SonoCase: 46yo c/o abdominal pain h/o cocaine use – sup mesenteric art dissection #FOAMed

Drs. Davis and Kendall write up a very interesting case in the Aug 2013 issue of Journal of EM where the ultrasound made the diagnosis, quite easily too. They discuss a 46 year old male with a history of current cocaine use AND a prior history of an aortic dissection, of course, who was complaining of sudden onset of abdominal pain and found to be severely hypertensive. The diagnosis on the top of their list was aortic dissection/aneurysm/rupture – and when they looked, they saw even more. Below is the abstract:

Background

A timely diagnosis of aortic dissection is associated with lower mortality. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, there is limited literature regarding the use of bedside ultrasound to identify superior mesenteric artery dissection, a known high-risk feature of aortic dissection.

Objective

Our aim was to present a case of superior mesenteric artery dissection identified by bedside ultrasound and review the utility of bedside ultrasound in the diagnosis of aortic emergencies.

Case Report

We report a case of superior mesenteric artery dissection found on emergent bedside ultrasound in a 46-year-old male complaining of abdominal pain with a history of cocaine abuse and prior aortic dissection. Bedside ultrasound in the emergency department revealed an intimal flap in the descending aorta with extension into the superior mesenteric artery prompting early surgical consultation before computed tomography because of concern for acute mesenteric ischemia.

Conclusion

Superior mesenteric artery dissection is a high-risk feature of aortic dissection and can be identified with emergent bedside ultrasound.

Just one of their images is displayed below – but take a look at the video in JEM to truly see the awesomeness. A subscription and password is required, but it’s a great journal with lots of cool ultrasound cases published almost every month.

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.”

To find out what they found and a description of the application in a concise format, 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…..”

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: 35 yr old – acute urinary retention, penile pain – by Drs. Peabody, Mailhot, Perera

In the recent issue of WestJEM, a case report of another excellent application for bedside ultrasound is described by our very own Dr. Phil Perera (yup, he is more than just the RUSH exam). A video where he discusses the ultrasound application and case follows….

“A 35-year-old man presented to the emergency department (ED) for acute urinary retention and penile pain for 4 hours. The patient denied any significant medical history or history of trauma. Physical exam revealed testicles that were nontender, without masses. However, a tender mass was felt at the distal end of the penis, adjacent to the urethral meatus. Placement of a Foley catheter resulted in a return of 700 cc of clear yellow urine and immediate resolution of the patient’s suprapubic and penile pain.

During the ED course, the Foley catheter was removed with a subsequent trial of voiding. Initially, the patient was able to void 15 cc of urine until the normal stream was abruptly cut off. The patient then complained of extreme penile pain, near the urethral meatus. A small, circular and firm mass was again palpated in the distal penile shaft. Bedside emergency ultrasound (EUS), performed with a 10 MHz linear array probe placed along long axis of penis, revealed a hyperechoic, dense and round structure with characteristic acoustic shadowing at the distal end of the urethra, with obstruction of the urinary flow (Video). The object, a 9 mm stone, was removed with forceps. Following stone removal, the patient experienced immediate pain relief and was able to spontaneously void.

While urethral imaging has traditionally been performed with retrograde urethrography (RUG), more recently ultrasound has been used to minimize the pain associated with RUG and to provide clinicians more detailed information about urethral pathology.² As demonstrated in this case, EUS allowed a prompt diagnosis of the patient’s condition with appropriate rapid treatment and removal of the urethral stone.”

SonoCase from EPMonthly: 19 yr old with food poisoning? hmm….by B. Pregerson and T. Wu

Merry Christmas everyone! For your reading pleasure this week, Id thought we would discuss a case whose topic is near and dear to my heart. In the most recent issue of EPMonthly, there is a great case and interesting “internal” discussion made quite humorously public by Drs. Pregerson and T. Wu of a young healthy male with right lower quadrant abdominal pain after eating at a “Roach Coach”…. which just so happen to have the best breakfast burritos, but I digress… The case discussion involves how the history and physical may help, how labs may (or may not) help and how an ultrasound can be of use to make you and your surgical colleagues feel better in taking the patient to the OR. There was a recent post on SonoSpot about ultrasound in appendicitis sharing data from a study about the CT findings when US “equivocal” cases arise.  When the ultrasound is positive – how great is that?! Quite a few studies recently on the topic and some of the more recent ones can be found here.

The case is followed by an extensive (and great) discussion of the technique, pearls and pitfalls of ultrasound in evaluating the appendix – because we all know there are quite a few. As far as the sensitivity ad specificity go, they state it best:

“Sensitivity & Specificity: Both the sensitivity & specificity of ultrasound for appendicitis are less than that of CT. In pediatrics the values are about 88% and 94% respectively, and in adults about 83% and 93%. (These numbers may vary depending on the experience of the ultrasonographer.) There are studies from Europe and Israel where they have used the “ultrasound first” approach for many, many years that show even better test characteristics. These values are actually not that bad when compared to CT scan whose sensitivity and specificity are around 94% and 95% respectively. Remember, however, that the performance characteristics for ultrasound can be significantly worse in overweight patients or those with overlying bowel gas. In addition, if the appendix is retrocecal or is lying in a difficult anatomical plane, the study will be more challenging.  Unfortunately, you may still have to do a CT scan if your ultrasound is non-diagnostic and your clinical suspicion is moderate to high, but the strategy of ultrasound first would likely decrease CTs by about 50%.”

And in kids…”You should be aware of the most recent recommendation of the American College of Radiology from the “Choosing Wisely” campaign, which states, “Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.” Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent.”

To diagnose appendicitis: look for a noncompressible a-peristaltic structure that attaches to the cecum that is larger than 7mm in diameter.

A great tutorial of ultrasound for the appendix can be found here by the UltrasoundPodcast guys:

SonoPearl – Look at the ENTIRE screen when evaluating an organ… a case by Dr. Teresa Wu and Brady Pregerson

In the most recent issue of EPMonthly, our good friend, Dr. Teresa Wu, and Brady Pregerson right up a case they had of a patient with abdominal pain. In their wisest and most sarcastic way, they present this case with a great teaching point (ok, there are many teaching points as you will find on the last page of the case – but one in particular that deserves special mention). Read on and see if you can get what that point may be…

“56-year-old otherwise healthy female who presented to the ED with a chief complaint of “severe abdominal pain” after she finished lifting boxes of heavy books at her job the day before. She states her pain is worse with movement and is better when she lies still. She has never had pain like this before, and today, it is 10 out of 10 in severity. The pain is described as sharp and tearing, but it does not radiate to her chest or back. She has no other associated symptoms, and she has tried Ibuprofen without any relief.

Her vital signs are all completely within normal limits and her physical exam is only remarkable for tenderness to palpation over her left rectus muscles, and a seemingly pulsatile aorta palpable through her thin abdominal wall. She has no rebound or guarding on abdominal exam, and she has no other abnormal findings. Given her symptoms and her palpable aorta, your senior resident decides it would be prudent to do a quick scan of her aorta to make sure nothing catastrophic is imminent.” The following image was obtained:”

The Aorta seems ok. Hmmmm…..Still wonder what happened to the case and what it was? Read the issue in depth and you’ll then get to know and love Teresa Wu as much as I do.

Hint – look at the entire screen when evaluating any organ by bedside ultrasound…..

SonoCase: 70 yr old fever, hypotensive after root canal, diarrhea & abd pain…”RUSH” +1

This case is one of those cases that make me so proud of the residents I work with…. Drs. Brianne Steele and Cesar Avila identified the need for a RUSH exam, but didn’t stop there – they noticed something during their RUSH and proceeded with another evaluation – obtaining the surprising diagnosis below, saving him time in the emergency department and canceling his CT scan that didn’t need to be done, which I then conclude controls his healthcare charge. period.

70 year old male with a history of (ready for it…)

SonoCase: good one by a good friend – 28yr old abdominal pain on EPMonthly!

Teresa Wu, Associate Residency Director, and Director of Ultrasound and Simulation Programs and Fellowships, for the Maricopa Emergency Medicine Program (otherwise known as “T Wu” – as shouting that loud over and over again gets even the innocent bystanders at the bar chiming in )- has joined her colleague, Brady Pregerson (who manages a free on-line EM Ultrasound Image Library and is the editor of the Emergency Medicine Pocketbook series) once again for a fantastic case highlighted in the recent issue of EP Monthly. Its about a 28 year old female walking in to the waiting room and telling the nurse she has abdominal pain

SonoCase: Pediatric lower abdominal bulge? What the…?

You know, working in the pediatric ER is always a joy since most children are going to do well (and most parents are worry warts – but who am I kidding, I would be too!). But sometimes I get a case that surprises me – and this is one of them. Of course, in hindsight, it makes sense, but still interesting given the way the kid presented: 4 year old boy, with a history of “retractable bulges a few years ago” comes to the ER after his mom noticed that he woke up that morning (4 hours prior to arrival) walking funny. She took down his very cute Star Wars pajama pants and saw this: