Author: UCSD Ultrasound

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Case 65: Knee Pain

Colleen Sweeney, Akash Desai

A 55-year-old female with no pertinent past medical or surgical history was brought in by ambulance after a bicycle accident with left knee pain.  She was unhelmeted while riding a bicycle going 10mph when she collided into an e-bike. Her left knee was caught in her handlebars; she denied head trauma and had no LOC.  

Vitals: BP 168/120, HR 70, T 96.0F, RR 22, SpO2 95% on RA, BMI 24.41 

Physical Exam: 
General/Neuro: alert, in acute distress, diaphoretic 
HEENT: normocephalic, atraumatic, EOMI 
CV: normal rate 
Resp: tachypneic 
Abdomen: flat, soft, no tenderness 
MSK: RLE normal 
L knee: +swelling, +deformity. Skin intact, small ecchymosis to left lateral knee. Knee diffusely tender to palpation. Sensation intact to light touch throughout. Palpable popliteal, PT, and DP pulses. Able to wiggle toes. Compartments compressible. Patient unable to tolerate any movement of L knee secondary to pain. 
L lower leg: +swelling from knee distally, no lacerations 
L ankle/foot: normal pulse, sensation intact to light touch throughout 

Radiographs were indicated and initially attempted at bedside, however were unsuccessful as the patient was unable to tolerate the pain. Radiography was delayed until two hours due to pain management and census.  In the interim, a POCUS was performed

Figure 1. Transverse view of infrapatellar lipohemarthrosis. 
Figure 2. Longitudinal view of infrapatellar lipohemarthrosis.  
Figure 3. Longitudinal view of tibia with cortical break (arrow). 

Xray findings: "Acute, comminuted, displaced proximal tibial fracture extending to the lateral and central tibial plateau.  Acute, mildly displaced and impacted fibular neck fracture.  No fracture or malalignment of the left ankle. "

The patient was admitted to the trauma surgery service. The next day, she underwent a left knee spanning external fixator for stabilization of the tibial plateau fracture. One week later, she had an ORIF for long-term fixation of the fracture as well as a hamstring tendon repair. 

Discussion

POCUS is increasingly utilized in acute musculoskeletal trauma. The patient’s gross knee deformity after a traumatic event led to POCUS utilization to provide rapid clinical guidance.  In this patient, ultrasound was complete half an hour prior to the first attempt at radiographs and over 2 hours prior to their completion, thus proving useful in differentiating the severity of a patient’s injury during prolonged wait times and facilitating early orthopedic surgery consultation. 

Ultrasound, though not a primary diagnostic modality for acute fractures, offers sensitivity of 87% and specificity of 70% for proximal tibial fractures specifically in cadaveric models [3]. In Figure 3, the cortical break visible on the left side of the image corresponds to the proximal tibial fracture seen on X-ray. 

Figures 1 and 2 both demonstrate lipohemarthrosis. The presence of hemarthrosis, rather than a simple joint effusion, raises the suspicion for an intra-articular injury or fracture, with ultrasound demonstrating a sensitivity of 90% and specificity of 86% for this finding [2]. When lipohemarthrosis is identified—most clearly visualized in Figure 2 as hypoechoic fat “bubbles” originating from the bone marrow—it is even more indicative of an intra-articular fracture, carrying 97% sensitivity and 100% specificity for such fractures [4]. In its early stage, lipohemarthrosis appears as scattered fat globules, which later settle into the characteristic triple-layer pattern of fat, serum, and blood products [5]. Recognition of hemarthrosis or lipohemarthrosis on ultrasound may help risk-stratify patients for joint aspiration, potentially reducing unnecessary aspirations and associated infection risk. 

The presence of lipohemarthrosis is highly suggestive of a distal femur or proximal tibial fracture. Recognizing these findings early allows clinicians to maintain a high index of suspicion for periarticular fracture prior to radiographic confirmation, enabling prompt immobilization, consultation, and fracture management. This early identification facilitates more efficient triage and throughput in the ED and underscores POCUS as a worthwhile adjunct in knee trauma in addition to traditional imaging such as X-ray, CT, and MRI [6].  

References:  

  1. Stannard JP, Lopez R, Volgas D. Soft tissue injury of the knee after tibial plateau fractures. J Knee Surg. 2010;23(4):187-192. doi:10.1055/s-0030-1268694 
  2. Taljanovic MS, Chang EY, Ha AS, et al. ACR appropriateness criteria® acute trauma to the knee. Journal of the American College of Radiology. 2020;17(5). doi:10.1016/j.jacr.2020.01.041  
  3. Demers G, Migliore S, Bennett DR, et al. Ultrasound evaluation of cranial and long bone fractures in a cadaver model. Mil Med. 2012;177(7):836-839. doi:10.7205/milmed-d-11-00407 
  4. Bonnefoy, O., Diris, B., Moinard, M. et al. Acute knee trauma: role of ultrasound. Eur Radiol 16, 2542–2548 (2006). Doi:10.1007/s00330-006-0319-x 
  5. Levrini G, Reggiani G, Vacondio R, Zompatori M, Nicoli F. Post-traumatic knee lipohemarthrosis: Temporal evolution with progressive separation of the three layers of the joint effusion by ultrasonography and computed tomography. European Journal of Radiology Extra. 2006;60(1):37-41. doi:10.1016/j.ejrex.2006.06.011  
  6. De Maeseneer M, Marcelis S, Boulet C, et al. Ultrasound of the knee with emphasis on the detailed anatomy of anterior, medial, and lateral structures. Skeletal Radiol. 2014;43(8):1025-1039. doi:10.1007/s00256-014-1841-6 

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            Case 64: Ocular emergencies: A case of macula-on retinal detachment seen on POCUS  

            Theresa Jo Thomas , Akash Desai

            Case: A 49-year-old female with a past medical history of type 1 diabetes on insulin and myopia presented to the emergency department for vision changes. The patient stated that three days ago she noticed “flashers” in the vision of her right eye which she described as “squiggly lines”. The patient stated that on the day of her presentation to the emergency department at 1100 she noticed the bottom half of her vision as “grayed out” when looking to the ground. She stated that the grey vision was not present when looking upwards. The patient denied trauma to the eye, recent illness, eye pain, or eye irritation.   

            Vitals : BP 129/87 HR 99 RR 17 SpO2 100% T 97.2 F  

            Physical Exam: 

            HEENT: Bilateral pupils equal, round, and reactive to light. Bilateral eyes without conjunctival injection, no hyphema or hypopyon. No pain with extraocular movements and extraocular movements intact. No notable trauma to orbit, no orbital bruising or tenderness.    Visual acuity was measured as below:

            • OD 20/50 Uncorrected 
            • OS 20/25 Uncorrected 
            • OU 20/50 Uncorrected 
            • OD 20/50 Corrected 
            • OS 20/30 Corrected 

            Given patient’s concerning presentation, a bedside ocular ultrasound was performed to help further differentiate the patient’s complaint. 

            Figure 1. Ocular ultrasound. Detached retinal membrane (R). The membrane is shown to be attached at the macula (M), lateral to the optic nerve (ON) which can be identified due to its characteristic nerve sheath shadow in the far field of the image.  
            Figure 2. Ocular ultrasound clip with evidence of retinal detachment with macula-on. Ultrasound performed with linear array transducer in the longitudinal plane. The detached hyperechoic, serpiginous membrane, in a vertical orientation, seen on the left side of the image in the posterior chamber is indicative of a retinal detachment. Notice here that the detachment edge begins lateral to the macula. Due to a temporary PACS connectivity issue at the time of scanning, the ultrasound images were documented via mobile device recording of the screen rather than direct export. This explains the presence of motion artifact and reduced image fidelity in the attached clip. 
            Figure 3. Differentiating between retinal detachment, posterior vitreous detachment, and vitreous hemorrhage with POCUS.  Source: POCUS 101

            ED Course  

            Ophthalmology was urgently consulted for concern for macula-on retinal detachment on bedside ultrasound. The patient was seen in the ED by ophthalmology who confirmed the diagnosis of macula-on retinal detachment, and the patient was scheduled for retinal surgery to occur later the same day. The patient was instructed to maintain NPO status and was discharged in hemodynamically stable condition to present to surgery as scheduled later that day.   

            Discussion  

            This case highlights the utility of POCUS in the diagnosis of retinal detachment. The presentation can vary, with patients often reporting an acute painless loss of vision or flashes and floaters [2]. Additional differential diagnoses include vitreous hemorrhage and posterior vitreous detachment, both of which can be identified on ultrasound. Retinal detachment is an ophthalmological emergency, while vitreous hemorrhage and posterior vitreous detachment can typically be managed with urgent outpatient follow-up with ophthalmology [2]. Thus, the diagnosis of retinal detachment is a time-sensitive diagnosis. The diagnosis of retinal detachment is typically made with dilated direct and indirect fundoscopic exams.  

            When performing ocular ultrasound for this purpose, the linear array transducer should be used to obtain both transverse and longitudinal views of the eye. The patient should be instructed to move the eye superiorly and inferiorly as well as horizontally while examining with ultrasound [3]. The finding of interest suggesting retinal detachment is the presence of a retinal flap [4].  If the membrane flap is attached in the posterior globe and does not cross the optic nerve, this is suggestive of retinal detachment. This is typically a thicker, more hyperechoic flap than what is seen with a vitreous detachment [3]. Vitreous detachments, on the other hand, can cross the midline and are not tethered to the optic disc [3]. Should the retinal detachment be visualized extending temporally from the base of the optic nerve, near the approximate location of the macula, it is suggestive of macula off retinal detachment [3].  Conversely, lack of visualization of a retinal flap in the area of the macula is suggestive of macula-on retinal detachment.  

            Ocular POCUS has been shown to diagnose retinal detachment reliably and accurately in the emergency department [5]. The standard of care includes urgent ophthalmology consultation as this problem is typically surgically managed to maximize vision preservation. Of note, macula-on retinal detachments have far better visual prognosis than macula-off retinal detachments, highlighting the importance of POCUS in facilitating early detection and vision-saving intervention.  Specifically, in macula-on cases, timely repair offers an opportunity to preserve central vision before permanent loss occurs, highlighting the value of ultrasound in distinguishing macula-on from macula-off detachments. It has been shown that emergency physicians can reliably exclude vitreous hemorrhage and detachment when performing POCUS to evaluate for retinal detachment [2]. We demonstrate here a case of macula-on retinal detachment identified on POCUS by an emergency physician.    

              

            References  

            1. POCUS 101. Ocular ultrasound pocket card [Internet]. POCUS 101; 2020 Aug [cited 2026 Jan 6]. Available from: https://pocus101.b-cdn.net/wp-content/uploads/2020/08/POCUS-101-Ocular-Ultrasound-Pocket-Card.pdf 
            2. Lahham S, Shniter I, Thompson M, Le D, Chadha T, Mailhot T, Kang TL, Chiem A, Tseeng S, Fox JC. Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department. JAMA Netw Open. 2019 Apr 5;2(4):e192162. doi: 10.1001/jamanetworkopen.2019.2162. PMID: 30977855; PMCID: PMC6481597.   
            3. Situ-LaCasse E, Adhikari SR. Ocular emergencies. Sonoguide [Internet]. American College of Emergency Physicians; 2020 Aug 18 [cited 2026 Jan 6]. Available from: https://www.acep.org/sonoguide/advanced/ocular-emergencies 
            4. Yoonessi R, Hussain A, Jang TB. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med. 2010 Sep;17(9):913-7. doi: 10.1111/j.1553-2712.2010.00809.x. PMID: 20836770. 
            5. Vrablik ME, Snead GR, Minnigan HJ, Kirschner JM, Emmett TW, Seupaul RA. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Ann Emerg Med. 2015 Feb;65(2):199-203.e1. doi: 10.1016/j.annemergmed.2014.02.020. Epub 2014 Mar 27. PMID: 24680547.  

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                    Case 63:  Point-of-Care Ultrasound in Inferior Glenohumeral Dislocation (Luxatio Erecta) 

                    Makhlouf Bannoud, Colleen Campbell

                     A 22-year-old male with no significant past medical history presented to the emergency department with right shoulder pain and visible deformity after a surfing injury. He reported that a wave forcefully pulled his surfboard while he was holding on, followed by an audible “pop.” He denied head trauma, distal numbness, weakness, or additional injuries. 

                    Vitals: BP 151/81 | HR 104 | RR 27 | Temp 97.8°F (36.6°C) | SpO₂ 93% 

                    On exam, the patient was in acute discomfort but alert and oriented. The right upper extremity was held in abduction with visible deformity and inferior displacement of the humeral head. Distal neurovascular exam demonstrated 2+ radial pulse, intact sensation in the axillary, median, radial, and ulnar distributions, and full motor strength in the hand. 

                    Point-of-care ultrasound (POCUS) of the right shoulder was performed prior to radiography to evaluate the glenohumeral joint. Ultrasound demonstrated inferior displacement of the humeral head relative to the glenoid fossa, consistent with inferior glenohumeral dislocation (Figure 1). No obvious joint effusion or cortical step-offsuggestive of displaced fracture was visualized. 

                    Figure 1: Inferior shoulder dislocation with humerus outside the glenoid fossa.

                     Ultrasound guidance was then used to perform an intra-articular anesthetic injection for analgesia prior to reduction (Figure 2).

                    Figure 2: Ultrasound-guided joint injection.

                    Moderate procedural sedation with propofol was subsequently administered. Closed reduction was performed successfully. 

                    Post-reduction POCUS demonstrated restoration of normal alignment between the humeral head and glenoid (Figure 3). 

                    Figure 2: Post-reduction ultrasound.

                    Follow-up radiographs confirmed interval reduction and revealed a Hill-Sachs deformity without definitive osseous Bankart lesion. Repeat neurovascular examination remained intact. The patient was placed in a sling and discharged with close orthopedic follow-up. 

                    Discussion 

                    Inferior glenohumeral dislocation, or luxatio erecta, accounts for less than 1% of shoulder dislocations [1]. The classic mechanism involves hyperabduction, driving the humeral head inferior to the glenoid fossa. Patients typically present with the arm fixed in abduction and inability to adduct the limb. 

                    Although radiographs remain standard for definitive diagnosis, point-of-care ultrasound has emerged as a reliable adjunct for rapid diagnosis of shoulder dislocation. Multiple studies have demonstrated high sensitivity and specificity approaching 100% for identifying glenohumeral dislocation [2]. Ultrasound allows dynamic assessment without radiation and can expedite care in high-volume emergency settings. 

                    The posterior transverse view is most commonly used, with the probe placed over the scapular spine to visualize the glenoid and humeral head relationship. In normal alignment, the humeral head appears centered over the glenoid. In inferior dislocation, the humeral head is displaced caudally relative to the glenoid, as demonstrated in this case. 

                    POCUS also facilitates ultrasound-guided intra-articular anesthetic injection. Compared to landmark-based techniques, ultrasound guidance improves accuracy of joint entry and reduces complications [3]. Intra-articular lidocaine has been shown to be comparable to intravenous sedation in facilitating reduction, with shorter ED length of stay and fewer adverse events [4].

                    In this case, ultrasound-guided anesthetic injection was used as adjunctive analgesia prior to procedural sedation. Vascular injury, although rare, may involve the axillary artery. For this reason, careful pre- and post-reduction neurovascular examination is essential. 

                    Associated injuries are common and include Hill-Sachs deformity, greater tuberosity fracture, rotator cuffinjury, and labral tears. [5] Post-reduction imaging in this case demonstrated a Hill-Sachs lesion, which may predispose young active patients to recurrent instability depending on lesion size and engagement. 

                    This case highlights the expanding role of point-of-care ultrasound in musculoskeletal emergencies. POCUS enabled rapid confirmation of inferior glenohumeral dislocation, guided intra-articular anesthetic injection, and verified successful reduction prior to radiographic confirmation. When integrated thoughtfully into clinical workflow, ultrasound enhances procedural safety, diagnostic efficiency, and patient comfort in the management of shoulder dislocation. 

                    References: 

                    [1] StatPearls. (2023). Inferior shoulder dislocations. In StatPearls [Internet]. StatPearls Publishing. Retrieved October 2025, from https://www.ncbi.nlm.nih.gov/books/NBK448196/ 

                    [2] Gottlieb, M., Holladay, D., & Peksa, G. D. (2019). Point-of-care ultrasound for the diagnosis of shoulder dislocation: a systematic review and meta-analysis. The American Journal of Emergency Medicine, 37(4), 757-761. 

                    [3] Aly, A. R., Rajasekaran, S., & Ashworth, N. (2015). Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. British journal of sports medicine, 49(16), 1042-1049. 

                    [4] Sithamparapillai, A., Grewal, K., Thompson, C., Walsh, C., & McLeod, S. (2022). Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis. Canadian Journal of Emergency Medicine, 24(8), 809-819. 

                    [5] Ostermann, R. C., Joestl, J., Hofbauer, M., Fialka, C., Schanda, J. E., Gruber, M., ... & Tiefenboeck, T. M. (2022). Associated pathologies following luxatio erecta humeri: a retrospective analysis of 38 cases. Journal of Clinical Medicine, 11(2), 453. 

                    [6] Flinders, A., & Seif, D. (2016). Point-of-Care Ultrasound in Diagnosis and Treatment of Luxatio Erecta (Inferior Shoulder Dislocation). Journal of Medical Ultrasound, 24(2), 70-73 

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                    Case 62: Undifferentiated Hypotension in the setting of Atrial Fibrillation with Rapid Ventricular Response

                    Lucia Hong, Elaine Yu

                    A 70-year-old male with a history of cirrhosis, COPD, HTN, T2DM, and large abdominal wall hernia who presented after being found down in his home by a neighbor. Upon arrival, the patient was hypotensive with systolic blood pressures in the 70s and in atrial fibrillation with RVR with heart rates in the 170s. He received 500mL intravenous fluids prior to arrival and was transported on supplemental oxygen. The patient was altered and unable to provide history.

                    On physical examination, the patient appeared acutely ill and minimally responsive. Mucous membranes were dry. Cardiovascular examination demonstrated tachycardia with an irregular rhythm. Lung examination revealed bilateral breath sounds without focal wheezes or stridor. The abdomen was distended with generalized tenderness and a large non-reducible abdominal wall hernia. Extremities were warm and perfused without significant peripheral edema. Neurologic examination demonstrated altered mental status with intermittent command following and spontaneous movement of all extremities.

                    Synchronized cardioversion was performed following sedation with fentanyl and midazolam, which resulted in sinus tachycardia with improvement in heart rate and blood pressure.

                    Vital Signs: BP: 94/62 | HR: 102 | RR: 25 | Temp: 100 °F| SpO₂: 99% on 5L O2

                    Following cardioversion, RUSH was performed with findings of a small pericardial effusion, a plethoric inferior vena cava with minimal respiratory variation, and abnormal right ventricular wall motion with apparent right ventricular enlargement (Figure 1).

                    Additionally, intra-abdominal free fluid concerning for ascites was also seen (Figure 2). These findings prompted further evaluation of cardiogenic, obstructive, and distributive shock.

                    Figure 1. Apical 4-chamber view showing right ventricular enlargement with wall motion abnormality characterized as hypokinesia of the right ventricular free wall and contraction at the apex.1

                    Figure 2. Abdominal ultrasound showing large ascites in the left lower quadrant.2

                    Labs: WBC 13.3, Hgb 6.9, lactate 2.1, troponin 192 -> 189, D-dimer 26,069

                    Imaging

                    CTA PE: No definite pulmonary embolism. Mild volume overload, probably cardiogenic.

                    CT Abdomen/Pelvis with contrast: 4.7 cm left anterior bladder wall abscess. Large volume ascites.

                    Discussion

                    Undifferentiated hypotension in the emergency department presents a diagnostic challenge, particularly in patients with multiple comorbidities and competing etiologies of shock. Rapid Ultrasound in Shock and Hypotension (RUSH) examination has emerged as a critical bedside tool allowing evaluation of physiologic contributors to shock prior to definitive diagnostic testing. The RUSH protocol integrates focused cardiac, vascular, pulmonary, and abdominal ultrasound assessment to assess hypovolemic, distributive, cardiogenic, or obstructive etiologies.3 Incorporation of early bedside ultrasound has been shown to alter the presumed category of shock in up to 50% of patients presenting with nontraumatic hypotension.4 RUSH is associated with faster diagnostic clarification and earlier targeted therapy in critically ill emergency department patients.5 The utilization of POCUS has demonstrated high specificity for detecting right ventricular strain patterns associated with obstructive shock states.6 Furthermore, POCUS can improve evaluation of volume status and reduce potentially harmful fluid overload in critically ill patients.7

                    In this case, the patient presented with hypotension, altered mental status, and atrial fibrillation with RVR. Multiple or mixed shock etiologies were plausible, including septic shock from intra-abdominal infection, cardiogenic shock related to arrhythmia or myocardial injury, and obstructive shock with pulmonary embolism. Additionally, hypovolemia was also considered given an initial Hgb 6.9. Identification of right ventricular wall abnormalities increased clinical suspicion for obstructive pathology, and a subsequent D-dimer was noted to be significantly elevated. CTA PE was completed that ruled out pulmonary embolism and demonstrated volume overload from a likely cardiogenic cause. Further CT images identified a bladder abscess as a source of sepsis. Additionally, RUSH examination findings contributed to cautious fluid administration and prompted consideration of alternative shock mechanisms.

                    This case highlights how POCUS guides subsequent decision-making. As emphasized in current American College of Emergency Physicians guidelines, POCUS serves as an extension of the physical examination and plays an increasingly central role in the early evaluation of critically ill patients in the emergency department.8

                    References

                    1. Kansara T, Quesada F, Park H, Ghosh K, Saeed M. McConnell’s Sign Still Holds Its Value: A Lesson Learned From Two Cases. Cureus. 2019;11(11):e6240. doi:10.7759/cureus.6240

                    2. Zuidewind P. Cirrhosis and portal hypertension. Case study, Radiopaedia.org. Published June 21, 2020. https://radiopaedia.org/cases/cirrhosis-and-portal-hypertension-1

                    3. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid ultrasound in shock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010;28(1):29–56.

                    4. Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med. 2004;32(8):1703–1708.

                    5. Atkinson PRT, Milne J, Diegelmann L, et al. Does point-of-care ultrasonography improve clinical outcomes in emergency department patients with undifferentiated hypotension? A systematic review and meta-analysis. Resuscitation. 2018;127:1–9.

                    6. Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950–957.

                    7. Marik PE, Monnet X, Teboul JL. Hemodynamic Parameters to Guide Fluid Therapy. Ann Intensive Care. 2011;1:1.

                    8. American College of Emergency Physicians. Emergency Ultrasound Guidelines. Ann Emerg Med. 2017;69(5):e27–e54.

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                    Case 61: Detection of Abdominal Aortic Aneurysm Using Point-of-Care Ultrasound

                    Sanjana Sanghani, Gerald Tolbert, Rachna Subramony

                    A 52-year-old male with a past medical history significant for hypertension and hyperlipidemia presented to the Emergency Department with two days of intermittent chest discomfort accompanied by mild epigastric pain. The pain was non-radiating, episodic, and not associated with nausea, vomiting, diaphoresis, syncope, or exertion. He denied recent trauma, heavy lifting, or prior similar episodes. There was no known personal history of vascular disease, tobacco use, or family history of aneurysmal disease.

                    An electrocardiogram demonstrated normal sinus rhythm without ischemic changes.

                    Vital Signs: BP 148/92 mmHg | HR 78 | T 98.1°F | RR 18 | SpO2 98% on room air

                    The patient appeared comfortable and in no acute distress. Cardiopulmonary examination was unremarkable, with normal heart sounds and clear lung fields. Abdominal examination revealed mild tenderness to deep palpation in the epigastric region without guarding, rebound tenderness, or palpable pulsatile mass. No abdominal bruits were auscultated. Peripheral pulses were symmetric and intact in all extremities, and there were no focal neurologic deficits.

                    Given the patient’s nonspecific symptoms, elevated blood pressure, and underlying cardiovascular risk factors, a point-of-care abdominal aortic ultrasound was performed to evaluate for occult aortic pathology. Bedside ultrasound examination of the abdominal aorta was performed using a low-frequency (2–5 MHz) curvilinear transducer. The aorta was evaluated in both transverse and longitudinal planes from the epigastrium to the aortic bifurcation, with measurements obtained from outer wall to outer wall, as recommended by established ultrasound guidelines.

                    Figure 1: Focal aneurysmal dilation of the abdominal aorta, with maximal diameter exceeding 3.0 cm, consistent with an ectatic aorta/ abdominal aortic aneurysm.

                    No free intraperitoneal fluid was identified on the focused abdominal assessment.

                    Discussion

                    Abdominal aortic aneurysm (AAA) is defined as a focal dilation of the abdominal aorta measuring ≥3.0 cm in maximal diameter or greater than 50% of the expected normal diameter. AAAs are most commonly infrarenal and fusiform in morphology, though saccular aneurysms—characterized by asymmetric outpouching—are less common and may be associated with higher rupture risk depending on etiology and size.

                    Point-of-care ultrasound (POCUS) is a highly effective, rapid, and noninvasive modality for the detection of AAA in the emergency department. Numerous studies have demonstrated that emergency physician–performed ultrasound has a sensitivity approaching 99% and specificity of approximately 98% for identifying AAA. This high diagnostic accuracy makes POCUS a first-line imaging tool, particularly in patients with atypical presentations, vague abdominal or chest symptoms, or when rapid risk stratification is required.

                    Importantly, AAA can present with nonspecific symptoms such as epigastric pain, back pain, or chest discomfort, and classic findings, such as hypotension or a palpable pulsatile mass, are often absent. Early identification using bedside ultrasound allows for prompt vascular surgery consultation and expedited confirmatory imaging, typically with CT angiography in hemodynamically stable patients.

                    Ultrasound evaluation focuses on identifying aneurysmal dilation, assessing morphology, and measuring maximal diameter. The presence of mural thrombus, commonly seen within AAAs, does not by itself indicate rupture but may be associated with embolic complications. While POCUS excels at identifying aneurysm presence and size, it has limitations: it cannot reliably assess suprarenal extension, branch vessel involvement, or small contained ruptures. Additionally, ultrasound is not sufficient to exclude acute aortic dissection or retroperitoneal hemorrhage, for which CT angiography remains the gold standard.

                    In this case, although the patient was hemodynamically stable and lacked classic symptoms of rupture, bedside ultrasound facilitated early recognition of significant aortic pathology that may have otherwise been delayed due to the nonspecific nature of his presentation.

                    Conclusion

                    This case underscores the critical role of point-of-care ultrasound in the emergency evaluation of patients with vague chest or abdominal symptoms and cardiovascular risk factors. Rapid bedside identification of an abdominal aortic aneurysm enabled early diagnosis, appropriate risk stratification, and timely specialty referral. POCUS remains an indispensable diagnostic adjunct in emergency medicine, particularly for the detection of life-threatening aortic pathology.

                    References

                    1. Tayal VS, Graf CD, Gibbs MA. Prospective Study of Accuracy and Outcome of Emergency Ultrasound for Abdominal Aortic Aneurysm. Acad Emerg Med. 2003;10(8):867–871. doi:10.1197/aemj.10.8.867
                    2. Society for Vascular Surgery. Practice Guidelines for the Management of Abdominal Aortic Aneurysms. J Vasc Surg. 2018;67(1):2–77. doi:10.1016/j.jvs.2017.10.044
                    3. Jang T, Docherty G, Aubin C, et al. Point-of-Care Ultrasound for the Detection of Abdominal Aortic Aneurysm in the Emergency Department. Ann Emerg Med. 2020;75(4):534–542. doi:10.1016/j.annemergmed.2019.09.002
                    4. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery Practice Guidelines on the Care of Patients with an Abdominal Aortic Aneurysm. J Vasc Surg. 2018;67(1S):2S–77S.e2. doi:10.1016/j.jvs.2017.10.044
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                    Case 60: A Stubborn Sore Throat: Insights through Ultrasound

                    Sneha Thandra, Anthony Medak

                    Case: A 19 year old female with a history of palpitations, shortness of breath, and syncope presents to the ED with throat pain with swelling for 3 weeks. The pain was noted to be bilateral, worsened with swallowing, but she was able to tolerate some oral intake. Patient had previously been seen on multiple occasions in ED/Urgent Care and had received dexamethasone without significant relief. She had not received antibiotics. Denied fevers or cough and had no PMH or known allergies. 

                    Vitals: BP 127/90 | Pulse 103 | Temp 98.2 °F (36.8 °C) | Resp 16 | Wt 58.1 kg (128 lb) | SpO2 100% 

                    On exam she is not in acute distress, her mucous membranes are moist. She phonates normally. There is slight peritonsillar fullness and an enlarged tonsil with notable tonsillar exudate on the right. No trismus or uvular deviation noted. The rest of her exam was normal.

                    Labs: WBC 22k

                    Images: Linear probe - Ultrasound Neck

                    Figure 1: Transcervical ultrasound of R peritonsillar abscess. Note highlighted hypoechoic material within parenchyma of tonsil.
                    Figure 2: Transcervical ultrasound of R peritonsillar abscess, with no flow evident on Doppler.
                    Video 1: Note the hypoechoic signal within the tonsil parenchyma.

                    ED Course: CT neck with contrast obtained revealed advancing tonsillitis with a right-sided tonsillar abscess. Abscess drainage attempted at bedside, but no purulence was obtained. The patient was given analgesic support (ketorolac and dexamethasone), IV fluids, and started on antibiotics (cefpodoxime and clindamycin). A referral to ENT was placed, and given that the patient was stable with no airway compromise, she was discharged with outpatient management.

                    Discussion: 

                    Peritonsillar abscesses (PTA) can form secondary to tonsillitis.

                    PTA is a common ED diagnosis (about 1 in 10,000 patients) that is a perfect application of point-of-care ultrasound (POCUS). Given the increased availability of POCUS in most ED/Urgent Care settings, the utility of a rapid and noninvasive imaging modality to evaluate for PTA can facilitate timely management, differentiate from cellulitis, and reduce the need for unnecessary CT imaging. This case illustrated the utility of POCUS in a 19 year old female with 3 weeks of persistent throat pain, where POCUS revealed an abnormal tonsil with a loculated anechoic fluid collection. Complications from PTA include airway obstruction, retropharyngeal abscess, among others. 

                    Although classic features of fever, sore throat, dysphagia, trismus, and “hot potato” voice can help with clinical diagnoses, overlapping features with other conditions including peritonsillar cellulitis, requires a tool with good sensitivity and specificity. Physical exam is noted to have a sensitivity and specificity of approximately 75% and 50%, respectively. However, a systematic review analyzing 18 studies from 1992 to 2021 that involved a total of 541 patients with PTA for a meta-analysis, found that POCUS has a sensitivity of about 74% and specificity of 79%. On subgroup analysis, although no significant difference was found between intraoral vs transcervical approaches (Figure 5), intraoral had a higher sensitivity (91% vs 80%) and transcervical had a higher specificity (81% vs 75%).1 Another study utilizing retrospective chart review found that POCUS reduced ED length of stay for patients: average of 160 minutes vs 293 minutes for patients where US was used compared to patients where US was not used. Specifically, after reviewing 58 charts, they found that 0% of patients diagnosed with ultrasound were admitted to the hospital, while 36.4% of patients where US was not used were admitted.2 

                    Beyond diagnosis, POCUS can assist in PTA treatment, improving aspiration outcomes. One study comparing US-guided versus non US-guided aspiration identified a success rate of 99% with POCUS and 80.3% without. In addition, ENT consultation rate was 12.9% with POCUS vs. 66% without POCUS use.3,4 Overall, POCUS offers advantages in evaluation of tonsillar cellulitis/PTA, while improving rates of successful aspiration, reducing unnecessary CT imaging, and thereby decreasing ED LOS. 

                    Figure 3: Demonstration of transoral (A) vs. transcervical (D) POCUS techniques. Panel B and E represent a normal tonsil. Panel C and F represent an abnormal tonsil with a loculated anechoic fluid collection. (*)indicates PTA, T indicates tonsil, S indicates submandibular gland (Kim et al., 2023).

                    References:  

                    1. Kim DJ, Burton JE, Hammad A, Sabhaney V, Freder J, Bone JN, Ahn JS. Test characteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta-analysis. Acad Emerg Med. 2023 Aug;30(8):859-869. doi: 10.1111/acem.14660. Epub 2023 Jan 30. PMID: 36625850.
                    2. Bryczkowski C, Haussner W, Rometti M, Wei G, Morrison D, Geria R, Mccoy JV. Impact of Bedside Ultrasound on Emergency Department Length of Stay and Admission in Patients With a Suspected Peritonsillar Abscess. Cureus. 2022 Dec 5;14(12):e32207. doi: 10.7759/cureus.32207. PMID: 36620852; PMCID: PMC9812542.
                    3. Gibbons RC, Costantino TG. Evidence-Based Medicine Improves the Emergent Management of Peritonsillar Abscesses Using Point-of-Care Ultrasound. J Emerg Med. 2020 Nov;59(5):693-698. doi: 10.1016/j.jemermed.2020.06.030. Epub 2020 Aug 19. PMID: 32826122.
                    4. Costantino TG, Satz WA, Dehnkamp W, Goett H. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg Med. 2012 Jun;19(6):626-31. doi: 10.1111/j.1553-2712.2012.01380.x. PMID: 22687177.
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                    Case 59: Abdominal and Pelvic Pain

                    Eli Tran, Elaine Yu

                    20YO female presented to the emergency department with 4-5 days of pelvic/abdominal pain, with abrupt worsening one day prior while resting. Her pain was sharp, sudden, and improved with ED analgesics. No dizziness, lightheadedness, or vaginal bleeding. LMP 4 weeks prior. She was not using birth control.

                    Exam: Vital signs were within normal limits. She appeared uncomfortable but non-toxic. She had pelvic and lower abdominal tenderness without guarding or rebound. No focal cardiopulmonary or neurologic abnormalities.

                    Labs

                    • WBC 14.6 to 18.7 with neutrophilia.
                    • Hgb 11.3
                    • hCG <1.
                    • Lactate 1.4.
                    • Coags normal.
                    • UA: SG 1.042, ketonuria, mild proteinuria; no hematuria.

                    Bedside pelvic ultrasound was performed with the following images:

                    Figure 1: Transabdominal ultrasound with free fluid in the pelvic region.

                    Figure 2: Transvaginal ultrasound with pelvic free fluid.

                    Figure 3: Transvaginal ultrasound with two cystic structures in the area of the left ovary.

                    ED Course

                    A formal pelvic ultrasound was ordered.

                    Figure 4: Pelvic free fluid with irregular cystic structure in area of left ovary consistent with a hemorrhagic cyst.

                    A CT scan of the abdomen and pelvis was ordered for concern of active hemorrhage. The CT showed showed a ruptured hemorrhagic ovarian cyst without active bleeding. There was also a finding of an absent left kidney with compensatory hypertrophy of the right kidney.

                    The patient remained hemodynamically stable and responded to analgesia. Her repeat hemoglobin after several hours was 12.4. Gynecology was consulted and recommended conservative management with 6-8 week follow-up.

                    The solitary kidney was an incidental finding unrelated to the current presentation. There was no hydronephrosis, obstruction, or infection. Renal function was preserved.

                    Discussion

                    The patient’s clinical picture and imaging are most consistent with a ruptured hemorrhagic ovarian cyst, a common cause of sudden pelvic pain with hemoperitoneum in reproductive-age women. Hemodynamic stability and absence of active bleeding support conservative management.

                    The incidentally detected solitary kidney is important to document but does not alter acute ED management. Most solitary kidneys identified incidentally in emergency imaging are congenital1-3 (unilateral renal agenesis or multicystic dysplastic kidney) or acquired (post-nephrectomy for tumor, trauma, or severe infection). Congenital solitary kidney accounts for the majority of incidental cases, often presenting with compensatory hypertrophy of the remaining kidney, as seen here.

                    Solitary kidney is associated with an increased long-term risk of CKD and hypertension, with some studies demonstrating >3-fold increased risk compared to individuals with two kidneys. The risk is highest in patients with vesicoureteral reflux or ureteropelvic junction obstruction, which occur in 17–48 percent of congenital cases. Cross-sectional imaging4-5 is generally sufficient for identifying and characterizing a solitary kidney; additional imaging (e.g., nuclear scintigraphy) is rarely required unless ectopic tissue or uncertain anatomy is suspected.

                    ED disposition: home with Gynecology and Nephrology follow-up

                    References

                    1. Kim S, Chang Y, Lee YR, et al. Solitary Kidney and Risk of Chronic Kidney Disease. Eur J Epidemiol. 2019;34(9):879-888.
                    2. Westland R, Schreuder MF, van Goudoever JB, et al. Clinical Implications of the Solitary Functioning Kidney. CJASN. 2014;9(5):978-986.
                    3. Urisarri A, Gil M, Mandiá N, et al. Risk Factors for CKD in Congenital Solitary Kidney. Medicine. 2018;97(32):e11819.
                    4. Krill A, Cubillos J, Gitlin J, Palmer LS. Abdominopelvic Ultrasound as a Diagnostic Tool for Solitary Kidney. J Urol. 2012;187:2201-2204.
                    5. Grabnar J, Rus RR. Is Renal Scintigraphy Necessary in Diagnosis of Congenital Solitary Kidney? Pediatr Surg Int. 2019;35:729-735.
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                    Case 58: Large Volume Paracentesis

                    Angela Wang, Benjamin Liotta

                    A 66-year old male with a longstanding history of alcoholic cirrhosis presents to the ED early in the morning requesting a paracentesis with 10 days of worsening abdominal distention in the setting of running out of his home furosemide several weeks prior. He denied fever, nausea, vomiting, or abdominal pain. 

                     Vitals:  BP 151/99, HR 101, RR 20, T 97.6F, SpO2 100% 

                    On exam, his abdomen was grossly distended with a positive fluid wave and no peritoneal signs. His last paracentesis was done 2 weeks prior with 10L of fluid removed. IR was consulted but would not have availability until late afternoon, and after discussion with the patient, a paracentesis was performed in the ED. Ultrasound was used to visualize the fluid pocket and patient anatomy, to minimize risk to the patient. 

                    Figure 1: Perihepatic view. Cirrhotic, nodular liver and visible Morison’s pouch. The pocket of ascitic fluid visualized is approximately 5cm deep 

                    Figure 2: Transverse pelvic view, hyperechoic bowel loops can be visualized, as well as a 8-10 cm deep fluid pocket 

                    Figure 3: Limited left upper quadrant view. While the splenorenal space can be visualized, the perisplenic space, where ascites tends to preferentially accumulate (over the splenorenal space), cannot be seen in this image. 

                    Therapeutic and diagnostic paracentesis for ascites is commonly performed in the ED. The most common etiology for ascites is alcoholic cirrhosis, which makes up 80% of cases in western countries¹. Other causes include malignancy and heart failure¹. Prior to widespread use of ultrasound for routine bedside exams, paracenteses in the ED were commonly performed based on landmarks and could be associated with complications such as bleeding and damage to surrounding structures. A 2005 clinical trial showed the benefits of using ultrasound to guide needle placement during this procedure, with the authors finding a 95% success rate (defined by fluid aspiration) when ultrasound was used compared to a 68% success rate with the traditional technique⁵. A 2013 article also found that the use of ultrasound in paracenteses was associated with a 68% decrease in bleeding-related complications compared to the traditional technique⁴. 

                    A 2019 position statement by the Society of Hospital Medicine establishes recommendations for effective use of ultrasound to guide paracentesis. Ultrasound allows both identification of more superficial blood vessels to avoid with needle insertion as well as visualization of the peritoneal cavity to survey the anatomy and qualitatively and quantitatively describe any fluid within. Damage to abdominal wall vessels such as the inferior epigastric artery or vein can cause catastrophic bleeding, morbidity, and mortality². Identification of these vessels with color doppler prevents inadvertent vessel wall injury. As the ultrasound beam is only several millimeters wide, it is important to obtain views of multiple angles of the needle insertion site to ensure there are no vessels or underlying structures along the path of the needle².

                    Ascitic fluid is hypoechoic, while bowel is often hyperechoic due to bowel gas. Organs may be more heterogenous and of intermediate echogenicity³. Ultrasound can also be used to assess the fluid pocket itself. For example, a fluid depth of 2cm is recommended for procedural safety³. Ultrasound is more sensitive than x-ray to fluid as it is able to detect as little as 100 ml of fluid, compared to 500 ml for x-ray². Presence of heterogeneity within the fluid pocket can be suggestive of loculations, which may indicate a more likely malignant or inflammatory cause of ascites. 

                    The 66-year-old patient above had an uncomplicated paracentesis with needle placement in the left lower quadrant, and over 8 liters of fluid were removed from his abdomen. He tolerated it well and was discharged from the ED shortly after with follow-up with his PCP as well as a recommendation for regularly scheduled paracenteses with radiology. 

                    References:

                    1. AGA Clinical Practice Update on the Management of Ascites, Volume Overload, and Hyponatremia in Cirrhosis: Expert Review Orman, Eric S. et al. Gastroenterology, Volume 169, Issue 7, 1547 - 1557 

                    2. Cho J, Jensen TP, Reierson K, Mathews BK, Bhagra A, Franco-Sadud R, Grikis L, Mader M, Dancel R, Lucas BP; Society of Hospital Medicine Point-of-care Ultrasound Task Force; Soni NJ. Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019 Jan 2;14:E7-E15. doi: 10.12788/jhm.3095. PMID: 30604780; PMCID: PMC8021127. 

                    3. Kumar A, Dancel R, Galen BT et al. Ultrasound Guidance for Paracentesis. N Engl J Med. 2022;386(7):e15. doi:10.1056/NEJMvcm2119156 

                    4. Mercaldi CJ, Lanes SF, Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. (2013). Chest, 143(4), 1010–1015. https://doi.org/10.1378/chest.12-0447 

                    5. Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study. Am J Emerg Med. 2005 May;23(3):363-7. doi: 10.1016/j.ajem.2004.11.001. PMID: 15915415. 

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                    Case 57: Positional Vertigo in the ED With Incidental Interatrial Shunt on Bubble Study

                    Carmon Controy, Akash Desai

                    44 y.o. male, brought by EMS from an outpatient procedure suite after sudden onset vertigo and gait instability following a right TMJ/ CNIII V3 injection. Patient experienced abrupt dizziness described as imbalance with ataxic gait, nausea, and one episode of emesis. The symptoms worsen with head movement/position change and improve at rest. No focal weakness, speech change, or headache reported. 

                    Pertinent PMHx: HIV on ART; cognitive impairment on donepezil/memantine; lumbar stenosis s/p L5–S1 decompression. Prior episodes concerning for TIAs/CVAs. 

                    Pertinent FHx: Patient states his father had a “hereditary hole in his heart” which was an incidental finding in his adult life, corrected with surgery.  

                    Vitals on Arrival: BP 146/88, HR 91, RR 16, SpO₂ 98% RA, afebrile 

                    Physical Examination:

                    • General: No distress. 
                    • Neuro: Alert/oriented; cranial nerves grossly intact; strength/sensation intact; left-beating nystagmus noted initially; abnormal ataxic gait on arrival. 
                    • Cardiopulmonary/Abdomen: Unremarkable. 

                    ED Imaging and Tests:

                    • CT/CTA Head & Neck (stroke protocol): No hemorrhage, large territorial infarct, LVO, or significant stenosis. 
                    • MRI Brain (DWI): “Questionable subtle punctate” diffusion restriction in the left thalamocapsular region—artifact favored; tiny acute ischemic focus possible. No hemorrhage or mass effect. 
                    • Neurology Consult: Vertigo most consistent with peripheral cause (positional trigger, brief episodes, improvement). HINTS/Dix-Hallpike negative when re-examined after symptom improvement. 
                    • Labs: CBC/BMP/coags unremarkable. 
                    • Cardiac Ultrasound: Transthoracic Echo with Agitated Saline (Bubble Study)
                      • Normal LV size and EF ~54%; mild concentric LVH; normal RV size/function; no significant valvular disease. 
                      • Bubble study positive: At rest, microbubbles appeared after 6–7 cardiac cycles; with Valsalva, a large, uncountable shower of bubbles traversed to the left heart—consistent with an interatrial shunt (e.g., PFO/ASD).

                    ED Course

                    Symptomatic therapy was provided (e.g., meclizine). Neurological symptoms improved during observation. Neurology judged low suspicion for central vertigo; recommended Epley if recurrent and discharge if symptoms resolved. Comprehensive stroke labs and imaging obtained. TTE with bubble study was positive for interatrial shunt as above, prompting recommendation for outpatient follow-up (stroke clinic/cardiology) to risk-stratify and discuss closure versus medical management in the context of prior suspected cerebrovascular events. 

                    Clinical course and neurology consultant assessment favored positional peripheral vertigo (likely posterior canal BPPV precipitated by head positioning during the OP nerve block procedure) over central causes; neuroimaging was equivocal for a tiny thalamocapsular DWI focus. However, the positive bubble study establishes an interatrial right-to-left shunt, providing a plausible pathway for paradoxical embolism. In a patient with a reported history of likely TIAs/CVAs (including possible TIA at the time of current evaluation), this finding heightens stroke risk considerations and may influence long-term secondary prevention (antithrombotic strategy) and candidacy for shunt closure after more thorough outpatient stroke-neurology/cardiology evaluation. 

                    Discussion 

                    This presentation is most consistent with peripheral, positional vertigo; the positive agitated-saline study is therefore best viewed as incidental to today’s symptoms.¹,² That said, a PFO is common (~20–25% of adults) and provides a plausible conduit for paradoxical embolism (especially when shunting becomes prominent with Valsalva), so its relevance is probabilistic and depends on clinical context rather than timing alone.³,² Frameworks like the Risk of Paraxodical Embolism (RoPE) score weigh age, event phenotype, and vascular risk factors to estimate whether a PFO is likely pathogenic versus incidental.⁴,⁵ Larger shunt burden and high-risk anatomy (e.g., atrial septal aneurysm) increase suspicion, while alternative mechanisms (occult AF, atherosclerosis, dissection, thrombophilia) must be assessed in parallel.⁶,⁵ 

                    For secondary cerebrovascular prevention, guideline-concordant work-up (e.g., rhythm monitoring for AF; targeted DVT evaluation; selective hypercoagulability testing) should inform therapy.⁷,⁶ In carefully selected patients 18–60 with a recent non-lacunar ischemic stroke of undetermined cause and a high-risk PFO, randomized trials (RESPECT long-term, CLOSE, REDUCE) show reduced recurrent stroke with percutaneous closure plus antiplatelet therapy compared with antiplatelet therapy alone, albeit with a small increase in atrial arrhythmias;⁸,⁹,¹⁰,¹¹ outside these criteria, optimized medical therapy is appropriate and decisions should be shared between stroke neurology and cardiology.⁶ Bottom line: (1) the PFO is likely incidental to this vertigo episode; (2) given prior TIAs/CVAs without a clear alternative mechanism, the PFO may have contributed to earlier events; and (3) the finding warrants formal risk stratification and guideline-based discussion of closure vs. medical therapy.⁴,⁵,⁶ 

                    References

                    1. Collins S, Guntheroth WG, Raghu G, et al. Agitated saline contrast echocardiography: Contraindications, complications, and safety. J Am Soc Echocardiogr. 2022;35(1):13-21. doi:10.1016/j.echo.2021.10.016 
                    1. Abdelmoneim SS, Mulvagh SL, Porter TR, et al. The clinical applications of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography guidelines update. J Am Soc Echocardiogr. 2018;31(3):241-274. doi:10.1016/j.echo.2017.11.013 
                    1. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59(1):17-20. doi:10.1016/S0025-6196(12)60336-X 
                    1. Kent DM, Ruthazer R, Weimar C, et al. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Ann Intern Med. 2013;158(5):285-292. doi:10.7326/0003-4819-158-5-201303050-00004 
                    1. Kent DM, Dahabreh IJ, Ruthazer R, et al. Device closure of patent foramen ovale in patients with cryptogenic stroke: RoPE-estimated attributable fraction and treatment effect. Stroke. 2020;51(7):2143-2150. doi:10.1161/STROKEAHA.119.028966 
                    1. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2021;52(7):e364-e467. doi:10.1161/STR.0000000000000375 
                    1. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236. doi:10.1161/STR.0000000000000024 
                    1. Saver JL, Mattle HP, Thaler DE. Patent foramen ovale closure versus medical therapy for cryptogenic ischemic stroke: a topical review. Stroke. 2018;49(6):1541-1548. doi:10.1161/STROKEAHA.117.018153 
                    1. Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med. 2017;377(11):1022-1032. doi:10.1056/NEJMoa1610057 
                    1. Mas J-L, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelet therapy after stroke (CLOSE). N Engl J Med. 2017;377(11):1011-1021. doi:10.1056/NEJMoa1705915 
                    1. Søndergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke (REDUCE). N Engl J Med. 2017;377(11):1033-1042. doi:10.1056/NEJMoa1707404 
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                    Case 56: Udderly Blinded: A Case of Chronic Ocular Trauma Unmasked by POCUS

                    Martin Day, Elaine Yu

                    A 69-year-old male with no significant past medical history presented to the emergency department after striking his right eye with the handle of a spray hose at work. He reported burning pain but denied bleeding, tearing, or other injuries. Eye movement did not exacerbate the pain. Notably, he had been chronically blind in the right eye since childhood after sustaining blunt ocular trauma from being kicked by a cow around age 12. He described no perception of light in that eye since then.

                    Vitals: BP 138/83 | Pulse 85 | Temp 98.4F (36.9C) | Resp 17 | SpO2 98%

                    Physical Exam:

                    On physical examination, the patient was alert and cooperative, not in acute distress. The right eye did not demonstrate periorbital ecchymosis or signs of obvious trauma. There was negative fluorescein uptake, extraocular movements intact, and pupil fixed. He had no light perception. His left eye was normal on examination.

                    A bedside ocular ultrasound was performed:

                    Figure 1. Bi-convex lens with hyperechoic but irregular borders.

                    Figure 2. Ocular ultrasound depicting hyperechoic debris within the posterior chamber and vitreous hemorrhage, represented as materials of varying echogenicity within the vitreous body.

                    ED Course

                    Pain was treated conservatively with topical anesthetics and fluorescein for exam. Patient did not require any acute intervention. He was reassured, educated on return precautions, and discharged in stable condition.

                    Discussion

                    Blunt ocular trauma can cause profound and often irreversible injury. In this patient, a cow kick to the eye at age 12 resulted in permanent blindness. Decades later, a new minor injury prompted re-evaluation, but his underlying chronic pathology was the dominant finding.

                    Despite an apparently benign surface exam—negative fluorescein, intact EOMI, no external trauma—ultrasound revealed chronic posterior segment pathology: vitreous detachment, hemorrhage, and irregular lens, consistent with his long-standing blindness. Notably, POCUS excluded emergent findings such as global rupture or retinal detachment.

                    The American College of Emergency Physicians recommends POCUS for assessing the posterior segment of the eye. Multicenter trials and meta-analyses convey high sensitivity and specificity for retinal detachment (96.9% sensitivity, 88.1% specificity), moderate diagnostic accuracy for vitreous hemorrhage (81.6% sensitivity, 82.3% specificity), and lower sensitivity (42.5%) but high specificity (96.0%) for vitreous detachment [1,2,3,5]. Additionally, POCUS was 100% sensitive and 97% specific for lens dislocation, and 100% sensitive and 99% specific for intraocular foreign body according to another meta-analysis [1,5].

                    Vitreous hemorrhage appears on ocular ultrasound as a fluid collection of variable echogenicity within the posterior chamber of the globe. The hemorrhagic material typically is mobile, shifting as the patient moves their eye while the probe remains still [2]. In chronic cases, fibrotic changes may cause the echogenic fluid collection to appear denser and more organized [1,2]. Vitreous detachment appears as a mobile, hyperechoic membrane in the posterior chamber, like vitreous hemorrhage, during kinetic examination [3]. Retinal detachment can be differentiated from vitreous detachment because it appears more echoic and anchored to the optic disc, which was not appreciated in this case [2,3]. The lens on ocular ultrasound may appear irregular in its position or contour [3]. This patient’s lens appeared typically centered behind the iris without evidence of dislocation. However, the margins were poorly defined, with irregular, asymmetric borders, suggestive of a lens irregularity [3,6].

                    In emergency medicine, ocular ultrasound offers a quick and effective means of evaluating both acute injuries and chronic sequelae. This case highlights the value of ultrasound in diagnosing both acute and chronic ocular pathology. It allows rapid, non-invasive assessment of posterior structures even when vision is absent or the anterior exam appears normal. A visit to the ED for a minor workplace incident uncovered sequela of a childhood injury. Additionally, clinical judgment helped guide diagnosis. With no suspicion of intraocular foreign body or orbital fracture, CT was deemed unnecessary. Ultrasound was sufficient to distinguish chronic from acute findings.  POCUS may be especially useful for assessing unreliable historians. POCUS does not replace the comprehensive ophthalmologic evaluation [4]. Nonetheless, it serves as a crucial tool for rapid bedside assessment for urgent intervention [4].

                    References

                    1. American College of Emergency Physicians. Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Irving, TX: American College of Emergency Physicians; 2023.
                    2. Lahham S, Shniter I, Thompson M, et al. Point-of-care ultrasonography in the diagnosis of retinal detachment, vitreous hemorrhage, and vitreous detachment in the emergency department. JAMA Netw Open. 2019;2(4):e192162. doi:10.1001/jamanetworkopen.2019.2162
                    3. Pyle M, Gallerani C, Weston C, Frasure SE, Pourmand A. Point of care ultrasound and ocular injuries: a case of lens dislocation and a comprehensive review of the literature. J Clin Ultrasound. 2021;49(3):282-285. doi:10.1002/jcu.22904
                    4. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002;9(8):791-799. doi:10.1111/j.1553-2712.2002.tb02166.x
                    5. Propst SL, Kirschner JM, Strachan CC, et al. Ocular point-of-care ultrasonography to diagnose posterior chamber abnormalities: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(2):e1921460. doi:10.1001/jamanetworkopen.2019.21460
                    6. Özdal M, Mansour M, Deschênes J. Ultrasound biomicroscopic evaluation of the traumatized eyes. Eye (Lond). 2003;17(4):467-472. doi:10.1038/sj.eye.6700382
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