Category: Clinical Cases

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Case 71: Chronic Back Pain

Letitia Mueller, Bryan Merte, Anthony Medak

A 73-year-old female presented from family health center for "unbearable" chronic back pain. She has a complex surgical history, including a T11-sacral posterior spinal fusion and an L3 corpectomy performed at a local outside hospital. She is chronically wheelchair-bound. The patient reported the pain is "stable" but reached a breaking point. She described "notches" forming on her thoracic spine. She denied acute lower extremity numbness, weakness, saddle anesthesia, or bowel/bladder incontinence. She denied fevers or recent trauma.

PMH: COPD on home O2, Hepatitis C, Major depressive disorder, Polycythemia, Pulmonary embolism, Schizophrenia, Active smoker                

Vitals: BP: 139/81, Pulse: 61, Temp: 98 °F, Resp: 16, SpO2: 95% on RA

Physical Exam:
General: Alert and oriented x4; non-toxic appearing.
MSK: Midline surgical scars over thoracic and lumbar spine. No bony step-offs, no deformity, and notably, no midline tenderness or skin changes.
Neuro: 5/5 strength in all extremities; sensation intact; no focal deficits noted.

Pertinent Labs: WBC 7.4k, Hgb 9.6, ESR >130, CRP 7.15

A bedside ultrasound was performed.

Abscess with "swirl sign" on compression circled in green. Reverberation artifact from metal hardware can be seen just deep to the abscess.

Learning Questions:

Q1: In a post-surgical patient with a "benign" physical exam but elevated inflammatory markers with the above ultrasound findings, what could be considered on the differential diagnosis?

A1: DDx would include: Abscess, seroma, hematoma…. Can you think of more? In this patient, the POCUS "Swirl Sign" suggests a purulent/infectious process. This was later confirmed by blood cultures positive for MRSA.

Q2: What do the cardiac ultrasound findings tell you about the patient’s hemodynamic status?

A2: The presence of a dilated Right Ventricle and the "D-sign" (septal flattening) indicates Right Heart Strain due to severe RV pressure overload. The RV is struggling to pump against significantly elevated pulmonary vascular resistance. This signifies that the patient is at higher risk for cardiovascular collapse.

ED Course:
Despite the benign physical exam, the markedly elevated inflammatory markers (ESR >130) and POCUS findings prompted a workup for deep-space infection. MRI of the spine confirmed edema and enhancement surrounding a 6.7 x 5.0 x 3.2 cm fluid collection within the surgical bed, involving a right-sided fusion rod. Patient was transferred to an outside hospital for continuity of care with prior surgical team for fluid drainage and spine hardware removal/revision.

During hospital admission:
Blood cultures confirmed MRSA Bacteremia, likely due to spinal abscess and infected spinal hardware. Patient was started on IV vancomycin and was scheduled for abscess drainage and spinal hardware revision surgery.

Discussion:

This case illustrates the application of point-of-care ultrasound (POCUS) as a bridge between a benign physical exam and definitive surgical management. A key sonographic finding in this case is the “swirl sign,” characterized by the movement of echogenic debris within a fluid collection when pressure is applied with the transducer. The presence of this "swirl" is highly suggestive of a complex collection, such as an abscess, hematoma, or seroma, rather than a simple cyst. In the context of a patient with significantly elevated inflammatory markers (ESR >130), this dynamic debris often points toward the purulent material of an abscess. By identifying this sign at the bedside, clinicians can escalate care, contrary to the approach that a benign physical exam might otherwise suggest. Also, given the artifacts created by metal hardware on MRI and CT, POCUS provides a rapid, non-invasive, and real-time imaging modality that can potentially reduce the time to directed antibiotic therapy or surgical intervention.

Beyond the localized infection, this case highlights the utility of POCUS in pre-operative risk stratification. The patient’s cardiac POCUS revealed a dilated Right Ventricle and a flattened interventricular septum (the "D-sign"). This is a hallmark of RV pressure overload, often seen in acute-on-chronic respiratory failure. According to the American Society of Echocardiography, the "D-sign" indicates that RV pressures have equaled or exceeded left ventricular pressures.

Despite a benign physical exam, bedside ultrasound identified a deep fluid collection. Additionally, cardiac POCUS provided immediate hemodynamic data, identifying RV pressure overload via the "D-sign”, which can be used for perioperative risk stratification in a patient with significant pulmonary disease. Ultimately, the bedside findings were confirmed by MRI, demonstrating that POCUS is a reliable tool for that allows for  rapid diagnosis and enhanced patient safety in complex surgical cases.

References:

  1. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-788. doi:10.1016/j.echo.2010.05.010
  2. Spinnato P, Patel DB, Di Carlo M, Bartoloni A, Cevolani L, Matcuk GR, Crombé A. Imaging of Musculoskeletal Soft-Tissue Infections in Clinical Practice: A Comprehensive Updated Review. Microorganisms. 2022 Nov 25;10(12):2329. doi: 10.3390/microorganisms10122329. PMID: 36557582; PMCID: PMC9784663.
  3. Subramaniam S, Bober J, Chao J, Zehtabchi S. Point-of-care Ultrasound for Diagnosis of Abscess in Skin and Soft Tissue Infections. Acad Emerg Med. 2016;23(11):1298-1306. doi:10.1111/acem.13049
  4. Vieillard-Baron A, Millington SJ, Sanfilippo F, et al. A decade of progress in critical care echocardiography: a narrative review. Intensive Care Med. 2019;45(6):770-788. doi:10.1007/s00134-019-05604-2
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Case 70: A Silent and Rapid Expansion

Natalie Sarafian, Elaine Yu

A 62-year-old male with a history notable for HFrEF (on Lasix), HIV, cirrhosis with varices, ulcerative colitis, methamphetamine use, and Hodgkin’s lymphoma (in remission) presents to the emergency department with acute onset shortness of breath and chest pain. His exertional dyspnea and exertional chest pain are also accompanied with lower extremity edema and orthopnea. Cardiac history is significant for CHF diagnosed in 2020, with a hospitalization in September 2025 for ADHF, and multiple recurrent admissions after being unable to take GDMT medications. Currently, he is adherent but misses medications about once weekly.

Vitals: BP 114/85, HR 103, RR 23, SpO2 94%, BMI 28.98

Physical exam: 2+ pitting edema in lower extremities bilaterally with a venous stasis rash

Labs: Troponin 85. BNPP > 13,000. Cr 1.23. Bilirubin of 1.54.

EKG: normal sinus rhythm with LBBB

A bedside ultrasound was performed:

Figure 1: Parasternal long axis view with severely decreased ejection fraction with trace pericardial effusion.
Figure 2: Parsternal short axis view with global hypokinesia and trace pericardial effusion.

ED Course: Cardiology was paged for the LBBB with troponin leak and heart failure exacerbation, with plan to admit to their service. In the interim, students performed another bedside ultrasound a few hours later for education.

Figure 3: Repeat examination showing increasing size of pericardial effusion.

Discussion:

Pericardial effusion management is routinely taught in medical education and encountered clinically. Pericardial effusions are present in about 6.5% of the general adult population and in 13-20% of high-risk emergency department patients [1]. Given its potential of developing into tamponade and its association with multiple diseases, prompt diagnosis is of utmost importance for proper treatment and prognosis of patients. Cardiac tamponade is an emergent consequence of a rapidly growing pericardial effusion, but it is infrequently encountered, with an incidence of 2 per 1000 people [2]. It is important to note that not all large pericardial effusions will devolve into tamponade; rather, a rapid rate of fluid accumulation creates tamponade [3].

The likelihood of discovering a pericardial effusion changes with a patient’s risk factors and underlying pathology. This patient had multiple comorbidities that are associated with cardiac pathology, including but not limited to CHF, methamphetamine use, HIV, lymphoma, and ulcerative colitis. In a meta-analysis of patients with pulmonary arterial hypertension, myocardial infarction, malignancy, and chronic heart failure, the pooled pericardial effusion prevalence was 19.5% [1]. Although pleural effusions are more common than pericardial effusions in CHF [5], pericardial effusions still demonstrate increased risk for all-cause mortality in CHF patients [6]. Now with antiretroviral therapies, studies have demonstrated low rates of pericardial effusions in HIV-positive outpatients [4]. Finally, the pericardium is a common site for lymphomas to metastasize [7], thus malignant pericardial effusions should also be considered in cancer patients.

Although echocardiograms are the basis of diagnosing pericardial effusions, a patient’s history, examination, EKG, or chest x-ray may raise suspicion [3]. Additionally, bedside ultrasound can also serve as an efficient and noninvasive diagnostic tool. POCUS has been found to reduce time to pericardiocentesis and expedite echocardiograms if indicated [8]. In fact, POCUS can be performed to confirm a pericardial effusion with 96-100% sensitivity and specificity [9]. Furthermore, when pericardial effusions are diagnosed in the emergency department, patients experience shorter hospital stays and reduced mortality [10].

Source: POCUS.org

When using POCUS to evaluate for pericardial effusions, measuring the effusion can help approximate the volume. It is important to note that up to 50 mL of fluid is normal and physiologic [10]. If there is clinical concern for tamponade, POCUS should evaluate for right ventricular diastolic collapse, late right atrial diastolic collapse, heart swinging, plethoric IVC, and mitral and tricuspid valve respirophasic flow variation [10]. Once a pericardial effusion and/or cardiac tamponade has been identified and diagnosed, treatment, ranging from conservative management to pericardiocentesis, should be considered.

In this patient’s case, the pericardial effusion was deemed small-moderate by the cardiology service and will be followed up with a formal echocardiogram.

References:

  1. Argulian, E. & Vogel, B. (2024) Evaluation of pericardial effusion. BMJ Publishing Group.
  2. Brown, B., Nigussie, B., Offor, R., & Graham-Hill, S. (2024). Fatal cardiac tamponade: The lethal progression of acute-on-chronic pericardial effusion. Cureus, PMC11264569.
  3. Shanker, D. A., Gaur, A., & Warriner, D. (2025). Pericardial effusion: Overview of aetiology, pathophysiology, diagnosis, and management. Cureus. https://pubmed.ncbi.nlm.nih.gov/41084698/
  4. Lind, A., Reinsch, N., Neuhaus, K., Esser, S., Brockmeyer, N. H., Potthoff, A., Pankuweit, S., Erbel, R., Maisch, B., & Neumann, T. (2011). Pericardial effusion of HIV-infected patients: Results of a prospective multicenter cohort study in the era of antiretroviral therapy. European Journal of Medical Research, 16(11), 480–483. https://pmc.ncbi.nlm.nih.gov/articles/PMC3351804/
  5. Natanzon, A. & Kronzon, I. (2009). Pericardial and pleural effusions in congestive heart failure—Anatomical, pathophysiologic, and clinical considerations. The American Journal of the Medical Sciences, 338(1). https://pubmed.ncbi.nlm.nih.gov/19574887/
  6. Georg M. Fröhlich, Philipp Keller, Florian Schmid, Mathias Wolfrum, Martin Osranek, Christian Falk, Georg Noll, Frank Enseleit, Markus Reinthaler, Pascal Meier, Thomas F. Lüscher, Frank Ruschitzka, Felix C. Tanner, Haemodynamically irrelevant pericardial effusion is associated with increased mortality in patients with chronic heart failure, European Heart Journal, Volume 34, Issue 19, 14 May 2013, Pages 1414–1423, https://doi.org/10.1093/eurheartj/eht006
  7. Mudra, S. E., Rayes, D., Kumar, A. K., Li, J. Z., Njus, M., McGowan, K., Charalampous, C., Kalam, K. A., Syed, A., Majid, M., Schleicher, M., Agrawal, A., Yesilyaprak, A., & Klein, A. L. (2024). Malignant pericardial effusion: A systematic review. CJC Open, 6(8), 967–972. https://pmc.ncbi.nlm.nih.gov/articles/PMC11357784/
  8. Moura de Azevedo, S., Duarte, R., Krowicki, J., Vázquez, D., Pires Ferreira Arroja, S., & Mariz, J. (2024). Heart in focus: Advancing pericardial effusion diagnosis with point-of-care ultrasound. Cureus, 16(12), e76681. https://pmc.ncbi.nlm.nih.gov/articles/PMC11781757/
  9. Merth, T. & Sachdeva, S. (2022). Pericardial effusion and tamponade: Diagnosis and treatment summary. https://emergencycarebc.ca/clinical_resource/clinical-summary/pericardial-effusion-and-tamponade-diagnosisand-treatment-summary/
  10. Rao, V. (2025). POCUS evaluation of pericardial effusion and tamponade. https://www.pocus.org/pocusevaluation-of-pericardial-effusion-and-tamponade/
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Case 69: Expedited Workup for a Low-Risk Pulmonary Embolism

Julia Kelly, Cameron Smyres

A 62-year-old man who was recently diagnosed with colon cancer presents to the ED after being diagnosed with a pulmonary embolism on outside CT imaging. The patient had a CT scan of his chest for cancer staging and an incidental PE was found. He was told to seek care at the ED. The patient is asymptomatic, and specifically denies chest pain, dyspnea, acute leg swelling and otherwise feels at his baseline. He denies any recent travel and has no history of blood clots in the past.

Vitals: BP 106/70 | Pulse 55 | Temp 98 °F (36.7 °C) | Resp 19 | Wt 79.8 kg (176 lb) | SpO2 98%

Physical Exam: The patient is not in acute distress, lying in bed and breathing comfortably on room air. Lungs are clear to auscultation bilaterally. 1+ pitting edema noted in shins bilaterally. The remainder of the exam is normal.

Labs: CBC with stable chronic macrocytic anemia (Hgb 11.7). CBC, PT and PTT wnl.

Figure 1: Parasternal long (no RV dilation)
Video 1: Parasternal short (no D sign present, symmetric squeeze of LV)

ED Course: Limited bedside cardiac ultrasound showed grossly normal heart function, without pericardial effusion or right ventricular dysfunction. No evidence of right heart strain. PE team was consulted who did not recommend formal echocardiogram based on patient’s lack of symptoms, hemodynamic stability, and reassuring bedside ultrasound. Patient was started on Eliquis and referred to PE clinic for outpatient follow up.

Discussion:

Pulmonary embolism (PE) is a potentially life-threatening diagnosis that can present with a variety of symptoms, from asymptomatic to sudden hemodynamic collapse. Approximately half of PEs are diagnosed in the emergency care setting,4 making rapid identification and risk stratification especially important. Mortality can reach up to 25-50% in massive PE without prompt treatment. POCUS has been shown to be highly sensitive for large PEs and in those with abnormal vital signs.1

A rapid bedside tool, POCUS can play an important role in risk stratification of patients with PEs by evaluating for right heart strain, though data shows its utility in diagnosing PE itself might be more limited5. Pulmonary emboli block blood flow to the lungs, increasing afterload, leading to right ventricular dysfunction (RVD). RVD is an important prognostic factor and can change management. In this case, bedside echo demonstrated no evidence of right ventricular dysfunction, supporting outpatient management with apixaban and close follow-up; in contrast, evidence of right heart strain may have prompted consideration of more aggressive therapies or inpatient monitoring.

There are several sonographic findings that suggest right heart strain, including RV enlargement (RV:LV ratio), abnormal septal motion such as septal flattening (“D-sign”), and McConnell’s sign (hypokinesis of RV with apical sparing, resembling a flailing sail3). These features reflect acute pressure overload on the RV from a significant pulmonary arterial obstruction. McConnell’s sign is an indication of acute RV strain, rather than chronic changes. Acute RV strain can also be distinguished from chronic overload with the absence of RV hypertrophy.5 It is important to note that the sensitivity of POCUS for detecting right heart strain in PE is limited. For example, McConnell’s sign shows high specificity but low sensitivity for acute PE: one study finding a pool estimate of 22% sensitivity and 97% specificity.4 Additionally, absence of right heart strain on POCUS does not exclude PE, and CT PE remains the gold standard for definitive diagnosis.

In summary, while POCUS did not reveal right heart strain in this patient with confirmed PE, its use provided timely bedside evaluation of cardiac function that contributed to risk stratification and informed clinical management. This case highlights POCUS’s role as a valuable tool in the assessment of suspected PE.

References

  1. Alerhand S, Sundaram T, Gottlieb M. What are the echocardiographic findings of acute right ventricular strain that suggest pulmonary embolism? Anaesth Crit Care Pain Med. 2021 Apr;40(2):100852. doi: 10.1016/j.accpm.2021.100852. Epub 2021 Mar 26. PMID: 33781986.
  2. Daley JI, Dwyer KH, Grunwald Z, Shaw DL, Stone MB, Schick A, Vrablik M, Kennedy Hall M, Hall J, Liteplo AS, Haney RM, Hun N, Liu R, Moore CL. Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs. Acad Emerg Med. 2019 Nov;26(11):1211-1220. doi: 10.1111/acem.13774. Epub 2019 Sep 27. PMID: 31562679.
  3. Day J BA RDCS. Right Heart Evaluation | Point-of-Care Ultrasound Certification Academy [Internet]. Point-of-Care Ultrasound Certification Academy. 2023. Available from: https://www.pocus.org/right-heart-evaluation/
  4. Fields JM, Davis J, Girson L, Au A, Potts J, Morgan CJ, Vetter I, Riesenberg LA. Transthoracic Echocardiography for Diagnosing Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr. 2017 Jul;30(7):714-723.e4. doi: 10.1016/j.echo.2017.03.004. Epub 2017 May 9. PMID: 28495379.
  5. Rudski LG, Wyman WL, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardio. 2010;23(7):685-713.
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Case 68: Erector Spinae Plane Block for Rib Fracture Pain

Anthony Galvez, Tommy Ngo, Akash Desai

A 62yo male with a history of HIV and hypothyroidism presents to the ED with left-sided chest pain and shortness of breath after a near-syncopal episode followed by a fall 3 days prior. The patient was carrying groceries when he suddenly felt lightheaded and fell to the ground. He denies loss of consciousness or head trauma and reports having not eaten or drinking anything all day. Since the fall, he has had progressively worsening left-sided chest pain and spasming.

Vitals: BP 157/87, HR 70, RR 18, T 98.3F, SpO2 98%

Exam:

  • The patient appeared uncomfortable, splinting with respirations, and was wearing a self-applied weightlifting brace over the left chest wall.
  • Chest wall examination revealed focal tenderness to palpation over the left lateral and posterior ribs without overlying ecchymosis, crepitus, or step-off deformity. There was no flail segment appreciated. Auscultation revealed clear and equal breath sounds bilaterally.
  • Cardiac exam was regular without murmurs.
  • The abdomen was soft and non-tender.
  • Neurologic exam was grossly intact with no focal deficits.

ED Course:

  • Syncope workup showed no significant electrolyte derangements or anemia.
  • Chest x-ray was obtained to evaluate for trauma which showed acute displaced left posterior 4th-7th rib fractures. No pleural effusion or pneumothorax was seen.
  • After administration of ibuprofen, acetaminophen, and oxycodone, the patient’s pain was still reported as 8-9/10. The patient was offered and consented to an erector spinae plane block for multimodal pain control.
  • The block was performed at bedside using ultrasound guidance (Figures 1-2). Half an hour after the block was performed, the patient’s pain had reduced to 4/10. The patient reported increased range of motion and subsequently was able to walk himself to the bathroom.
  • The patient was subsequently cleared by trauma surgery for discharge home with multimodal pain control and follow up with PCP.
Figure 1: With transducer dot caudally, the needle is inserted and aimed at the transverse process. A faint echogenic line represents the needle terminating on the transverse process (TP).
Figure 2: With the needle pressed against the transverse process, the anesthetic is injected just below the erector spinae muscle. An arrow depicts the injectate, which should be seen spreading across the underside of the erector spinae (ES) muscle.

Discussion
Effective pain control in patients with rib fractures is critical to prevent complications such as atelectasis, pneumonia, and respiratory failure.1,2 Traditional management often relies on systemic opioids, which carry known risks including respiratory depression, cough suppression, and delirium.3 The erector spinae plane block (ESPB) is a regional anesthesia technique that provides effective analgesia for thoracic wall pain while reducing opioid requirements.4,5,6 In this case, ESPB resulted in a clinically meaningful reduction in pain and improved range of motion after failure of multimodal oral analgesia and facilitated safe discharge from the emergency department. The ESPB is well suited for the emergency room setting as it can easily be done at bedside using ultrasound guidance and is performed away from the pleura and other critical structures.5,6 Additionally, this technique is more technically straightforward in comparison to paravertebral or epidural blocks, which require greater technical expertise and carry higher risk.7,8 By targeting the fascial plane at the level of the transverse process, there is consistent blockade of the dorsal rami, with variable anterior spread to the ventral rami and intercostal nerves, allowing the ESPB to effectively provide broad unilateral analgesia across multiple rib levels4,5,9,10 (Figures 3-5).

Figure 3. Probe positions and corresponding ultrasound views at three lateral levels: spinous process (midline), transverse process (~3 cm lateral), and rib. The transverse process appears blunted and squared vs. the rounded rib shadow; pleura is visible deep to the rib but obscured behind the TP. (Source: Highland Ultrasound).
Figure 4. Posterior thoracic musculature with the right side partially reflected to expose the spine. The needle (center) is shown targeting the ESP at the level of the transverse process. Both superior and inferior approaches are demonstrated with the ultrasound transducer (blue) positioned in the parasagittal plane. Yellow nerves visible on the left demonstrate the multilevel coverage achieved by cephalocaudal LA spread. (Source: Regional Anesthesiology and Acute Pain Medicine).
Figure 5. Cross-section at T5 showing local anesthetic (dark blue) injected into the erector spinae plane (ESP), with anterior spread (light blue) toward the dorsal ramus (DR), ventral ramus (VR), and intercostal nerves (IC). Needle target is deep to the erector spinae (ES) and rhomboid (Rh), superficial to the transverse process (TP). (Source: Highland Ultrasound)

References:

  1. Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth. 2017;118(3):474-475. doi:10.1093/bja/aex013
  2. Luftig J, Mantuani D, Herring AA, Dixon B, Clattenburg E, Nagdev A. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med. 2018;36(8):1391-1396. doi:10.1016/j.ajem.2017.12.060
  3. Peek J, Smeeing DPJ, Hietbrink F, Houwert RM, Marsman M, de Jong MB. Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2019;45(4):597-622. doi:10.1007/s00068-019-01116-w
  4. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621-627. doi:10.1097/AAP.0000000000000451
  5. Kumar G, Kumar Bhoi S, Sinha TP, Paul S. Erector spinae plane block for multiple rib fracture done by an emergency physician: a case series. Australas J Ultrasound Med. 2021;24(3):167-172. doi:10.1002/ajum.12261
  6. Jiang M, Peri V, Ou Yang B, Chang J, Hacking D. Erector spinae plane block as an analgesic intervention in acute rib fractures: a scoping review. Local Reg Anesth. 2023;16:81-90. doi:10.2147/LRA.S414056
  7. Palachick BJ, Carver RA, Byars DV, Martyak MT, Collins JN. Erector spinae plane blocks for traumatic rib fractures performed by nonspecialized emergency physicians: a prospective, interventional study. Am Surg. 2022;88(9):2124-2126. doi:10.1177/00031348221078428
  8. Elawamy A, Morsy MR, Ahmed MAY. Comparison of thoracic erector spinae plane block with thoracic paravertebral block for pain management in patients with unilateral multiple fractured ribs. Pain Physician. 2022;25(6):483-490.
  9. Ivanusic J, Konishi Y, Barrington MJ. A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 2018;43(6):567-571. doi:10.1097/AAP.0000000000000789
  10. Chin KJ, El-Boghdadly K. Mechanisms of action of the erector spinae plane (ESP) block: a narrative review. Can J Anaesth. 2021;68(3):387-408. doi:10.1007/s12630-020-01875-2

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Case 67: D-sign in a Post-Cardiac Surgical Patient

Liz Temple, Colleen Campbell

A 51-year-old male patient with past medical history of mitral valve prolapse s/p complex mitral valve repair with left atrial appendage exclusion and repair of atrial septal defect complicated by perioperative pericarditis was directly admitted to the ICU following outpatient echocardiography findings of new right heart strain. Since his open heart surgery, he began to develop progressive dyspnea on exertion and orthopnea accompanied with dizziness and lightheadedness. His exertional capacity has decreased from 3 miles to 100 yards over one week. He otherwise denied fevers,

chills, abdominal pain, or dysuria. He completed an outpatient echo which showed evidence of new severe RV dysfunction which was new compared to his post-operative echo after his complex cardiac surgery which showed preserved RV function. CT PE was completed to rule out PE and did not show evidence of a clinically significant PE as the cause of his new onset RV dysfunction. Bedside cardiac ultrasound was also performed once the patient arrived to the floor.

Vitals: BP 128/75 | Pulse 86 | Temp 97.7 °F (36.5 °C) | Resp 17 | SpO2 98% | BMI 24.4 kg/m²

Physical Exam:

Gen: well appearing, NAD

HEENT: normocephalic, atraumatic, moist mucous membranes, sclera anicteric, EOMI

CV: WWP, RRR, radial pulses 2+, JVP ~9cm

Resp: no increased work of breathing, no accessory muscle use, speaks in full

sentences, breathing comfortably on RA, CTAB

Abd: soft, nontender, nondistended

Ext: no lower extremity edema

Neuro: moves all limbs spontaneously, no facial asymmetry, no dysarthria, EOMI

Labs: Troponin within normal limits

Figure 1. Cardiac POCUS with parasternal long axis showing dilated right ventricle (RV). No evidence of a significant pericardial effusion although there appears to be an echogenic focus on anterior RV free wall.
Figure 2: Parasternal short axis view from formal echocardiogram displaying the “D-sign” of right ventricular strain.
Figure 3: Apical 4-chamber view from formal echocardiogram demonstrating septal bowing into left ventricle most prominently during diastole.

Discussion

The “D-sign” on cardiac POCUS can help to identify right heart strain of varying etiologies, and is often considered a canonical sign for pulmonary embolism. This finding is most clearly visualized using a parasternal short axis view where the left ventricle appears as a D-shaped structure as a result of right ventricular overload which causes the interventricular septum to bow towards the left heart.1,2

While the D-sign has a high specificity (83%), it has a low sensitivity (53%) for pulmonary embolism. Moreover, there are a series of other underlying etiologies of right heart strain that may be associated with this ultrasound signature apart from pulmonary embolism.3

More specifically, right ventricular strain can be stratified by whether it is a result of pressure overload versus volume overload. In a patient with right ventricular pressure overload, elevated pressures on the right side are present both during systole and diastole, and therefore the left ventricular “D-shape” is present throughout the cardiac cycle. Pathologies that correlate with right ventricular pressure overload include pulmonary embolism, pulmonary hypertension, chronic right hear failure with hypertrophy, left-sided heart failure, and ARDS. Conversely, in patients with right ventricular volume overload, the sequelae of volume overload are most apparent during diastolic filling, so the D-sign is most obvious at end diastole while the left ventricle appears more normal and circular shaped during end-systole.4 Conditions that correlate with right ventricular volume overload may include severe tricuspid regurgitation, decompensated heart failure, and excessive volume resuscitation.1

A quantitative tool that is used to distinguish these forms of overload is the Eccentricity Index which utilizes the cross-sectional measurement of the left ventricular cavity in the parasternal short axis view. The index is a proportion between the measurement of length parallel to the septum (D2) and perpendicular to the septum (D1): EI = D2/D1. An EI>1 is suggestive of the D sign. In settings of pressure overload, the EI will be greater than 1 in systole and diastole. In settings of volume overload, the EI is less than 1 in systole and greater than 1 in diastole (Figure 4).5

Figure 4: Eccentricity index calculation to distinguish between right ventricular pressure and volume overload. Source: Pocus 101

In this particular case, it is clear that the interventricular septal bowing is variable throughout the cardiac cycle (Figure 1-3) and the D-sign is most evident at end diastole which would suggest a ‘volume overload’ subset of RV strain. Moreover, the EI follows a pattern consistent with right ventricular volume overload, although this was not measured during the formal echo. The etiology of this volume overload RV strain may have been partly attributed by volume overload as he had an elevated JVD and a plump IVC on formal echo. However, considering the context of his recent open-heart surgery with pericarditis and evidence of RV free wall mobility limitation (Figure 3), there was higher suspicion for external compression or inflammation as the cause of his rapid onset RV dysfunction. A subsequent CT scan suggested evidence of possible pericardial clot resulting in external RV compression. The patient was subsequently scheduled for left and right heart catheterization for further assessment of cardiac pressures as a result of this new onset RV strain on ultrasound before proceeding with further surgical intervention.

This case demonstrates the utility of bedside POCUS and clarity of the D sign as a marker for right ventricular dysfunction, presents the eccentricity index as a tool for distinguishing between pressure and volume overload, and the importance of maintaining a broad differential, beyond pulmonary embolism, for the D-sign on cardiac ultrasound. 

References:

  1. Dinh V. The D Sign - Right Heart Strain from Pressure vs Volume Overload. POCUS 101, https://www.pocus101.com/the-d-sign-right-heart-strain-from-pressure-vs-volume-overload/ (accessed October 17, 2025).
  2. Cativo Calderon EH, Mene-Afejuku TO, Valvani R, et al. D-shaped left ventricle, anatomic, and physiologic implications. Case Rep Cardiol 2017; 2017: 4309165.
  3. Fields JM, Davis J, Girson L, et al. Transthoracic echocardiography for diagnosing pulmonary embolism: A systematic review and meta-analysis. J Am Soc Echocardiogr 2017; 30: 714-723.e4.
  4. Tanaka H, Tei C, Nakao S, et al. Diastolic bulging of the interventricular septum toward the left ventricle. An echocardiographic manifestation of negative interventricular pressure gradient between left and right ventricles during diastole. Circulation 1980; 62: 558–563.
  5. Ryan T, Petrovic O, Dillon JC, et al. An echocardiographic index for separation of right ventricular volume and pressure overload. J Am Coll Cardiol 1985; 5: 918–927.

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Case 66: Rapid Diagnosis of Hemorrhagic Ovarian Cyst in a Reproductive-age Patient

Brigid Larkin, Colleen Campbell

A 20-year-old female with no significant past medical history presented to the emergency department with 5 days of focal right lower quadrant abdominal pain progressively worsening in severity. The pain was constant and non-radiating, accompanied by generalized abdominal discomfort, nausea, and intermittent light-headedness. Her last menstrual period occurred 3 weeks prior. She denied vaginal bleeding, dysuria, hematuria, constipation, diarrhea, or hematochezia. Past surgical history was unremarkable. Family history was notable for uterine fibroids in her mother and maternal grandmother.

Vital signs: BP 118/67 mmHg | Pulse 89 | Temp 99.1 Fº | Resp 16 | SpO2 100%

Physical exam:  The patient was well-appearing but uncomfortable. Her abdomen was soft with mild distention and diffuse tenderness, with voluntary guarding on deep palpation. No CVA tenderness was appreciated.

Labs: Hgb 11.3, WBC 18.7, Negative urine pregnancy test, lactate WNL, Urinalysis negative

Bedside Ultrasound:

  • RUQ/Biliary: no evidence of cholelithiasis or cholecystitis
  • Appendix: no evidence of appendicitis
  • Pelvic/Transvaginal: large adnexal cyst structure (~5cm) with internal echoes suggestive of a hemorrhagic cyst; free fluid visualized in the pelvis. No evidence of intrauterine pregnancy.
Figure 1. Ovary with Adnexal Mass

A CT scan was ordered which showed a hemorrhagic ovarian cyst with mild hemoperitoneum. OBGYN was consulted and recommended no acute surgical intervention. They recommended fluids and outpatient follow-up with repeat ultrasound of right ovarian cyst at 6 weeks.

Discussion:

Acute pelvic pain in reproductive-age women represents a broad differential diagnosis including appendicitis, ectopic pregnancy, ovarian torsion, pelvic inflammatory disease, and ruptured ovarian cyst. Point-of-care ultrasound (POCUS) serves as an essential early diagnostic tool because it is rapid, radiation free, and able to identify adnexal pathology and free intraperitoneal fluid even before CT imaging is obtained.

Hemorrhagic ovarian cysts are typically functional cysts resulting from bleeding into a corpus luteum or follicular cyst. Sonographically, they often demonstrate reticular internal echoes, a lacy or fibrin-strand appearance, or a mixed echogenicity depending on the age of the clot.1,2 Cyst rupture is more likely if the cyst is 5 cm or greater.  Color flow can be used to evaluate for active extravasation.  Symptoms accompanying rupture include sudden severe abdominal pain or near syncope.  Free fluid may be present in the pelvis, with swirling sometimes visible for brisk bleeds. Transvaginal POCUS is highly sensitive for detecting free intraperitoneal fluid of as little as 10cc, making it a valuable adjunct when evaluating patients with suspected hemoperitoneum.3

In this case, the adnexal mass with internal echoes and associated free fluid on POCUS raised concern for a hemorrhagic cyst with rupture, prompting timely gynecologic consultation and confirming findings on CT.

Hemorrhagic cysts frequently mimic appendicitis due to overlapping localization of pain and peritoneal irritation. Studies show that up to 20-30% of reproductive-age women evaluated for appendicitis ultimately have a gynecologic etiology, underscoring the importance of early pelvic imaging.4 The patient’s leukocytosis and focal RLQ tenderness initially broadened the differential, but POCUS rapidly narrowed the diagnosis.

Most hemorrhagic ovarian cysts are self-limited and managed conservatively with pain control and follow-up imaging.5 Indications for intervention include hemodynamic instability, large-volume hemoperitoneum, or concern for ovarian torsion. In this case, the patient remained stable, with moderate hemoperitoneum on CT and no evidence of torsion or persistent bleeding.  Oftentimes with cyst rupture, repeat CBC is indicated to evaluate for ongoing blood loss.

POCUS is a recommended first-line tool in the evaluation of acute pelvic pain in the emergency department. The American College of Emergency Physicians notes the utility of pelvic ultrasound for identifying adnexal masses, cyst rupture, free fluid, and excluding ectopic pregnancy in reproductive-age females.6  While transvaginal ultrasound is the standard of care for evaluation of the ovaries, transabdominal POCUS is highly effective in early triage and in resource-limited or time-sensitive settings.

This case demonstrates the significant diagnostic value of POCUS in identifying adnexal pathology early in the clinical course, guiding appropriate consultation, and avoiding unnecessary CT radiation. Recognition of characteristic sonographic features of hemorrhagic ovarian cysts empowers emergency physicians to differentiate benign from life-threatening causes of pelvic pain.

References:

  1. Jain, K. A. (2002). Sonographic spectrum of hemorrhagic ovarian cysts. Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine, 21(8), 879–886. https://doi.org/10.7863/jum.2002.21.8.879
  2. Talat, H., Tul-Sughra Murrium, S. K., Suleman, T., Tallat, E., Naveed, F., Hussain Shah, S. J., & Hina Zulfiqar, G. E. (2022). Sonographic Findings of a Gynecological Cause of Acute Pelvic Pain – A Systematic Review. Journal of Ultrasonography, 22(90), e183–e190. https://doi.org/10.15557/jou.2022.0030
  3. Kimura, A., & Otsuka, T. (1991). Emergency center ultrasonography in the evaluation of hemoperitoneum: A prospective study. The Journal of Trauma, 31(1), 20–23. https://doi.org/10.1097/00005373-199101000-00004
  4. Andersson, R. E. B. (2004). Meta-analysis of the clinical and laboratory diagnosis of appendicitis. The British Journal of Surgery, 91(1), 28–37. https://doi.org/10.1002/bjs.4464
  5. Bottomley, C., & Bourne, T. (2009). Diagnosis and management of ovarian cyst accidents. Best Practice & Research. Clinical Obstetrics & Gynaecology, 23(5), 711–724. https://doi.org/10.1016/j.bpobgyn.2009.02.001
  6. American College of Emergency Physicians. Emergency Ultrasound Guidelines. ACEP;2016. https://www.acep.org/siteassets/sites/acep/media/ultrasound/pointofcareultrasound-guidelines.pdf
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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.

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