can avoid removing the spleen or the trauma surgeons can avoid removing the spleen, they will do that. Most adults can avoid splenectomy for most injuries. The goal is to keep them calm, quiet, not moving a whole lot, and repeat imaging in just a few days. If they're unstable, though, they may require splenectomy or ligation of those splenic vessels that are bleeding. If they do have a splenectomy, remember that they should be vaccinated against those encapsulating organisms, the haemophilus, the pneumococcal organisms, the meningococcal organisms, and then they have a really slow return to play. If they've had a non-operative recovery, that return to play is two to six months and two is really aggressive. They probably shouldn't even consider return to play for at least three months, so three to six. For some very elite athletes, they may opt for splenectomy because the operative return to play really gets down as low as about six to eight weeks, right? Once they've had that surgery, it's a post-surgical recovery because you're now not worried about that secondary splenic injury, the spleen is out. So that may actually slant you in some cases towards a splenectomy, though you really need to think about the risks and benefits of that and the sort of complications that may come from having a splenic patient long-term and really what that means for your patient. So weigh that really carefully. I know there have certainly been some discussions like that in certain very, very high-level athletes. All right, next slide. So here's a picture of the coronal image on the screen right, patient's left, obviously. There's a picture of the spleen with a big laceration through it. All right, and we'll move on and we'll talk about some liver, oh, sorry, we've got more pictures of the spleen. So spleen, there's sort of a pictogram on our left here that shows some free fluid. We'll talk about what the ultrasound pictures look like of this, but it shows the spleen there and the kidney with a dark layer of fluid. Thank you, Julie, for being my mouse in between, a dark layer of free fluid in between at the splenorenal interface. And then on our screen right, the spleen there is just floating in a giant hematoma of blood there. That's a huge spleen that's about to probably come out. All right, next we'll talk about some mono. So infectious mononucleosis, EBV and CMV, classic clinical triad, fever, pharyngitis, lymphadenopathy. I think we're all pretty well checked out on the diagnosis of mononucleosis. Our classic clinical teaching that we should not consider return to contact sports before 21 days. And I will tell you, I practiced this way for years until Jill Sylvester from the Air Force and came through our military fellowship, our consortium fellowship in DC here many years ago. Jill did this great study with our colleagues in 2019, military case series, they looked at 826 cases of mono. And in their study, only 74% of their splenic injuries happened within 21 days. About 90% happened within 31 days, but that showed that there was a significant proportion of their injuries, which happened between that third and fourth week. So that's actually been practice changing for me, that actually has made me counsel my athletes a little bit differently, especially when going back to contact or collision sports about the risk associated with that three-week return versus that four-week return. I think I've really changed the way I counsel athletes in terms of considering that fourth week, unless I'm thinking about really low-risk sports, track or something, tennis, something that's really relatively low risk. Or if we have a better sense that maybe they had symptoms for an extra week. Remember that imaging is really not helpful in that return to play decision. A lot of people want to say, let's ultrasound the spleen, let's CAT scan the spleen, let's say it's normal size, that's really not helpful in making that decision. All right, let's talk about the liver now. We are going to talk about the liver. So remember that the liver can be injured again in blunt trauma, right upper quadrant trauma, also penetrating, but that's usually not our mechanism here. Again, it can also be fatal if unrecognized or untreated. Our presenting symptoms will be similar to the spleen, but on the other side, abdominal pain may refer to the right shoulder or the shoulder blade. May have nausea and vomiting, in fact, a lot of splenic, or sorry, hepatic injury patients will have nausea and vomiting. On exam, we're gonna have right upper quadrant tenderness. Again, that tenderness may give you kind of a Murphy's sign like a gallbladder. They may take that sort of gaspy deep breath as you try to palpate that right upper quadrant. They may have that pain that refers to the shoulder blade or to the shoulder. There may be echemosis or again, that peritonitis as signs of hemoperitoneum. And again, the hypertension and tachycardia may be late. Remember that hepatomegaly here, just like mononucleosis increases the size of the spleen, which makes it increase the risk of rupture. Hepatomegaly is gonna increase the risk of injury here, increase the risk of liver injury. So obesity, hepatitis, alcohol, certain other drugs and toxins and autoimmune diseases, which increase the size of our liver, also increase the risk of liver injury when we suffer trauma. So we think about those things and how they may impact. If you've got somebody who's got a palpable liver when you do their PPE and they're gonna be participating in a contact or collision sports, maybe think about whether they need a little extra protection or padding. All right, next slide. Again, ATLS, kind of how we manage these. If you think someone's got a liver injury, send them, send them fast, send them early, especially if you're far from help or far from a trauma center. Again, there's a grading system that we don't really need to go into for the sake of the CAQ or for the sake of this lecture. About 80% of cases will resolve with observation. Unlike the spleen, we can't just take it out. So we have to really do everything we can not to operate on the liver. Livers don't really like to be operated on. They just bleed and bleed more and bleed more. But if the patient is unstable, sometimes they do have to go in and do some surgical exploration to achieve hemostasis or sometimes some IR guided procedures to embolize whatever's bleeding. Often a repeat CT scan is done in five to seven days to confirm that there's been no progression of the injury. And there can be complications, including bilomas, hepatic abscesses. These sometimes need to be drained. So secondary procedures are often needed, which again can prolong that return to play, prolong that recovery. This return to play really needs to be individualized. And we're talking months, months and months and months of return to play after hepatic injury. So again, these are rare in our usual Olympic sports, our usual high school sports and college sports. But if you're working, covering extreme sports, motor sports, equestrian sports, these are things you certainly may see. All right, moving on. Some pictures of hepatic injuries. Again, we'll see some more ultrasounds in a little bit, but that's the edge of the lung there, screen left in that upper left picture and the edge of the liver. And again, dark fluid there in between, little arrow sign put in there by my ultrasound buddies who like to give us arrows to make things pretty. And then on the right, we've got a giant hematoma there off the edge of what is really a gigantic liver. All right, moving on. All right, hollow organ injuries. So these are really rare, but there are a couple and included on the reference list, there are a couple of case reports here that I thought were worth including. Often with direct blow or deceleration mechanism, and I think these are worth including because you have to like just remember the zebra because they're not so rare that you won't see one. And if you don't remember to think of it, you're not gonna think of it when it happens to you. So remember this one when you see pain out of proportion or when the exam just doesn't fit. So this case here with this picture was actually at a football game. This was actually a spectator in the stands who took a ball to the abdomen. There was a case that was presented at the ACSM meeting several years ago, which was actually a football player who kind of had a clothesline injury in the middle of the game. Came out just before halftime, lots of pain, some nausea. Diaphoretic just looked awful, but had a pretty benign exam, a soft belly, no ectomosis. This patient presented similarly. And that's kind of the key. These patients look like they feel awful. They appear toxic, but their exam's really benign. It's soft, it's not rigid. They're in pain, but they're not really more tender on exam than they are. Again, pain out of proportion. They may or may not have free air on an abdominal X-ray because the amount of air that's escaped from the perforated small bowel is really a tiny amount. CT is better if you can get some oral contrast in, but if you see the little bubbles of air there are tiny. In this case, you could actually see them on the case that was presented at ACSM. There were no free air bubbles, but when they did the, they actually had to do delayed imaging about six hours later and saw some stranding. They actually saw some leakage of bowel contents that was actually causing some stranding and inflammation. Ultrasound in these cases will be negative. It's not helpful because there's no free fluid and no leakage of fluid. So these are cases where you just have to have an index of suspicion and know that when something's not looking right, you just have to keep looking, keep going. All right, renal injuries. I said we weren't gonna do too much of the GU system, but I will throw in a little bit about renal injuries. Just remember the direct below to the flank, especially in collision sports can cause a renal injury. Usually these are self-limited. Very rarely do they require a nephrectomy. Symptoms are usually flank pain. You'll sometimes see some echemosis, hematuria. When a patient comes in or an athlete tells you that they're seeing blood in their urine, certainly be concerned. They tell you their urine looks dark, be concerned. If you're concerned about a renal injury though, you might actually have to do a dipstick because the hematuria might be microscopic. If you're really concerned that you've got a renal injury, they may need a renal ultrasound or a three-phase CT or an IV urogram. I've never ordered a urogram unless a urologist actually asked me for one. The three-phase CT is a dry CT and then a 90 second IV contrast CT and then a five to 15 minute delay CT. So it gets different phases of the renal parenchyma so they can actually look. One is actually a renal mass phase, which probably doesn't affect us in this point. And the other one kind of shows us the ureters and the bladder better. Again, there's a grading scale for the renal injuries. And in most cases, we're gonna be looking at sort of the grade ones and twos. Those usually resolve in 24 to 48 hours. Once the hematuria has resolved, we can start a gradual return to play. Think about maybe some padding if you're worried about them getting hit in that area again. Much has been written about the athlete with a solitary kidney, whether they should be allowed to play contact or collision sports. Again, very, very, very few cases of renal injuries that have required nephrectomy. So this is usually considered to be a risk benefit discussion to be had with the athlete, with their parents. In many cases, there are the congenital solid kidney, there's solitary kidney patients who don't know that they only have one kidney until they're imaged for some other reason. So I think that in some cases you won't know that. There are some athletes, my nephew only has one kidney. He had a Wilms tumor when he was a baby. So he knows he had one taken out. And that's a discussion that my sister and her husband have with coaches as he's playing sports growing up. He's only eight. So these are not a lot of conversations they've had, but it's something that they've certainly thought about. So that's a discussion you'll wanna have in terms of risks and benefits with athletes and their parents as they go. All right, I talked a little bit about horses. So this is one where you might imagine that both the jockeys and the horses might have renal injuries, right? So think about renal trauma. In this case, I'll tell you actually everybody was okay. Both the horses and the jockeys were okay in this case. The horses currently on the ground did actually then kick the guy in the number one horse that that jockey who's currently mounted kicked him in the jaw. So the only real injury out of this was that the guy who's currently mounted on the horse ended up with a fractured jaw. But otherwise everybody turned out okay. But you could imagine with trauma like this, you could end up with a liver, a spleen, a kidney, thoracolumbar fracture, and who knows what else. So these are the kinds of things that I think about. GU injuries are altogether a topic for another lecture, but I will throw in a couple of little pearls here. But when we talk about trauma, blood at the urethral meatus is bad. Don't ever put a Foley in somebody who has blood at the urethral meatus. That's just a pearl of trauma wisdom. And the answer is always retrograde urethrogram. That's never the answer in real life. We don't do those anymore, but on the CAQ or any test question, if the words blood at urethral meatus is in the question, the answer is retrograde urethrogram. So file that away someplace. All acute and traumatic testicular and scrotal pain should be evaluated with an ultrasound. So I don't care what the question says. If there's acute and traumatic testicular or scrotal pain, the answer is an ultrasound. And then just a practical thing. If you think a testicle is twisted, untwist it. Untwist it immediately. Don't wait for help. Don't phone a friend. If you think there's testicular torsion, detour the testicle. And the way to think about that, that I was taught was open the book, right? So think about there being like the, I mean, like you're holding a book and you open the book and it's not half a twist, it's multiple twists. I probably, we see these in the ER probably two or three a year and they detour and they detour and you just kind of have to have a shock and awe moment with the patient and say, you're gonna really not like me for the next 30 seconds. And then we're gonna be friends again. And if you think the testicle is twisted, detour it. Don't wait for the ultrasound. Don't wait for the urologist. Save the testicle. All right, that's all I have to say about GU injuries. All right, now we're gonna talk a little bit about ultrasound because who doesn't love ultrasound? The FAST exam, the focused assessment of sonography and trauma, and the E stands for extended. So the idea is that intraperitoneal organs lead to hemoperitoneum. We've talked a little bit about that and that the blood goes to predictable locations with gravity. So as you lay down the supine patient, the blood goes with gravity to the supine portions, dependent portions, and that blood is fluid, right? We've all been doing ultrasound this year as part of our fellowships and training. We know that fluid is dark, easily detectable on ultrasound and that we're really good at finding fluid on ultrasound. So it's a great screening test for that. And so go forward to one and we'll talk about where we find it. So I've got five spots here. We'll talk about where we find, but the places where fluid likes to go. So you've got the right upper quadrant at Morrison's pouch or the hepatorenal junction. We've got the left upper quadrant at the splenorenal junction or the lianorenal junction. We've got the right and left paracolic gutters, which you could look at too, and that's not really part of the FAST exam, but you can always go along the paracolic gutters. The pelvic cul-de-sac or the pouch of Douglas is another place. So right behind the bladder. So again, all the places where blood would settle with gravity, that's where the fluid goes. All right, so how much can you see? So minimum detectable on ultrasound is somewhere between 200 and call it 500 or 600 cc's of blood. And how much blood depends on like where you're looking, how fast it's bleeding, how good you are at finding it on ultrasound and then how the patient is positioned. CT can see a little bit less than that. So between 100 and 250 cc's of free fluid or blood. So it's a little bit more sensitive. And if you're ancient like me, when trauma and trained in ATLS two decades ago, when we did DPL, so diagnostic peritoneal lavages, the way we used to do this was they would teach us to actually open the fascia with a little one cc NIC. We'd actually cut down to the abdominal peritoneal fascia. We would take a liter of saline and lavage the peritoneum. And then we would drain all that fluid back out. And then we would send off that fluid or we would look at that fluid, just hold it up to a piece of paper and hold it up to the light to see whether or not there was blood in the fluid. But then we actually had to violate the peritoneum to evaluate it, which in the end turned out to not be a really good thing for a lot of people. But it was very sensitive. We could see basically as little as 20 cc's of blood by doing this. But ultimately, ultrasound's a pretty good screening test for this. So let's talk about how we do the test. So actually let's, okay. Let's talk about the limitations. So what can we not see? So we can't see things when there's sub-Q error, right? So if there's any sub-Q error, so if we've got like a pneumothorax or we've got sub-Q error in the chest, we're not going to see well. You've got big gastric distention, right? So error is the enemy here. Gastric distention is going to be in the way. Patients who have a large body habitus, so a lot of sub-Q fat, it'd be hard to penetrate the ultrasound to get down into the abdominal cavity. Operator dependent, right? Like all things, right? It's not like putting somebody through the CT scanner and we're just going to see the images that can come up. We actually have to obtain our own images. And then we're not going to have great views of the bowel. So we talked about those duodenal injuries. We're not going to see those very well. Hard to see the diaphragm. And we really don't get any good view of the retroperitoneal space. So if there's any kidney injuries, if we're looking at retroperitoneal injuries, we're worried about bleeds back there, we're really not going to get a great view of that space. All right, so CAT scan. Why don't we just get CAT scans on everybody? Well, it's great, sensitive and specific. They can see those holobiscus injuries, can see the retroperitoneum, non-invasive, but time-consuming, right? Patients got to go to the hospital. They're expensive, need contrast. So like we've got this kind of pro and con here. Like, what are we going to do? So I think that there's times for CT. There's time when it's the right thing to do. But if we can do a quick screening test with the ultrasound, sometimes that's really helpful too. Sometimes we end up doing both and that's okay. But I think that there are times when we can do one or the other and we can make a good choice. All right. This is the slide I keep thinking was coming up next. So we've got our clinical picture, right? That's how we start all of our exams. We think, what do we think is going on? What am I worried about? And then there are five key views that we do as part of the extended FAST exam. The subxiphoid view, the right upper quadrant view, the left upper quadrant view, the suprapubic view, and then the extended view, which is the lung views. That's the E part. So we're going to go through each of these and we're going to look at some pictures of each. All right. So this is the subxiphoid view. So this is probably one of the harder ones to get because you really got to take the probe. I'll kind of demonstrate on myself. You got to kind of really cram it under the xiphoid process. When you do this in the supine patient, it really almost has to be flat to the patient, right? So it's really going to be almost parallel with the patient and pushing, like pointing towards the manubrium. And really, it doesn't matter if you get a great two chamber or four chamber view of the heart. Sometimes you will on some patients, sometimes you won't. You're going to be using the liver tip as kind of an acoustic window here. But really what you're looking for is you're looking for a pericardial effusion, right? We're really just looking at that pericardium to see if we've got a pericardial effusion. That's what the black outline here is on that left-hand picture, right? So you can see there, we're outlining the pericardium. And if you see, it's the same picture there, right and left. And you can see there's really no fluid. And on the next picture, we'll show you some that have fluid. So, see the difference? So on the first, the last one, there was really no fluid there. This one, we've got some fluid around the heart. These are easier to see when you do on some patients. So next time you've got your co-fellows or you've got some residents around that you can kind of cajole somebody into letting you look at their heart, do this a little bit and take some views. And it's easier to see on dynamic view when you can see the heart beating. Just get a look around the heart and see. You can see here, we've got a pretty marked effusion here. We've got about a centimeter of fluid all the way around. All right, next to you, I think we've got one more. Yeah, there's one more. So here you can actually see, we get a pretty good view of the heart. We get almost all four chambers there. And you can see we've got a pretty good size pericardial effusion going all the way around. All right, right upper quadrant view. I think the key here is we call this the right upper quadrant view, but you can see by the pictogram in that lower corner, really what you're doing is you're taking the probe and you're going almost all the way down to the bed. So you're going in almost the mid axillary line and taking the probe almost all the way down parallel to the stretcher. And what you're looking for is you're going to look for that hepatorenal interface. And we'll show you what that looks like on the next slide. But if I see any mistake here, it's people start too anteriorly and they end up looking at the gallbladder and they can't find the kidney. So if you do anything, start almost at the stretcher and move from posterior to anterior and you'll have more success finding this view. All right, so let's show you what the normal one looks like. So this one shaded in on the left shows you left-hand side liver, right-hand side kidney. And then if you look at this, you can kind of see the echo texture of the normal liver there, normal kidney. Those should abut each other. They should come right up to each other and kind of kiss each other right there in the middle with zero fluid in between. No layer of fluid in between. The next couple of pictures will show you some abnormal. So there you go. You see just a sliver of the liver on the left and then the kidney there in the middle of the picture and a big little lake of fluid. All that black fluid is abnormal there. So free fluid there in between AB normal. We can't say that's blood. In fact, if you ever work with patients who have ascites, I will say Georgetown is like one of the liver transplant capitals of the East Coast. So we see a lot of patients with ascites. Patients with ascites are excellent to practice your FAST exam on because the free fluid of ascites looks just like hemoperitoneum. So they're excellent to practice on if you ever have an opportunity. All right, next one. We have another. This one's much more subtle. You see again that normal echo texture of the liver there taking up most of our image there on the left. We've got the kidney on the right and just a sliver of free fluid marked there with that blue arrow in between. I think we have one more. Here we go again. Big liver up top on the left, kidney down low in the middle and just a skosh of fluid in between. And again, even just that little bit of fluid is enough to tell us that there's free fluid in the belly. That shouldn't be there. Again, with the right clinical picture, that's enough to tell us that there's free fluid and we need to do something about that. All right, I think we have, oh wait, one more. Okay, again, free fluid there between the liver and the kidney. Can kind of look like anything. All right. Suprapubic view. If you've done any OB ultrasound, this is just like you would go looking for heart tones in a first trimester patient or an early second trimester patient. I'm going to go well below the umbilicus and point towards the pubic bone and we're going to look for the look for the bladder. A full bladder certainly gives you a good sonographic window because we're going to be looking behind the bladder for that free fluid. All right so the next view shows us again bladder. If you've got a female patient we'll see the bladder and then the uterus and then where that black curve linear line is on the left picture is where we're looking for free fluid. The picture on the right is showing us a normal so there's no free fluid. We're looking at bladder, round uterus in the middle and no free fluid behind it. Normal normal picture. All right so this one we've got a little bow tie of fluid, little curve of fluid on the left and the right. Male patient here no uterus or a female whose uterus has been taken out I suppose. And the next picture again bladder, little bowel gas behind giving us some some scatter there but we've got some free fluid there just just to the left of the bladder. All right and one more here that's a little bit of fluid there behind the bladder again. All right the left upper quadrant view very much like the right upper quadrant. You want to put the uh probe uh almost in the mid axillary line go down again to the stretcher and then I move from posterior to anterior. Again I think if there's one error to be made here it's to think of the left upper quadrant as if it's an anterior abdominal view. It's really not it's really almost almost posterior and we're looking for that splenorenal interface. We'll go ahead one and we can see again it's going to look kind of like this. It's hard to get a really good view of the spleen and kidney together but the kidney will look much like it did on the other side. So this is normal with the spleen uh kind of hugging up against the kidney. Again there should be just no fluid in between those two. And this one I really look for that kidney first. You'll get that that you'll see the calyces and then look for the spleen to touch it. And then we'll see some abnormals. This one's hard to see the kidney but if you see the bright white line of the diaphragm and you see the spleen and the equitecture of the spleen finding that black fluid which in this case we'll assume is blood but all we really know is that it's free fluid you see that free fluid around the spleen is abnormal even though we don't really have a good view of the kidney in this in this picture. The next one we get a little hint of the kidney in that lower right hand corner but again we've got that that tip of the spleen just floating in in free fluid there. So even again without a great view of the kidney we've got we've got a spleen that's just kind of floating in free fluid which is bad. Next view this one we've got a better view of the kidney there in the lower right we've got the spleen and then really just a trace of free fluid up there just under the diaphragm but again that's enough to get us concerned. And then the enhanced views uh there are a couple here check above the diaphragm we're going to look for hemothorax north pneumothorax really doesn't replace chest x-ray but this is kind of a good uh a good screening tool again and I'll tell a little story here that I also um suggest that you can check the suprapubic view for for pregnancy or for ectopic remember that you can have ruptured ectopic as another non-traumatic reason to have free fluid in your belly or to have abdominal pain. I will point out and I've done this once I'm gonna let my error not be your error you can do that entire fast exam and scan your way all the way around a late trimester pregnancy in somebody who is obese enough to hide a late trimester pregnancy because you get all the way to the suprapubic view and you see bladder and a very heterogeneous thing in the uterus that looks like a heterogeneous thing that could be a fibroid which is really a baby's brain if you are zoomed in way too far to see a biparietal diameter because you go all the way around the whole body of the fetus right because you're way up in the corners and you're way up at the subxiphoid and you're way down low so I will say I went all the way around not a late trimester but I went all the way around a second trimester baby once so don't do that if somebody might be pregnant please scan around the parts that might be pregnant and then think about if you see free fluid in the belly of a reproductive age female think about the possibility that this there could be a ruptured ectopic pregnancy as well in addition to any other traumatic causes because that certainly can be life-threatening as well all right let's talk about the enhanced portion here so in that view where we saw here where we were just up under the clavicle we are looking at sort of two rib spaces here what we're doing is sort of look at the second and the third or the third and the fourth looking um in a in this orientation here and what we're going to look is that we're going to look at the pleural line and what we're looking at is the the layers of the pleura as they slide against each other and as we're looking at the layers um what you see they call beads on a string or ants marching but you'll actually see movement as those layers of pleura slide against each other um and once you've seen it once you know exactly what it looks like but you won't see that if there's a pneumothorax because the pleura is gone right if one layer pleura has pulled away from the from the other then you won't have those two layers sliding against each other so that's what you're doing find the rim find the pleura and see this is an easy one to practice with somebody in clinic all you got to do is you know find a rib and and look uh so that's one and then once you find that uh you can switch it over into m mode um and use your imagination um once you you put it into into mode so they call this um waves crashing on the seashore that that view on the left if it's normal right so the top part would be the waves see the waves and the bottom part is the sand seashore that's normal if you have a pneumothorax you don't get normal once you put it into m mode you get what they call the barcode sign or the stratosphere sign all you get is waves right so just lines lines lines lines lines no sand so i say if you see the normal you see enough normals you'll recognize when it's abnormal so anytime you get that you can do some scanning on people when you're doing belly scans or anything else or any other part i i think this is a great one if you're doing shoulders if you're doing somebody's shoulder an ultrasound and clinic go ahead and and look at their lung because it's one extra view it's an easy one to do just see the normals a couple of times and then it's easy to recognize the abnormal when you see them all right so that's pneumothorax uh hemothorax this is kind of down uh in that uh spleen and kidney again uh remember when we saw the diaphragm earlier so we've got in that right picture you've got um spleen kidney you've got the diaphragm kind of arcing in in between and then we've got free fluid but now the free fluid is above so remember we see that splenal renal interface and they're really up tucked tight to each other that free fluid is not between the spleen the kidney and the diaphragm those are all tucked in tight now the free fluid is above the diaphragm it's now up above so that's now a hemothorax it's not hemoperitoneum so think about which side of the diaphragm the blood is on when you're looking at that left upper quadrant view all right uh this is uh plural fluid again again so we couldn't really that was really wasn't fair of me to say that was a hemothorax that was really fluid in the in the chest we can say it's plural fluid i can't say it's blood you can just say it's free fluid again same thing here and then we'll move on all right so pediatric fast exam um cute picture of one of my children and i'm embarrassed to say i don't remember which one it is because at that age they look the same um god that's bad okay um so what we will say about the pediatric fast exam is it's not as sensitive uh the studies show that the pediatric exam is sensitive somewhere ranging between 30 to 80 which is to say yeah right so recognize that somewhere around a third of kids with solid organ injuries won't have hemoperitoneum which means that that that solid organ injury stays encapsulated within the organ itself which means you may not actually see free fluid um if it's positive it's positive right the specificity is still really good it's just not as sensitive uh so if you've got little kids especially and you're worried um the ultrasound is fine if it's positive but it's negative and your index of suspicion is high you still probably want to go ahead and get them to a hospital and get them scanned uh probably with a ct even though we like to avoid the radiation if we can all right so abdominal injuries are common uh those severe abdominal injuries are pretty rare i think that knowing the difference uh means we got to pay really close attention we got to have a high index of suspicion we got to be good with exam skills if you're not thinking about splenic injuries if you're not thinking about hepatic injuries you're not thinking about those retroperitoneal injuries you're never going to diagnose them i think the e fast exam is easy it's non-invasive it's a great screening test uh it's not the be all end all it doesn't uh alleviate the need for ers and hospitals entirely uh but i think it can give us some reassurance it can uh help us out a lot uh and it certainly can uh confirm our suspicious when we're worried and help move us towards making the right decisions remember that no free fluid does not mean no injury uh it just means no free fluid right now um if you're worried be worried uh and uh definitely do the right thing so i think from there we'll throw out to any questions that was wonderful thank you very much thank you for helping of course of course i enjoy being nirvana um so i you know i loved your comment on pre-participation exams doing that abdominal exam and checking for hepatomegaly and then potentially offering preventative padding in order to prevent injury um but that also kind of wondering do you routinely recommend and if so in what situations would you recommend padding once an athlete is safe to return to play in someone who has had a splenic or a hepatic injury you know i think that that's a tough one right because i think that there's probably not a lot of um there's probably not there's probably no data right and i think that there's uh i think when i've looked at this recently most of the case series are old everything sort of says these big ranges of return to play and how we get back into exercise and activity um there's no literature or data specifically on what kind of padding is right i think it depends on the sport a lot i think it depends on the athlete and their position and their comfort um i certainly have some athletes who love uh padding uh for their various injuries and have wanted that after surgery or after trauma i have some that absolutely hate it and would uh and take it off no matter what we put on them um but i've certainly worked with a lot of different athletic trainers and equipment folks to try to come up with strategies that i think make everybody feel a little bit more comfortable about getting an athlete out there i think number one is trying to figure out what is the goal right i think um the goal is to minimize the extension or worsening of a current injury uh to minimize the risk of recurrent injury uh and to decrease pain and discomfort and then i think sort of last is to increase athlete confidence so that they feel more comfortable about being out there um i think if we're worried about extending the in the current injury they probably shouldn't be out there if we're talking about abdominal trauma right so if that's our reason for going out there and padding it up maybe we should rethink whether they're going um maybe ditto if we're worried about recurrent injury right so if they've got a splenic injury and i'm worried that they're going to have a recurrent splenic injury it's probably too soon for them to be going out on the field right um but that's something we could talk about but probably too soon um if it's an abdominal hematoma right or a bruise a contusion and we're worried about making it worse or recurrent then then maybe some padding makes sense if it's for athlete comfort or confidence i think there's a lot of new products out there that make this really possible some of the shirts and jerseys with the with the high density foam in it and padding i think there are a lot of products out there that make that really possible now and i think that the the big reason i always try to ask myself though what are we doing this for and what's our reasoning and then does that reasoning make sense am i doing it for the right reason and then if i am doing it for the right reason okay now how do we do it yeah i think that's a really good point not to get them back soon because we want them to play and prevent them from worsening injury we know isn't ready to go prime time but giving them that confidence that they can play because they are healthy um another question that came up in the chat is not necessarily trauma related but is um abdominal visceral related and just whether or not you have any recommendations for return to play after um an athlete has had an appendectomy or cholecystectomy yeah i think those are really good questions and i think it really depends on the um well it's really qualified it depends uh it depends on the athlete depends on the sport depends on the surgeon and the approach so i think that with the um with many of the new minimally invasive approaches to these surgeries a lot of the new appendectomies are being done laparoscopically with just like two ports now and if one of the reports is umbilical um that's really pretty nice now i will say a lot of our surgeons now are actually treating appendicitis with antibiotics and so at least are postponing appendectomy to a time at which it is more convenient and so at least for a handful of our athletes we've had the opportunity to in-season treat with antibiotics and postpone appendectomy to post-season which has actually been kind of a game changer and they've offered the same um during covid actually the very beginning of covid they um did the same american college of surgeons recommended the same for cholecystectomy they started treating acute cholecystitis uh with antibiotics as well which was kind of a game changer because it started making the same option for cholecystitis as well this idea that we could treat with antibiotics maybe and postpone surgery to a time when it's more convenient so i think that's opened some new doors i think that though if it's done laparoscopically you're really in the probably still the several week range um because you have to worry about the risk of i mean the biggest risk is going to be that you're going to end up with some kind of hernia at the even the port sites um and the last thing you want is an athlete with an abdominal hernia or an umbilical hernia at any of their port sites so i think work with your surgeons to kind of come up with a timing plan and then talk to them about your sort of planning for um approach and could they use an approach and a scope approach that might especially for your sport and for your athlete maximize their return to play options and minimize the time wonderful another question would be um if you have a negative fast exam on an athlete who is you're either evaluating in this in the locker room or on the sideline would that um give you enough reassurance that you would decide not to send them to the emergency department for low to moderate suspicion of a bleed that's a really good question and i think that all comes down to sort of pre-test probability right so how big was my suspicion that made me ultrasound them um i admit that as um and it totally depends on where gosh is such i hate being the person who keeps answering it depends right so i'm the person who like has my butterfly and i keep my butterfly ultrasound on the sideline with me right so i'm pretty likely to pull it out and ultrasound things just because i can't so it takes a pretty low bar for me to decide to ultrasound somebody at halftime um because i can um also it depends on kind of where i am so if i'm covering like georgetown football i have the upside of knowing that our er is 700 yards up the hill right so if i make the decision not to send them and that's the wrong decision i can like reverse that decision and get up the hill in four and a half minutes right that's really different if i make that decision and i am six counties away in the middle of nowhere on a dark and stormy night right so i think it kind of depends on did i do that ultrasound because i was really concerned because this guy because it was that guy who fell off the horse right if i'm at the race track and it's that guy who got like trampled on by the horse the jockey who weighs 111 pounds and the 1200 pound horse ran over him at 40 miles an hour and he's pale and diaphoretic and hypotensive and tachycardic and clutching his spleen and i ultrasound that and he goes and it looks okay and he's still pale and diaphoretic and tachycardic and clutching his spleen i'm probably still going to send him to the hospital right um that's a little different than if i just pull out the ultrasound because i think it's cute and i want to show somebody something because i think i can find the splenorenal interface right so it kind of depends on the pre-test probability right those are all of the questions that we have in the chat and um we are at technically time but if anyone else has any other questions or if you have any kind of final parting thoughts or takeaway points um we we appreciate no glad to have everybody here i think that this is one of those things that uh just love to love to have people thinking about i think that again we think a lot about the musculoskeletal stuff and um i think that one of the things that um i see matt sesley on here matt and i do emergency action planning together and uh one of the things that matt and i talk a lot about is sort of the game planning you do on the sidelines is that like the more you can sit and think to yourself when covering a game or a race or whatever what would i do if like what would i do right now if somebody had an mi what would i do right now if somebody you know had a aortic dissection which we didn't talk about not usually traumatic but um i think we think a lot about what would i do if somebody had an open fracture what would i do if somebody had a cervical spine injury but sort of throw some of these what would i do if somebody had a kidney injury into the mix because i think some of those are ones we don't think about all the time uh and they'll kind of test you a little bit to think about how would i how would i manage that if uh you know if that was what was going on perfect um andy i don't know if we are going to do a post um presentation survey but um dr hudson i just want to thank you for your excellent presentation and your time tonight um but i know that um i learned a lot and i appreciate all that you did all right thank you everybody thanks you guys for having me thank you

3rd Edition, CASE 56

3rd Edition

Uro-Genital

abdominal visceral trauma

injury evaluation

management strategies

CAQ preparation

FAST ultrasound

hemoperitoneum

return-to-play protocols

sports medicine

organ injuries