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!