Obtain the perihepatic view.

Look for free fluid between the diaphragm and the liver (subdiaphragmatic) – remember the sweep of the transducer from anterior to posterior position to evaluate the entire area of the hepato-diaphragmal area.

Look for free fluid between the liver and the kidney (Morison’s pouch) – – remember the sweep of the transducer from anterior to posterior position to evaluate the entire area of the hepato-renal recess.

Move the probe anteriorly and caudally to look for free fluid at the anterior tip of the liver and sweep again.

Intraperitoneal fluid appears as a black anechoic (black) area.

The original Focused Assessment with Sonography for Trauma (FAST) and the extended eFAST protocols were developed for assessment of trauma patients.

These address two concerns – pneumothorax and internal bleeding in the thorax or abdomen.

In Essential Emergency Ultrasonography we move away from the protocols towards a focused questions approach.

Ask a clinical question and answer it with all you have got – including the transducer.

We do recognise, however, that in the multi-trauma patient, the following questions your transducer can help you with are: does the patient have 1) a pneumothorax? 2) a hemothorax? 3) a hemopericardium? 4) an intraabdominal bleeding?

No. 1, 2 and 3 are covered by the previous lessons. In the following we only address no. 4 by answering the question “Is intraperitoneal free fluid visible?”

At this point, you should feel confident in how to obtain the abdominal views.

If you do not feel confident, please review the previous topics.
If you do feel confident – now move on to answering the focused questions.

The focused questions in focused ultrasonography of the abdomen are:

Intraperitoneal fluid does not only gather in the rectovesical pouch.

In men it can be seen either in the rectovesical pouch or surrounding the the intestines, or both.

Notice the peritoneum marked as a red line as its anatomy is important for understanding where to look for intraperitoneal fluid while scanning

In adults, the normal largest abdominal aortic diameter is <3.5 cm

Above 3.5 cm, there is an exponentially increasing risk of rupture within the next 5 years with increasing maximal diameter size, but the size at rupture is >5.0 cm in 90% of cases.

Ruptured abdominal aortic aneurism is a clinical diagnosis – no ultrasonographic findings can rule out a ruptured aneurism.

However, the classical triad of pain, hypotension and pulsatile abdominal mass due to rupture is only seen in 25-50% of patients and ultrasonography may aid the diagnosis.

The pelvic view is one of the most difficult to interpret as a novice.

This is because of a lot of shadowing and disturbance from the surrounding structures e.g. bowel and bony structures of the pelvis.

In the image below this is especially seen as the dark areas of bony shadowing on each of the sides of the male bladder in the male pelvic view.

These areas should not be confused with intraperitoneal fluid.

Intraperitoneal fluid does not only accumulate in the rectouterine pouch.

In women ultrasonographic signs of fluid can be found in the rectouterine pouch, between the uterus and the bladder (vesicouterine pouch) or surrounding the intestines.

Notice the peritoneum (red line) as its anatomical location is important for understanding where to look for intraperitoneal fluid while scanning.

The perisplenic view is obtained in the same way as perihepatic view.

Be aware that a slight rotation on the transducer in order to avoid rib shadowing should be done with a clockwise rotation as opposed to the counter-clockwise rotation in the perihepatic view.

In the perisplenic view, the following structures are seen: