A 24-year-old male with no past medical history presented to the ED with a gunshot wound (GSW) to the left flank. He was at a nightclub when he heard a loud pop and then had severe pain in his back. He was transported to the hospital by medics and had stable vital signs en route. The medics established two large bore IVs. Trauma surgery was notified prior to the patient’s arrival.
Initial VS: BP 135/68, P 89, SpO2 98% on RA
Primary Survey:
Airway: patent, protecting
Breathing: non-labored, equal breath sounds bilaterally
Circulation: pale, diaphoretic, palpable femoral pulses
Disability: GCS 15
Exposure: clothing removed
Secondary survey was significant for a moderately agitated male who was intermittently lethargic with GSWs to the left flank and right buttocks.
FAST exam was completed after the primary survey. Here is a view of the RUQ:
You can see a stripe of anechoic free fluid in Morison’s pouch.
Next a view of the pelvis was obtained:
You can see complex fluid in front of the bladder. This is what clotted blood looks like.
A cardiac view was obtained. There was low suspicion for pericardial effusion, but the providers wanted to better assess volume status in this patient that appeared critically ill, but had normal vital signs.
In this parasternal long view, you can see that the function is hyperdynamic despite a normal heart rate. The walls of the left ventricle are almost completely touching during systole.
Young patients with severe trauma can maintain normal vital signs initially and then rapidly deteriorate. In this patient, ultrasound was used to diagnose free fluid in the abdomen and then identified a hyperdynamic heart. Blood products were given based off of the appearance of the ultrasound and not the patient’s vital signs.
The patient had declining mental status in the ED and was intubated for airway protection. CXR and abdominal XR were both obtained after intubation. No bullet was seen on the x-rays. The patient was then transported to the OR for an exploratory laparotomy.
His initial lactate was 14.
In the OR, he was found to have multiple injuries to the small bowel and an injury to the sigmoid colon. The bullet was thought to have entered his left flank and exited through his right buttocks. His hemoglobin was 12 after receiving 5 units of packed red blood cells and 2 units of fresh frozen plasma.
Bottom line: Ultrasound in trauma can be more than an eFAST exam. It can assess volume status and help guide resuscitation.
