September Case #2: Shortness of Breath

38 y/o AAM presents to the ED with complaints of epigastric pain radiating to his chest for 1 week.  He admits to SOB, but denies N/V/D or cough.  Subjective F/C and generalized body aches.  Recent weight loss of >50 lbs in the past several months.
PMHx:  HTN
PSHx: none
SocHx:  h/o tobaco use, but quit recently; occasional ETOH; marijuana and cocaine use
FamHx; none

PE: BP 173/117, P 101, R 18, T 98.3, Pox 100% (RA)
GEN: WNWD, AAM, NAD
CHEST: CTA B, nonlabored
CV: RRR, IV/VI SEM, +bruit/thrill
ABD:  soft, NTND, +BS
EXT:  no C/C/E, no splinter hemorrhages

Bedside US is performed as the patient is without history of a murmur:

What is your diagnosis?

What is on your differential for etiology of this diagnosis?

September Case #1: Blindness- Discussion

This patient has a normal retina and optic nerve, but appears to have a lens dislocation in the L eye along with some hyperechoic debris in the posterior chamber which may represent vitreous hemorrhage vs scar tissue.

Lens Dislocation

Lens dislocation or ectopia lentis, is a rare condition characterized by a displacement of the lens of the eye.  If the lens lies completely outside of the lens patellar fossa, then it is dislocated or luxated.  Lens subluxation is definied as a partially displaced lens which stil lies in the lens space.  The dislocation of the lens results from the disruption of the zonular fibers of the lens and the degree of disruption is proportional to the degree of lens displacement.

The most common cause of lens dislocation is trauma, but it can also be congential.  It is also associated with Marfan's, homocystinuria, Weil-Marchesani, sulfite oxidase deficiency, and hyperlysinemia.


Patients with lens dislocations usually complain of varying degrees of decreased visual accuity depending if it is a partial or complete dislocation.  In trauma patients, be aware that other ocular signs of trauma may also be present such as retinal detachment, vitreous hemorrhage or globe rupture.

On Ultrasound, the lens is normally located posterior to the iris and anterior chamber and appears as a hyperechoic or white line.

 

When it is dislocated, the lens will appear as an ovoid structure floating in the posterior chamber.

Be sure to evaluate the eye with the patient looking straight ahead first, then with the eyes looking medial and lateral.  This allows visualization of the entire eye.

September Case #1: Blindness

60 y/o AAM presents to the ED with complaints that he is having difficulty seeing out of his R eye over the past several days.  He states that he has not been able to see out of his left eye for about 10 years and never had this complaint evaluated.  He denies pain, trauma, drainage or headache.
PMHx: HTN
PSHx: none
FamHx: DM, CAD
SocHx: +tob (ippd); no ETOH or IVDU

PE: BP 170/83, P 99, R 16, T 98.6, POx 99% (RA)
GEN:  WNWD AAM, NAD
EYE:  visual accuity 20/100 OD, 20/200 OS;  EOMI;  lids, lashes and lacrimals normal;  no conjunctival injection;  no fluoresceine uptake or dendritic lesions;  no FB or rust ring noted;  anterior chamber flat and narrow, no cell and flare; L pupil irregular and minimally reactive;  IOP 16OD, 20OS;  no seidel's sign;  fundoscopic exam limited

Bedside US performed:

What is the diagnosis?

July Case #1: Flank Pain

80 y/o WF presents to the ED with left flank pain for 1 day.  Her pain has been constant and she denies dysuria, frequency or hematuria.  Denies N/V/D.
PMHx: HTN
PSHx: pacemaker
All: NKDA
SocHx: occ ETOH, denies tob or  drugs

PE: BP 132/64, P 70, R 16, T 98.0, Pox 99% (RA)
GEN:  WNWD, WF, NAD
CHEST: CTA B, non labored
CV: RRR, no M/R/G
ABD: soft, NTND, +BS
GU: L CVAT

Bedside US is performed:

 

What is the diagnosis?
What is the color doppler artifact noted and how does it occur?

Special thanks to Guest Presenter: Dr. Sarah Bogle!

Testicular Torsion Ultrasound Protocol

So, we've had a couple of cases presented here, but how exactly do you do a testicular exam you ask?  Well, lets discuss it...

Testicular ultrasound was not included in the 2008 revision of the ACEP Emergency Ultrasound Policy Statement, but it may make it into the next revision.  Testicular ultrasound is pretty easy to perform and can rule out testicular torsion rapidly which can expedite a trip to the OR in these patients.  Time is Testicle, remember?

Perform your normal history and physical exam, attempt to manually detorse the testicle if needed.  Consult the Urologist (order a ultrasound, if they request it), then perform your bedside ultrasound.  This way, the Urologist is already on their way down to the ED and, hopefully, you can provide some useful info when they get down there.

Positioning:
Have your patient lying supine in bed, lay a towel down on thier legs at the groin level and have them place thier scrotum on the towel.  Then place another towel over their penis pointed toward thier umbilicus.  Now the scrotum is isolated between the two towels.

Scan Protocol:
Using a linear high frequency probe, scan through the affected testicle in the longitudinal position.  The testicle should appear as a oval or egg-shaped structure that is medium grey speckled with black.  You may see a hyperechoic or white linear structure in the midline which is the mediastinum teste.

Scan through the testicle in a longitudinal plane from medial to lateral.  Then turn your probe 90 degrees to the patient's right to view the testicle in a transverse plane.  In this plane, the testicle should appear as a circular medium grey speckled tissue.

Scan through the testicle in the transverse plan, cranial to caudal.  Using color flow doppler, identify the small vessels in the testicle.

Now place the spectral doppler gates over one of the vessels you seen on color flow.  This will create a spectral doppler tracing which will either illustrate an artial waveform or a venous waveform.

 arterial waveform

venous waveform

 You need to document both to rule out torsion.  If you are unable to document flow, then torsion is highly likely.

Seems pretty simple doesn't it?  Try it out the next time you are ruling out torsion and see how it can expedite patient care!

May Case #2: Testicular Pain- Discussion

This patient does not have testicular torsion, but has epididymitis, likely secondary to a sexually transmitted disease (GC, chlamydia, etc).

Epididymitis

Epididymitis is the number one cause of acute scrotal pain and is due to the inflammation of the epididymis, usually due to  bacterial invasion.   Most commonly this infection stems from Chlamydia and Neisseria gonorrhea.  Symptoms include acute scrotal pain, discharge and may include fever or dysuria.

On ultrasound, acute epididymitis is diagnosed by a hypoechoic epididymis or an epididymis that appears darker grey than the testicle itself.  Color doppler shows increased blood flow in the epididymis.

For more images of epididymitis: ultrasound cases of epididymitis

May Case #2: Testicular Pain

22 y/o WM presents to the ED with acute onset of testicular pain X 2 h.  He denies F/C, N/V/D.  He is currently sexually active with 1 partner.  He denies dysuria, hematuria, penile discharge, lesions or pain.

PMHx:  none
PSHx:  none
Meds:  none
All: NKDA
SocHx:  +tob (ippd), +ETOH (6 pk/d), no drug use

PE:  BP 123/85, P 68, R 12, T 98.4 (o), Pox 99% (RA)
GEN:  WNW, WM, NAD
CHEST:  CTA B, nonlabored
CV:  RRR, no M/R/G
ABD: soft, NTND, +BS, DRE norm tone, heme -
GU:  no inguinal LAD, penis without lesions or discharge, testicles with normal lie, +TTP R testicle

Bedside US is performed:

 

 

What is the diagnosis?

Procedure: Paracentesis

A patient presents to the ED with complaints of gradually worsening shortness of breath and abdominal pain.  He admits to daily alcohol use and abdominal fullness.  You note that his abdomen is distended with a fluid wave and diffuse tenderness to palpation.  You are concerned about new onset ascites and spontaneous bacterial peritonitis.  So how do you tap his belly?

Paracentesis

If the patient has been tapped previously, then using the previous site is preferable.  Now in this instance, there is no previous site, so there are 2 preferred sites.  The first is the infraumbilical approach, which is located about 2 cm below the umbilicus.  The other choice is the lateral approach, 4-5 cm cranial and medial to the anterior superior iliac spine in the lower quadrants.  If using the infraumbilical approach, be sure to make sure the bladder is empty.

Now, ultrasound certainly makes positioning much easier.  Using a low frequency 3-5 MHz transducer, scan through the abdomen to find the largest pocket of fluid.  Now, without moving the patient, prep the area and sheath the probe with a sterile cover.  Now place the probe in a longitudinal plane (probe indicator to the pt's head) and find the largest pocket of fluid.  Insert the needle in alignment with the midline seam on the probe.  The needle is then advanced in real time through the abdominal wall, watching the needle (hyperechoic structure) enter the peritoneum on ultrasound.  By using this technique, you are able to stay away from bowel or when using the infraumbilical approach, bladder.


Ultrasound Guided Paracentesis from Jax Emergency Medicine on Vimeo.

May Case #1: Abdominal Pain- Discussion

This patient has splenomegaly due to hyperviscosity syndrome.  She had a relapse of her leukemia and developed tumor lysis syndrome due to her overwhelming tumor burden while in the hospital.  She was noted initially to be anemic and thrombocytopenic and later required transfusions of both PRBCs and platelets. 

Splenomegaly

On ultrasound, splenomegaly is defined as a longitudinated measurement of the spleen greater than 13 cm (in adults). 

Although it is not a disease state itself, it is usually a response to underlying pathology.  Causes of splenomegaly include:

• neoplasm or myeloproliferative disorders (lymphomas, leukemias, metastatic disease)
• infectious processes (TB, EBV, CMV, HIV, Lyme disease, RMSF)
• portal hypertension or systemic congestion (CHF, cirrhosis)
• chronic transfusion

Hypersplenism is indiscriminate destruction of the formed elements of the blood by an enlarged spleen.  Any blood line can be affected (erythrocytes, neutrophiles or platelets) alone or in combination.  Splenic hypertrophy leads to premature destruction of cells by splenic macrophages, an exaggeration of the spleen's normal function of removing senescent cells.  Splenectomy may correct cytopenia.

May Case #1: Abdominal Pain

40 y/o AAF presents with c/o abdominal pain, constipation and occasional vomiting over approximately 1-2 days.  She also c/o generalized weakness and occasional headaches with blurry vision.
PMHx:  Leukemia (last chemo about 2 months prior), chronic pain syndrome, depression
Meds:  oxycontin, lortab, stool softener
SocHx:  denies tobacco or ETOH
FamHx:  HTN, DM
All: NKDA

PE: BP 110/62, P 89, R 20, T 99, POx 99%
GEN: WNWD, AAF, moderate distress
CHEST:  CTA B, non labored
CV:  RRR, no M/R/G
ABD:  distended, fullness in L hemi-abdomen with diffuse TTP, no rebound or guarding, +BS
EXT:  no C/C/E
SKIN:  no rashes noted

Bedside ultrasound is performed:

 

What is the abnormality visualized here?
What is the diagnosis?

Special thanks to Dr. Erin McBride for this case write up!

Literature Review #3: Needle Thoracostomy

Do you really need to place a chest tube after a patient is "needled" in the field?

According to a recent article in the Journal of Ultrasound in Medicine, you may not need to convert that needle thoracostomy to a tube thoracostomy in every patient.1  This study was performed to assess if all patients who were needled in the field actually had a pneumothorax. 


In this prospective study, patients who received a needle thoracostomy in the field had an E-FAST exam performed upon arrival to a Level I Trauma Center during the secondary survey (57 patients over 3 years).  26% of these patients appeared to have a normal lung sliding sign on ultrasound and the thoracostomy catheter was removed.  Each patient then had a CT scan that confirmed the absence of a pneumothorax.

Although this study does seem positive, it does raise some important questions.  First of all, the length of the catheter was not noted in this article, which has been shown to affect the failure of needle thoracostomy.  Ball et al note up to a 65% failure rate in needle thoracostomies when using a 3.2 cm catheter, compared to a 4% failure rate in those performed with a 4.5 cm catheter.2  Which brings us to the second point, the size of the patient.  Were those patients in the failed needle thoracostomy group morbidly obese or highly muscular?  Although McLean et al note that a 4.5cm catheter length should be long enough to penetrate most patient's chest wall (mean anterior chest wall thickness of 2.1-2.3 cm), they note that large BMIs may exceed 4.5 cm in catheter length.3  Was the failure of the needle to penetrate into the chest cavity due to the thickness of the chest wall?  Increased tissue on the chest wall may account for both the difficulty in auscultation of breath sounds and the failure of the needle to penetrate the lung cavity.  Other factors to note in this study is the small sample size (57 patients total) and that the seven physicians who performed the scans had significant ultrasound training.  Could someone with less ultrasound experience achieve the same results?

Although there are some flaws in this study, I like it overall.  It would be interesting to see a study looking at EMS use of ultrasound in the field to determine pneumothorax.  Would it change how many people had a needle thoracostomy in the field if an ultrasound was performed before they were needled?  Would ultrasound be as reliable in the hands of less experienced sonologists?  Good research project...


1.  Blaivas, M. Inadequate Needle Thoracostomy Rate in the Prehospital Setting for Presumed Pneumothorax: an Ultrasound Study. J Ultrasound Med 2010; 29:1285-1289 PMID: 20733183
2.  Ball, C et al. Thoracic Needle Decompression for Tension Pneumothorax: Clinical Correlation with Catheter Length. Canadian Journal of Surgery. June 2010; 53:184-188 PMID: 20507791
3.  McLean, A.R., et al. Ultrasound Determination of Chest Wall Thickness: Implications for Needle Thoracostomy. Am J Emerg Med. 2010 Oct 12 [Epub ahead of print] PMID: 20947279

World Congress Messages

I attended the 1st World Congress on Ultrasound in Medical Education and it was really interesting.  Here is some food for thought:

• There are currently 4 medical schools here in the US that are using ultrasound in their curriculum during all four years.  Ultrasound is used to aid in teaching normal anatomy and physiology, pathology and pathophysiology in the first two years.  Third year students are taught clinical diagnosis with the aid of portable ultrasound during their clinicals.  Senior medical students are mentoring those in lower classes, performing research projects in US, and completing specialized electives in US.  Check out these two schools who are leading this charge:  University of South Carolina US Curriculum & University of California at Irvine US Curriculum
• The University of South Carolina has their own Ultrasound Education Center that allows students to spend time in the lab practicing and even allows them to check out machines and phantoms for further study.  Wow!!!
• Other medical schools are incorporating US into workshops and preparation for the clinical years, teaching their students ultrasound guided line placement and basic scan protocols such as the FAST or RUSH exam.
• Portable US can be used just about anywhere: many international groups are using portable US to reduce the risk of maternal mortality in third world countries where it is highest and they are seeing real differences in the lives of the people they serve.  Others presented US uses in austere environments such as disaster sites, like Haiti, high altitude locals, such as climbing base stations, and even the International Space Station.
• Although there is not an International consensus on ultrasound use, we are heading in that direction.  As more and more non-radiologists are performing POC US, standards for its use are a must.  Interestingly enough, ACEP was recognized as one of the earliest governing medical bodies to create a consensus statement and create guidelines for its use.

Lastly, this conference has inspired me to continue my "Ultrasound Evangelism" and I plan to continue to spread the message of point of care US.  I hope to incorporate it into the medical student rotation this coming academic year.  Any residents who would like to help, please let me know!

World Congress on Ultrasound in Medical Education

I am currently attending the 1st World Congress on Ultrasound in Medical Education in Columbia, SC.  Day 1 was very educational: discussions of how to use point of care ultrasound can be used in areas outside of the hospital was the most interesting:

• EMS use to expedite trauma care by performing the FAST exam en route has been shown to reduce time to the OR.  
• Incorporation of ultrasound into medical school curriculum can increase the understanding or both anatomy and physiology in the first 2 years of medical school.  
• Ultrasound use in areas where other imaging technologies are either impractical, unaffordable or unavailable such as disaster areas, free rural clinic and even in space (NASA). 

There have also been some cool lectures on simulation and ultrasound e-learning (this blog is both a low fidelity simulation and e-learning!).  I hope to learn some new stuff that we can use back in Jax.

April Case #2: Scrotal Pain- Discussion

This patient has Fournier's Gangrene.  He appears to have good flow to the affected testicle as visualized by both a venous and arterial waveform on spectral doppler which rules out torsion.  However, he had gas in the scrotum which id diagnostic for Fournier's.  The patient was started on IV antibiotics and was admitted to the hospital.  He ultimately underwent a scrotectomy but did not require further perineal debridement.

Fournier's Gangrene

Fournier's gangrene is a type of necotizing fasciitis involving the perineum and genitals, most commonly infecting men, but has been known to affect women and children as well.
Risk factors include:

• diabetes
• alcohol abuse
• advanced age
• renal failure
• immunocompromised states.  

It is a mixed flora infection of both aerobes and anaerobes.  It can result in significant morbidity and mortality, including loss of the testicles and resultant cystomies.

Physical Exam findings:

• edema to the scrotum 
• tenderness to palpation of both scrotum and testicles
• crepitus (only 64% of patients)

Although CT scan is gold standard for the diagnosis, ultrasound can be done at the bedside to expedite the diagnosis and treatment.  It can also confirm the diagnosis in less obvious cases since ultrasound can visualize gas in the tissue prior to the appearance of crepitus.

Ultrasonographic appearance of Fournier's Gangrene:

• Marked tissue thickening
• local hyperechoic areas with distal acoustic shadowing with scatter indicative of subcutaneous air
• peritesticular fluid
• enlarged and hypoechoic epididymis indicating epididymitis

 

 References:

Emergency Ultrasound of the Scrotum: A Review of the Commonest Pathologic Conditions. Demosthenes D, et al. Curr Probl Diagn Radiol. Jan/Feb 2011 

Fournier's gangrene and its emergency management. Thwaini A, et al. Postgrad Med J. 2006 Aug;82(970):516-9. 

Fournier gangrene: rapid diagnosis with bedside ultrasonography. Heiner JD, et al. CJEM. 2010 Nov;12(6):528-9. 

Emergency diagnosis of Fournier's gangrene with bedside ultrasound. Morrison D, et al. Am J Emerg Med. 2005 Jul;23(4):544-7.

Name Change

You might have noticed that I've changed the name and adrress slightly.  Same great content, now just in a slightly different package!

Ski Lift

Ever had a problem placing an IJ under ultrasound guidance in a patient with a short neck?  So here is a little trick to get great visualization in the longitudinal or sagital plane.  I know what most of you are thinking, "Did you say long axis for IV placement?  That's really hard!" 

This technique is nicely descrbed by Jason Nomura in his blog and includes a video illustrating the technique.  Check it out!

Ski Lift Video

April Case #2: Scrotal Pain

42y/o AAM presents to the ED with c/o scrotal pain for the past 4 days.  He denies trauma or penile discharge and denies any recent sexual activity.  He denies dysuria, F/C or abdominal pain.
PMHx: none
PSHx: none
Meds: none
Allergies: NKDA
SocHx: denies tob, ETOH, or drugs

PE: BP130/85, P126, R16, T99.8, Pox 99% (RA)
GEN: WNWD, AAM, NAD
CHEST: CTA B
CV: tachy, RR, no M/R/G
ABD: soft, NTND, +BS
GU: L hemiscrotum edematous > R, no crepitus or ulceration, +TTP to L hemiscrotum, testicles with normal lie B and no TTP, no penile lesions or drainage, no inguinal LAD, DRE good tone, heme neg, prostate WNL

Bedside US is performed and illustrates the following:

What's the diagnosis?

Thanks to Dr. Christina Gindele for submitting this case!