SonoCase: 54yr old abdominal pain, fever, vomiting – common US app by Dr. Hisset @emnews #FOAMed

The May 2013 issue of EM News highlights one of the basic, yet most difficult, ultrasound applications to perform. It is one of the most common abdominal applications given how common the disease process shows itself in the emergency department. Nice work to Dr. Hisset, a first year resident! from Louisiana, on writing this review.

The case: “A 54-year-old woman presents to the emergency department with four days of fever, abdominal pain, nausea, and vomiting. She reports that all of this started after eating pork at a casino buffet. She is not jaundiced on exam, but has severe pain to palpation of the entire abdomen, worst in the right upper quadrant with a positive Murphy’s sign. Her blood pressure is 96/52 mm Hg, pulse is 110 bpm, and her temperature is 100.4°F. Fluid resuscitation is started, and a bedside ultrasound is performed.”

Screen Shot 2013-05-09 at 9.33.44 AMTo find out what they found and a description of the application in a concise format, go here.

SonoCase: 22yr old male blunt trauma to scrotum – by Dr. Cannis et al. in @westjem #FOAMed

March 2013 was a great month for ultrasound case reports and publications – especially in Western Journal of Emergency Medicine! Once again, the team from USC highlight a case where ultrasound is used at its best. As they state: “its greatest asset lies in the ability to rapidly make the diagnosis of a time-sensitive medical condition, enabling the [emergency phsyician] to mobilize resources and expedite treatment, which might otherwise be delayed. The use of [emergency] US for the evaluation of scrotal injury from blunt trauma exemplifies this point.” Isn’t it great when you include ultrasound in your examination of a patient who you will call a specialist for anyway, but to also describe the injury to them in detail, including whether there is hematoma, blood flow, or other findings – and expedite specialty care? YES! They do an excellent job in describing scrotal anatomy, the risks of missing injuries, and the findings of the case while reviewing scrotal ultrasound and the literature around it as well. This is worth the time to read it!

The case: “22-year-old male with no significant past medical history presented to the Emergency department approximately 3 hours after he was in an altercation, during which he sustained multiple blows to the head, stomach, and genital area with a large flashlight. His primary complaint was of severe testicular pain.

Physical examination revealed a calm, well-developed male in mild distress due to pain. Vital signs included a blood pressure 132/85 mmHg, heart rate of 90 beats per minute, respiratory rate 16 breaths per minute, and temperature 98.9°F. On examination of the genitals, the penis was normal. His scrotum was enlarged to approximately the size of a grapefruit, and the overlying skin was erythematous. The scrotal area was exquisitely tender to palpation, making it impossible to reliably identify or examine either testis, despite the use of parenteral opioid analgesia. A urinalysis was obtained, which was normal and notably negative for blood.” The ultrasound study showed:

Read on more, as there are more videos, and a great description of scrotal trauma and injuries with an evidence based review.

 

A great pictorial review of testicular ultrasound and pathology, go here.

SonoCase: 61yr old with leg swelling, chronic cough, intermittent chest pressure – by Dr. Torregrossa et al. in @westJEM #FOAMed

This case is one where if I were the doctor, my immediate response may have been hidden from the patient. Inside voice would NOT have stayed in. Wow! Dr. Torregrossa and the team at USC discuss a case published in March 2013 Western Journal of Emergency Medicine of a patient where there obviously was no bedside ultrasound performed for the duration of his symptoms. “How long was that?” you may ask… ONE YEAR! Wow! He saw his doctor (check), he got a chest Xray (check), he got an EKG (check). Good thing he finally got an ultrasound study ….

The case: “61-year-old male with a 1-year history of bilateral lower extremity swelling and a chronic cough was referred to the emergency department (ED) for an abnormal echocardiogram. The patient also reported experiencing intermittent episodes of chest pressure. He stated that he was referred from his doctor after he received a cardiac echocardiography examination that showed possible mitral valve vegetations. On review of systems, he also admitted to intermittent chest palpitations. On physical examination, his vital signs included a blood pressure of 127/75 mmHg, heart rate of 80 per minute and regular, respiratory rate of 18 per minute, pulse oximetry of 98% and temperature of 98.0°F. The rest of the physical examination was normal. An electrocardiogram demonstrated normal sinus rhythm and the chest radiograph was unremarkable. ED bedside ultrasound (EUS) showed….”

To read on the topic so that you will know some of the literature behind it – go here.

SonoCase: 32yr old with right flank pain, fever, cough – by Dr. McKaigney in @westJEM

In the March 2013 issue of Western Journal of Emergency Medicine, Dr. McKaigney highlights a case that illustrates there is more to a thoracic and right upper quadrant bedside ultrasound study than just free fluid, renal and gallbladder evaluation. You must look everywhere and appreciate when something looks abnormal. I always say, know what NORMAL looks like, because when you see something abnormal, you’ll identify at least that, then want to find out what that abnormality is by further testing.

The case: “A 35-year old male presents to the emergency department (ED) with what he describes as right-sided upper back and flank pain, which he attributes to a “cupping” procedure the day prior. The cupping procedure is an alternative medicine practice that uses local suction to theoretically stimulate blood flow and promote healing. He had no previous issues with the procedure. On further history he reported having had approximately 6 weeks of intermittent fevers, cough, anorexia and general malaise. He had seen multiple naturopathic physicians for these complaints, before an urgent care visit one week earlier. At that time, he had been started on azithromycin and doxycycline for a presumptive diagnosis of pneumonia. In the interim week he reported an improvement in his febrile symptoms and overall well-being. He was an otherwise healthy heterosexual male, without drug use or travel outside the country. He had no known sick contacts.

On physical examination his vital signs included a blood pressure of 116/75 mmHg, a heart rate of 119 beats per minute, and a respiratory rate of 20 breaths per minute. His temperature in the ED was 36.2°C. Oxygen (O2) saturation was 97% on room air. The patient was alert, and appropriate with no signs of respiratory distress. Pertinent physical findings revealed typical, non-tender cupping marks on his back. More concerning was an absence of breath sounds on the right side of the chest on auscultation. His abdomen was soft and non-tender. The remainder of the physical examination was non-contributory.

The initial diagnostic test ordered was a chest radiograph, which showed 80% opacification of the right hemithorax, consistent with pneumonia and associated parapneumonic effusion seen in Figure 1. A bedside ultrasound was subsequently performed in the ED, initially in order to examine the size of the pleural effusion in which a startling discovery was made…..”

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So, “what is that?” – you may be asking…. and what happened to the patient, what can be done about it, and what is the evidence based review on the topic? Read on as Dr. McKaigney does an excellent job in discussing it all….here

SonoCase: 72yo demented, abdominal distension -by Drs Teresa Wu/Brady Pregerson in @EPMonthly #FOAMed

Once again another great case by Drs. Teresa Wu and Brady Pregerson in EP Monthly. Whenever I read their cases, I can actually imagine myself going through the case too. This is especially true for this one, as it is a prime example of how ultrasound can get you the diagnosis immediately, and how ultrasound can be utilized in the elderly and demented nursing home patients who get sent to the emergency department for “she just doesn’t seem normal” or, in this case, “abdominal distension”. Trust me, both can actually end up with the same diagnosis. It’s also a great entry as it speaks of a procedure that all emergency physicians should know how to do – it is too easy!

The case: “72-year-old male brought in by his nursing home aide for abdominal distension. He has a history of dementia and is primarily bedridden at baseline. The patient cannot give any reliable history, but on physical exam, his otherwise thin abdomen shows obvious signs of suprapubic distension. Your intern recaps his vital signs, which include tachycardia at 120 bpm, a blood pressure of 190/86 mmHg, a respiratory rate of 20/min, and a normal temperature and O2 saturation.”…. So, the differential diagnosis? Well, you should always think of the most emergent first, like an abdominal aortic aneurysm, which can also be diagnosed by ultrasound immediately – as discussed in a prior post of another elderly patient with altered mental status. (To see more sonocase posts in evaluating the altered patient, go here). Other badness? perforated bowel, volvulus, mesenteric ischemia, hemorrhage…. Oh, the list keeps going on and on when you have an elderly patient, a demented patient, a nursing home patient – or, in this case, it was all of the above!

Whenever I am evaluating the elderly patient with abdominal complaints, I think bedside ultrasound immediately (of course, with a very low threshold for CT scan since they can have anything happen! – and let’s be honest, they aren’t the ones we think about when we talk of the radiation risks… But, healthcare bill/cost? That’s a whole other conversation…). After as best of a history and physical exam that I can get (it can be challenging when they are demented and no caregiver at the bedside! Calling the nursing home is always done but usually they are too sick or the person on the other end of the line gives limited information), I bring my ultrasound machine and explore their abdomen: FAST (which also gives you a good look at the kidneys for hydronephrosis), Aorta, Gallbladder, Bladder, Bowel, +/- Pelvic/Testicular (depending on exam). Doing that may give you the answer, as in the case highlighted above…. to find out what they found and what happened to that patient, read on here. Trust me, you’ll love it.

SonoCase: The Unusual/Unclear Case of Neck Pain – by Drs. Teresa Wu and Brady Pregerson in EPMonthly

Drs. Teresa Wu and Brady Pregerson once again bring us an interesting SonoCase – one of the best that I have read – as it involves humor and a realistic description of a typical day in the emergency department, both physical exam skills and ultrasound skills, and most importantly, interpretation of your ultrasound image of vascular pathologies.

In this month’s issue of EP Monthly, they describe a case of a 50 year old with a history of diabetes and heroin use on home IV antibiotics for tarsal osteomyelitis with gradual onset fo left sided neck pain without fever or difficulty swallowing, or sore throat. She has pain with movement of her neck and her oropharynx is clear. Hmmmm, so the diagnosis is not presenting itself and whenever that happens to me, I gra the ultrasound machine to see if it can provide more information – just as they did. They get the below image with compression of his left neck with the linear probe:

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What do you think? Well, to find out what it is and read about the technique and excellent pearls and pitfalls to this bedside ultrasound application, click here.

SonoCase and Discussion of Pelvic Ultrasound: 32yr G1P0 at 7wks, c/o vaginal spotting – in WestJEM #FOAMed

Drs. Abdi, Stacy, Mailhot, and Perera once again describe a case where ultrasound made the difference in clinical management of a patient. Their case is published in WestJEM with a great tutorial video (see below) accompanying it.

Emergency physicians perform bedside ultrasound in 1st trimester abdominal pain and vaginal bleeding to “rule in” an intrauterine pregnancy, but the better way to describe how we think about it is “ruling out” any signs of an ectopic pregnancy. By doing it in the emergency department, it has been shown to decrease length of stay of these patients, and increase their satisfaction. With a full bladder, a transabdominal pelvic ultrasound is performed with a regional assessment of the pelvic organs to visualize for confirmation of an intrauterine pregnancy (yolk sac or fetal pole within a gestational sac in the uterus). You may need to empty the bladder and perform a transvaginal ultrasound if the above does not provide the information you need (I bring the ultrasound machine with me to the bedside when I first meet them so that I can do the history, physical, and ultrasound right off the bat). If there is an identifiable pregnancy then an evaluation for a fetal heart and its rate is assessed in order to characterize it as a “live” intrauterine pregnancy. But, if there is no contents within the gestational sac (a potential pseudosac), or if there is no gestational sac, then the concern for ectopic pregnancy still exists. Of course, in a recent post, we discuss that even those cases may turn out to have a normal pregnancy despite an elevated beta hcg level, calling into question whether the “discriminatory zone” should be used to guide our management.

Let’s go back to their case: The brilliance of this case, however, isn’t that they found an ectopic or illustrate what I describe above, instead it illustrates that there are other diagnoses that may be apparent on ultrasound that is causing the pelvic pain and vaginal spotting. And, if you don’t look, or if you are unfamiliar with what you are seeing on the screen, you may miss it – or mistakingly call it an intrauterine pregnancy.

The case: 32 yrs old G1P0 known pregnant at 7weeks by last menstrual period with lower pelvic cramping and vaginal spotting. A bedside ultrasound is performed and the video below describes what they saw…. read more on the case here.

Since “being pregnant” is a diagnosis that can be made, we shouldn’t stop there after we have identified an intrauterine pregnancy. We shouldn’t simply state “you’re pregnant” and discharge them home without further consideration of the etiology of their pelvic pain. Something else may be causing it. (to read about other cases using pelvic ultrasound, go here.) Other findings/diagnoses to consider in 1st trimester pelvic pain or vaginal spotting:

1. Ovarian cyst or torsion (see this case report in J of EM that discussed exactly why you should continue to evaluate with bedside US).

2. Fibroid

3. Appendicitis

4. Mass/cancer

5. Infection – anywhere (Pelvic inflammatory disease, tubo-ovarian abscess, UTI, colitis/proctitis, etc)

6. Heterotopic pregnancy- consider in patients on fertility drugs

SonoCase: 40yo: cough, fever, mylagias – typical viral infection? – By Teresa Wu/Brady Pregerson in EPMonthly #FOAMed

Drs. Teresa Wu and Brady Pregerson (in the current issue of EPMonthly) once again discuss an interesting case that is more than meets the eye, and thankfully they continue their humorous sarcasm and start the case by speaking of an average day in our emergency departments these days: “This is the third time this week that you have had to close your ED. All of the beds in the hospital are full, and your ED is bulging at the seams with sick patients that aren’t going anywhere anytime soon. You are holding 10 admissions at the present moment, and the hallways are lined with patients calling “doctor” every time you walk by. As much as you hate doing so, you concede to the request to close to ambulance traffic and then walk briskly over to the chart rack to see what you can do to help improve the current situation. Your eager intern is right on your heels and says he has a new patient to present to you. “This should be a really simple case,” he spurts out. You raise your eyebrows and bite your tongue.”……

They (meaning, the intern) describe a case of a 40 year old female who has had what seems like an upper respiratory infection for 4 weeks, that’s just not going away, and now with sharp chest pain worse when coughing. While going to evaluate the patient, they give one of the best pearls that all residents  should know: ““Teaching point number one is conservation of energy. One of the best ways to be efficient is to ensure that you minimize the amount of time wasted. If you might need the ultrasound machine, take it with you so you don’t have to walk back out of the room to go get it.” They then proceed to perform the beginnings of the RADIUS study, which highlights Echo, thoracic and IVC ultrasound for the short of breath/dyspneic patient. The patient complains of pain when lying back, which causes the spide-y sense to go up and be confirmed when seeing the below picture on the echo:

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To read more on the case and their great clinical pearls click here to get to EPMonthly’s online site.

To read a prior post emphasizing the need to perform an ultrasound for any presumed or confirmed pericarditis by going through a another case… and some studies, click here.

SonoCase: 57yr old altered mental status, h/o Hep C & TIPS, new murmur – By Dr. Perera & team

In the most recent issue of WestJEM, a very interesting ultrasound case by Drs. Wendler, Schoenberger, Mailhot and Perera was published illustrating that if you dont look, you won’t get the diagnosis! How bedside ultrasound solved the case! Below is only the beginning of the case:

“A 57-year-old Hispanic male presented with a 1-day history of altered mental status. He had a past medical history significant for alcohol abuse, hepatitis C and Child-Pugh Class B cirrhosis. He had undergone TIPS placement an unknown number of years before presentation to the ED. Additionally, he had been previously hospitalized for hepatic encephalopathy due to noncompliance with his medical regimen.

On physical examination, the patient appeared comfortable and calm. He was alert, but oriented to name only. Vitals signs were temperature 98.1°F pulse 78 beats/ min, respiratory rate 16 breaths/min and blood pressure 130/89 mmHg. The patient was noted to have scleral icterus, and his abdominal exam revealed moderate ascites without tenderness, rebound, or guarding. Unexpectedly, on cardiac auscultation, the patient was noted to have a 2/6 systolic and a 2/6 diastolic murmur with ectopy. A 12-lead electrocardiogram (ECG) was obtained in addition to standard laboratory studies to elucidate the cause of the patient’s altered mental status.

The serum white blood cell count was 6,500/mm3 without neutrophilic predominance, hemoglobin of 10 g/dL, BUN of 10 mg/dL and a creatinine of 0.6 mg/dL. The patient was noted to have an elevated ammonia level at138 umol/L. The 12-lead ECG showed normal sinus rhythm with multiple premature atrial contractions. To further assess cardiac function, a bedside EUS was performed…..” (see below)

Oh, but there’s more! The case isnt over, nor the discussion – read more!

SonoStudy: Thoracic ultrasound in identifying pneumothorax progression in the intubated – the lung point

In the Feb 2013 issue of Chest, Oveland et al studied porcine models, introducing air at incremental levels to identify if thoracic ultrasound is as accurate as CT scanning for the detection pneumothorax progression in the intubated patient. They found that “the accuracy of thoracic ultrasonography for identifying the lung point (and, thus, the PTX extent) was comparable to that of CT imaging. These clinically relevant results suggest that ultrasonography may be safe and accurate in monitoring PTX progression during positive pressure ventilation.”

“Background:  Although thoracic ultrasonography accurately determines the size and extent of occult pneumothoraces (PTXs) in spontaneously breathing patients, there is uncertainty about patients receiving positive pressure ventilation. We compared the lung point (ie, the area where the collapsed lung still adheres to the inside of the chest wall) using the two modalities ultrasonography and CT scanning to determine whether ultrasonography can be used reliably to assess PTX progression in a positive-pressure-ventilated porcine model.

Methods:  Air was introduced in incremental steps into five hemithoraces in three intubated porcine models. The lung point was identified on ultrasound imaging and referenced against the lateral limit of the intrapleural air space identified on the CT scans. The distance from the sternum to the lung point (S-LP) was measured on the CT scans and correlated to the insufflated air volume.

Results:  The mean total difference between the 131 ultrasound and CT scan lung points was 6.8 mm (SD, 7.1 mm; range, 0.0-29.3 mm). A mixed-model regression analysis showed a linear relationship between the S-LP distances and the PTX volume (P < .001).

Conclusions:  In an experimental porcine model, we found a linear relation between the PTX size and the lateral position of the lung point. The accuracy of thoracic ultrasonography for identifying the lung point (and, thus, the PTX extent) was comparable to that of CT imaging. These clinically relevant results suggest that ultrasonography may be safe and accurate in monitoring PTX progression during positive pressure ventilation.”

Full article found here.

To see the lung point, you visualize the pleural line using the linear probe (indicator toward the patient’s head) starting from anterior chest wall (2nd intercostal space, mid-clavicular line) to inferior-lateral chest wall, and look out for the area where the lack of lung sliding or comet tail artifacts reverts back to normal lung sliding with comet tail artifacts. Blaivas, et al, studied this, showing that bedside ultrasound can detect size of pneumothorax through identification of the lung point location. Below is a video fo the lung point: