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.

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

  1. It seems that Cannis and team did a great job identifying a severe testicular injury on Emergency USS. However, then got a formal USS to confirm their findings.
    In the context of an ischaemic teste, would the clinical findings and EUS not be enough to go to OR?
    Was it the urology service who requested the formal?
    It seems that the obtaining of the formal USS is a frequent issue in ED and delays time. And in this case, time would be critical.
    Is it that ED Doc’s are not good enough at USS? Or that or colleagues just don’t trust us yet??

    • Dr. Oliver, those questions are great ones and the answers can vary depending on the institution. Im not sure of how USC and Radiology have agreed on ultrasound findings and management as the emergency physicians there are quite savvy with bedside ultrasound and do make medical decisions based on their ultrasound. Ther are common factors as to why a radiology “complete” study would be done in addition to the emergency department’s “limited” study. First, a limited study screens and, at times, diagnosis the etiology of the patient’s symptoms but in a limited study technique. It can occur that limited studies require a more complete assessment to answer specific questions for which specialists need answers. Also, if there are no workflow solutions or ability for the bedside ultrasound studies to be visualized by the specialists remotely, it is possible for radiology to perform the study for image archiving and review (but the ED doctors can still contact the specialist when identifying an emergent disease for them to head to the hospital or come evaluate the patient in a timely fashion). There are also some academic and teaching institutions who want both the emergency residents and radiology residents to be able to learn and perform ultrasound and have agreed to have both a bedside limited study done in addition to a radiology complete study (if positive) for both resident specialists to become educated. These are only a few of the reasons, and when the emergency department physicians are savvy with ultrasound, their specialists trust them, and those doctors can act on those findings. Sadly, bedside ultrasound is still very new to some emergency groups and they are just now learning it, so it will take time for global acceptance. Thanks for the questions and for reading SonoSpot!

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