March Case #2: Abdominal Pain

31 y/o AAF presents to the ED with complaints of abdominal pain increasing over the past 3 days.  She denies N/V/D or F/C.  She admits to vaginal discharge and dysuria.  She denies vaginal bleeding.  LMP 1 month prior?

PMHx: G5P2
PSHx: none
Meds: none
Allergies: NKDA
SocHx: +tob/ETOH/cocaine

PE: BP 110/72, P 75, R 16, POx 100% (RA)

GEN: WNWD, AAF, appears in pain
CHEST:  CTA B, nonlabored
CV:  RRR, no M/R/G
ABD:  diffusely TTP, greatest over suprapubic/pelvic area with guarding and mild rebound, +BS
PEL: cervix thick and closed, erthymatous and friable with copious purulent discharge protruding from the os, +TTP over R adenexa, no masses palpable

WET PREP: sheets of WBCs, no trich, yeast, occasional clue cells

Bedside ultrasound is performed and reveals the following:



Ectopic from UF-Jax Emergency Medicine on Vimeo.

What is the diagnosis?

Thanks to Dr. Kristin McKee for submitting this case!

Literature Points #2: Point of Care Ultrasound

Although not a new thing, point of care (POC) ultrasound was brought to the forefront of the medical community with an article in the most recent issue of the New England Journal of Medicine.  In this article, EM physician, Christopher Moore and OB, Joshua Copel discuss the nature and scope of POC ultrasound.  Although not tailored to Emergency Medicine, this article highlighted the use of POC ultrasound in many specialties outside of radiology as a way to make diagnoses at the bedside.  Interestingly enough, this has created a backlash in the American Ultrasound community, which includes radiologists, who believe that physicians performing POC US will bring us back to the dark ages.  What do you think, should ultrasound be in the hands of all providers?


Point of Care Ultrasound Review: New England Journal of Medicine

E-Learning

I just got back from the Learning Solutions Conference and Expo in Orlando, FL.  Dr. Saboto, Vivek and I attended this cool E-Learning Conference last week, and it has us all fired up!  Although this conference was not specifically for medicine or even academics, it was really educational none the less.  We attended sessions on the technical aspects of electronic learning such as creating widgets, mobile apps and on-line courses, but also learned about incorporating social media into education (so look for me on Twitter now too!).  I hope to incorporate some of my ideas into resident and medical student education, so be on the look out for expansion from the blog.

Although not specifically ultrasound related, here are a few cool educational blogs that I stumbled across this week, so check them out!

Academic Life in Emergency Medicine
EMCrit
Life in the Fast Lane
ERCast
Better in Emergency Medicine
The Central Line
Takeokun.com
Z Dogg MD

Enjoy!

New Ultrasound Technology Review

This week we are going to review the latest in new bedside ultrasound technology.  This info is taken from an upcoming article on technologic advancements in EM Ultrasound, that was written for EM Pulse by Dr. Adrian Elliot and myself.  So keep a look out for the full article in future issues...

The Most recent push in ultrasound technology is the miniaturization of the ultrasound machines to handheld devices.  Multiple companies have released handheld ultrasound imaging devices in the past few years.  Some of these devices are the size of larger cellular phones, making them easy to carry around at all times.  Siemens was the first to release a "pocket ultrasound," the Acuson P10.  This unit starts up in 5 seconds and can be used for cardiac and abdominal applications.  It weighs in at a hefty 1.6 pounds and stores both video clips and still images.

Accuson P10

Signostic has created a hand held ultrasound machine with a high-resolution LCD touch screen display and text and voice annotation, called the Signos.  It is the lightest at 11.2 ounces.

Signos personal ultrasound

GE has also released a handheld unit this past year called the Vscan.  It is the size of a smartphone, but is a self-contained unit.  It boasts a 3.5-inch color display with an easy user interface and a 4 GB memory card.  The entire unit weighs 14 ounces and has the ability to perform color flow doppler imaging.

Vscan

The MobiUS, produced by Mobisante has recently gained FDA approval as a handheld ultrasound device that actually utilizes a smartphone-based platform.  The device uses the Toshiba TG01 smart phone and the probe connects via a USB connection.  It can connect to wifi or cellular network, allowing the user to send images wirelessly via the Internet.  The whole system weighs 13 ounces and although it is not out for purchase yet, the estimated price will be $5,000 for a single probe system.

MobiUS

The increased portability of these ultrasound systems will make them attractive for pre-hospital, disaster settings and even remote locations leading to earlier diagnoses.  These machines also cost significantly less than their larger counterparts, making their purchase more palatable to departments.

Other current ultrasound advancements include educational technology.  For practitioners continuing to learn how to use ultrasound technology, there is an abundance of websites and smart phone-based applications dedicated to emergency ultrasound education.  While there are no dedicated Android-based or Blackberry-based ultrasonography apps, there are currently six different EM-focused applications downloadable for the Apple iPhone.

March Case #1: Chest Pain- Discussion

CXR illustrated a RUL pneumonia and CBC resulted a WBC of 20.5 with 11% bandemia.  The patient was eventually placed on BIPAP and Cardiology was consulted for pericarditis.  Cardiology refused admission and the patient was admitted to Internal Medicine.  Formal echo demonstrated a moderate to large pericardial effusion with strands and echo densities.  The patient was started on high dose aspirin, antibiotics and was transferred to the Cardiology service for pericardiocentesis, which drained approximately 2 liters of purulent fluid.

Bedside Echocardiology

Cardiac ultrasound in the ED is a quick and useful procedure.  Indications for bedside echo include cardiac arrest, thoracic trauma (both penetrating and blunt force), unexplained hypotension and evaluation of cardiac function.  The identification of pericardial effusion is one of the major goals of bedside echo.  When an effusion is identified, it is important to look for signs of pericardial tamponade.  Tamponade can be identified by the presence of right heart diastolic collapse.  During normal cardiac motion the ventricles will expand during diastole and move inward during systole.  In the case of tamponade, there is a paradoxical motion of the right ventricle.  Instead of expanding during diastole, the right ventricle with collapse inward.  This will appear as if an invisible finger is pushing the outer wall of the right ventricle inward.  Regardless of the size of the effusion, if right heart collapse is present, emergent pericardiocentesis is warranted.

Over the past twenty years the method of pericardiocentesis has evolved from blind entry to ultrasound guided.  The location for entry had been solely from the subxiphiod view, but the left parasternal border may also be used.  Direct ultrasound visualization and guidance toward the area of maximum accumulation of fluid and to the area where the effusion is closest to the transducer, decreases the risk of pneumothorax and liver penetration.  A 16-gauge needle is used and the catheter may be left in place for further aspiration at a later time.

For further procedural details, check out Sonoguide:
http://sonoguide.com/pericardiocentesis.html

March Case #1: Chest Pain

52 y/o AAM presents to the ED with 3 days of cough, pleuritic chest pain, SOB, and night sweats.  Pain is substernal, sharp, worse with deep inspiration/coughing and non radiating.  Pain is 10/10.  Upon further questioning, the patient admits to streptococcal pneumonia and bacteremia 10 days prior, only partially treated with rocephin.

PMHx: latent tuberculosis
PSHx: none
Meds: Ibruprofen, theraflu
Allergies: NKDA
FamHx: diabetes
SocHx: lives alone, denies tobacco and ETOH, admits to cocaine

PE: BP134/80, P 116, R 22, T 98.1, Pox 100% on 2L NC
GEN: thin AAM
HEENT; dry mucous membranes, no JVD
CV: tachycardic, regular, + friction rub, no peripheral edema
CHEST: shallow and rapid, diffuse rhonchi
ABD: soft, NTND, +BS
NEURO: no deficits

EKG illustrates the following:

Bedside Ultrasound is performed:

Pericardial Effusion from UF-Jax Emergency Medicine on Vimeo.

What is the diagnosis?

How would you treat this in the ED?

Thanks to Dr. Dileep Ravi for submitting this case!