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

Visual Journal of Emergency Medicine (2017) 1–2 Contents lists available at ScienceDirect 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 Ultrasound (POCUS) in a patient with undifferentiated hypotension MARK ⁎ Michael Halperina, , Siu Fai Lia, Andrew Shannonb a b Jacobi Medical Center, Department of Emergency Medicine, Bronx, NY, USA 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) A fifty-nine year old male was brought to the emergency department for altered 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)2 of the right kidney with retroperitoneal hematoma ( Fig 2) About 5% of renal lacerations are grade III and these generally not require surgical intervention because they don’t involve vascular injuries in the renal pedicle, which can be salvaged with intra-arterial embolization.3 His initial hemoglobin was 11.8 g/dL, which dropped to 8.0 g/dL He was transfused units of red cells, and admitted to ⁎ Fig Right upper quadrant abdominal view with clot (outlined by asterisks) in between kidney and liver parynchema surgical intensive care unit He was successfully managed non-operatively 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 at http://dx.doi.org/10.1016/j.visj.2016.10.004 Corresponding author E-mail address: halperin.mike@gmail.com (M Halperin) http://dx.doi.org/10.1016/j.visj.2016.10.004 Received 14 August 2016; Received in revised form October 2016; Accepted 30 October 2016 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/) Visual Journal of Emergency Medicine (2017) 1–2 M Halperin et al online version at http://dx.doi.org/10.1016/j.visj.2016.10.004 References 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 Moore EE, Shackford SR, Pachter HL, et al Organ injury scaling: spleen, liver, and kidney J Trauma 1989;29(12):1664–1666 Kawashima A, Sandler CM, Corl FM, et al Imaging of renal trauma: a comprehensive review Radiographics 2001;21(3):557–574 Fig Axial image from CT abdomen and pelvis showing right kidney laceration with retroperitoneal hematoma Appendix A Supplementary material Supplementary data associated with this article can be found in the ... J Trauma 1989;29(12):1664–1666 Kawashima A, Sandler CM, Corl FM, et al Imaging of renal trauma: a comprehensive review Radiographics 2001;21(3):557–574 Fig Axial image from CT abdomen and pelvis... abdomen and pelvis showing right kidney laceration with retroperitoneal hematoma Appendix A Supplementary material Supplementary data associated with this article can be found in the ... rapid ultrasound in shock in the evaluation of the critically III Emerg Med Clin N Am 2010;28:29–56 Moore EE, Shackford SR, Pachter HL, et al Organ injury scaling: spleen, liver, and kidney J Trauma