Month: June 2025

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Case 49: ARDS

Kayhon Rabbani

A 22 year old male who has no past medical history presented with a 3 day history of viral URI-like symptoms with sore throat, dry cough, shortness of breath, and dyspnea on exertion. The patient was an active marine recruit with many other members in his company being sick during this time. Shortly prior to arrival, the patient became unable to walk short flights of steps without becoming short of breath. The patient otherwise had no respiratory or cardiac history. He had no family history of sudden cardiac death or early MI. The patient denied fevers, chills, chest pain, pleuritic chest pain, positional chest pain, abdominal pain, flank pain, dysuria, hematuria, diarrhea, or any other associated symptoms.

Vitals: BP 87/56 | Pulse 96  | Temp 98.6 °F (37 °C)  | Resp 28 | SpO2 92%

On physical examination, the patient was alert and in acute distress. Patient presented with tachycardia, hypotension, hypoxia, and tachypnea. Mucous membranes were dry. Respiratory exam revealed decreased air movement, breath sounds, and faint crackles in the right lower lung field.

A bedside echocardiogram was performed.

Figure 1: POCUS echocardiogram in 4 chamber apical view demonstrating a small pericardial effusion.

Figure 2: POCUS lung exam revealed bilateral B lines anterosuperior aspects of the lungs.

Figure 3: Lung consolidation and pleural effusion demonstrating positive "spine sign."

The patient was initially stable but desaturated upon position change. The patient was persistently hypoxic with significant work of breathing on BiPAP before escalating to intubation, remaining persistently hypoxic in the mid 80s post intubation on a ventilator.

Discussion

Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure characterized by rapid onset of widespread inflammation in the lungs. It is defined by the Berlin criteria, which include acute onset within one week of a known clinical insult, bilateral opacities on chest imaging not fully explained by cardiac failure or fluid overload, and severe hypoxemia with a PaO2/FiO2 ratio of less than 300 mmHg.[1-3]

Common differential diagnoses for ARDS include cardiogenic pulmonary edema, pneumonia, and pulmonary embolism. Cardiogenic pulmonary edema can be differentiated by the presence of signs of fluid overload and cardiac dysfunction, often confirmed by echocardiography. Pneumonia may present with localized infiltrates and clinical signs of infection, while pulmonary embolism typically presents with sudden onset dyspnea, pleuritic chest pain, and may be confirmed by imaging studies such as CT pulmonary angiography.[1][4-5]

On physical examination, patients with ARDS often present with tachypnea, dyspnea, and diffuse crackles on auscultation. Hypoxemia is a hallmark, and patients may exhibit signs of respiratory distress such as use of accessory muscles and cyanosis. Imaging studies, particularly chest radiography, typically reveal bilateral alveolar infiltrates. Computed tomography (CT) scans can provide more detailed images, showing patchy or diffuse ground-glass opacities and consolidations.[1-2][6]

Point-of-care ultrasound (POCUS) is a valuable tool in the diagnosis and management of ARDS. Lung ultrasound findings in ARDS include the presence of multiple B-lines (indicating interstitial syndrome), spared areas, pleural line thickening, and subpleural consolidations. Cardiac ultrasound can help differentiate ARDS from cardiogenic pulmonary edema by assessing left ventricular function and the presence of pleural effusions.[7] Combining lung and cardiac ultrasound can enhance diagnostic accuracy and guide management decisions in critically ill patients with acute hypoxemic respiratory failure.[7]

References

  1. Saguil, A., & Fargo, M. V. (2020). Acute Respiratory Distress Syndrome: Diagnosis and Management. American family physician, 101(12), 730–738.
  2. Meyer, N. J., Gattinoni, L., & Calfee, C. S. (2021). Acute respiratory distress syndrome. Lancet (London, England), 398(10300), 622–637. https://doi.org/10.1016/S0140-6736(21)00439-6
  3. Matthay, M. A., Zemans, R. L., Zimmerman, G. A., Arabi, Y. M., Beitler, J. R., Mercat, A., Herridge, M., Randolph, A. G., & Calfee, C. S. (2019). Acute respiratory distress syndrome. Nature reviews. Disease primers, 5(1), 18. https://doi.org/10.1038/s41572-019-0069-0
  4. Papazian, L., Calfee, C. S., Chiumello, D., Luyt, C. E., Meyer, N. J., Sekiguchi, H., Matthay, M. A., & Meduri, G. U. (2016). Diagnostic workup for ARDS patients. Intensive care medicine, 42(5), 674–685. https://doi.org/10.1007/s00134-016-4324-5
  5. Sekiguchi, H., Schenck, L. A., Horie, R., Suzuki, J., Lee, E. H., McMenomy, B. P., Chen, T. E., Lekah, A., Mankad, S. V., & Gajic, O. (2015). Critical care ultrasonography differentiates ARDS, pulmonary edema, and other causes in the early course of acute hypoxemic respiratory failure. Chest, 148(4), 912–918. https://doi.org/10.1378/chest.15-0341
  6. Zompatori, M., Ciccarese, F., & Fasano, L. (2014). Overview of current lung imaging in acute respiratory distress syndrome. European respiratory review : an official journal of the European Respiratory Society, 23(134), 519–530. https://doi.org/10.1183/09059180.00001314
  7. Corradi, F., Brusasco, C., & Pelosi, P. (2014). Chest ultrasound in acute respiratory distress syndrome. Current opinion in critical care, 20(1), 98–103. https://doi.org/10.1097/MCC.0000000000000042
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Case 48: The Gut Feeling Was Right

Kanchi Mehta

A 38yo male with history of diverticulitis complicated by sepsis presented to the ED with lower quadrant abdominal pain. He noted that the pain started 2 weeks ago and became worse. He reported normal bowel movements in the morning, denied fever/chills, nausea, vomiting, or genitourinary symptoms. A recent colonoscopy was notable for moderate sigmoid diverticulosis and a 4mm sessile sigmoid polyp that was resected.

Past medical history: Diverticulitis, ADHD, eczema, insomnia, loose stools

No past surgical history.

Vitals: BP 107/65 | Pulse 73 | Temp 98 °F (36.7 °C) | Resp 18 | BMI 25.35 kg/m²

A bedside ultrasound was performed, and the following image was obtained:

Figure 1: Diverticula with bowel wall edema

Uncomplicated acute diverticulitis characteristics on ultrasound are:

  • thickened bowel wall >5mm
  • presence of diverticula with focal outpouching or bowel wall discontinuity
  • noncompressible pericolic fat inflammation with hyperechogenic halo around bowel serosa
  • sonographic tenderness with compression

Outcome:

General surgery was consulted for possible surgical evaluation, which was deferred after findings on CT noted to be non-surgical. Patient was sent home with ciprofloxacin 500mg BID for 7 days and metronidazole 500mg TID for 7 days. Patient was also educated on return precautions.

References:

  1. Nazerian P, Gigli C, Donnarumma E, et al. Diagnostic accuracy of point-of-care ultrasound integrated into clinical examination for acute diverticulitis: a prospective multicenter study. Ultraschall der Med 2021;42(6):614–22. English.
  2. Cohen A, Li T, Stankard B, et al. A prospective evaluation of point of care ultrasonographic diagnosis of diverticulitis in the emergency department. Ann Emerg Med 2020;76(6):757–66.
  3. Damewood, Sara et al. “Gastrointestinal and Biliary Point-of-Care Ultrasound.” Emergency medicine clinics of North America vol. 42,4 (2024): 773-790. doi:10.1016/j.emc.2024.05.006
  4. https://www.ultrasoundcases.info/cases/abdomen-and-retroperitoneum/gastrointestinal-tract/diverticulosis-and-diverticulitis/
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Case 47: Abdominal Wall Perforation

Cloie June Chiong

A 37 year old male with a past medical history of ulcerative colitis, now status-post total abdominal colectomy with a creation of end ileostomy, left-sided ureteral lysis due to retroperitoneal fibrosis, robotic-assisted proctectomy with creation of an ileoanal pouch and diverting loop ileostomy, extensive lysis of adhesions and right-sided ureterolysis, and ileostomy takedown in 2024 presents to the ED with diffuse abdominal pain that began this morning and sweats beginning last night. The pain was 4/10 with rest, 7/10 with standing, and 8/10 with ambulation. The pain radiated to the right shoulder this morning while lying in bed. He denied nausea and vomiting. He endorsed intermittent testicular pain, reduced oral intake, and decreased voids, but urinated and defecated without pain. Did not report any abnormal concerns with stool input through anastomosis.

Vitals: BP: 122/78 | Pulse: 78 | Temp: 98.6°F | Resp: 16 | SpO2: 100%

Physical Exam showed a soft, flat, non-distended abdomen. A surgical scar was present. There was generalized abdominal tenderness and guarding throughout the abdomen with palpation, without rebound or rigidity. He had tenderness in the lower quadrants > upper quadrants, left > right. There was no hernia present. The remainder of the physical exam was unremarkable.

Labs: WBC 16.9

A bedside ultrasound was performed on the abdomen:

Figure 1: Pneumoperitoneum

Figure 2: Pouchitis

Discussion:

Pneumoperitoneum, a critical condition marked by the presence of free air in the abdominal cavity, typically arises from a perforated hollow viscus and is a rare yet serious cause of acute abdominal pain1,2. This condition requires immediate surgical intervention due to its potential for high mortality. Detecting serious conditions based on abdominal pain alone during physical examinations is challenging due to low sensitivity. Differential diagnoses for acute abdominal pain may include inflammatory bowel disease complications, intra-abdominal abscesses, perforations, bowel obstructions, mesenteric ischemia, and pancreatitis.

While abdominal X-ray and computed tomography of the abdomen are considered as more conventional standards for imaging, ultrasound also serves as a rapid, radiation-free diagnostic tool for detecting gastrointestinal perforations3. The diagnostic performance of ultrasonography for pneumoperitoneum has shown to have a sensitivity of 93%, accuracy of 90%, specificity of 64%, and positive predictive value of 97%, versus plain radiography (79%, 77%, 64%, and 96%, respectively)4.

One key ultrasonographic finding in cases of gastrointestinal perforation is the presence of the peritoneal stripe sign, which shows equidistant, horizontal or vertical reverberations posterior to the abdominal wall and can extend to the lower edge of the monitor, creating a striped pattern of alternating dark and light hyperechoic lines. A “comet tail” appearance may also be present as a result of reverberation artifacts caused by pockets of free air, which acts as a barrier to ultrasound waves2,5.

An additional technique used in ultrasound for detecting a pneumoperitoneum is the "shifting phenomenon." This involves repositioning the patient to observe the movement of air and the peritoneal stripe sign within the peritoneal cavity, confirming the presence of free air6. The "scissors maneuver" further confirms this technique by placing a linear probe in the right epigastric region without abdominal compression; reverberation artifacts are observed and manipulated by pressing and releasing the caudal end of the probe, showing movement of the free air and reverberation artifacts away from the anterior liver5.

The use of ultrasound not only confirmed the presence of pneumoperitoneum, but also allowed for immediate surgical intervention, underscoring its high sensitivity and the crucial impact of rapid assessment capabilities in emergency settings. Point-of care ultrasound should be considered as a potential first-line form of diagnostic imaging for abdominal perforation.

References:

  1. Nazerian, P., Tozzetti, C., Vanni, S. et al. Accuracy of abdominal ultrasound for the diagnosis of pneumoperitoneum in patients with acute abdominal pain: a pilot study. Crit Ultrasound J 7, 15 (2015). https://doi.org/10.1186/s13089-015-0032-6
  2. Chao, A., Gharahbaghian, L., & Perera, P. (2015). Diagnosis of pneumoperitoneum with bedside ultrasound. The western journal of emergency medicine, 16(2), 302. https://doi.org/10.5811/westjem.2014.12.24945
  3. Jiang L, Wu J, Feng X. The value of ultrasound in diagnosis of pneumoperitoneum in emergent or critical conditions: A meta-analysis. Hong Kong Journal of Emergency Medicine. 2019;26(2):111-117. doi:10.1177/1024907918805668
  4. Bacci, M., Kushwaha, R., Cabrera, G., & Kalivoda, E. J. (2020). Point-of-Care Ultrasound Diagnosis of Pneumoperitoneum in the Emergency Department. Cureus, 12(6), e8503. https://doi.org/10.7759/cureus.8503
  5. Taylor, M.A., Merritt, C.H., Riddle, P.J. et al. Diagnosis at gut point: rapid identification of pneumoperitoneum via point-of-care ultrasound. Ultrasound J 12, 52 (2020). https://doi.org/10.1186/s13089-020-00195-2
  6. Yum, J., Hoffman, T., & Naraghi, L. (2021). Timely Diagnosis of Pneumoperitoneum by Point-of-care Ultrasound in the Emergency Department: A Case Series. Clinical practice and cases in emergency medicine, 5(4), 377–380. https://doi.org/10.5811/cpcem.2021.4.52139
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Case 46: Skin and Soft Tissue Infection

Alma Fregoso Leyva

73 year old male with a past medical history of coronary artery disease, congestive heart failure, COPD, pulmonary fibrosis on 5L NC, and left lower extremity prosthetic joint infection s/p total femur replacement presented via EMS with 3 days of worsening left lower leg pain and swelling. He reported pain around the left lower leg down to the foot. His symptoms were associated with chills and fatigue. He reported compliance with Eliquis. 

Vitals: BP 92/80, Pulse 100, Temp 98.1 F, RR 11, SpO2 93% on 5L NC 

Physical Exam:
- General: A&O x4
- Cardiac: RRR
- Lungs: CTAB w/o increased work of breathing while on 5L NC
- Extremities: 1+ non -pitting edema of right lower extremity, 2+ at left lower extremity. Intact sensation to light touch at left lower extremity, able to wiggle all toes, diffuse swelling below the left knee and down to the foot L>R, with diffuse tenderness. No crepitus or pain out of proportion. Erythema over anterior shin, scattered skin excoriations of bilateral lower legs. 

Bedside ultrasound was performed and the following images were obtained: 

Figure 1: Left popliteal vein.

Figure 2: Collapsed left popliteal vein.

Figure 3: Cobblestone appearance of the left lower leg.

DISCUSSION

Concern for deep vein thrombosis (DVT) was present given asymmetric edema and pain, Point-of-care ultrasound (POCUS) was performed and DVT was ruled out. Ultrasound of the lower leg also demonstrated “cobblestoning”. Left lower extremity and peri-prosthetic fluid collection found on CT. The patient was started on antibiotics for the SSTI. 

POCUS has become a valuable tool in the Emergency Department given its availability, portability, lack or radiation and tolerability by patients. Skin and soft tissue infections (SSTIs) are primarily diagnosed clinically based on history and physical exam, but imaging is used to assess beyond superficial tissue. Clinically SSTIs are characterized by symptoms such as erythema, swelling, warmth, pain, fever, chills and leukocytosis, especially in patients with predisposing factors. The primary sonographic finding in cellulitis is referred to “cobblestone” appearance, this appears as fluid collects in the subcutaneous tissue. However, this pattern is not unique to cellulitis and may be seen in other medical conditions. POCUS is valuable for diagnosis abscesses, guiding drainage and plays a crucial role in evaluating severe soft-tissue infections such as necrotizing fasciitis. When POCUS is performed prior to incision and drainage, it can help prevent invasive procedures over vascular or neoplastic lesions that can resemble abscesses on physical exam. Studies have shown that the use of POCUS is more accurate for diagnosing abscesses than clinical examination alone. 

REFERENCES

1. Hazra, Darpanarayan; Elshehry, Ashraf. Cobblestone Appearance in Point-of-Care Ultrasonography (POCUS). Current Medical Issues 22(1):p 54-55, Jan–Mar 2024. | DOI: 10.4103/cmi.cmi_128_23 
2. Koppa BM, Kelly CT. Point-of-care ultrasound in skin and soft tissue infections. J Hosp Med. 2024 Oct;19(10):938-944. doi: 10.1002/jhm.13467. Epub 2024 Jul 31. PMID: 39082276. 
3. Subramaniam, Sathyaseelan, et al. "Point‐of‐care ultrasound for diagnosis of abscess in skin and soft tissue infections." Academic Emergency Medicine 23.11 (2016): 1298-1306. 

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