Clip 1: Free fluid in the hepatorenal space.
EMS rolls a 20s F into Resus 1 after she passed out at work. She’s pale, lethargic but awake... looks like she’s about to code. Bilateral large gauge access goes in immediately. Can’t get much info as she’s barely holding onto consciousness, we raise her legs to get every last drop of blood up to her heart. Systolic BP in the 60s, HR also in the 60s.
POCUS Hepatorenal space shows free fluid (Clip 1 above), and pelvic views reveal copious hyperechoic content likely representing clot, and no IUP (Clip 2 below). A great nurse places a foley and runs a urine hcg, returning quickly to the resus bay in no time with a positive result. She’s resuscitated with blood products and is emergently taken to the OR by both EM and OBGYN where she's found to have 4.0 liters of massive hemoperitoneum from a ruptured ectopic.
The Evidence: Free fluid predicts the need for operative management in ectopic pregnancy (Moore et al, 2008), vital signs don’t correlate with hemoperitoneum [notice the normal HR here] (Hick et al, 2001), and the most sensitive place to look for hemoperitoneum is the caudal edge of the liver (Lobo et al, 2017).
Outcome: She walked out of the hospital a couple days later in good condition and is doing well at a recent follow up visit.
Clip 2: Transverse sweep through the pelvis with hyperechoic content throughout, likely clot, and no intrauterine pregnancy.