severe renal injury detected by emergency department point of care ultrasound pocus in a patient with undifferentiated hypotension

Contents lists available atScienceDirect Visual Journal of Emergency Medicine journal homepage:www.elsevier.com/locate/visj Visual Case Discussion Severe renal injury detected by Emergen

Contents lists available atScienceDirect Visual Journal of Emergency Medicine journal homepage:www.elsevier.com/locate/visj

Visual Case Discussion

Severe renal injury detected by Emergency Department Point of Care

Michael Halperina,⁎, Siu Fai Lia, Andrew Shannonb

a Jacobi Medical Center, Department of Emergency Medicine, Bronx, NY, USA

b University of Florida, Department of Emergency Medicine, Jacksonville, FL, USA

A R T I C L E I N F O

Keywords:

Rapid Ultrasound for Shock Exam

RUSH exam

Kidney laceration

Renal laceration

Point of Care Ultrasound (POCUS)

Afifty-nine year old male was brought to the emergency

depart-ment for altered depart-mental status after being found lying in the grass He

had alcohol on his breath and was suspected to be severely intoxicated

Unable to provide any history, he was initially hypotensive (BP 77/44),

afebrile (97.0 F), without tachycardia or tachypnea, and normal

oxygenation on room air The only obvious physical exam findings

were an abrasion to his left eyebrow and blood at his urethral meatus

Given his undifferentiated hypotension, however, a RUSH (Rapid

Ultrasound for SH(ock)1 exam was performed, showing free fluid

(Video) in the right upper quadrant Additionally, a large collection

in that right upper quadrant ( Fig 1) was thought consistent with

hematoma given the RUSH exam findings and that a similarly

prominent echogenic stripe was not noted on the left In retrospect,

however, another possibility is that this is perinephric fat within

Gerota’s fascia

After resuscitation with one liter of normal saline, the blood

pressure stabilized and he was taken to CT scan, which revealed an

American Association for the Surgery of Trauma (AAST) grade III

laceration (no urinary extravasation)2of the right kidney with

retro-peritoneal hematoma (Fig 2)

About 5% of renal lacerations are grade III and these generally do

not require surgical intervention because they don’t involve vascular

injuries in the renal pedicle, which can be salvaged with intra-arterial

embolization.3His initial hemoglobin was 11.8 g/dL, which dropped to

8.0 g/dL He was transfused 3 units of red cells, and admitted to

surgical intensive care unit He was successfully managed non-opera-tively as his hemodynamics and blood counts normalized, had no further bleeding, and was doing well at recent clinic follow up Supplementary material related to this article can be found online

athttp://dx.doi.org/10.1016/j.visj.2016.10.004

Fig 1 Right upper quadrant abdominal view with clot (outlined by asterisks) in between kidney and liver parynchema.

http://dx.doi.org/10.1016/j.visj.2016.10.004

Received 14 August 2016; Received in revised form 4 October 2016; Accepted 30 October 2016

⁎ Corresponding author.

E-mail address: halperin.mike@gmail.com (M Halperin).

Visual Journal of Emergency Medicine 7 (2017) 1–2

2405-4690/ © 2016 The Authors Published by Elsevier Inc.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

MARK

Appendix A Supplementary material

Supplementary data associated with this article can be found in the

online version athttp://dx.doi.org/10.1016/j.visj.2016.10.004 References

1 Perera P, Mailhot T, Riley D, Diku M The RUSH exam: rapid ultrasound in shock in the evaluation of the critically III Emerg Med Clin N Am 2010;28:29–56.

2 Moore EE, Shackford SR, Pachter HL, et al Organ injury scaling: spleen, liver, and kidney J Trauma 1989;29(12):1664–1666.

3 Kawashima A, Sandler CM, Corl FM, et al Imaging of renal trauma: a comprehensive review Radiographics 2001;21(3):557–574.

Fig 2 Axial image from CT abdomen and pelvis showing right kidney laceration with

retroperitoneal hematoma.

2