Author: UCSD Ultrasound

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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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Case 55: Diagnosing Posterior Ocular Chamber Abnormalities with Point-of-Care Ultrasound

Kevin Vo, MD; Rachna Subramony, MD

Case Presentation:
A 31-year-old male with no significant past medical history presented to the Emergency Department with bilateral blurry vision, left greater than right. He had been evaluated earlier that day by an optometrist and referred for concern of retinal detachment. The patient reported flashes and floaters of uncertain duration but denied eye pain, discharge, foreign body sensation, headache, or trauma.

Vital Signs: BP 132/77 mmHg | HR 60 bpm | Temp 97.3°F | RR 16 | SpO₂ 99%

Physical Examination:
The patient was in no acute distress. Ocular exam revealed mild conjunctival injection bilaterally. Intraocular pressures were 17 mmHg OS and 13 mmHg OD. Fluorescein exam showed no corneal uptake. Neurologic exam was normal; the patient was alert and oriented ×3 without focal deficits. The patient reported a superior visual field deficit in the left eye.

A bedside ultrasound was performed.

Figure 1 (video) : Echogenic detached membrane visualized in the posterior chamber of the left eye

Figure 2 (video): Detachment tethered to the optic nerve.

Discussion: 

Point-of-care ultrasound (POCUS) is a valuable adjunct for emergency physicians in evaluating posterior ocular abnormalities. While anterior and external ocular conditions can often be diagnosed through history and physical examination, posterior chamber visualization is frequently limited in the emergency department due to the lack of specialized ophthalmic equipment and suboptimal exam conditions.

POCUS offers a noninvasive, rapid, and radiation-free imaging modality that can enhance diagnostic accuracy in the acute care setting. Meta-analyses and prospective studies have demonstrated POCUS sensitivity of 94–97% and specificity of 88–96% for detecting retinal detachment1,2,3. Given this high sensitivity, POCUS can serve as an effective rule-out tool when used in conjunction with ophthalmologic evaluation.

Retinal detachment typically appears as an echogenic, undulating membrane tethered to the optic nerve, a finding considered diagnostic in multiple studies.1,5 In this case, the optic nerve was difficult to visualize in the same plane as the detached membrane, making it challenging to definitively distinguish retinal from posterior vitreous detachment (Figure 2). However, given the patient’s corresponding visual field deficits and characteristic sonographic findings, the likelihood of retinal detachment remained high.

The use of POCUS for diagnosing vitreous detachment differs from its performance for retinal detachment. In one prospective study, sensitivity and specificity were 42.5% and 96% respectively.3 Another meta-analysis showed POCUS’s sensitivity to be 67% and specificity to be 90%. For other posterior eye pathologies, such as lens dislocation, foreign body, and globe rupture, sensitivity and specificity were high.1 The application of POCUS in this case was more suited for determining the presence of a retinal detachment and guiding the subsequent steps in management and further ophthalmologic assessment. The presence of vitreous detachment is difficult to rule out with the use of ultrasound alone. 

Conclusion:
This case demonstrates POCUS’s utility as an adjunct to ophthalmologic examination in the evaluation of posterior ocular pathology. Retinal detachment, which typically requires more urgent intervention than posterior vitreous detachment, can be rapidly identified using POCUS in the emergency setting. In this case, ophthalmology was consulted, and the patient subsequently underwent a left eye vitrectomy with perfluoro-octane (PFO) tamponade for treatment of his retinal detachment.

References: 

1.Propst SL, Kirschner JM, Strachan CC, et al. Ocular Point-of-Care Ultrasonography to Diagnose Posterior Chamber Abnormalities. JAMA Network Open. 2020;3(2):e1921460. doi:https://doi.org/10.1001/jamanetworkopen.2019.21460 

2.Gottlieb M, Holladay D, Peksa GD. Point‐of‐Care Ocular Ultrasound for the Diagnosis of Retinal Detachment: A Systematic Review and Meta‐Analysis. Carpenter CR, ed. Academic Emergency Medicine. 2019;26(8):931-939. doi:https://doi.org/10.1111/acem.13682 

3.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 Network Open. 2019;2(4). doi:https://doi.org/10.1001/jamanetworkopen.2019.2162 

4.Ocular Ultrasound Made Easy: Step-By-Step Guide - POCUS 101. POCUS 101. Published 2018. Accessed August 4, 2025. https://www.pocus101.com/ocular-ultrasound-made-easy-step-by-step-guide/#Posterior_Vitreou s_Detachment_PVD 

5.Kim DJ, Francispragasam M, Docherty G, et al. Test Characteristics of Point‐of‐care Ultrasound for the Diagnosis of Retinal Detachment in the Emergency Department. Theodoro DL, ed. Academic Emergency Medicine. Published online December 17, 2018. doi:https://doi.org/10.1111/acem.13454

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Case 54: Point-of-Care Ultrasound in Polycystic Kidney Disease with Hepatic Involvement

EJ Curtis, Colleen Sweeney, Colleen Campbell

A 70-year-old man with a past medical history of hypertension, obstructive hypertrophic cardiomyopathy, atrial fibrillation status-post Watchman procedure, and end-stage renal disease secondary to polycystic kidney disease (status-post renal transplant in 2014, complicated by chronic kidney disease stage 5 of the transplanted kidney) was brought to the emergency department after being found on the floor by his daughter. On arrival, the patient had generalized weakness, lightheadedness, and epigastric pain.

Vital signs: BP: 77/60 mmHg | HR: 103 | RR: 20 | T 37.3C

On physical exam, the patient appeared chronically ill and had scattered ecchymoses on bilateral upper extremities which he attributed to the recent fall. He also had bilateral lower extremity pitting edema which he says is stable since stopping furosemide. His abdomen was tender to palpation in the epigastric region with no rebound or guarding.

A bedside ultrasound was performed to evaluate for the source of abdominal pain.

Figure 1. Hepatorenal Junction

Figure 2. Splenorenal Junction

Figure 3. Multi-cystic liver parenchyma

Discussion:

Blood cultures grew out pseudomonas aeriginosa.  Patients with PKD can get septic from infected cysts however the source of his infection was not clear.

Polycystic kidney disease (PKD) is the most common inherited cause of end stage renal disease (ESRD) with the most common form, Autosomal Dominant PKD (ADPKD) affecting around 500,000 people in the United States and between 1 in 400 to 1 in 1000 births1. ADPKD is a progressive, multisystem disease associated with extrarenal manifestations of disease most associated with cysts in other organs such as the liver, seminal vesicle, and pancreas though connective tissue disorders including mitral valve prolapse, intracranial aneurysms, and abdominal hernias are also commonly reported2. Transplant of kidney is usually more successful after nephrectomy of native kidneys, with 1 year survival >90% and median survival of 18.7 years.

Polycystic liver disease (PLD), the most common extrarenal manifestation of PKD, is characterized by the presence of cysts in greater than 50 percent of the liver3. Between 75 and 90 percent of patients with ADPKD have associate PLD4. Notably, there is an inherited form of PLD, which is distinct from PKD but it is less common than PKD and is rarely associated with concurrent renal cysts 5.

The presence of innumerable hepatic cysts, as demonstrated in this case, provides a valuable sonographic teaching example for learners. It is critical to recognize that while renal disease is the primary driver of morbidity and mortality in ADPKD, extrarenal manifestations such as polycystic liver disease, intracranial aneurysms, and cardiac valvular disease are important contributors to patient outcomes and should be monitored and included as part of the differential diagnoses when these patients present to the emergency department. 

References:

  1. Mahboob M, Rout P, Leslie SW, Bokhari SR. Autosomal Dominant Polycystic Kidney Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. Updated March 20, 2024. Available from: NCBI Bookshelf 
  2. Pirson Y. Extrarenal manifestations of autosomal dominant polycystic kidney disease. Adv Chronic Kidney Dis. 2010 Mar;17(2):173–80. doi:10.1053/j.ackd.2010.01.003 
  3. Henriques MSM, Villar EJM. Chapter 17: The Liver and Polycystic Kidney Disease. In: Li X, editor. Polycystic Kidney Disease [Internet]. Brisbane (AU): Codon Publications; Nov 2015. doi:10.15586/codon.pkd.2015.ch17 
  4. Harris PC, Torres VE. Polycystic kidney disease. Annu Rev Med. 2009;60:321–37. doi:10.1146/annurev.med.60.101707.125712 
  5. Cnossen WR, Drenth JPH. Polycystic liver disease: an overview of pathogenesis, clinical manifestations and management. Orphanet J Rare Dis. 2014 May 1;9:69. doi:10.1186/1750-1172-9-69 
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Case 53: Forgo the CT Scan: Utilization of Ultrasound In Conjunction With Clinical Tools In Diagnosing Acute Appendicitis

Jeremy Santiago, Anthony Medak

77-year-old female with a past medical history of diabetes mellitus and rheumatoid arthritis presented to the emergency department with 2 days of abdominal pain. Pt reports that she began feeling abdominal pain diffusely that has now moved to RLQ. States pain was worsened with movement, and she tried taking Pepto Bismol and Tylenol at home with no relief. She feels like her appetite has decreased due to the pain. She denies urinary symptoms, changes in bowel movements, nausea/vomiting, cough, fever, chills, chest pain, or back pain. Patient endorses she is currently taking methotrexate for her RA. Surgical hx notable for prior salpingo-oophorectomy and hysterectomy.

Vitals: BP 132/58 | Pulse 79 | Temp 98.4 °F (36.9 °C) | Resp 16 | Wt 52.2 kg (115 lb) | SpO2 100% | BMI 19.14 kg/m²

Physical Exam:

On physical examination the patient was alert and nontoxic appearing without any evidence of acute distress. The abdomen was soft, flat, and non-distended with tenderness to palpation in the RUQ and RLQ. There was no guarding, rebound tenderness, or evidence of peritoneal signs. There was positive McBurney point tenderness on exam, with a negative Murphy’s sign and Rovsing’s sign.

Labs: WBC 13.6, Lipase 9, U/A negative, CMP unremarkable.

Based on the history, physical examination, and labs, the Modified Alvarado score was 7, indicating probable/likely appendicitis. A focused bedside ultrasound examination of the RUQ and RLQ were conducted utilizing the curvilinear transducer.

Figure 1. Two separate dilated segments of the appendix were appreciated with periappendiceal fluid. A hyperechoic structure is noted within the lumen without shadowing concerning for possible appendicolith.

Figure 2. A longitudinal dilated segment of the appendix is visible with periappendiceal fluid.

Figure 3. CT abdomen and pelvis with contrast in axial and coronal views demonstrate acute appendicitis with a measured diameter of 9mm and associated fat stranding/periappendiceal fluid.

Discussion

Acute appendicitis is one of the most prevalent abdominal surgical emergencies worldwide with over 300,000 hospital visits reported annually within the U.S. alone [4,5]. Appendicitis is often a delayed or missed diagnosis, and one of the most common malpractice cases that Emergency Physicians face [2]. For many providers, the diagnostic accuracy of CT imaging, ability to detect other acute causes, and the fear of missing appendicitis are the reasons many providers opt for CT imaging in the workup of acute abdominal pain. Appendicitis can be characterized as uncomplicated or complicated based on presence of perforation, abscess, or necrosis in addition to histological findings. Management of acute appendicitis generally consists of medical, surgical, or combined modalities [4,5]. Although many institutions and societies have recommendations and guidelines for managing acute appendicitis with antibiotics alone, an appendectomy is the only definitive management, and patients often warrant prompt surgical evaluation.

The diagnosis of appendicitis is typically made utilizing clinical examination, laboratory markers, and imaging. Common symptoms include initial vague abdominal pain that localizes to the RLQ, anorexia, nausea with or without vomiting, diarrhea, and fever. Given the location of pain and non-specific symptoms associated with acute appendicitis, a broad differential diagnosis and additional workup should be considered [4,5,7].  CT imaging is considered the gold standard by The American College of Radiology and the most often preferred imaging modality by surgeons with an accuracy > 95%, (Sensitivity 91-96%, Specificity 90-95%) when compared to abdominal ultrasound (Sensitivity 78%, Specificity 83%) [5].  Ultrasound findings of acute appendicitis include appendiceal diameter >6mm, presence of appendicolith, increased periappendiceal fat stranding, and lack of appendix compressibility [4]. Risk stratifying tools such as the Modified Alvarado Score (MAS) can also be used to determine the likelihood of acute appendicitis without further imaging, with reported sensitivity and specificity up to 95% and 90% respectively, utilizing a cut off score of 7 [3,6,7].

Several studies have looked at the combination of MAS with abdominal ultrasound and demonstrated an increased sensitivity and diagnostic accuracy of acute appendicitis when utilized together. The combination of these two clinical tools to rule in appendicitis may save time, avoid unnecessary radiation, and subsequently reduce complication rates or negative appendectomies [1,3,6,7]. In the case of this patient, her clinical presentation and exam were consistent with acute appendicitis (MAS of 7). Bedside POCUS was notable for a dilated appendix with periappendiceal fluid and a possible appendicolith concerning for acute appendicitis. The positive POCUS findings in addition to MAS ≥ 7 made acute appendicitis very likely and her diagnosis was later verified on abdominal CT imaging.  Her negative urinalysis and prior history of total hysterectomy made genitourinary sources of symptoms less likely, thus blunting the alternative diagnostic benefits of CT imaging. She underwent an appendectomy and had confirmed acute appendicitis and periappendicitis with abscess formation on pathology. No appendicolith was identified on imaging or pathology however, despite our POCUS findings.

As POCUS availability and experience becomes more common amongst Emergency Medicine providers, the use of abdominal ultrasound in conjunction with risk stratifying tools such as the Modified Alvarado Score may be beneficial to rule-in acute appendicitis in uncomplicated patients for whom you have a high clinical suspicion. These tools may be especially useful in resource- limited settings or when obtaining CT imaging may significantly delay patient care.

References

  1. Al-wageeh, S., Alyhari, Q. A., Ahmed, F., Altam, A., Alshehari, G., & Badheeb, M. (2024). Evaluating the Diagnostic Accuracy of the Alvarado Score and Abdominal Ultrasound for Acute Appendicitis: A Retrospective Single-Center Study. Open Access Emergency Medicine, 16, 159–166. https://doi.org/10.2147/OAEM.S462013
  2. Chaudhary, Snehansh Roy, and Shambo Guha Roy. "The Diagnostic Uncertainties and Legal Precedents in Appendicitis Malpractice." Academic Radiology (2025).
  3. Kanumba ES, Mabula JB, Rambau P, Chalya PL. Modified Alvarado Scoring System as a diagnostic tool for acute appendicitis at Bugando Medical Centre, Mwanza, Tanzania. BMC Surg. 2011 Feb 17;11:4. doi: 10.1186/1471-2482-11-4. PMID: 21329493; PMCID: PMC3050681.
  4. Lotfollahzadeh S, Lopez RA, Deppen JG. Appendicitis. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493193/
  5. Moris D, Paulson EK, Pappas TN. Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA. 2021;326(22):2299–2311. doi:10.1001/jama.2021.20502
  6. Nasiri, S., Mohebbi, F., Sodagari, N. et al. Diagnostic values of ultrasound and the Modified Alvarado Scoring System in acute appendicitis. Int J Emerg Med 5, 26 (2012). https://doi.org/10.1186/1865-1380-5-26
  7. Sirpaili, Santosh MSa; Rajthala, Lilamani MSa; Banmala, Sabin MBBSb; Gautam, Pratima MSa; Ranabhat, Sangita MSa; Ghatani, Sangita Raj BScc; Shrestha, Eruka Bachelor in Nursingd. Efficacy of modified Alvarado score combined with ultrasound in the diagnosis of acute appendicitis: a prospective analytical study. Annals of Medicine & Surgery 86(5):p 2586-2590, May 2024. | DOI: 10.1097/MS9.0000000000001932
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Case 52: The Role of FAST in Penetrating Thoracoabdominal Injury

Brandon Woo, Elaine Yu

A 28 year old male with unknown past medical history presented to the emergency department with a single gunshot wound sustained to the anterior chest just prior to arrival. He was brought in by family members who reported a witnessed traumatic gunshot wound to the chest by an unreported individual. The patient complained of trouble breathing and was severely agitated in the setting of pain. He required 75 mg IV ketamine for moderate sedation while obtaining vital signs, ultrasound, and intravenous access. The team prepared for urgent intubation in the setting of possible respiratory decompensation and activated massive transfusion protocol.

Vitals: BP 151/81 | Pulse 104 | Temp 97.8º F (36.6ºC) | Resp 27 | Wt 122.2 kg (269 lb 6.4 oz) | SpO2 93%

On physical exam, the patient was in acute distress and diaphoretic, reporting trouble breathing but speaking in full sentences. He was alert and oriented to person, place, and event. Primary trauma assessment: patent airway, rapid shallow breathing, and capillary refill less than 2 seconds. Secondary survey revealed an approximately 1 cm open wound with active bleeding to the subxiphoid region. There were no step-offs or deformities to the spine and no other obvious signs of trauma externally. There were equal breath sounds, and 2+ pulses were present in the radial and posterior tibialis arteries. The remainder of the exam was unremarkable.

A FAST exam was performed to evaluate for free fluid, hemothorax, or pericardial effusion.

Figure 1: Subxiphoid view

Figure 2: RUQ view

Figure 3: LUQ view

Figure 4: Pelvic view (transverse).

Figure 5: Pelvic view (longitudinal).

Figure 6: Chest X-Ray

Discussion:

The extended Focused Assessment with Sonography for Trauma (eFAST) is a validated rapid, bedside trauma tool, classically validated in hemodynamically unstable patients with blunt trauma where delays in imaging may be fatal. However its use in penetrating trauma is situational. The sensitivity of ultrasound is significantly lower for bowel injury, retroperitoneal bleeding, and intra-abdominal bleeding [1]. This patient was hemodynamically stable, which typically decreases the urgency for bedside ultrasound. However the patient’s agitation, tachypnea, and uncertain injury trajectory of a subxiphoid entry wound made thoracic and abdominal evaluation critical.

The presence of pelvic free fluid (Figures 4,5) and tachycardia with hyperdynamic ventricles (Figure 1) raised concern for intra-abdominal injury and potential hemorrhage. The location of free fluid in a supine trauma patient is influenced by gravity, with the rectovesical or rectouterine pouch being common sites of accumulation [1]. This patient had been upright prior to arrival and was agitated and repositioned multiple times, raising the possibility that the visualized pelvic fluid was gravitational rather than an isolated pelvic organ injury.

Figure 7: Abdominal X-ray.

Free fluid was visualized only in the suprapubic view, which may be due to localized pelvic injury, supported by the bullet location on KUB (Figure 7), or redistributed by gravity from another source, given that the patient had been upright and repositioned prior to evaluation. The absence of fluid in the right or left upper quadrants does not exclude intra-abdominal hemorrhage, particularly in the setting of penetrating trauma, where eFAST sensitivity varies significantly by region and injury type [1,2].  Retroperitoneal bleeding or bowel injury are often missed with eFAST alone, both possibilities in this case.

A meta analysis of over 24,000 trauma patients demonstrated eFAST sensitivity and specificity, respectively, for intra-abdominal free fluid (74%, 98%), pericardial effusion (91%, 94%), pneumothorax (69%, 99%) [2]. In the suprapubic view, sensitivity ranges from 80 - 90%, with specificity ~ 99%, and detection thresholds as low as 100 - 150 mL [2]. The RUQ view, Morison’s pouch, has a sensitivity 85 - 96% and specificity 98%, but typically requires at least 200 mL of fluid for reliable detection [2]. The LUQ view, splenodiaphragmatic space, demonstrates sensitivity 70 - 85% with specificity 98 - 99% [2]. These ranges reflect variations in body habitus, fluid pooling, and operator dependency. These views are widely taught per guidance of the ACEP Sonoguide [5].

A randomized controlled trial found that while FAST did not reduce mortality, it significantly improved workflow and led to a faster time to diagnosis, fewer CT scans, shorter hospital stays, and lower costs [3]. Additional studies have shown that even when eFAST yields false negative results, outcomes are favorable as long as patient status is closely monitored and reassessed [4]. These statistics demonstrate eFAST’s strength in ruling in injuries when positive, but its limitations in ruling out injuries when negative, especially in penetrating trauma, where sensitivity can range from 28-100% depending on trajectory, organ involved, and injury severity [5]. 

In this case, eFAST was used as an adjunct to clinical decision making, not a replacement for formal imaging or serial exam. Its findings enabled structured handoff, avoiding unnecessary invasive interventions, and highlighted how point-of-care ultrasound can be safely integrated into trauma workflows even when patients fall outside classical indications. Additional data are needed to clarify how patient position prior to arrival, upright versus supine, affects the sensitivity and specificity of eFAST in trauma assessment, particularly in the evaluation of intra-abdominal free fluid. 

References:

  1. Tewari V, et al. The efficiency of focused assessment with sonography for trauma (FAST) vs. CT in penetrating torso trauma. J Emerg Trauma Shock. 2024;17(1):3–9.
  2. Netherton S, Milne WK, Proctor C, et al. Diagnostic accuracy of eFAST in trauma: a systematic review and meta-analysis. Can J Emerg Med. 2019;21(6):727–738.
  3. Stengel D, Bauwens K, Sehouli J, et al. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries: a randomized controlled trial. JAMA. 2017;317(11):1110–1119.
  4. Sierzenski PR, et al. Clinical outcomes after false-negative FAST in hypotensive trauma patients. BMC Emerg Med. 2023;23:45.
  5. American College of Emergency Physicians (ACEP). Trauma Ultrasound (eFAST). Sonoguide. Available at: https://www.acep.org/sonoguide/basic/fast
  6. https://www.bcpocus.ca/organscans/efast/
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Case 51: Utility of the Spine Sign in Detecting Pleural Effusion on POCUS

John Hermez

A 74 year-old male with a past medical history of metastatic castration-resistant prostate cancer complicated by cauda equina necessitating laminectomy decompression, chronic RLE DVT on apixaban and chronic hypotension presented to the emergency department accompanied by his spouse for altered mental status. Per the patient’s wife, he experienced cognitive decline and increasing weakness for one week prior to presentation. Two days prior to his arrival in the ED, the patient became more confused and agitated with his wife reporting that he appeared to be hallucinating intermittently. While he typically ambulates without assistance and straight-catheterizes himself, he has been unable to care for himself independently.

Vitals: BP 91/53 | Pulse 85 | Temp 98.1 °F (36.7 °C) | Resp 12 | Wt 92.3 kg (203 lb 7.7 oz) | SpO2 98% | BMI 29.1 kg/m²

Physical Exam:

On exam, the patient is in no acute distress and is oriented only to his name. He has diffuse anasarca with 2+ right lower extremity edema and 1+ left lower extremity edema. He is not pale or cyanotic and has shallow respirations on room air with diminished lung sounds and a flat JVP.

Labs: WBC 25.7 and initial lactate 2.2. Hb 9.5 PLT 98, Urine cloudy and orange, growth pending

ECG: NSR at 82 bpm with occasional PVCs, no evidence of ST changes

CXR: Compared to prior, there are new heterogenous bibasilar lung opacities and atelectasis possibly representing pneumonia. No definite pleural effusion or pneumothorax. Stable cardiac silhouette.

To clarify cardiac function and better characterize pulmonary status, a bedside point of care echocardiography was performed.

Figure 1: Trace pericardial effusion seen on parasternal short axis view.

Figure 2: Sagittal right sview demonstrating the thoracic spine sign

Discussion:

Radiographic imaging of the thorax is routinely performed in the ED to aid in the diagnosis of a wide range of cardiopulmonary manifestations. While upright chest x-rays are the Gold Standard for detecting pneumonia in patients, the detection of pleural effusion may be less clearly visualized. Meta-analysis has shown that the screening sensitivity of ultrasound may be 94% as compared to 51% for chest x-ray, in spite of having similar specificity.1 In this case, we rapidly obtained a point-of-care echocardiogram and pulmonary ultrasound to guide medical decision making in a patient with advanced metastatic disease and anasarca with equivocal radiograph.

A parasternal short axis view was obtained (figure 1) and demonstrated a trace pericardial effusion estimated to be 3mm without evidence of gross systolic dysfunction. Although the right ventricle was poorly visualized during diastole, the small volume of effusion and history of chronic hypotension was reassuring against tamponade physiology. Acquisition of a right subcostal view (figure 2) demonstrated the thoracic spine sign which is a reliable indicator of pleural effusion or hemothorax.2

Figure 3: Subcostal view labelled to identify anechoic pleural effusion (image courtesy of Stanford Medicine 25)5

The spine sign is a sonographic description of the visualization of vertebral bodies above the level of the diaphragm, which indirectly indicates that a thoracic fluid collection is present. When there is no thoracic free fluid present, an abrupt loss of the vertebral bodies occurs at the diaphragm due to air in the lungs impeding transmission.2 Pleural effusions and traumatic hemothorax can both represent fluid collections, hence the utility of subcostal imaging in the eFAST exam to evaluate thoracic trauma. One study on closed chest trauma has shown the absence of the spine sign to have a negative predictive value of 97.8% in assessing pleural effusion.3 The focused use of ultrasonography in the emergency department is regarded of high value in the early detection and diagnosis of multiple pathologies. Algorithmic exams such as the RUSH protocol provide rapid feedback on the physiology of a critically ill patient which can guide management and are recommended both by the American College of Emergency Physicians and Critical Care Societies.4 The potential applications of ultrasonography in resource-limited, austere environments by prehospital personnel are also of particular interest given novel advancements in AI-technology and focused training protocols.

In spite of a technically challenging exam, this case was an excellent example of the utility of multimodal imaging to clarify cardiopulmonary status in the ED. The patient was treated with broad antibiotic therapy for suspected urosepsis and admitted to the hospital for multidisciplinary care. He later was scheduled for therapeutic thoracentesis and surgical evaluation for a scapular fluid collection. 

References:

  1. Yousefifard M, Baikpour M, Ghelichkhani P, Asady H, Shahsavari Nia K, Moghadas Jafari A, Hosseini M, Safari S. Screening Performance Characteristic of Ultrasonography and Radiography in Detection of Pleural Effusion; a Meta-Analysis. Emerg (Tehran). 2016 Winter;4(1):1-10. PMID: 26862542; PMCID: PMC4744606.
  2. Dickman, E., Terentiev, V., Likourezos, A., Derman, A. and Haines, L., 2015. Extension of the Thoracic Spine Sign: A New Sonographic Marker of Pleural Effusion. Journal of Ultrasound in Medicine, 34(9), pp.1555-1561.
  3. Vargas CA, Quintero J, Figueroa R, Castro A, Watts FA. Extension of the thoracic spine sign as a diagnostic marker for thoracic trauma. Eur J Trauma Emerg Surg. 2021 Jun;47(3):749-755. doi: 10.1007/s00068-020-01459-1. Epub 2020 Aug 17. PMID: 32803497.
  4. Seif D, Perera P, Mailhot T, Riley D, Mandavia D. Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol. Crit Care Res Pract. 2012;2012:503254. doi: 10.1155/2012/503254. Epub 2012 Oct 24. PMID: 23133747; PMCID: PMC3485910.
  5. “The Spine Sign.” Edited by Stanford Medicine 25 Bedside Medicine Symposium, Stanford Medicine 25, Stanford Medicine 25 Bedside Medicine Symposium, stanfordmedicine25.stanford.edu/blog/archive/2018/thespinesign1.html. Accessed 25 May 2025.
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