A 22 year old male is retrieved to ED after a nasty workplace accident where he was pinned between a truck and wayward forklift. He had sustained injuries to his head/face, upper thorax and perineum, however our most significant concern was regarding his right lower limb. He had a displaced, angulated compound femur fracture that required sedation and pre-hospital reduction. There were reports of significant bleeding at the scene.
No immediate interventions were required following his primary survey, but his right limb revealed a nasty tissue defect and open fracture (now splinted). There was no active blood loss, but his leg distal to the injury was pale and cold with no appreciable dorsalis pedis or posterior tibial pulses.
Here are his initial xrays….
As there was concerns regarding intraabdominal and pelvic injuries; he was taken to radiology for CT, including angiography of his lower limbs….
Recently, a colleague of mine was wanting to perform a diagnostic tap on a patient with cough, fever and a CXR suggesting a left sided pleural effusion….
I was asked to perform a bedside USS to mark out the safest place to perform the pleural aspirate.
I percussed the chest to the dullest point and then slapped the ultrasound on (left posterior chest wall, longitudinal plane, just below tip of scapula).
This is what I saw…
Needless to say the needle was re-sheathed and the procedure aborted. I am convinced that if we were going by x-ray and clinical examination alone we would have created more problems for this guy.
What made a difference….
- Turner JP, Dankoff J. Thoracic ultrasound. Emerg Med Clin North Am. 2012 May;30(2):451-73.
- Ultrasound Podcast Episode 31 (Pneumothorax & Pleural Effusion) & Episode 32 (Pneumonia & ARDS)
A few days ago I was looking after a 31/40 gestation restrained passenger from low-speed MVA with a slight seatbelt abrasion in her RIF & mild suprapubic pain. She looked well, HR 70 with BP 108 systolic and no features of peritonism.
As I placed the US-probe on for her FAST, this was the first image I acquired…..
A motorcyclist is minding his own business, stationary at a set of lights and is rear-ended by a car at ~60-70km/h. He is thrown 10 meters or so from his bike and lands on his left side. Remarkably he is systemically well, except for significant left lateral chest wall pain !!
You think he has reduced air-entry on the left side, but is he’s not dyspnoeic, nor hypoxic. The remainder of his primary survey is unremarkable.
This is his supine CXR…
EFAST showed no evidence of free intraperitoneal fluid, but this is what I saw on the chest….