Free Fluid? Not just in Trauma!

63yo M c/o severe abdominal pain that awoke him from sleep at 0600.  Presented to ED at 1200 c/o lower abdominal pain.  Triage nurse noted patient to be slightly pale so placed the patient into the resuscitation room.  +Nausea, no vomiting; no back pain; no chest pain; no SOB; no travel.

O/E: BP: 185/79, HR: 90, RR 16, O2 Saturation: 100% RA, Temperature: 36.5 degrees Celsius

Looks uncomfortable, slightly pale.  CVS/Resp – WNL; Abdo: No scars, umbilical hernia present – reducible, but noted to be discoloured – thought to represent Cullen’s sign.  Tender to palpation diffusely over abdomen, no guarding no rebound.  Peripheral pulses present, extremities warm to touch.

Let’s pull out the POCUS!

Bedside POCUS: Aorta <3cm from xiphoid to bifurcation; RUQ – Free Fluid at caudal tip, hypoechoic mass can be seen projecting into liver.  LUQ – no FF present

Vitals were stable but because of positive POCUS for FF, patient was expedited for CT abdomen (within 5 minutes of arriving to resuscitation room).  His CT report was received within minutes of his CT being completed and showed a moderately large hemoperitoneum with active extravasation from a large gallbladder mass invading the liver.

Patient was sent to Interventional Radiology where he had embolization within 45 minutes of his presentation.  His hemoglobin dropped 30 points from the time he presented to the ED to the time he went for embolization.

POCUS was extremely helpful in the care of this patient.  His free fluid was picked up immediately and he had imaging and embolization done in an expedited manner because of this.  Had POCUS not been available or utilized, his stable vital signs may have masked the true urgency of his presentation and his disposition may have taken longer to reach leading to a potential adverse outcome.

Learning point: Checking for free fluid in the abdomen should not be limited to trauma patients.

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