April Case #1: Eye Pain Discussion

This patient has large cataracts bilaterally and a vitreous hemorrhage in the right eye, confirmed by head CT.

She received compazine, benadryl and her home BP meds and her headache resolved without further treatment and she was discharged home.  The headache was likely secondary to her untreated HTN.

Ocular Ultrasound

Ultrasound has been used to evaluate the eye since the late 1960s, but has only been adopted for ED use for the past decade.   It is an easy non-invasive way to evaluate the eye in patients who present with:

• vision loss
• eye pain
• suspected foreign body
• ocular trauma
• patients with closed head injury. 

Using a high frequency probe (preferable linear, but could use an endocavitary probe if that's all you have), have the patient close their eye and fill their eye socket with ultrasound gel.  Place the probe gently on the orbit over the closed lid in the transverse plane.  Brace your hand by creating a "kickstand" with your pinky finger, and fan through the eye top to bottom.

Make sure that you identify all anatomy and note any abnormalities. 

In this case specifically, there is an abnormality of the lens.  Normally only the posterior portion of the lens is visible, but with cataracts, the entire lens become apparent as a hyperechoic region.

This case also presents an interesting finding in the vitreous humor. There appears to be a hyperechoic area, but is it a retinal detachment or a vitreous hemorrhage? 

 

Vitreous hemorrhage appears as echogenic material in the posterior chamber.  Depending on the age and severity, a vitreous hemorrhage may have a varied appearance on ultrasound.  Small dots or linear areas may be fresh mild hemorrhages but more severe and older bleeds can organize and forms membranes.  Gravity may layer out vitreous bleeds inferiorly.

 Retinal detachment could be mistaken for a older layered out vitreous hemorrhage to the untrained eye. However, note that usually retinal detachments appear as a hyperechoic wavy line in the posterior to lateral globe, not as a linear or straight line.

For further information on ocular pathology check out Sonoguide.com (http://sonoguide.com) or my Ophthalmic Ultrasound lecture.

On another note, there is a cool trick in evaluating pupillary constriction with ultrasound in patients with significant ocular/facial trauma where you are unable to open the eye.  Ultrasound can be used to visualize the pupil if there is so much edema to the orbit that the lid cannot be retracted.  This is performed by placing the ultrasound probe on the edematous affected eye while a light is shined on the contralateral pupil and the pupil in the affected eye is monitored.  The pupil will retract and an opening within is visualized.


Pupilary Dilation from UF-Jax Emergency Medicine on Vimeo.

 Thanks to Michelle Lin for this awesome ultrasound trick!  Check out her blog for this and other cool tricks of the trade:
Academic Life in EM trick of trade:pullilary constriction

Thanks to ED Tech and Future Ultrasonographer Todd for being the model for this post!

April Case #1: Eye Pain

A 73 y/o AAF presents to the ED with eye pain and headache for the past 12 hours.  She states that she has been blind for the past 3 years, but has never had pain associated with her lack of vision.  She reports a 10/10 headache which began gradually after she came home from hemodialysis earlier in the day.  She denies nausea, vomiting, fever or neck stiffness.  She describes her headache as global in nature.

PMHx:  DM, HTN, ESRD, cataracts

PSHx: none

Meds: blood pressure and diabetes meds

Allergeries: NKDA

SocHx:  lives with her daughter, denies ETOH, drugs or tobacco use

PE: BP 221/110, P 60, R 16, T 98.5, Pox 98% (RA)

GEN: WNWD, AAF, appears in pain, moaning

HEENT: Pupils difficult to visualize due to cataracts, EOMI intact, no scleral injection or icterus, lids lashes and lacrimals normal without evidence of infection, fluoresceine uptake negative, unable to visualize fundus, difficult to visualize anterior chamber clearly due to large cataracts, IOP normal.  No temporal TTP, normal neck flexion

CHEST:  CTA B, nonlabored

CV:  RRR, no M/R/G

ABD: soft, NTND, +BS

Bedside ultrasound is performed to evaluate the retina and for ICP. 

 

What do these images demonstrate?  

Thanks to Dr. Ashley Doescher for the images in this case!

No posts?

Sorry for the lack of posts last week, but I was on a much needed vacation!  I am back with renewed vigor and ready for more ultrasound discussion!

March Case #2: Abdominal Pain Discussion

 This patient has a large ectopic pregnancy visible on ultrasound with fetal motion and cardiac activity.  The patient was consulted to OB/GYN and they took her to the OR immediately.  During her laparotomy, the patient was found to have a large amount of clotted blood in the pelvis (about 1L) and a ruptured right ampullary ectopic pregnancy.  She was also noted to have a boggy uterus with adhesions, consistent with PID.  The patient had a right salpingo-oophrectomy and was treated with antibiotics.

Ectopic Pregnancy

Ectopic pregnancy is an abnormal pregnancy that occurs outside of the uterus.  It is noted to be associated with PID in 50% of cases.  Women who have undergone surgical sterilization are at increased risk of ectopic pregnancy, especially after the 2nd year after the procedure.  After ectopic, 33% of women go on to later have a normal pregnancy.  Another third will have another ectopic.  The woman's age, previous successful pregnancies and the cause of a previous ectopic will predict the likelihood of having a successful pregnancy in the future.

The mortality rate of ectopic pregnancy in the US has decreased in the last 30 years to less than 0.1%.

 

Note that the placement of the ectopic will determine how rapidly an ectopic will become symptomatic.  Those in the fimbrial region will develop more before they become symptomatic due to the fact that that portion of the Fallopian tube is wider than the rest.

It is really important when looking to rule out ectopic that you evaluate the uterus in 2 planes.  The ectopic in this case could easily have been missed.  The gestational sac and fetus appear so close to the uterus that it would be easy to mistake this pregnancy for one in the uterus.  However, when you take a closer look at the video, notice that the endometrial stripe is anterior to the gestational sac and that there is a thin line of anechoic fluid.  Taking a few minutes to carefully note where the pregnancy is, can save a lot of trouble in the future!  Let's look at the video again, slowed down a bit and with the areas of interest pointed out...

Ectopic Pregnancy Explained from UF-Jax Emergency Medicine on Vimeo.
 
Did you catch it this time?

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!