At a hospital in Duhok, located in northwestern Iraq, an ambulance arrives carrying a 13-year-old boy who has been severely injured. The ambulance traveled three hours from the remote area in which the accident occurred. The medics report that the patient was part of a group of children that had been playing with remains of an IED placed by ISIS when it exploded. The patient was approximately 66 feet from the explosion. Three other children closer to the explosion were killed instantly.
Trauma to the boy's left lower extremity was obvious. He is alert and crying. His blood pressure was 110/70 mm Hg, his heart rate was 130 bpm, respiratory rate was 30 bpm, and his SpO2 was 99% on room air. IV access is obtained, and resuscitation begins.
Multiple wounds are also seen on his anterior chest and groin, most notably to the epigastric area. No active bleeding is noted, but the abdomen is tender to palpation, particularly in the epigastric area.
A bedside ultrasound is performed, and a large amount of free fluid is noted in the pelvis (Image 1) and a small amount in the pericardium (Image 2). Multiple hyperechoic foci are seen within the liver (Image 3), which is shrapnel from the blast injury.
The general surgeon and thoracic surgeon are consulted to evaluate the patient before he is taken to surgery. Liver injury is noted intraoperatively and repaired, and the pericardium is opened, revealing only serous fluid. The surgery goes smoothly, and the patient is transferred to the surgical ward. He recovers steadily over the next few days, and is discharged in good condition 10 days later. Incidentally, the pericardial fluid was later found to be acid-fast bacilli positive.
The FAST exam is a powerful tool in examining these types of patients, and this is particularly true in austere environments where resources are limited. The real underlying story in this case is the terrible cost of war and the reality that exists right now in many parts of the world. Blast injury is frequently associated with battlefield injuries and is not something that we commonly encounter in the typical ED, and it may be something that seems foreign and exotic to many emergency physicians. Unfortunately, these types of injuries are common in many conflict-torn areas of the world, and often the victims are those unassociated with the conflict — children and civilians.
Tip of the Month
It's easy to become disoriented when trying to distinguish the right and left ventricles on the apical view. If you point the indicator toward the patient's left, the left ventricle will always be on the same side of the screen as the indicator dot.
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