Hi, I'm Kathy Bidlock. I am an associate professor at Rocky Vista University and going to do an ultrasound consult on this case of renal laceration and talking about leftover quadrant FAST exam. So leftover quadrant is just one of the views that we use for the FAST exam, and I'm not going to go through the whole exam here. We're just going to talk about this one view because it's pertinent to the case. You'd want to use your machine on either the FAST or abdomen setting. You would want to use a phased array transducer. You can use a curvilinear transducer as well if that's all you have, but you may have trouble getting in between the rib spaces with the curvilinear, and you may have to turn your transducer just a little bit clockwise to get into that space a little bit better. You're going to have the indicator towards the patient's head. You're in the posterior axillary line and the eighth intercostal space, and the image on the right shows these structures that you'll be looking at, the spleen, left kidney, lung, diaphragm, and that area. So with this exam, your hand may be going pretty deep into the bed to get to this structure because it's pretty posterior, especially compared to the right side. So often this is called the knuckles on the bed approach to this. So just remember that if you have a patient who's able to lie on their side, you could do it that way as well, but oftentimes that's not the case. So this is just a labeled image on the right showing the area of lung tissue, the diaphragm, which is very hyperechoic, the spleen, and the left kidney. This is just that same image color-coded and outlined for better visualization. The areas that we would see fluid potentially are the parasplenic space right between the diaphragm and the spleen, and also the area between the spleen and the left kidney, as well as the spleen tip. We see most commonly fluid collecting in the parasplenic space rather than between the spleen and the kidney because of the presence of the splenorenal ligament. And again here, you may have to deal with rib shadowing, and so you may have to move up and down amongst ribs or keep watching between when the patient is breathing to get good visualization. So an artifact that we will see commonly is this mirror artifact, and this is totally normal. We anticipate seeing this here. This is because our diaphragm is so hyperechoic and highly reflected, and it's just right next to the air in the lung tissue. And this causes this mirrored image just deep to the diaphragm. It's a very normal artifact to see and be aware of. So looking back at our case, where would we actually see fluid if we had done a left upper quadrant ultrasound during this case? The CT scan showed paranephric fluid, and there are three different locations where you can commonly see fluid on the left upper quadrant VAST scan. The most common area is the parasplenic space, which is here on blue, and sometimes you have to move a little bit more approximately to see that whole area, which is the picture on the right. Another area where you'll see fluid is the spleen tip, and then the third area is the splenorenal recess. This is a little bit less commonly seen just because there is a splenorenal ligament, but you could potentially see fluid in all of these areas. Now, if you see fluid on your VAST exam, you're going to want to get emergent treatment, obviously. We do have a few slides here just going more in depth into renal ultrasound views for those who are interested. This is just a long axis view of the left kidney. It's labeled on the right showing the renal pelvis and other important structures. This is the same thing, just a transverse view of the kidney with the labeled image on the right once again.

3rd Edition, CASE 56

3rd Edition

Uro-Genital

FAST exam

left upper quadrant

renal laceration

phased array transducer

splenorenal ligament