Case 9

Case #9: Leg pain

HPI: 44yo female without PMH presents to the ED from her primary doctor's office with a chief complaint of "left lower extremity swelling." The patient had noted increased swelling and discoloration to her entire left leg over the past several days. She has no risk factors for blood clots.

Physical Exam:

Extremities: Unremarkable bilateral upper extremities and right lower extremity. Left lower extremity reveals a swollen leg with 1+ pitting edema extending to the proximal thigh; leg is painful to the touch with a "milk white" appearance consistent with phlegmasia alba dolens; 1+ DP pulse with delayed cap refill

Bedside Ultrasound:

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What is abnormal about this ultrasound?

What structures do you see?


Under compression, the vein does not completely compress. Actually it doesn't compress at all!

Diagnosis:

DVT found to be a result of May-Thurner Syndrome

May-Thurner Syndrome (MTS), also known as Iliac Vein Compression Syndrome, occurs when the common iliac vein is compressed because of the overlying common iliac artery. This is typically compression of the left common iliac vein caused by the right common iliac artery. As the aorta descends along the left lateral side of the inferior vena cava, its terminal branch will cross on top of (and sometimes compress) the left terminal branch of the IVC against the lumbar spine. This compression can lead to discomfort, decreased venous return, and ultimately deep venous thrombosis. As the DVT initiates at a proximal location in the lower extremity, the thrombus can be very large and propagate quickly.

Ultrasound Education:

Lower extremity venous compression via ultrasound is compression of the venous system at 1cm increments to evaluate for DVT. A linear probe is used in this process.

Starting at the proximal thigh within the groin, the vein is compressed by pressing the probe into the skin surface at a 90 degree angle and noting the collapsing of the vein under external pressure. Arteries near to the vein will most likely not compress. Arteries are thick-walled, pulsatile and "bouncing" in comparison to the thin-walled easily collapsible veins. The bedside ultrasonographer will start the exam at the point where the Greater Saphenous Vein (GSV) of the superficial venous system meets with Common Femoral Vein (CFV) of the deep venous system. The EM provider then tracks the vein distally through the Femoral Vein, and finally moves the probe to the posterior aspect of the knee to evaluate the Popliteal Vein.

During compression with the probe, the anterior and posterior walls must touch for the vein to be called completely compressible. If they do not touch during compression with the probe, there is concern for a thrombus at that location. Following each vein as distally as possible until no longer able to discern the vein ensures evaluation of the entire deep venous system via ultrasound.

Additional resources:

1. http://www.emdocs.net/case-rare-cause-dvt-young-healthy-patient/ -a great review on May-Thurner written by an expert in the field ;)

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377287

-Bristol Schmitz MD

Case 8

HPI: 22yo female with one day of abdominal pain. Initially cramping but worsening in severity, now characterized as sharp. Worse with standing and walking.

Physical Exam: 

Abdominal- LLQ and suprapubic tenderness

UA- no infection

Wet mount- positive for yeast

Bedside US- large right adnexal mass

OB/Gyn Ultrasound (US) in the ED?

Abdominal pain in the female patient is often not straight forward, as there are a great number of mimickers that involve pathology in the uterus and adnexa.  Any pain which is described as "low" or present in the back/flank should compel one to consider gynecologic etiologies. In the event where the history strongly suggests gynecologic pathology, US is the imaging of choice. Both transabdominal ultrasound (TAUS) and transvaginal ultrasound (TVUS) provide excellent resolution of lower abdominal structures. More broadly, US is a low-cost, low-risk (no radiation) alternative to other diagnostic imaging. Specifically, in an ED setting it has great utility to "rule out badness." TAUS offers an ample opportunity for bedside evaluation and rapid triage in the event of an unstable or highly undifferentiated patient.

How to perform:

The transabdominal (TAUS) portion of the Ob/gyn US exam should be undertaken with the patient in the supine position. A full bladder is preferred as it will provide better echogenic windows when completing a TAUS (the opposite is true for TVUS). Orienting the probe indicator towards the head, the provider will scan through the longitudinal plane from right to left with the probe placed just superior to the pubic symphysis. All relevant anatomy should be visualized including the uterus, Pouch of Douglas, and adnexal anatomy (ovaries included). Then the transducer is rotated into the transverse plane to obtain views of the uterus from cervix to fundus.

Make sure to capture images of relevant anatomy including ovaries, endometrial stripe, and IUP if present. A video that tracks through the entire uterus to prove the absence of IUP is helpful. Additionally, videos that sweep through an entire ovary can be useful in characterizing a cyst, if present.

US findings of ovarian pathology

Locating the ovaries can be challenging as they often reside in different locations throughout the pelvis for different individuals. You may have to do some ovary hunting. A normal ovary is likely to have a number of follicles present and often resembles a "chocolate chip cookie" as shown below. As always with US, fluid-filled structures such as follicles (<1cm), marked by arrowheads below or cysts (>1cm) will appear anechoic (black). The surrounding ovarian parenchyma is a brighter strip surrounding the follicles (arrow).

When evaluating cysts on US, both size and characterization matter. A simple cyst is defined as one that is less than 5cm in size. Simple cysts are characterized by circular/ovular border without irregularities. They should be anechoic (black) throughout, demonstrating no shadows or internal echoes that might be indicative of hemorrhage, debris, or loculations. The image below is an example of a hemorrhagic luteal cyst. Note the increased echogenicity (shadowing) within the asterisk-marked structure (luteal cyst) compared to the anechoic follicles (arrowheads).

Now let's apply those aforementioned principles to the patient in this case using the images below:

TVUS of RIGHT ADNEXA

What do you see that is abnormal? How would you characterize the abnormalities? Size? Features?

TVUS of RIGHT ADNEXA

This is a large (8.5 cm x 7 cm) complex cyst (blue), defined by its loculations (purple) and dependent debris (red).

Treatment

Any luteal cyst greater than 3cm requires gynecologic follow-up. Any complicated cyst, defined as >5cm of loculated with internal debris should be referred to gynecology for either consultation in the ER or outpatient follow-up depending on the patient's clinical status.

For example, a complicated appearing cyst in a febrile, hypotensive sexually active female may be a tubo-ovarian abscess. Similarly, if free fluid is seen in the pelvis in conjunction with a complex cyst in a hemodynamically unstable patient presenting with sudden onset abdominal pain, she may have had a ruptured ectopic pregnancy vs ruptured hemorrhagic cyst vs ovarian torsion. These scenarios require gynecologic consultation in the ER with possible disposition to the OR. In such cases, bedside US can be useful in painting a clearer clinical picture to a consultant.

In the stable female patient with abdominal pain, detection of a cyst or abnormal structure on bedside TAUS warrants further imaging with a formal TVUS for better characterization. Such a study will permit risk stratification of a cyst including simple vs complex, as well additional criteria to determine the likelihood of neoplastic pathology or malignancy. Specifically, a set of criteria known as the "Simple Rules" (see reference #1 below) are relied upon, because any one characteristic is not diagnostically predictive. These criteria take into account size, blood flow, loculations, borders, free fluid, acoustic shadowing, and presence/absence of papillary structures. While these rules are beyond the scope of practice of Emergency Physicians, they are often used by gynecology and oncology when evaluating adnexal cysts.

 

Additional resources:

1. https://www.ncbi.nlm.nih.gov/pubmed/26800772

2. https://www.uptodate.com/contents/ultrasound-differentiation-of-benign-versus-malignant-adnexal-masses?topicRef=3207&source=see_link#H579334644

3. Chapter 7 Pregnancy- Matthew Dawson and Mike Mallin. "Introduction to Bedside Ultrasound: Volume 1" Free iBook.

 

May Tape Review for CME

Thursday, 5/3 at 10:00am

Thursday, 5/10 at 8:30am

Thursday, 5/17 at 11:00am

Thursday, 5/24 at 9:00am

Thursday, 5/31 at 11:00am

Case 7

Abnormal Echo

HPI: 75 year old man with past medical history of CAD s/p CABG, diabetes, hyperlipidemia and hypertension who presents to the ED from his cardiologist's office after an abnormal echocardiogram. He had no complaints of shortness of breath, chest pain, dizziness, lightheadedness, syncope; the stress echocardiogram was routine given his history of CAD.

Physical Exam: Clear S1 and S2 with no additional cardiac sounds including no murmurs, rubs, gallops. Lungs were clear to auscultation. The remainder of the exam was unremarkable.

Bedside Ultrasound:

us 1.gif
us 2.gif

-What is abnormal about this echo?

-How do you position the probe to obtain these echo views?

Our bedside ultrasound showed a well-circumscribed ovoid mass in the left atrium that moved with the mitral valve. Given the location and shape of the mass, it appeared to be a cardiac myxoma.

PARASTERNAL LONG AXIS

unnamed.jpg


-Position the probe just lateral to the sternum in the left third or fourth intercostal space

-Troubleshooting tip: if visualization is difficult, consider placing the patient in the left lateral decubitus position to bring the heart closer to the chest wall.

APICAL 4-CHAMBER

unnamed-1.jpg


-Position the probe at the cardiac apex approximately in the 5th intercostal space in the mid axillary line

-To avoid foreshortening the view, one should place the probe at the lowest intercostal space in the most lateral position to obtain a good view.

-Troubleshooting tip: if the patient is particularly skinny and the ribs are close together you can have them position their left arm above their head to expand the rib spaces.

Differentiating masses on echocardiogram: Masses noticed on echocardiograms are concerning for tumors (such as myxomas, papillary fibroelastoma, and carcinoid tumors), vegetations, and thrombi in the order of most to least common etiologies. One of the key differentiators is location. Thrombi are located in the left ventricle in patients with severe cardiomyopathy or ventricular wall aneurysms or mechanical valves. Migrating emboli would be noticed on the right side of the heart in the vast majority of cases. Vegetations need to be considered in the appropriate clinical situation, such as bioprosthetic valves or intravenous drug users and are most often on the upstream side of the mitral or tricuspid valves. Myxomas, the most common cardiac tumor, are predominantly in the left atrium. Given this key differentiator it is critical to get good views of all four chambers often using an apical 4-chamber view. Additionally, the parasternal long view can give a good view of the mitral valve (looking for vegetations), the left atrium (looking for myxomas), and the left ventricle (looking for thrombi). Lastly, using a parasternal short view one can visualize any of the valves as well as ventricular aneurysms and associated thrombi.

Noting the shape of the mass is also important. Vegetations and thrombi tend to be irregular in shape while the vast majority of myxomas have smooth surfaces and are ovoid or circular in nature. However, a small portion of thrombi can have smooth ovoid borders on ultrasound.

Cardiac myxomas: Cardiac myxomas account for nearly half of all cardiac tumors and are the most common benign tumor of the heart.  Most are sporadic however there have been familial forms. They are more common in women with a 3:1 preponderance. They can be found in any chamber of the heart, but 75-90% occur in the left atrium. Often they are not found until they are 5-6 cm in size.

Cardiac myxomas can present with numerous symptoms. They can cause valvular obstruction leading to chest pain, pulmonary edema, shortness of breath with exertion and syncope. They can degenerate and cause embolic symptoms such as strokes in 30-40% of patients. Additionally, they can present with fevers, body aches, fatigue, weight loss and Raynaud's phenomenon. These constitutional symptoms are related to the myxoma's production of interleukin-6. In 20% of cases the individual is asymptomatic and it is an incidental finding.

Diagnosis is made via echocardiogram with transesophageal being slightly more sensitive and specific than transthoracic. CT and MRI are other diagnostic imaging options.

Urgent surgery is needed as patients are at risk of sudden cardiac death. Local recurrence happens in approximately 3% of cases and is higher in familial etiologies.

Conclusion: The patient was admitted to the hospital and had a transesophageal echocardiogram confirming a large mobile mass in the atrial cavity with appearance consistent with a myxoma. The patient went for myxoma resection on day 2 of his admission and discharged after 11 days in the hospital.

Additional resources:

-Au AM. "The cardiac mass: is it a thrombus, tumor or vegetation? Take it in the context of the disease" JBR Journal of Clinical Diagnosis and Research 2016; 4(1)

-Lone RA et al. "Atrial myxoma: trends of management." International Journal of Health Sciences 2008;2(2):141-151.

-Mendoza CE, Rosado MF, Benal L. "The role of interleukin-6 in cases of cardiac myxoma." Texas Heart Institute Journal 2001;28(1):3-7.

-Torregrossa J et al. "Ultrasound diagnosis of a left atrial myxoma in the emergency department." Western Journal of Emergency Medicine 2013;14(2):130-131.

-Kyle Bernard MD

Case 6

 

RUQ Abdominal Pain

HPI: 70 y/o F with no significant PMH who presented with several days of RUQ abdominal pain. Patient endorses fevers and chills, denies nausea, vomiting, diarrhea.

Brief Exam: RUQ abdominal tenderness on deep palpation. Murphy's sign negative.

Bedside Ultrasound of the Right Upper Quadrant:

LONGITUDINAL:

TRANSVERSE:


Diagnosis: Cholecystitis

Management: General surgery was notified and came to evaluate the patient. She was started on IV fluids, antibiotics, made NPO, and cholecystectomy was scheduled for the next morning.

How to perform a Gallbladder US:

-Use the curvilinear probe

-Patient should be supine. Place a large amount of gel on the patient's right upper quadrant.

-Start by placing the probe in a longitudinal plane (indicator towards the patient's head) under the right costal margin along the midclavicular line.

-Sweep through the RUQ to find the gallbladder, which will be an anechoic elongated structure.

-To help identify the gallbladder, look for a strongly reflective, hyperechoic thick fibrous band known as the main lobar fissure which connects the main portal vein to the gallbladder.

-Once the gallbladder is identified, use sweeping strokes in both the longitudinal and transverse plane to evaluate the entire gallbladder. Look for gallstones, pericholecystic fluid, determination of gallbladder wall thickness, and perform the sonographic "Murphy's Sign".

-To measure the gallbladder wall, choose an area on the anterior wall peripendicular to the imaging plane as this is the closest to the probe and therefore the most accurate. A measurement greater than 3mm is considered abnormal.

Brief Review and Ultrasound Education:

Abdominal pain is a common complaint in the Emergency Department. If the pain is in the patient's RUQ, the ultrasound can be used to identify pathology in the gallbladder. The gallbladder should be scanned for gallstones, determination of wall thickness, pericholecystic fluid, and the sonographic "Murphy's Sign".

Gallstones are bright, hyperechoic areas within the gallbladder. They are highly reflective and as a result produce posterior acoustic shadowing. They tend to rest in the most dependent portion of the gallbladder. Having the patient turn on the side or change positions will often change the location of the gallstone, allowing you to visualize it within different anatomical planes. Pericholecystic fluid appears as an anechoic outline adjacent to the gallbladder wall.

Findings consistent with acute cholecystitis include wall thickening >3mm as discussed above, pericholecystic fluid, and presence of a sonographic "Murphy's sign". Note that the presence of gallstones themselves does not mean the patient has cholecystitis but rather cholelithiasis. At least one of these other findings is required to make the diagnosis of cholecystitis.

Additional Resources:

Sonoguide. Ultrasound Guide for Emergency Medicine Physicians. https://www.acep.org/sonoguide/biliary.html

Emergency Ultrasound Podcast. J. Christian Fox https://itunes.apple.com/us/podcast/emergency-ultrasound/id429668403?mt=2

 

Brianna Miner MD

Case 5

Case #5: Shortness of breath

HPI: 89 year old male with history of afib, HTN, HLD, pulm HTN, CAD, CHF presenting with two days of palpitations and increasing shortness of breath with substernal chest pain. CXR seen below:

Read as: “Increased  perihilar  and  basilar  airspace  opacities  along  with  likely  small  pleural  effusions.”

What is the sensitivity and specificity of CXR in detecting pleural effusion? How about US?

Position patient in the sitting position where the most dependent area will be the costophrenic angle.  Using the transabdominal probe, position the indicator probe towards the patient’s head and place in the midaxillary line towards the bottom of the rib cage so as to obtain a sagittal view.

This is a similar view to the RUQ scan during the FAST exam but the landmarks are slightly different in that you do not need to identify the kidney. Identify the liver, the diaphragm and the thoracic cavity. Additionally, you should be able to see the spine in the far field and as the patient breathes, you can identify the echogenic lung within the effusion if one is present.

One notable sign found with pleural effusions is the “spine sign” in which the hyperechoic line of anterior spine can be seen extending into the thoracic cavity. In a normal healthy person, the spine sign will stop abruptly at the level of the diaphragm as the healthy air filled lung does not allow for sufficient conduction to see the spine in this area. Fluid is an excellent conductor and allows the sound waves to travel and reflect off of the thoracic spine.

Chest X-rays are able to detect 50ml of fluid on a lateral upright film, however in the Emergency department a single AP view is what is obtained. Blunting of the costophrenic angle is not appreciated until at least 200cc of fluid has collected. This leads to a sensitivity of 78.4% and specificity of 76.4% compared to CT scan (Brixey et al, 2011).

In contrast, bedside ultrasound has been proven to detect 20ml of fluid reliably with one meta analysis demonstrating a sensitivity of 93% and specificity of 96% compared to CT scan (Soni et al, 2015).

A thoracentesis is still needed for complete characterization, however thoracic ultrasounds may be utilized to identify pleural effusions as illustrated in this case. One study suggests that you may be able to characterize the effusion based on ultrasonographic findings.

An effusion seen in conjunction with B-lines on ultrasound is highly suggestive of a transudative etiology secondary to congestive heart failure. If complete lung consolidation is appreciated on ultrasound, it is can be concerning for malignancy(Prina et al) in addition to pneumonia, pulmonary edema, etc.

Bedside ultrasound in the Emergency Department has an ever growing list of applications. In the thoracic ultrasound we see a more reliable modality for detecting effusions than the traditional x ray. It is nearly as sensitive and specific as the gold standard CT at a fraction of the cost and time. It is a valuable tool to have in the Emergency Medicine Tool box.

References:

1. Brixey AG, Luo Y, Skouras V, Awdankiewicz A, Light RW. The efficacy of chest  radiographs in detecting parapneumonic effusions. Respirology. 2011Aug;16(6):1000-4.

2. Soni NJ, Franco R, Velez MI, Schnobrich D, Restrepo MI, Mayo PH. Ultrasound in the Diagnosis and Management of Pleural Effusions. J Hosp Med. 2005 Dec 10(12): 811-816.

3. Prina E, Torres A, Carvalho CRR. Lung ultrasound in the evaluation of pleural effusion. J Bras Pneumol. 2014 Jan-Feb, 40(1): 1-5.

 

Happy Learning!

Emma Burch MD 

Case 4

Shoulder Pain

HPI: 74yo F presents with 4 days of L anterior shoulder pain. She moved some boxes the day before the pain started but doesn't remember the time of onset. Pain is worse with any movement of the shoulder and unrelieved with tylenol or heat pad. No redness, rash, fever, pain in other joints, numbness or weakness besides limitation secondary to pain. No prior similar episodes, shoulder surgeries or diagnoses made related to the shoulder. Generally healthy, lives alone, takes care of self.

Physical Examination: No acute distress. Holding L arm in a position of comfort with shoulder adducted and internally rotated and elbow flexed. Radial pulse 2+. Median/ulnar/radial nerve distributions are motor intact and sensation intact to light touch. Normal strength compared to opposite extremity however effort is limited secondary to pain with shoulder flexion and adduction as well as elbow flexion. Tenderness present on anterior shoulder and anterior proximal third of humerus. No tenderness over scapula, elbow, wrist. No deformity, skin changes, or signs of infection. Compartments soft.

ED Shoulder Ultrasound?

The differential for shoulder pain is broad and includes rotator cuff tendinopathy, glenohumeral joint arthritis, AC joint pathology, biceps tendon pathology, and referred pain (ACS, gallbladder, cervical radiculopathy). Once other pathologies are ruled out, ultrasound is a great tool to evaluate the bones and muslces/tendons- the attributes that give the shoulder its mobility and expose it to injury also expose it to sound waves! The bones can be assessed for fractures, dislocations, post-reduction assessments, and AC and sternoclavicular joint spaces. The rotator cuff muscles/tendons as well as the biceps tendon can be imaged for tears or tendinosis, which are hypo- or anechoic regions in the muscle fibers. A tear can be full or partial thickness, and in general is more anechoic, well defined, and associated with bony irregularity (relative to the general swelling of tendinosis). Calcific tendinitis may show areas of hyperechoic calcium with shadowing. Focal areas of tendon discontinuity and loss of homogeneous hyperechoic architecture can indicate chronic tendinopathy and risk for rupture.

The long head of the biceps tendon is located in the biceps groove, bordered medially by the lesser tuberosity and laterally by the greater tuberosity.

 

How to perform: Have the patient sit with the palm up on the thigh to rotate the biceps groove anteriorly. The tendon can be assessed in both long and short axis, typically proximal to distal. The contralateral shoulder can be used for comparison. Supination and pronation of the forearm or internal and external rotation of the shoulder can reveal subluxation or dislocation of the tendon from the bicipital groove.

 

Biceps tendon probe placement:


Normal short axis biceps tendon view:

The long head of the biceps tendon fits snugly in the bony bicipital groove and shows a tightly packed hyperechoic, uniform pattern and is closely approximated to the bone.

Our patient:

Diagnosis: Biceps tendonitis


ltrasound findings of tendinitis: The hypoechoic area surrounding the long head of the biceps tendon represents significant edema. We do not see large hypoechoic areas within the tendon that would indicate a partial tear, and the fact that the tendon is present in the bicipital groove indicates there is not a proximal rupture and displacement.

Biceps tendon injuries include a spectrum of disorders including acute tendinitis (inflammation and swelling, more often in the young or middle aged) leading to chronic tenosynovitis (an inflammatory process distinct from the acute infectious variety). This may lead to degenerative tendinosis which is chronic degeneration from failed healing and repetitive trauma, typically in older patients. "Tendinopathy" is a more general term and may not include acute inflammation. Proximal biceps tendinopathy is more common than distal. There can also be subluxation or complete displacement of the tendon, as well as partial and complete tears. General shoulder pathology often coexists (impingement, labrum injuries, or rotator cuff tendinopathy or instability) which alters shoulder mechanics and contributes to proximal biceps stress and tedinopathy more often than a specific mechanism.

The pain of biceps tendinitis is typically located over the anterior, proximal shoulder and radiates distally over the biceps, worsened by activity and sometimes associated with a catching or snapping sensation.

Continued forceful biceps contraction can cause biceps tendinopathy to be complicated by biceps tendon rupture. Typically during activity, patients can feel a "pop" with swelling, decrease in muscle strength, "Popeye's deformity" (if the tear is complete), and pain. However, if there is a chronic painful tendinopathy, acute rupture can provide relief of pain.

Treatment:

Management of biceps tendinitis is conservative and includes rest, ice and compression. A sling can be used as needed during activity. Discuss the complication of frozen shoulder (adhesive capsulitis) from excessive sling use and recommend removing the sling when possible (at night, etc) with range of motion as tolerated. They should discuss physical therapy with their primary doctor. A short course of NSAIDs may be useful as well (consider topical for localized musculoskeletal pain).

For tendinopathy/tendinitis, patients should be electively referred to orthopedic surgery for possible steroid injection or MRI to look for partial tears or additional injuries in the rotator cuff or labrum. Distal biceps tendon rupture requires urgent referral to consider surgery because distal ruptures cause more functional limitation than proximal rupture. Surgery should be within a week to prevent contracture of the tendon- if this happens, the surgeon has to use the palmaris longus for a graft (and one out of five people don't have it!) Distal ruptures can be distinguished from proximal: they occur in ages <50, cause more weakness, pain is more localized to the elbow, the Popeye's sign is located higher (similar concept to the high-riding patella in a patellar tendon rupture vs quadriceps rupture), and the proximal tendon can be visualized in the correct location in the bicipital groove on ultrasound. Proximal ruptures are typically in the elderly, cause pain more localized to the shoulder, have a more distal Popeye's sign, and usually cause minimal functional limitation so treatment is usually conservative based on the patient's activity level, occupation, personal preference. The distinction between distal and proximal rupture can be difficult and ultrasound use is limited when visualizing the more distal biceps; so if you aren't sure where the rupture is, obtain an urgent referral.

Additional resources:

Chapter 15 Shoulder- Matthew Dawson and Mike Mallin. "Introduction to Bedside Ultrasound: Volume 1" Free iBook https://itunes.apple.com/us/book/introduction-to-bedside-ultrasound-volume-1/id554196012?mt=11

European Society of MSK Radiology: Shoulder Ultrasound pdf https://essr.org/content-essr/uploads/2016/10/shoulder.pdf (thanks for the source, Ryan Freedman!)

Sonosite shoulder ultrasound video: https://www.youtube.com/watch?v=QelYPkMLAOk

-Dan Deweert MD

Case 3

HPI: 28-year-old male who presents to the Emergency department with right lower quadrant abdominal pain for 4 days. Pain is associated with vomiting and subjective fevers. No urinary complaints. WBC: 18.

Brief exam: Tenderness to palpation to the right lower quadrant. 

Imaging: Bedside ultrasound of the right lower quadrant

  What structures do you see?

What is abnormal about this ultrasound?

Appendix is outlined in Red

Diagnosis: Acute appendicitis

Management: Surgical Consultation and Antibiotics

Ultrasound Education:

The use of bedside ultrasound to evaluate a patient with abdominal pain is a common practice in the emergency department. Frequently ultrasound is used in the evaluation of a patient with possible appendicitis. Overall sensitivity of ultrasound in appendicitis is 86 to 92%. This exam can be quickly performed in the emergency department and avoids the significant radiation associated with Computed Tomography (CT).

Probe selection: Linear high frequency probe is ideal. The lower frequency curvilinear transducer maybe used in larger patients.

Approaches to locate the appendix:

1.     Ask the patient to point to the area of maximal pain. Small movements of the ultrasound probe in that location may reveal the appendix.

2.     Follow ascending colon down to the cecum. The Appendix will be noted coming off the cecum.

3.     Find the iliac artery. Adjacent to the vessel will be the appendix. 

Sonographic findings for appendicitis:

1.     Blind ended finger like structure with lack of peristalsis

2.     Non-compressible under pressure

3.     Diameter> 7mm

4.     Appendicolith maybe visualized

5.     Periappendiceal fluid is suggestive of inflammation

Limitations of Ultrasound:

1.     Patient size

2.     Operator Experience

Additional resources:

1.     Brief review on the use of ultrasound for appendicitis: Appendicitis Ultrasound Podcast

2.     Mallin M, Craven P, Ockerse P, Steenblik J Forbes B, Boehm K, Youngquist S. Diagnosis of Appendicitis by bedside Ultrasound. Am J Emerg Med. 2015 Mar;33 (3):430-2

3.     Elikashvili I, Tay ET, Tsung JW. The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis. Acad Emerg Med. 2014;21(2):163-70.

Case 2

 

HPI: 70 yo male presents to the ED complaining of about 6 days of seeing "white floaters" out of his right eye followed by a sudden onset of painless loss of vision to the right eye at approximately 11am today, described as "something coming up over my eye."

 

Brief Exam: EOMI. Left pupil is reactive to light. +relative afferent pupillary defect on the right. Visual acuity: only able to distinguish gross hand motion on the right; 20/40 on the left.

 

Bedside Ultrasound of the Right Eye:

What do you see? What is abnormal about this image?

 

Diagnosis: Retinal Detachment

 

Management: Ophthalmology was notified and came in that evening to evaluate the patient and schedule an urgent clinic appointment for the following morning for further evaluation and possible corrective procedure.

How to perform an Ocular Ultrasound:

-Use the linear high frequency probe

-Patient should be supine, with the head tilted back. Place a large amount of gel on top of the patient's closed eye. You may place a Tegaderm adhesive barrier over the eye or place a cover over the probe to maintain a clean field.

-Do not put direct pressure on the eye when scanning; you may brace your hand on the patient's nasal bridge or forehead for balance.

-Scan in the transverse and longitudinal planes. You may also ask the patient to look in multiple directions while scanning as this can help you to distinguish a retinal detachment or vitreous hemorrhage.

Brief Review and Ultrasound Education:

The retina is comprised of multiple layers of specialized neurons that convert light into neural signals that are further processed in the visual cortex. If this layer becomes detached from the underlying retinal epithelium, visual loss can occur. The extent of visual loss depends on the location and extent of the detachment.

The detachment itself is most commonly a result of physiologic degeneration and liquefaction of the vitreous body (aka humor) in the posterior chamber, resulting in a "posterior vitreous detachment." As the vitreous pulls off of the retina, it can tear a small retinal hole, allowing the now-liquefied vitreous humor to travel through the retina and begin to dissect the remaining retina off of its underlying epithelium. This occurs commonly in patients aged 55 to 70 years old. Additional but less common etiologies include cataract surgery and myopia (both result in accelerated degeneration of vitreous body) as well as trauma (sudden acceleration of vitreous body).

Note that it is helpful to determine if the retinal detachment involves the detachment of the macula (and therefore fovea). If it is a "macula on" detachment, then the defect is typically corrected within 24 hours or so to prevent further dissection of the retina and further loss of vision. It it is a "macula off" detachment, and this is accompanied by loss of central visual acuity, surgery can be delayed several days.

Concomitant vitreous hemorrhage or prior cataract surgery can make traditional fundoscopy difficult. However, in an emergency physician's hands, ocular ultrasound has been demonstrated to have a sensitivity and specificity ranging from 97-100% and 83-100%. Traditionally, a linear echogenic membrane protruding off the posterior surface of the eye into the vitreous chamber can be visualized. This linear membrane will move with eye movements. Occasionally, additional non-linear echogenic materials from concomitant vitreous hemorrhage can be seen as well.

Additional Resources:

A brief review of retinal detachment: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3948016/

Using ocular ultrasound for evaluation of retinal detachment in ED: https://www.ncbi.nlm.nih.gov/pubmed/24680547

 

Case 1

HPI: 34yo female presents with abdominal pain located in the RLQ. Found to have + pregnancy test on arrival with LMP approximately 1 month ago. No vaginal bleeding. HCG in 500s.

 

Imaging: Formal pelvic ultrasound reveals "cyst-like structure" in endometrium without a fetal pole. No adnexal masses. Normal ovarian blood flow. No significant free fluid.

Event: Patient has syncope in the ER.  

Bedside Ultrasound in the RUQ:


hat structures do you see?

What is abnormal about this ultrasound?

 

Bedside Ultrasound in the suprapubic view:

Where is the uterus?

Is there a gestational sac?

What is abnormal about this ultrasound?

Diagnosis: Ruptured ectopic pregnancy

Ultrasound Education:

A FAST exam is indicated in any clinical situation in which there is concern for intra-abdominal free fluid or hemorrhage. It is used most often in blunt and penetrating cardiac and abdominal trauma, but is also used when investigating ectopic pregnancy.  A moderate amount of free fluid in the abdomen is highly suggestive of an ectopic in the right clinical situation and a FAST exam can reduce the time to diagnosis and treatment of ectopic pregnancy.

 

This patient has a "pseudo-sac" which is a small collection of intrauterine fluid without presence of a yolk sac, fetal pole, or double-decidual sign (where the decidua lining the uterine cavity meets the decidua lining the gestational sac).  However early pregnancies can appear similar to a "pseudo-sac".

 

During the FAST exam, the patient lies supine, such that fluid will first accumulate in Morrison's pouch as seen on this ultrasound.  The 4 views of the FAST exam include:

 

1) RUQ (Morrison's pouch)

2) LUQ (Splenorenal recess)

3) Suprapubic area

4) Subxiphoid area (pericardium)

 

Additional resources: 

-Free fluid in Morison's pouch on bedside ultrasound predicts need for operative intervention in suspected ectopic pregnancy. https://www.ncbi.nlm.nih.gov/pubmed/17554008

-Use of a beta-hCG discriminatory zone with bedside pelvic ultrasonography https://www.ncbi.nlm.nih.gov/pubmed/21310509

-Accuracy of first-trimester ultrasound in diagnosis of intrauterine pregnancy prior to visualization of the yolk sac: a systematic review and meta-analysis https://www.ncbi.nlm.nih.gov/pubmed/25393076