FAFF Positive, fast tracked

A female patient in her 30s presented to ED with a 1 day history of acute abdominal pain. She reported right iliac fossa pain that was sharp in nature and in the last 2 hours was unbearable. Enroute to hospital her partner reported she fainted and had to be helped out of the vehicle. She opened her bowels normally that day and was passing urine without concerns. Her last menstrual period was just over a month ago and she developed PV spotting today which she attritubuted to a delayed period. After triage she was asked for a urine sample - after mobilisating out of the toilet she collapsed and was brought to Resus.

PMHx: Nil

Gynae: One previous pregnancy, nil complications.

Vitals in Resus:- RR24, S98% on RA, HR 140, BP 70/40mmHg, T36.2ºC, GCS 15, Pain score 9/10

An A-to-E assessment was done and on examination she had a peritonitic abdomen and was most tender in the right iliac fossa. The urine sample was dipped and was B-HCG positive. A patient in shock with RIF peritonism and a positive B-HCG urine test made a ruptured ectopic pregnancy the top differential diagnosis. An immediate bedside Focused Asssessment for Free Fluid (FAFF) ultrasound scan was carried out:

The image shows a view of 'Morrison's pouch' - the hepatorenal angle. There is a large volume of free fluid. In this context, this is presumed bleeding from a ruptured ectopic pregnancy. This patient was urgently referred to Gynaecology and taken directly to theatre where the diagnosis was confirmed with a large volume haemoperitoneum and a salpinectomy was performed. 

Learning Points:

In critically unwell patients with an acute abdomen and haemodynamic instability, a rapid bedside scan showing positive free fluid suspicious for hameoperitoneum (in FAST-trauma or FAFF-atraumatic senarios) allows rapid decision making for surgeons to take patients directly to theatre to control haemorrhage and persue direct exploratory diagnosis and avoid life threatening delays in CT.

Trainee Lead Editor: Dr Amy Knowles, ST5

Checked: Dr Ahmed Abdul-Ghani, Lead Project Consultant