Proof I learnt something from you all!

After the case from the other week and Dr Casey Parker talking to me about using USS as much as possible to save on radiation I had this patient present to me on nights.

52 y/o male.

Had been chopping wood and fell backwards when he tripped on a piece. striking his R side on the block.

Very painful but given 3mg of morphine in ambulance and settled by the time he hit ED.

PMH Atrial fibrilation, on dabigatran.

Initial inspection below showed a large swelling with area of bruising centrally.

Palpation revealed it was tight and tender.  Abdo was SNT.

So im thinking bleed into lumbar sheath, but if only there was a way to image that at 11pm without radiology in the building. So I whipped out the USS machine and..

Sorry about the quality of the photo from my phone couldnt get it to take better.

Showed a 2cm by 8cm area of low density with some heterogenous material within this. felt consistent with bleed into lumbar sheath. dip urine negative for blood.

Oral analgesia, advised to stop dabigatran for 2 days.

Follow up:  Pt doing well. Impressive bruising which developed later not photographed sorry (saw him in the supermarket)

So it appears not only working out excessively but also chopping wood is to be avoided whilst anticoagulated (actually the chopping wood seems a bit more obvious)

Comments

  1. Difficult to see on the photo of the USS, but what layer is that fluid in?
    Is it deep to fascia or not…?

  2. People on dabigatran should not be allowed near axes… Full stop!
    Love the use of US to define the injury. So much better than examinguessing.
    Did you do a FAST to look for free blood from other visceral injury?
    Nice work
    Casey

    • def agree bout axes! fast scan was neg as expected but doesnt change much as he never looked like theatre material. was interested in his R kidney views which were normal. guessed the would be someone who could go down the page kidney road. thanks for advice comments :)

  3. Did you consider whether this could be a Morel-Lavalle lesion? Is it deep or superficial to fascia?

    S

    • my feeling (untrained uss) was superficial. I had him reviewed the following day as thought “could this be more complicated?” honestly had not heard of M/L lesions before. they were happy just bleed 2nd trauma and anticoagulation. thanks for the comments :)

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