Case # 13: What Lies Beneath

A 30 year old male presents to the emergency department after blunt trauma to the face from an altercation. He notes he was punched several times in the face but did not pass out. His exam is notable for significant right periorbital ecchymosis and edema with inability to open his eye. You are unable to perform a direct eye exam given the significant periorbital swelling.  A CT maxillofacial is performed which shows an isolated right inferior orbital wall fracture.

Vitals: T 98.6 HR 85 BP 142/81  RR 14 O2 98% on RA

Prior to ENT consultation, a bedside ultrasound of the orbits is performed.  In spite of being unable to open the eye, what can you tell your consultant regarding your exam?

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Answer and Learning Points

Answer

Using ultrasound as an adjunct to your exam, you are able to tell the consultant that there is a normal appearing, reactive pupil and that the extra-ocular movements of the eye are intact. The consultant is appreciative over the phone and is happy to come in and see the patient whom after evaluation is discharged home with close outpatient follow up.

Learning Points

It is often the case where a patient suffers such significant facial trauma that a complete physical exam of the orbit due to periorbital swelling is not possible. Ultrasound can be a critical tool in these cases to provide useful information to assess for multiple potential pathologies. Previous studies have shown the ability of ocular ultrasound in trauma to detect elevated intracranial pressure (via optic nerve sheath diameter), retinal detachment, vitreous hemorrhage, and retrobulbar hematoma. It can also be used for early detection of muscular entrapment in the case of an orbital wall fracture, as well as performed serially for pupillary response in patients with significant neurological injury at risk for deterioration and potential herniation.

  • To evaluate extraocular movements:
    • Prepare the patient by laying the bed backwards and having their face parallel to the ceiling,  supporting the patient's head and neck with a pillow or blanket.
    • (Optional) Place a tegaderm over the eye. If you do, ensure there is no air between the tegaderm and the eyelid.
    • Place a small amount of ultrasound gel on the closed eyelid  and prepare the linear probe with the gain turned almost all the way up.
    • Stabilize your hand on the patient's nasal bridge or zygoma, with the probe marker to your left, and place the probe transverse on the orbit with minimal pressure being applied directly to the eye. This is very important in trauma as the area is likely painful and theoretically the patient could have a ruptured globe.
    • Adjust the depth to ensure the optic nerve is just visualized at the bottom of the screen. The anterior chamber and lens should be used as visual landmarks to ensure you are in proper location.
    • Next, have the patient look left and right, then turn the probe to a sagittal orientation and have the patient look up and down. During these maneuvers you should be evaluating for symmetric movements of the orbit in each direction.
    • If you do not appreciate symmetric movements of the orbit in all directions then you may have entrapment of an extraocular muscle.
  • To evaluate for pupillary response and shape:
    • Be sure to dim the lights in the room prior to performing this exam to allow for an adequate pupillary response.
    • Gently apply the linear probe with gel in a transverse plane just inferior to the eye, angling superiorly towards the patient's head (Depending on the location of the swelling around the eye, you can also place the probe superior to the eye, angling inferiorly towards the patient's feet).
    • Keep flattening out your probe angle relative to the skin until you have a cross section of the pupil and iris in view.
    • The pupil should be evaluated for symmetry as an asymmetric or oblong pupil could suggest globe rupture. You can then shine a light in the affected or non-affected eye (consensual light reflex) and observe the pupil for constriction.

 

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Blaivas M. Bedside emergency department ultrasonography in the evaluation of ocular pathology. Acad Emerg Med 2000;7:947-50.
    2. Blaivas M, Theodoro D, Sierzenski P. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med 2002;9(8):791-9.
    3. Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med 2008;15(2):201-4.
    4. Tayal VS, Neulander M, Norton HJ, et al. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med 2007;49(4):508-14.
    5. Harries A, et al. Ultrasound assessment of extraocular movements and pupillary light reflex in ocular trauma. Am J Emerg Med 2010 28(8):956-9.

Case # 12: Bilateral Vision Loss

A 45 year old male with poorly controlled DM presents with bilateral vision loss. His right eye vision acutely worsened 3 days ago with the sensation of a curtain moving back and forth across his visual field. Today his left eye vision acutely worsened with flashes and floaters occurring. He denies any trauma, headache, or new medications.

Vitals: T 98.6 HR 90 BP 149/87  RR 16 O2 98% on RA

A bedside ultrasound of the orbits is performed,  what is the next best step in management?

Left Eye

Left Eye

Right Eye

Right Eye

Answer and Learning Points

Answer

The ultrasound clips demonstrate hypoechoic material in the orbits bilaterally, swirling around with subtle eye movement. This is consistent with bilateral vitreous hemorrhage. The diagnosis was discussed with the patient and he was referred to ophthalmology clinic for dilated eye exam in 24 hours.

Learning Points

Vitreous hemorrhage is a common diagnosis (though usually unilateral) seen in poorly controlled diabetes. The most frequent etiologies include proliferative diabetic retinopathy, posterior vitreous detachment, and ocular trauma, with trauma more common in patients under the age of 40. Since it is difficult to obtain  a good physical exam of the posterior aspects of the eye without a dilated exam, there is high utility in the use of point of care ultrasound in evaluating for acute pathology.  It can be used to distinguish vitreous hemorrhage and retinal detachment, which have significantly different prognoses and treatment pathways. To perform an ocular ultrasound, follow these steps:

    1. Prepare the patient by laying the bed backwards and having their face parallel to the ceiling,  supporting the patient's head and neck with a pillow or blanket.
    2. Place a tegaderm over the eye (optional). If you do, ensure there is no air between the tegaderm and the eyelid.
    3. Place the ultrasound gel on the tegaderm and prepare the linear probe with the gain turned almost all the way up (this will help you visualize both retinal detachment and vitreous hemorrhage.
    4. Stabilize your hand on the patient's nasal bridge or zygoma, with the probe marker to your left, and place the probe transverse on the orbit with minimal pressure being applied directly to the eye.
    5. Adjust the depth to ensure the optic nerve is just visualized at the bottom of the screen. The anterior chamber and lens should be used as visual landmarks to ensure you are in proper location. Next, have the patient look up, down , left and right (oculokinetic echography), to assess for any abnormalities in the posterior aspects of the eye.
    6. Repeat this technique with the probe marker pointed superiorly and have the patient again look in all directions.

Retinal detachment: The common POCUS findings include a thin linear structure tethered to the optic nerve.  It flaps back and forth as the eye is moved giving it the appearance of “swaying seaweed”. This is an ophthalmologic emergency, especially if the macula is still attached,  the ophthalmologist should be immediately consulted.

Vitreous hemorrhage: You will notice a diffuse mobile opacity often described as a “snow globe” that is exacerbated with moving the eye from side to side. If this is seen in a diabetic patient with floaters, there is a high likelihood that the diagnosis is a vitreous hemorrhage. These patients will still need follow up with ophthalmology for further management, but typically there will not be an emergent intervention.

Author

This post was written by Sam Frenkel, MD, PGY-2 UCSD EM. It was reviewed by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Yoonessi R, Hussain A, Jang TB. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med. 2010;17(9):913-7.
    2. Dawson, Mallin. Introduction to Bedside Ultrasound, Volume 2. 2013. Apple iBook.
    3. Kilker B, Holst J, Hoffmann B. Bedside ocular ultrasound in the emergency department. Eur J Emerg Med. 2014;21(4):246-253.
    4. Shinar Z, Chan L, Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med. 2011;40(1):53-57. 

Case # 11: Look and You Will Find

A 32 year old healthy female with no past medical history presents to the emergency department with left sided flank pain x 2 days.

Vitals: T 98.6 HR 72 BP 126/82  RR 12 O2 98% on RA

A bedside ultrasound of the left kidney is performed, what is the next best step in management?

Q40_Simple cyst

Answer and Learning Points

Answer

The ultrasound image demonstrates a simple cyst located in the cortex of the kidney. The cyst can be described as anechoic, homogenous, with thin and smooth walls, and would be a type I lesion according to the Bosniak classification system (image below). There is no evidence to suggest obstructing hydronephrosis. The Bosniak classification for renal cysts was developed in the 1980s as an attempt to standardize the description and management of complex renal lesions. Based on classification of the renal lesion, the likelihood of malignancy can also be predicted. While the Bosniak classification was initially described and validated with CT imaging, newer data suggests that ultrasound may be sufficient to follow renal cysts that are minimally complex (Bosniak I & II).

Learning Points

 

    • Given the bedside ultrasound demonstrates a Bosniak I lesion in the left kidney, the patient can be reassured that this finding is very unlikely to be malignant and she can be referred to a primary care provider for follow up in several weeks for formal outpatient renal ultrasound.
    • Incidental findings are frequently found on point of care ultrasound and while most of them are benign it is of utmost importance to ensure proper follow up when identified. Specifically with renal cysts, this is a common occurrence and most can be followed with renal ultrasound as long as they are simple (Bosniak I or II).
    • One pitfall to be aware of is that renal cysts can be mistaken for hydronephrosis and lead to unnecessary imaging and work up (especially in patients presenting with acute flank pain). Therefore it is critical to note the differences between a simple renal cyst and hydronephrosis. As seen in the comparison above renal cysts tend to (but not always) be located in the renal cortex and are both spherical and very well circumscribed. On the other hand, hydronephrosis is centrally located, and tends to branch outwards like a tree. If there is uncertainty, I recommend performing evaluation in both transverse and longitudinal planes to fully characterize your finding. The opposite kidney in the patient can also be used for comparison.

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

1. Muglia VF, Westphalen AC. (2014) Bosniak classification for complex renal cysts: history and critical analysis. Radiol Bras 47(6): 368–373.

2. McGuire BB, Fitzpatrick JM. (2010) The diagnosis and management of complex renal cysts. Curr Opin Urol 20:349–354.

3. Case courtesy of Dr Matt Skalski, Radiopaedia.org. From the case rID: 20989

Case # 10: A Mechanical Issue

A 32 year old male was carrying a heavy pipe overhead with his right arm and slipped falling forward, onto the right side. He notes pain in the right shoulder, worse with any movement. His right arm is flexed and internally rotated for comfort.

Vitals: T 98.6 HR 95 BP 143/91  RR 14 O2 98% on RA

A bedside ultrasound of the right shoulder is performed, what is the next best step in management?

Screen Shot 2017-11-18 at 11.09.45 AM

Answer and Learning Points

Answer

Shoulder dislocation reduction. The ultrasound image shows anterior displacement of the humeral head with respect to the glenoid fossa consistent with an anterior shoulder dislocation. A hematoma is also noted within the joint space which is very commonly associated with a traumatic shoulder dislocation. 

Ultrasound diagnosis of anterior shoulder dislocation

Learning Points

    • Ultrasound is useful for both the initial diagnosis and reduction confirmation of a shoulder dislocation, as well as for intra-articular injection of local anesthetic; however in a traumatic dislocation, an initial x-ray should be obtained to evaluate for any associated fracture.
    • To perform the exam, a low frequency curvilinear transducer should be used. The operator should stand behind the patient, on the side of the affected shoulder, and place the ultrasound system directly in front of the patient for easy visualization. The probe should be placed on the posterior aspect of the scapula, parallel and just inferior to the scapular spine. This will allow direct visualization of the glenohumeral joint.
  • Proper probe placement for evaluation of glenohumeral joint.
    • In a normal shoulder the glenoid and humeral head articulate nicely and this can be appreciated on ultrasound with internal and external rotation of the patient's arm, however with dislocation, the humeral head and glenoid will not be aligned. In anterior dislocation, the humeral head will be deep to the glenoid, while in a posterior dislocation, the humeral head will be more superficial to the glenoid.
  • Normal glenohumeral ultrasound anatomy
    • Ultrasound is especially useful to confirm successful shoulder relocation and prevent both a prolonged stay in the emergency department waiting for a post reduction x-ray, as well as re-sedation if this was required for a difficult shoulder reduction.
    • Lastly, this same ultrasound view can be used for in-plane needle guidance to provide intra-articular anesthesia using a lateral needle entry approach.
    • For a 5 minute video tutorial on  ultrasound for shoulder dislocation , click here to watch this excellent video at 5 Minute Sono.
In vivo shoulder reduction!

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

Case # 9: A Transplant Dilemma

A 52 year old male with a h/o kidney transplant presents to the emergency department with pain over his transplanted kidney site (right pelvic region). He also notes increased weakness, nausea and a significant decrease in urine output. He denies any fever. He states he is compliant with his anti-rejection medications.

Vitals: T 99.0 HR 105 BP 165/91  RR 18 O2 98% on RA

A bedside ultrasound is performed, what is the next best step in management?

tx_severe hydro

Answer and Learning Points

Answer

Insertion of foley catheter. The clip above demonstrates severe hydronephrosis of the patient's transplanted kidney. A foley was inserted in the emergency department with immediate output of 1.5 L of clear urine. The patient was found to be in renal failure secondary to his urinary outlet obstruction. He was admitted to transplant surgery and his renal function improved over the next day; he was discharged home with a leg bag and urology follow up. Below is a repeat ultrasound of his transplanted kidney after drainage of his bladder: 

Learning Points

    • Urinary obstruction in a transplanted kidney can be missed initially as pain over the patient's graft site and decreased urine output is easily contributed to possible rejection or infection.
    • The differential diagnosis of acute renal failure in the transplanted kidney is broad (see table below) and emergency department management should include a thorough evaluation for prerenal, intrinsic and post renal causes, in consultation with a transplant service.
    • All renal transplant patients presenting with acute renal failure should have a formal renal ultrasound with doppler to evaluate the graft however often this is not available immediately and a bedside ultrasound can assist with rapid identification of acute urinary obstruction.

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Kadambi PV., Brennan DC., Chon J. (2017). Evaluation and diagnosis of the patient with renal allograft dysfunction. In T.W. Post, B. Murphy, & A. Lam (Eds.), UptoDate. Available from https://www.uptodate.com/contents/evaluation-and-diagnosis-of-the-patient-with-renal-allograft-dysfunction

Case # 8: A Case of Comparision

A 40 year old male presents to the emergency department with pain to the entire right thumb and wrist for 1 day.  He notes that he suffered a small puncture wound to his right thumb 1 day ago while working on his car.  The patient has notable circumferential, non-erythematous swelling to his right thumb with tenderness along the flexor tendon. There is also fullness of the dorsum of his wrist. He is holding his fingers flexed and has pain radiating into the wrist with any movement of his fingers or wrist, especially with extension of his fingers.

Vitals: T 98.7 HR 90 BP 132/81  RR 13 O2 98% on RA

A bedside ultrasound is performed, what is the next best step in management?

Normal Left Thumb in Long Axis

Normal Left Thumb in Long Axis

Abnormal Right Thumb in Long Axis

Abnormal Right Thumb in Long Axis

Answer and Learning Points

Answer

Empirical antibiotic therapy and orthopedic surgery consultation for infectious flexor tenosynovitis (FTS).  The patient meets 4 out of 4 Kanavel's signs and has ultrasound evidence of FTS suggested by a thickened tendon with surrounding anechoic fluid.

Short Axis View of Right 1st Digit demonstrating hypoechoic fluid surrounding tendon.

Learning Points

    • FTS is often a clinical diagnosis and examination (Kanavel's signs) is thought to have high sensitivity (91.4-97.1%) but low specificity (51.3-69.2%) for infectious FTS [2]; however a negative exam does not rule it out completely.
      • Kanavel's signs include:
        • Finger held in slight flexion
        • Fusiform swelling
        • Tenderness along the flexor tendon sheath
        • Pain with passive extension of the digit
    • FTS is treated with empirical antibiotic  therapy as well as early surgical debridement and drainage. Delays in diagnosis can lead to local spread of infection, compartment syndrome and necrosis.
    • While there is not high quality evidence describing the use of emergency department point of care ultrasound (POCUS) to diagnose FTS, previous radiographic studies have found ultrasound to be more sensitive than clinical exam for detecting tenosynovitis [3].
    • Common ultrasound findings for FTS include:
      • Hypoechoic or anechoic edema or debris within the tendon sheath
      • +/- thickening of the tendon sheath
    • The ultrasound examination should be performed using a linear probe, examining the affected tendon (and normal tendon on other hand for comparison), in both the longitudinal and transverse plane.
      • Small rocking or fanning motions should be used to ensure perpendicular orientation of the probe to the tendon to avoid artifact secondary to anisotropy.
    • As in all uses of POCUS in the emergency department setting, findings should be interpreted in conjunction with clinical examination and history when evaluating for infectious FTS. We believe POCUS for infectious FTS can be used to increase diagnostic certainty and even expedite care and aggressive treatment however a normal exam should not be used to rule out this diagnosis.

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Padrez, K., Bress, J., Johnson, B., & Nagdev, A. (2015). Bedside Ultrasound Identification of Infectious Flexor Tenosynovitis in the Emergency Department. Western Journal Of Emergency Medicine, 16(2), 260-262. doi:10.5811/westjem.2015.1.24474
    2. Kennedy CD, e. (2017). Differentiation Between Pyogenic Flexor Tenosynovitis and Other Finger Infections. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 21 October 2017, from https://www.ncbi.nlm.nih.gov/pubmed/28720000
    3. Hmamouchi I, Bahiri R, Srifi N, et al. A comparison of ultrasound and clinical examination in the detection of flexor tenosynovitis in early arthritis. BMC Musculoskelet Disord. 2011;12(1):91.

Case # 7: A Case of Asymmetry

A 22 year old male presents to the emergency department with a sore throat for 1 week. The pain is predominately on the left side and is associated with difficulty opening his mouth and fever. He was placed on amoxicillin 3 days ago but notes that his symptoms have progressed. He appears uncomfortable.

Vitals: T 101.4 HR 105 BP 132/81  RR 14 O2 98% on RA

A bedside ultrasound is performed, what is the next best step in management?

PTA

Answer and Learning Point

Answer

Incision and drainage. The patient presents with lateralizing pharyngitis symptoms associated with fever and trismus concerning for peritonsillar abscess (PTA). The ultrasound clip demonstrates a well circumscribed, hypoechoic fluid collection abutting the left tonsil confirming this diagnosis (see color overlay below).

Previously, physicians relied solely on the physical exam findings of peritonsillar swelling and uvular deviation to make the diagnosis of PTA. However, this approach lacks accuracy, with studies showing a sensitivity and specificity of 75% and 50% respectively [1]. This uncertainty leads to increased CT utilization, repeat drainage attempts and ENT consultation. Intraoral ultrasound is a novel technique that can be used by emergency physicians (EP), both for diagnosis and drainage of PTA. A recent randomized control trial found the use of intraoral ultrasound (vs. traditional landmark technique) to be significantly more reliable for differentiating between PTA and peritonsillar cellulitis. Additionally, this study also demonstrated increased success in PTA drainage by EPs with the use of intraoral ultrasound guidance [2].

Data from Costantino et al

Learning Points

    • An endocavitary probe should be used when PTA is suspected to differentiated between PTA and peritonsillar cellulitis; and assist with drainage if necessary.
    • If an endocavitary probe is not available, or if the patient cannot open their mouth wide enough to pass the probe, an alternative approach, known as the telescopic submandibular approach can also be used and is explained here.
    • When using ultrasound, the distance from the oral mucosa to the center of the PTA should be measure. The plastic sheath of an 18-gauge needle (preferably a spinal needle to allow the barrel of the syringe to be outside of the patients mouth) should be cut to this length to prevent puncturing any deeper structures during drainage.

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Scott PM, e. (2017). Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 2 October 2017, from https://www.ncbi.nlm.nih.gov/pubmed/10435129
    2. Costantino TG, e. (2017). Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 2 October 2017, from https://www.ncbi.nlm.nih.gov/pubmed/22687177

Case # 6: Not Your Average Syncope

A 25 year old female presents to the emergency department with acute abdominal pain and a syncopal episode. She notes a positive home urine pregnancy test 1 week ago. She appears mildly uncomfortable with a tender abdomen. A bedside ultrasound is performed, a clip is shown below. What are the findings of the ultrasound clip and what is your diagnosis?

Vitals: T 98.7 HR 120 BP 95/72  RR 20 O2 98% on RA

Image courtesy of Elizabeth Owen, MD

Image courtesy of Elizabeth Owen, MD

Answer and Learning Point

Answer

The ultrasound clip demonstrates a large amount of free fluid between the spleen and the diaphragm. There is also a sliver of echogenic material above the capsule of the spleen suggestive of clotted blood. Morison’s pouch (not shown) was also noted to be significantly positive for free fluid. Given the patient’s unstable vitals and the clinical history, this was concerning for a ruptured ectopic pregnancy. OB was consulted immediately and the patient was taken to the OR. The diagnosis of ruptured ectopic pregnancy was confirmed during laparotomy. The patient did well.

While the FAST exam has traditionally been used in trauma, there has been increasing use to diagnose intra-abdominal bleeding as a source of hypotension in medical patients. Specifically with regards to ectopic pregnancy, data has suggested that positive free fluid in Morison’s pouch is highly predictive of operative intervention with a positive likelihood ratio of 112 (Sens 50%, Spec 99.5) [1]. A retrospective study in 2001, looking at emergency medicine physician performed ultrasound, demonstrated that identifying patients with a suspected ectopic pregnancy and free fluid in Morison’s pouch decreased the time to diagnosis and treatment [2].

Learning Points

    • All women of childbearing age presenting with abdominal pain and syncope should be presumed to have a ruptured ectopic pregnancy until proven otherwise
    • Transabdominal ultrasound to evaluate for free fluid should be utilized by the emergency physician in cases of suspected ruptured ectopic pregnancy to assist with risk stratification and rapid diagnosis
    • As in trauma patients, evaluation for free fluid should be performed with the patient supine (or preferably Trendelenburg position as this increases the sensitivity of identifying free fluid in Morison’s pouch [3])
    • A curvilinear (preferred) or phased-array probe should be used to evaluate the abdomen for free fluid and it is critical to completely visualize the most inferior portion of Morison's Pouch, including the caudal tip of the liver & inferior renal pole, as this is where free fluid will collect first
    • A positive pregnancy test and positive free fluid in Morison’s pouch is essentially diagnostic of a ruptured ectopic pregnancy (though ruptured splenic artery aneurysm should also remain on your differential)

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Moore C, Todd WM, O’Brien E. Free Fluid in Morison’s Pouch on Bedside Ultrasound Predicts Need for Operative Intervention in Suspected Ectopic Pregnancy. Acad Emerg Med. 2007; 14(8):755-8.
    2. Rodgerson JD, Heegaard WG, Plummer D, Hicks J, Clinton J, Sterner S. Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Acad Emerg Med. 2001; 8:331–6.
    3. Abrams BJ, Sukumvanich P, Seibel R, Moscati R, Jehle D. Ultrasound for the detection of intraperitoneal fluid: the role of Trendelenburg positioning. Am J Emerg Med. 1999;17:(2)117-20.

Case # 5: It’s Not Always Blood

A middle aged male s/p TURBT (transurethral resection of bladder tumor) 1 day ago presented with lower abdominal pain and no urine output from his foley catheter. A bladder scan was performed which was ~ 50 cc. What's the dx?

Vitals: T 98.7 HR 110 BP 117/70  RR 18 O2 98% on RA

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Answer and Learning Point

Answer

The image above is of Morrison's pouch, demonstrating significant free fluid within the peritoneal cavity. Given the recent TURBT and lack of urinary output from the patient's foley catheter, this suggests that the fluid identified is consistent with urine secondary to intraperitoneal bladder perforation. This was later confirmed by CT cystogram and shortly after the patient was taken to the operating room for definitive repair.

Learning Points

    • Bladder perforation from TURBT is relatively rare with an incidence of clinically significant perforations of 1.3%. Furthermore, intraperitoneal bladder perforation only accounts for ~17% of these, making it quite uncommon [1]. A small number of intraperitoneal bladder perforations are also associated with small bowel or colon injury [2].
    • While around 30% of bladder ruptures from TURBT are detected intraoperatively, the remainder present postoperatively (mean time to diagnosis of 6 days) with lower abdominal pain and/or decreased urine output [2].
    • CT cystogram is the gold standard for diagnosis of bladder perforation and can provide information on location of the perforation as well as whether it is intraperitoneal or extraperitoneal [3].
    • As demonstrated in the case above, ultrasound can be used as an imaging adjunct at the bedside to rapidly detect intraperitoneal fluid to expedite consultation with urologic services and definitive CT imaging.
    • The treatment of extraperitoneal perforation of the bladder is usually conservative via prolonged foley catheter drainage. For intraperitoneal lesions, open-surgical exploration and repair is recommended [1-2].
    • Emergency department management of these patients should consist of rapid diagnosis, broad spectrum antibiotic therapy, fluid resuscitation as needed, and urgent urological consultation.

Author

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Rausch S, e. (2017). [Transurethral resection of bladder tumors: management of complications]. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 2 September 2017, from https://www.ncbi.nlm.nih.gov/pubmed/?term=24806801
    2. Golan S, e. (2017). Transurethral resection of bladder tumour complicated by perforation requiring open surgical repair - clinical characteristics and oncological outc... - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 2 September 2017, from https://www.ncbi.nlm.nih.gov/pubmed/20860654
    3. COMPLICATIONS OF TRANSURETHRAL RESECTION OF BLADDER TUMORS. Eric A. Singer MD, MA and Ganesh S. Palapattu MD. Complications of Urologic Surgery: Prevention and Management, Chapter 25, 295-302

Case # 4: To Bolus or Not to Bolus?

 

 

A 67 year old male with a PMHx of DM presents with a chief complaint of cough and generalized weakness.

Vitals: T 102.4 HR 127 BP 77/58  RR 24 O2 88% on RA

You place the patient on O2 via nasal cannula and activate the sepsis protocol. He is empirically treated with broad spectrum antibiotics and IVFs are started. The chest x-ray shows multifocal pneumonia and you call hospital medicine to admit the patient.  “What’s the blood pressure now,” the hospitalist asks. You glance at the monitor and murmur back, “92/63, but he looks pretty good.” The hospitalist asks you to insert a central line, start vasopressors, and contact the ICU. Instead, you wheel the ultrasound machine into his room, and ultrasound his IVC. Does this patient require a central line and vasopressors?

Answer and Learning Point

Answer

No, the patient’s IVC is small and collapsing almost 75% with normal respiratory variation. This predicts a fluid-responsive state. The patient was given another liter of lactated ringers, his blood pressure improved to 108/69, and his lactate cleared. You start maintenance IV fluids, call the hospitalist back, and the patient is admitted upstairs and does well.

Learning Points

    • Fluid responsiveness is a controversial topic that continues to plague emergency medicine physicians and intensivists alike
    • In patients whom a fluid bolus is being considered, ultrasound can be a useful tool to assess for cardiac function, lung fluid status (interstitial edema) and whether a patient will improve their cardiac output in response to this fluid challenge
    • A recent study showed that the cIVC (inferior vena cava collapsibility) can be used as a predictor of who will be a fluid responder [1]
      • cIVC = (IVC expiratory diameter - IVC inspiratory diameter)/IVC expiratory diameter
      • Patients with a cIVC > 25% are likely to be fluid responders (LR + 4.56)
      • Patients with a cIVC < 25% are unlikely to be fluid responders (LR - 0.16)
    • The IVC should be examined in the subxiphoid region with the probe in a sagittal plane, and can be found by first identifying the right atrium and following this caudally
      • A back-up approach involves using the liver as an acoustic window , placing the probe in the mid axillary line in a coronal plane,  and fanning anteriorly and posteriorly until the IVC is visualized
      • The IVC should be measured 3 cm caudal to the junction of the right atrium and IVC [2]
    • M-mode can be used to evaluate the cIVC and has the advantage of measuring the exact same spot along the IVC over an extended period of time
    • As with all adjuncts to clinical decision making, fluid responsiveness should not be determined solely on a single ultrasound measurement such as cIVC but should be taken into context with the rest of the clinical picture

Author

This post was written by Amir Aminlari, MD, Ultrasound Fellowship Director at UCSD.

References

Corl KA, e. (2017). Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathing critically-ill patients. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 19 August 2017, from https://www.ncbi.nlm.nih.gov/pubmed/28525778

Nagdev AD, e. (2017). Emergency department bedside ultrasonographic measurement of the caval index for noninvasive determination of low central venous pressure. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 19 August 2017, from https://www.ncbi.nlm.nih.gov/pubmed/19556029