SonoCase: 72yo back pain & hypotensive – by Dr. Calvin Hwang @helixcardinal #FOAMus #FOAMed

Another great guest post! – by Dr. Calvin Hwang, aka @helixcardinal  – as well as the senior resident at Stanford/Kaiser EM program who updates the @StanfordEMRes residency twitter feed, provided an excellent case that illustrates a reason/indication to perform bedside ultrasound – especially the Echo/IVC and Aorta applications – illustrating why these applications are imperative to the RUSH protocol – along with good clinical judgement. Enjoy!

“Code 3 ringdown from EMS: 70 yo F coming in with 3 days of chest, back and abdominal pain, hypotensive with SBP in the 70s.

On arrival, patient is grimacing in pain, pale, diaphoretic.  She is otherwise healthy with no past medical history.  Just arrived from Thailand 1 week ago to visit her daughter and had been complaining of pain in her chest, back and abdomen.  Went to a primary care physician where she was noted to be hypotensive and sent to the ED.

Initial vital signs: BP 73/30, HR 110, T37.0, RR 25

With the trusty bedside ultrasound, I immediately went to where I thought would be the diagnosis: ruptured AAA…..but…..

The abdominal aorta scan : I was shocked when I noticed it to be of normal caliber.  Nevertheless, I worked my way up the abdomen to the subxiphoid view when I saw:

Though it was atypical for the patient to be hypotensive and tachycardic, the presence of a pericardial effusion without tamponade suggested aortic dissection to me.  My attending got on the phone to prepare to transfer the patient while I contacted the radiologist to clear the CT scanner.  Though I attempted to view the descending aorta and aortic outflow tract on a more focused echo in the brief interim through a parasternal approach, I was unable to obtain good windows.  The IVC was plump and the rest of the FAST was negative.  A quick Chest XR was done:

…..which did not show a wide mediastinum according to radiology.  The patient was whisked away to the CT scanner and within 45 minutes of ED arrival, the diagnosis of a Stanford type A aortic dissection with pericardial effusion (but not tamponade) was confirmed.  This would not have been possible without bedside ultrasound as I think most clinicians would have been falsely reassured by the normal CXR (widened mediastinum only present in 60% of aortic dissections¹).

The patient was fluid resuscitated with crystalloid, her BP improved to 100/60 and HR came down to the 80s.  While awaiting transport, I attempted to place an arterial line for close BP monitoring.  However, approximately 60 minutes after ED arrival, the patient became progressively bradycardic and coded.  My institution’s cardiothoracic surgeons were already at bedside and performed a sternotomy with pericardial window.  Despite our efforts, we were never able to obtain return of spontaneous circulation and the patient was pronounced. These patients rarely make it to the ED due to how quickly they can decompensate, but if they do, quickening the diagnosis may help get them the intervention they need (clinical suspicion and appropriate use of bedside ultrasound is key), although a high mortality still exists.

1. Aldeen A, Rosiere L.  “Focus on: Acute Aortic Dissection.” ACEP News, July 2009.

SonoCase: Renal Ultrasound for Renal Colic: a cost/benefit analysis? by @EPMonthly #FOAMed

Once again, Drs. Teresa Wu and Brady Pregerson do an excellent job in highlighting a case in EP Monthly (and a topic that I am so incredibly passionate about – not only because of the benefit to the patient, the minimizing of CT scans/radiation, and the time spent in its work up – but also in health care cost and expediting diagnosis and management.) What am I talking about? Well, RENAL ULTRASOUND for RENAL COLIC. Yeah, I know, it sounds obvious. But, I heard of a patient the other day (again!) who had a known history of kidney stones, who had the same pain as her prior kidney stone flank pain, who begged to not have yet another CT scan done since it would have been her 13th for this at the age of 40. I highlighted this topic and other studies on it in a prior post, and AIUM posted a sound judgment series written by Drs. Chris Moore and Leslie Scoutt on this topic too.

So, let’s talk about TWu and Brady’s addition to the mix. Of course, they always start off their case with humor, yet reality, by saying : “I have to do a cost-benefit analysis of the situation,” your eager intern replies. It’s the end of the academic year and you are forcing your soon-to-be R2s to become more autonomous and confident in their management plans. You are amazed at the various answers you now get when you ask the simple question, “What do you want to do?” You ask your intern to summarize the case for you. He just finished evaluating a 21-year-old male who presented to your ED with back pain. The patient states that his “back is killing him” and he thinks he strained his muscles working out too hard at the gym last week. He just started doing CrossFit and he’s worried that he overdid it. The patient notes that the pain is 10/10 and that he has had minimal relief with his friend’s Vicodin. He’s tried icing his back and even sat in the hot tub all weekend per his friend’s recommendation. Nothing is working so his friend told him to come into the ED to get a prescription for something “stronger.”……

“Your question about whether or not this young 21 year old needs any imaging is giving him pause. “I think the cost of the imaging and the risk of radiation are too high. I don’t think there’s much benefit to keeping the patient here any longer. Plus I don’t know what we’d be looking for,” he replies. You are happy with your intern’s logic and pop into the room to see the patient. Within seconds, you realize that Vicodin and a hot tub probably won’t fix this patient’s pain. The patient is sitting hunched over on the stretcher rocking back and forth in pain. He has no appreciable tenderness to palpation over any of his back muscles, and there is no asymmetry or tightness on your exam. You are unable to reproduce or worsen his symptoms with testing his range of motion, but he is definitely rubbing his right lower back to try to ease his pain. You walk out of the patient’s room and grab your intern and the ultrasound machine. As you head back towards the patient’s room, you pimp your intern on the other more serious causes of low back pain. Acknowledging that you have the ultrasound machine in tow, your clever intern starts rattling off the diagnoses that can be easily made with bedside ultrasound. AAA, atypical appendicitis, cholecystitis, nephrolithiasis, abscess, etc. Since the patient is sitting upright and hunched over in pain, your intern decides to start his scan with a view of the right flank….”

BAM! oh yeah – do you see it? Weren’t expecting that? Funny what happens when you look, right? You must read about their findings and the pearls and pitfalls of renal ultrasound – go here for the true meat of the article.

SonoCase: 45 yr male- flank pain & hematuria- not always a kidney stone – by Dr. Marzec et al. in @westjem #FOAMed

Western Journal of Emergency Medicine must be great proponents of bedside ultrasound! I love that journal! Of course, I am biased as I am one of the section editors, but these cases deserve mention. There have been quite a few in the March 2013 issue and this case in particular is a great review of renal ultrasound and what to lookout for in bedside ultrasound. Limited renal ultrasound typically involves an evaluation for hydronephrosis, but it is important to know what normal ultrasound anatomy looks like, as you may identify something else…. Dr. Marzec et al. at USC do a great job at discussing their case, describing their ultrasound, and giving a literature review on the finding. The case:

“A 45-year-old male with no previous medical history presented to the emergency department (ED) with 1 week of hematuria and left flank pain. The patient had noted that over the preceding 4 days his urine had progressed from a pink color to dark red. He had also experienced left flank pain that was sharp, non-radiating, and increasing in severity over the week prior to presentation. He denied a history of renal calculi, weight loss, fevers, fatigue, or abdominal masses. Upon physical examination, his vital signs included blood pressure of 157/89 mmHg, heart rate of 64 beats/min, temperature of 97.4 °F, respiratory rate of 18 breaths/min, and oxygen saturation of 99% on room air. The patient appeared comfortable. His abdomen was soft, non-tender and non-distended. The patient had left-sided costo-vertebral angle tenderness to palpation. There was frank hematuria in the urine sample at bedside. Subsequent microscopic analysis revealed > 50 red blood cells and 4–10 white blood cells. Bedside emergency ultrasound (EUS), initially performed to look for hydronephrosis, showed ….”

To read on the case, what happened, and a great review of the literature of ultrasound’s utility with this finding compared to other imaging modalities, 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: “My back hurts, I just need a med refill.” Yeah, except….

This case scares me. Truly. We have all had patients with this chief complaint, maybe on a weekly, if not daily, basis. You know the one – guy comes in, says he has been diagnosed with …. lets see, its usually “herniated disk”, “muscle strain”, “sciatica”, or he may throw out a term that gets more of your attention like “stenosis”, but usually it’s just “I have a bad back” and now on narcotics (because there’s just no other way – ugh!) and just needs a refill. He may even have an empty bottle in hand. He just might ask for the medicine by name : “Norco 10s work really well, but my doctor put me on Oxycontin now. Can you give me enough for a month?” Response: “uh… No.” But I digress…..lets go to our crazy-scary case…

SonoCase (and studies): Renal colic, do we really need to get another CT?

38 year old male with a history of kidney stones c/o severe right flank pain, radiating to the groin, “feels just like my kidney stones” with small amount of blood in his urine, begging for pain meds. Ok, I know this is not the most mysterious case, but when I looked over his chart he has a radiology list of 8 CT scans over the last 5 years to evaluate for kidney stones! Why? Do we really work in an era where we MUST know the diagnosis instead of just being able to screen for the emergent conditions, and treat by using our clinical judgement… and bedside ultrasound? I sure hope not, because that’s not how I practice. This is not the first-time flank pain patient, although some would argue that you dont need to get a CT for that either if labs and ultrasound are clear/negative. This is also not the elderly patient that could have belly-badness that will die soon –  but not from CT scan-radiation-induced cancer, that’s for sure.