Case 27: Ectopic Pregnancy

A 43 year old female with no past medical history presents to the Emergency Department (ED) with lower abdominal pain for the last three hours. She says she knows she is pregnant from a home pregnancy test, but has not had any appointment with obstetrics and has not had an ultrasound yet. She denies any vaginal bleeding.  

Vitals: BP 120/65 mmHg, HR 85, O2 100% on RA.

She is comfortable appearing, her abdominal exam shows mild tenderness to palpation diffusely in the lower abdomen with no rebound and her pelvic exam shows a closed os with no bleeding.

Her point-of-care urine pregnancy test is positive.

You perform a trans-abdominal bedside ultrasound, what do you see?  What are your next steps?

pelvic free fluid
ectopic
positive fast

Answer and Learning Points

Answer:

The first image is a transverse view of the uterus that shows free fluid in the retcouterine pouch (Pouch of Douglas). The second image is another transverse view of the uterus that also shows free fluid in the rectouterine pouch and then fans through to scan the uterus and adnexa. From what we see there is no gestational sac in the uterus and if you look closely there appears to be a heterogenous structure in the left adnexa. The final view is a FAST view in the right upper quadrant, looking at Morrison's Pouch. We see free fluid here as well. 

These findings - a positive pregnancy test, free fluid in the pelvis and no clear intra-uterine pregnancy indicates an ectopic pregnacny until proven otherwise. The next step should be a tranvaginal ultrasound and consultation with Gynecology. 

Conclusion and Learning Points:

The transvaginal ultrasound revealed a left-sided ectopic pregnancy, as seen in the following picture. They identified a fetal pole and even a fetal heart rate in the ectopic pregnancy. The patient was taken to the operating room with Gynecology and had a salpingectomy without complications. She was discharged home three days later. 

Learning Points:

    • Any female of child-bearing age with abdominal pain should be considered for ectopic pregnancy
    • Ultrasound findings in ectopic pregnancy will not always show the ectopic itself, but rather findings suggestive of ectopic:
      • Intra-abdominal free fluid
      • No clear intra-uterine pregnancy (patients with ectopic will sometimes still have a "pseudo-gestational sac" that appears similar to a gestational sac, but there will be no yolk sac or fetal pole)
      • Heterogenous adnexal structure
    • You should not wait for B-HCG measurements to consider ectopic pregnancy, case reports have shown ectopic pregnancies with minimal HCG levels can still rupture (1)

References

1. Fu, Joyce, et al. Rupture of ectopic pregnancy with minimally detectable beta-human chorionic gonadotropin levels: a report of 2 cases. J Reprod Med. 2007 Jun;52(6):541-2.

This post was written by Charles Murchison MD and Anthony Medak MD, with further editing by Amir Aminlari MD.

Case 26: Genicular Nerve Block for Knee Pain – A Novel Technique

A 68 year old female with no significant past medical history presents to the Emergency Department (ED) with one day of right knee pain after falling off her bicycle onto her right side. She was immediately unable to bear weight on her right leg. 

 

Vitals: T 98.3, HR 73, RR 18, BP 114/70, SpO2 99%

 

Right leg exam: mild right knee effusion. No ligamentous laxity. Tenderness to palpation over lateral joint line > medial joint line. Tenderness to palpation over proximal anterior tibia. Knee extension limited due to pain. Neurovascularly intact with soft compartments.

 

Radiographic imaging demonstrated an isolated right tibial plateau fracture depression of the lateral plateau. The patient reports she is in severe pain but dislikes taking both over-the-counter and opioid pain medications. 

What nerves may be targeted to provide pain relief to her knee while maintaining motor function? What anatomic landmarks should be used on ultrasound to identify the branches of this nerve?

Answer and Learning Points

The genicular nerves derive from various major lower extremity nerve branches (femoral, obturator, sciatic, tibial) nerves and provide sensation to the knee capsule and joint. Cadaveric studies suggest that most genicular nerves are easily identifiable landmarks that may be used for therapeutic purposes. 5  Genicular nerve blocks (GNB) are traditionally used in this setting of chronic osteoarthritis knee pain via radiofrequency ablation or perioperative knee pain via ultrasound (1-4, 9).

The use of a GNBs in the ED is a novel technique to provide motor-sparing, pain relief for acute knee pain. This 68 year old patient with an isolated lateral tibial plateau fracture reported 4/10 pain over her proximal tibia at rest and 8/10 over her proximal tibia with movement. Written informed consent was obtained for GNBs of her right knee. Anatomic landmarks for the superior lateral (Image A,B) , superior medial (Image C,D), and inferior medial (Image D,E,F) genicular nerves were identified on ultrasound.

genicular nerve block

genicular nerve block

genicular nerve block

The ultrasound probe was placed in the sagittal orientation for each site. The superior lateral genicular nerve was located on ultrasound at the junction of the lateral femoral epicondyle and the epiphysis of the shaft of the femur, adjacent to the superior lateral genicular artery (Image A,B). The superior medial genicular nerve (SMGN) can be identified on ultrasound at the junction of the medial femoral epicondyle and the epiphysis of the shaft of the femur, adjacent to the superior medial genicular artery (Image C, D). The inferior medial genicular nerve (IMGN) can be identified on ultrasound at the junction of the medial tibial epicondyle and the epiphysis of the shaft of the tibia, adjacent to the inferior medial genicular artery (Image E, F, G) (6-8).

Under ultrasound guidance and using sterile technique, the skin was first anesthetized with 1% lidocaine after each site. A 21-gauge, 2 inch echogenic needle was inserted percutaneously and advanced under ultrasound guidance using an out-of-plate technique to inject 1.5 mL of 0.5% bupivacaine around the right superior lateral, superior medial, and inferior medial genicular nerves. 

Learning points

    • Genicular nerves derive from several lower extremity nerves and supply sensory innervation to the knee. 
    • The superior lateral, superior medial, and inferior medial genicular nerves are commonly targeted for pain relief with chronic knee osteoarthritis and postoperative pain.
    • The SLGN, SMGN, IMGN are easily located on ultrasound using anatomic landmarks (junction between epicondyles and epiphysis of the femur and tibia, adjacent to paired genicular arteries).
    • To obtain the images, you can use the linear probe in the sagittal location over lateral femoral epicondyle, medial femoral epicondyle, and medial tibial epicondyle.

References

1. Ahmed, Arif. “Ultrasound-guided radiofrequency ablation of genicular nerves of knee for relief of intractable pain from knee osteoarthritis: a case series.” British Journal of Pain, vol. 12, no. 3, 2017, pp. 145-154, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6058456/. Accessed 18 November 2020.

2. Caldwell, George L. “Reduced Opioid Use After Surgeon-Administered Genicular Nerve Block for Anterior Cruciate Ligament Reconstruction in Adults and Adolescents.” HSS Journal, vol. 15, no. 1, 2019, pp. 42-50, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6384209/. Accessed 18 November 2020.

3. Cankurtaran, Damla. “Comparing the effectiveness of ultrasound guided versus blind genicular nerve block on pain, muscle strength with isokinetic device, physical function and quality of life in chronic knee osteoarthritis: a prospective randomized controlled study.” Korean J Pain, vol. 33, no. 3, 2020, pp. 258 - 266, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336352/. Accessed 18 November 2020.

4. Erdem, Yusuf. “The Efficacy of Ultrasound-Guided Pulsed Radiofrequency of Genicular Nerves in the Treatment of Chronic Knee Pain Due to Severe Degenerative Disease or Previous Total Knee Arthroplasty.” Med Sci Monit, vol. 25, 2019, pp. 1857 - 1863, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6423735/. Accessed 18 November 2020.

5. Fonkoué, Loïc. “Distribution of sensory nerves supplying the knee joint capsule and implications for genicular blockade and radiofrequency ablation: an anatomical study.” Surgical and Radiologic Anatomy, vol. 41, 2019, 1461–1471(2019), https://link.springer.com/article/10.1007/s00276-019-02291-y#citeas. Accessed 18 November 2020.

6. Güzelküçük, DemIr. “A different approach to the management of osteoarthritis in the knee: Ultrasound guided genicular nerve block.” Pain Medicine, vol. 18, no. 1, pp. 181 - 183, https://academic.oup.com/painmedicine/article/18/1/181/2924744. Accessed 18 November 2020.

7. Kim, Doo-Hwan. “Ultrasound-Guided Genicular Nerve Block for Knee Osteoarthritis: A Double-Blind, Randomized Controlled Trial of Local Anesthetic Alone or in Combination with Corticosteroid.” Pain Physician, vol. 21, 2018, pp. 41 - 51, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6058456/. Accessed 18 November 2020.

8. Protzman, Nicole. “Examining the feasibility of radiofrequency treatment for chronic knee pain after total knee arthroplasty.” PM&R, vol. 6, no. 4, 2014, pp. 373 - 376, https://pubmed.ncbi.nlm.nih.gov/24373908/. Accessed 18 November 2020.

9. Sahoo, Rajendra K. “Genicular nerve block for postoperative pain relief after total knee replacement.” Saudi J Anaesth, vol. 12, no. 2, 2020, pp. 235 - 237, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164458/. Accessed 18 November 2020.

This post was written by Julia Sobel MD, with editing from Jessica Oswald MD, Charles Murchison MD and Amir Aminlari MD.

Case 25: Aortic Dissection

A 44 year old male with a history of heroin abuse presents to the emergency department with altered mental status.  Per EMS, the patient was found on the street with decreased level of consciousness and poor respiratory effort.  EMS was concerned about opioid overdose, and he was treated with 4mg Narcan, with improvement in his mental status.  

Upon arrival to the ED, he was noted to be agitated and tachypneic with RR in the 40’s.  

Vitals: BP 90/65 mmHg, HR 110, O2 100% on RA, glucose 158.

He is alert and oriented to person, month, and place, but appears agitated and confused.  He denies any complaints other than shortness of breath, and states he felt fine before using heroin.  He denies any past medical history.

Exam notable for tachycardia, diffuse rhonchi throughout all lung fields, 2+ nonpitting lower extremity edema.  He is neurologically intact with 2+ pulses throughout.

A bedside echocardiogram was performed, what do you see?  What are your next steps?

PS long
dilated aortic root
aortic dissection suprasternal ultrasound
abdominal aortic dissection ultrasound
abdominal aortic dissection ultrasound
dissection to iliacs ultrasound

Answer and Learning Points

Answer:

The first two images show a parasternal long-axis view, with a dilated aortic root measuring approximately 4.2cm.  Also notice the pericardial effusion with a homogenous layer that appears fixed to the pericardium.  At the time it was unclear whether this represented a clot within the pericardial sac, or was superficial to it.

Given the dilated aortic root, a suprasternal short-axis view was obtained to assess the proximal aorta, with the short axis view seen on the third image.  A flap was visualized in the aortic lumen, significant for an ascending aortic dissection.  The dissection was then visualized in the abdominal aorta, extending distal to the common iliac arteries, seen in the last images.

The patient was placed on esmolol drip and later required vasopressor support.  CT angiography was obtained, confirming a Type A aortic dissection.  He was transferred to a nearby hospital for emergent repair of his ascending and descending aortic dissection.  

Per the operative report, the patient had developed a significant pericardial effusion by the time he reached the OR, and the visualized homogenous layer above most likely represented a blood clot within the pericardium.

Learning Points:

    • While CTA remains the gold standard for diagnosis of aortic dissection, POCUS remains a great tool for diagnosing both ascending and descending aortic dissection, particularly in the unstable patient.
    • In addition to directly visualizing the dissection flap, TTE can also be used to identify patients with high risk features, such as those with cardiac tamponade, severe aortic dilatation, severe aortic regurgitation, regional wall motion abnormalities, and decreased ejection fraction (1).
    • TTE has been shown to have a sensitivity of 78-90% and specificity 87-96% for type A dissection in older studies (2,3), and in more recent studies showing improved sensitivity up to 97-99% (1,4,5) and specificity 100% (4) with improved image quality.
    • The suprasternal notch views are particularly useful in evaluating the proximal ascending aorta, and allow the operator to assess for aortic dissection, coarctation, dilatation of the aortic arch, and retrograde flow from the descending aorta.

References

1. Sobczyk D, Nycz K. Feasibility and accuracy of bedside transthoracic echocardiography in diagnosis of acute proximal aortic dissection. Cardiovasc Ultrasound. 2015;13:15.

2. Evangelista A, Flachskamp FA, Erbel R, Antonini-Canterin F, Vlachopoulos C, Rocchi G, et al. Echocardiography in aortic diseases: EAE recommendations for clinical practice. Eur J Echocardiogr. 2010;11:645–58. doi: 10.1093/ejechocard/jeq056.

3. Nienaber CA, von Kodolitsch Y, Nicolas V, Siglow V, Piepho A, Jaup T, et al. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med. 1993;328:1–9. doi: 10.1056/NEJM199301073280101.

4. Cecconi M, Chirillo F, Constantini C, Iacobone G, Lopez E, Zanoli R, et al. The role of transthoracic echocardiography in the diagnosis and management of acute type A aortic syndrome. Am Heart J. 2012;163(1):112–8. doi: 10.1016/j.ahj.2011.09.022.

5. Nazerian, P., Vanni, S., Castelli, M. et al.Diagnostic performance of emergency transthoracic focus cardiac ultrasound in suspected acute type A aortic dissection. Intern Emerg Med9, 665–670 (2014). https://doi.org/10.1007/s11739-014-1080-9

This post was written by Rachna Subramony MD, Alex Anshus MD, with editing from Sukhdeep Singh MD, Charles Murchison MD and Amir Aminlari MD.

Case 24: Diverticulitis

 

A 56 year old male with a history of uncomplicated diverticulitis presented to the emergency room with left lower quadrant pain and loose stools for the last six days. He denies fever, vomiting or blood in hist stool 

Vitals: T 97.3   BP 152/81   HR 91       RR 18      SPO2 97% on RA

 

You physical exam shows tenderness to palpation in the left lower quadrant with no peritoneal signs. You are on the fence about getting a CT abdomen and pelvis with contrast to look for an abscess versus treating this as uncomplicated diverticulitis. You decide to throw the ultrasound probe on the area of his pain. What do we see in these images? How would this change management?

 

Answer and Learning Points

Answer:

The three videos and two images show diverticulitis with an abscess or phlegmon beneath the bowel loops. Though CT is the gold standard for diagnosing diverticulitis, ultrasound is relatively sensitive in the diagnosis and has the advantage of being cheap, fast and radiation-free (1). 

When looking for diverticulitis on ultrasound physicians will typically use a "lawn mower" approach to the left abdomen to search for areas of affected bowel. One way to get to the area of interest more quickly is simply ask the patient to point to the area of maximal tenderness and start there, similar to appendicitis or small bowel obstruction. There are a few findings on ultrasound that indicate diverticulitis (2,3):

  1. Thickening of bowel wall, typically at least 4-5mm
  2. Echogenic fat surrounding the bowel, which is representative of fat stranding seen on CT
  3. Diverticulum
diverticulitis ultrasound
Wall thickening and fat stranding

 

Ultrasound is also helpful in looking for abscess, such as in our case. We see there is an area of hypoechogenicity with no color flow, representing likely abscess adjacent to the bowel.  

 

Our patient ultimately got a CT scan that confirmed he had diverticulitis with abscess. He was admitted to medicine with GI and surgery consults following.

References

(1) Lameris, W et al. Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy. Eur Radiol. 2008 Nov;18(11):2498-511.

(2) Schwerk, WB et al. Sonography in acute colonic diverticulitis. A prospective stud. Dis Colon Rectum. 1992 Nov;35(11):1077-8

(3) Mazzei M et al. Sigmoid diverticulitis: US findings. Crit Ultrasound J. 2013 Jul 15;5 Suppl 1(Suppl 1):S5.

This post was written by Charles Murchison MD, with editing from Colleen Campbell MD and Amir Aminlari MD.

Case 23: Diastolic Dysfunction

diastolic dysfunction echo

 

A 79 year old female presented to the emergency room with worsening dyspnea on exertion.  She reported orthopnea, leg swelling, and only being able to walk a few steps without getting short of breath. She denied chest pain, fever, or productive cough, and she had been compliant with her medications. Of note, the patient was seen 3 weeks ago for chest pain, at which point she had a dobutamine stress echo that demonstrated non-reversible ischemic changes. During examination, the providers noted JVD, crackles at bilateral bases, and bilateral lower extremity pitting edema. 

 

Vitals: T 97.3   BP 152/81   HR 83       RR 18      SPO2 97% on RA

 

Your initial impression is a slamdunk heart failure exacerbation. However, a bedside ECHO is performed normal ejection fraction. This doesn’t appear to be the classic HFrEF exacerbation you’ve seen countless times before. What do we see in the echo below? What does it tell us about this patient's diastolic function?

 

diastolic dysfunction echo
e e' echo

Answer and Learning Points

Answer:

The two images above are an apical four chamber view with the doppler gait measuring mitral inflow velocity and tissue doppler, respectively. They show Grade 1 diastolic dysfunction.

Assessing for diastolic dysfunction is best achieved with an apical four chamber view and involves two measurements: mitral inflow and tissue doppler. Mitral inflow velocity is measured by placing pulsed-wave doppler at the mitral valve leaflet tips. During diastole, there are two surges of blood flow through the mitral valve. The first is Early filling immediately after the valve opens (E wave), representing ventricular relaxation. The second wave comes from the Atrial kick (A wave). In normal diastolic function, the E wave should be larger than the A wave because most of the blood enters the ventricle during relaxation, with the atrial kick subsidizing this.

Look at the diagram below to see how the E/A wave changes with the different grades of diastolic dysfunction. In our patient, the A wave was larger than the E wave so we knew this patient had grade 1 diastolic dysfunction, i.e. impaired relaxation. This happens when the stiff ventricle no longer pulls most of the blood in with relaxation (as relaxation is impaired), so the atrial kick does most of the diastolic filling. Our patient was admitted to cardiology for IV diuresis and medical optimization.

For patients whose E wave is larger than their A wave, it can be unclear whether this is a normal, pseudonormal or restrictive pattern. Tissue doppler can help further assess whether this. Place the doppler gate at the mitral valve annulus to assess left ventricular muscle relaxation. As diastolic dysfunction worsens, the ability of the left ventricle to relax will progressively worsen. Looking at the diagram below again, we see that in normal diastolic function the e' wave will be larger than the a', but as the ventricle loses its ability to relax the e' wave will get smaller. If the e' is the same size or smaller than the a' this represents diastolic dysfunction. 

diastolic dysfunction

Learning Points:

  • Heart failure with preserved ejection fraction makes up half of the patients with heart failure.
  • HFpEF can be assessed in the apical four chamber view by evaluating the mitral valve inflow at the leaflet tips and tissue doppler at the annulus.
  • The E wave is blood flow through the mitral valve during early diastole and the A wave is during the atrial kick.
  • In one study, sensitivity and specificity of diagnosing clinically significant diastolic dysfunction was 92% and 69% respectively for emergency physician conducted echocardiography (1).

References

This post was written by Megan Jackson, PGY1 at UCSD Emergency Medicine Residency Program. Editing was provided by Charles Murchison, MD and Amir Aminlari MD

Case # 22: Abdominal Aortic Aneurysm

abdominal aortic aneurysm

 

A 72 year old male with known abdominal aortic aneurysm (5.7 cm s/p fem-tib bypass, L AKA) presents for 3 weeks with diarrhea and mild LLQ pain. No nausea, vomiting, fever, back pain, urinary symptoms, or blood in stool. He has no localizing abdominal exam & no peritoneal signs, strong even radial pulses, and normal cardiopulmonary exam. On further chart review, patient is noted to have a 5+ cm aorta for the past 2 years, with the most recent CT scan a few weeks ago showing growth from 5.5 cm to 5.7 cm. An abdominal ultrasound is performed with the following findings.

Vitals: 

T 98.7 HR 64 BP 167/80 RR 18 O2 100%

What are we concerned about for this patient and why? What is the interpretation of the abdominal ultrasound? What are the next steps for management in the ED?

 

Courtesy of The Pocus Atlas

Answer and Learning Points

Answer:

The patient’s presenting complaints (diarrhea, mild abdominal pain) do not coincide with the classic triad of ruptured AAA (hypotension, back pain, pulsatile abdominal mass). In addition, this patient is hemodynamically stable and comfortable, which is reassuring. However, ruptured AAA can have a wide variety of presentations and should always be considered in patients with known large AAA. In addition, this patient had a known AAA >5 cm for the past two years with poor vascular surgery follow-up, and the risk for rupture for AAA’s 5.0-5.9cm increases by 5-10% each year. (1)

As this patient recently had a CT scan a few weeks ago revealing large, stable AAA, the decision was made to investigate via ultrasound rather than undergo more radiation from CT. Ultrasound is also highly sensitive and specific for detecting AAA. (2) The above images show the AAA has a large intramural thrombus with no evidence of leaking fluid nor dissection flap. The AAA is stable, measuring a similar width of 5.7 cm. The clinician can investigate further by doing a RUSH exam to reassure against intraperitoneal bleeding and other types of shock. Elective aortic surgery is recommended for patients with AAA >5.5 cm, because at this threshold the risk of rupture is greater than risk of surgery, therefore it is reasonable to consult vascular surgery for this patient in the ED. (1)

 

Learning Points

  • Ruptured AAA being a surgical emergency and nearly uniformly fatal. Risk of rupture is proportional to size of AAA:AAA rupture risk
  • Elective aortic surgery is the most effective management, however, is not recommended until the aneurysm exceeds 5.5 cm diameter. In the ED setting, it is reasonable to consult vascular surgery for an asymptomatic patient with an incidental finding of aneurysm >5.5 cm. (1)
  • A systematic review of seven studies (n=655) evaluated operating characteristics of emergency department ultrasonography for AAA. With AAA defined as >3cm dilation of aorta, the review showed that ultrasound yielded excellent diagnostic performance. (2)

  • An effective abdominal aortic ultrasound requires:

(1) Evaluation of the entire aorta from the subxiphoid area to the iliac branch bifurcation. Most abdominal aortic aneurysms lie in the infrarenal aorta.

(2) Moving bowel gas out of the way with the probe with either graded compression or curvilinear probe with larger footprint

(3) Careful differentiation aorta from IVC. The aorta will be anterior to the vertebrae and the left of the IVC.

(4) Measuring outer to outer wall. Clot can create can second inner wall and falsely decrease aortic width measurement.

References

(1) Abdominal Aortic Aneurysms (AAA) - Cardiovascular Disorders. Merck Manuals Professional Edition. Accessed July 9, 2020. https://www.merckmanuals.com/professional/cardiovascular-disorders/diseases-of-the-aorta-and-its-branches/abdominal-aortic-aneurysms-aaa

(2) Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013;20(2):128-138. doi:10.1111/acem.12080

(3) Michelle H-B. Tips and Tricks: Big Red - The Aorta and How to Improve Your Image. ACEP Emergency Ultrasound. Accessed July 9, 2020. https://www.acep.org/how-we-serve/sections/emergency-ultrasound/news/february-2016/tips-and-tricks-big-red---the-aorta-and-how-to-improve-your-image/

This post was written by Caresse Vuong, MS4; with editing by Charles Murchison, MD and Amir Aminlari MD

Case # 21: A 28 Year Old With Shortness of Breath

echo d sign

 

A previously healthy 28-year-old male presents to the Emergency Department complaining of one month of fatigue, shortness of breath, and dyspnea on exertion. These symptoms were preceded by symptoms of a viral illness which initially improved; however, he had recurrence of symptoms two weeks ago. He was seen at urgent care five days ago and was given steroids and albuterol without improvement. The patient otherwise denies any infectious symptoms, leg swelling, or risk factors for pulmonary embolus or deep vein thrombosis.  

VS: T: 97.7F    BP: 129/87.    HR: 109     RR: 16.    SP02: 95%

Patient is alert and oriented, non-toxic in no distress, and behaving appropriately. Cardiac exam shows a RRR, no murmurs, rubs, or gallops. Lung exam is consistent with shallow breaths and dyspnea with conversation, otherwise lungs are CTAB with no wheezing, rales, or rhonchi. The patient has no chest wall tenderness, no JVD, and no lower extremity edema.

You perform a bedside ECHO and you see the following. What do you see and what is your most likely diagnosis? What is your next step in management?

apical 4 rv strain
psla rv strain
pssa rv strain

Answer and Learning Points

Answer:

In all three cardiac views, there is dilation of the right side of the heart. In the parasternal short axis you see septal bowing into the left side of the heart, also known as the “D” sign (named after the shape of the left ventricle). These findings are indicative of elevated right sided pressure, or right heart strain, which can be seen in conditions such as acute pulmonary embolism, pulmonary hypertension, COPD, and right ventricular infarction. Given the relatively thin free wall of the right ventricle, the likely cause of right heart strain in the above scenario is an acute process.

The patient had a CT scan that revealed extensive pulmonary emboli in all segmental and subsegmental arterial divisions of the lung with findings consistent with pulmonary artery hypertension and severe right heart strain. The EKG obtained had evidence of right heart strain including right axis deviation and diffuse T-wave inversions. The patient was started on heparin and admitted to the ICU.

Learning Points

  • The reported sensitivity and specificity of echocardiography in demonstrating right heart dysfunction are around 56% and 42% respectively (1)
  • Described features of right heart dysfunction include (2)
    1. Dilation of the right ventricle
      • The RV normally appears triangular-shaped and is two-thirds the size of the LV in apical four view (3)
    1. Interventricular septal flattening
      • AKA the “D sign” on parasternal short view or paradoxical septal motion on apical four view
    1. Right ventricular hypertrophy (right ventricular free wall thickness >5mm in diastole)
      • When present, implies some degree of chronicity to the inciting hemodynamic insult
    1. Right ventricular hypokensia
      • Typically quantified as a tricuspid annular plane systolic excursion, as measured by M-mode from the apical 4 chamber view, <1.6 cm
    1. Plethoric vena cava

References

  1. He, H., et-al. Computed tomography evaluation of right heart dysfunction in patients with acute pulmonary embolism. J Comput Assist Tomogr. 2006;30 (2): 262-6.
  2. Rudski, L.G., 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. (2010) Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. 23 (7): 685-713
  3. Mallin, M, Dawson, M. Introduction to Bedside Ultrasound: Volume 2. Emergency Ultrasound Solutions, 2013. Apple Books. https://books.apple.com/us/book/introduction-to-bedside-ultrasound-volume-2/id647356692. Accessed April 17th, 2020.


The following authors contributed to this post:

Danika Brodak, MD; Amir Aminlari, MD; Rachna Subramony, MD; Colleen Campbell, MD

Case # 20: Right Lower Quadrant Pain

A 40 year old male presented with a 4 day history of right lower quadrant pain. He reported that the pain was at its worse when it started but gradually improved. When in the ED he noted only minimal discomfort without the help of analgesics.  He denied ever having anorexia, fever, chills, nausea, vomiting, GU complaints. During examination, he had moderate tenderness to palpation in the right lower quadrant without rebound or guarding. 

Vitals:  T 97.7F    BP 130/77    HR 66    RR 16   SP02 100%

An abdominal ultrasound of the RLQ was performed and the following images were seen. What do you see and what is your most likely diagnosis? 

ezgif.com-crop (4)

ezgif.com-crop (2)

Answer and Learning Points

Answer

In both the longitudinal and transverse views, you see a tubular structure in the right lower quadrant that is non- compressible, greater than 6mm (measures 15.6 mm), and lacks peristalsis. You can also appreciate some dependent free fluid around the appendix. These findings are consistent with the diagnosis of acute appendicitis.

CT abdomen/pelvis showed a retrocecal appendix with finding of acute uncomplicated appendicitis. No bowel obstruction or intra-abdominal/pelvic abscesses. Labs showed a slight leukocytosis to 14, otherwise were reassuring. Patient was given a dose of Zosyn in the emergency department and take to the OR for appendectomy by general surgery.

Learning Points

    • Appendicitis is the most common abdominal surgical emergency that presents to the ED in western countries [1]. 
    • The sensitivity and specificity of ultrasound for the diagnosis of appendicitis appears to be around 86% and 81%, respectively, based on results from older studies [2]. 
    • Ultrasound can be used to diagnosis acute appendicitis and may be the imaging modality of choice in certain patient populations such as pregnant women and children [3]. 
    • To obtain images you can use either the linear or curvilinear probe. Ask the patient to point where exactly they hurt and place the probe there. If you don’t see it you can use the landmark of the iliac crest (most lateral), psoas muscle (posterior), and iliac artery (most medial). Move superior and inferior along the iliac artery and the appendix should be just anterior to iliac artery. If you still haven’t found it, “lawnmower” along the right lower quadrant. Look for a tubular, blind ended pouch that has no peristalsis. It should be compressible and measure <6mm in AP diameter [4]. 

References

    1. Caterino, S., et al. Acute abdominal pain in emergency surgery. Clinical epidemiologic study study of 450 patients. Ann Ital Chir. 1997; 68: 807-817.
    2. Lim H, Bae S, Seo G: Diagnosis of acute appendicitis in pregnant women: value of sonography. AJR Am J Roentgenol 1992;159(3): 539–542.
    3. Excerpt From: Mike Mallin & Matthew Dawson. “Introduction to Bedside Ultrasound: Volume 2.” Emergency Ultrasound Solutions, 2013. Apple Books. https://books.apple.com/us/book/introduction-to-bedside-ultrasound-volume-2/id647356692Mallin, M, Dawson, M. Introduction to Bedside Ultrasound: Volume 2. Emergency Ultrasound Solutions, 2013. Apple Books. https://books.apple.com/us/book/introduction-to-bedside-ultrasound-volume-2/id647356692. Accessed April 18th, 2020.
    4. www.5minsono.com

 

The following authors contributed to this post:

Amir Aminlari, MD; Danika Brodak, MD; Michael Macias, MD

Case # 19: Under Pressure

A 27 year-old female presented to the emergency department with a two week history of headache, posterior eye pain, visual changes. She denied trauma, fever, focal neurological changes, or visual field deficits. She was seen by the optometrist earlier in the day and was sent to the ED for further evaluation.  Her neurological examination was normal. 

Eye exam: PERRL, EOMI, no injection/discharge, visual acuity 20/15 OS, 20/20 OD, IOP L19, R19

An ocular ultrasound is performed and the images below are seen. What do you see and what is your most likely diagnosis? What is your management?

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Left eye

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 Right eye

Answer and Learning Points

Answer

On both images of the right and left eye you see papilledema which is demonstrated as a bulging optic disc protruding into the posterior chamber.

CT Head non-contrast was obtained which showed " a partially empty pituitary sella which can be seen with intracranial hypertension, otherwise no acute findings." Ophthalmology was consulted. Their exam was unremarkable except for bilateral papilledema. An LP was performed which showed an elevated OP at 36. After large volume CSF removal the patient reported improvement in symptoms. Closing pressure was 22. The CSF studies were unremarkable. Patient was discharged with an MRI/MRV performed as outpatient and neuro-ophthalmology follow up. MRI brain showed mild flattening of the optic nerve heads which is nonspecific but could correlate with intracranial hypertension in the right clinical setting. 

Learning Points

    • Papilledema may be directly visualized with ultrasound as a bulging optic disc elevated more than 0.6mm from the retina. There are also studies that show a correlation between increased intracranial pressure and optic sheath nerve diameter greater than 5mm when measured 3mm posterior to the retina. (1-4)
    • A width of > 5mm has a pooled sensitivity of 90% and specificity of 85% for detecting an ICP > 20mmHg in trauma patients with head injuries (5-6)
    • It is important to note that the optic nerve sheath diameter should be measured when the sides are parallel, as it can be artificially increased otherwise.  (7)
    • When obtaining an ocular ultrasound use the high frequency linear probe on the ocular setting. If there is not an ocular setting, it is best to err on the high side with regard to gain.
    • Although controversial, some sources advise to avoid ocular ultrasound when concerned about globe rupture as any pressure on the eye could worsening the rupture.

References

    1. Marchese, R.F., et al. Identification of optic nerve swelling using point-of-care ocular ultrasound in children. Pediatric Emergency Care. 2018; 34(8):531-536. 
    2. Kimberly, H.H., Shah, S., Marill, K., & Noble, V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Academic Emergency Medicine. 2008; 15(2):201-4. 
    3. Amini, A., et al. Use of the sonographic diameter of optic nerve sheath to estimate intracranial pressure. The American Journal of Emergency Medicine. 2013; 31(1):236-9.
    4. Xu, W., Gerety, P., Aleman, T., Swanson, J., & Taylor, J. Noninvasive methods of detecting increased intracranial pressure. Child’s Nervous System. 2016; 32(8):1371-86. 
    5. Dubourg, J., et al. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Medicine. 2011;37(7):1059–1068.
    6. Rajajee, V., Vanaman, M., Fletcher, J.J., & Jacobs, T.L. Optic nerve ultrasound for the detection of raised intracranial pressure. Neurocritical Care. 2011;15(3):506–515.
    7. Mallin, M, Dawson, M. Introduction to Bedside Ultrasound: Volume 2. Emergency Ultrasound Solutions, 2013. Apple Books. https://books.apple.com/us/book/introduction-to-bedside-ultrasound-volume-2/id647356692. Accessed April 17th, 2020.

The following authors contributed to this post:

Amir Aminlari, MD; Danika Brodak, MD; Michael Macias, MD; Rachna Subramony, MD

Case # 18: Respiratory Distress: It’s not all COVID.

During the COVID-19 pandemic, a 67 year old woman is brought to the ER by family for respiratory distress and altered mental status. She was alert but not oriented and unable to answer questions on arrival with moderate respiratory distress. Family stated that she had a history of asthma and takes "other" medications, but where otherwise unaware of her past medical history. She had been using her inhaler without relief and has not had any sick contacts, cough or fever. 

Vitals: T: 98.7, HR: 112, BP: 190/110, RR: 40, SpO2 80 on RA

She was in moderate respiratory distress, crackles on exam, no pitting edema. She was placed on a non-breather (avoiding NIPPV) and a thoracic plus cardiac ECHO was preformed. 

After reviewing the images, what would you do next?

 

 

CHF vs COVID 1.1
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CHF vs COVID 3
IVC gif

Answer and Learning Points

Answer

The images would suggest that this patient is most likely suffering from heart failure with an acute exacerbation. There are diffuse B-lines, obvious decrease contractility and a dilated IVC. These images are not typical of COVID-19 infections, which have pleural thickening and scattered b-lines (see COVID section).  This patient was put on a nitro drip and given diuretics, with a significant improvement in her respiratory status in the ER. She ultimately tested COVID negative and was discharged from the hospital after aggressive diuresis. 

During the same shift, numerous COVID-19 positive patients were seen. Below are images of COVID-19 cases for comparison and more can be found at The POCUS Atlas. 

While the sensitivity and specificity of ultrasound to diagnosis COVID-19 has yet to be determined, this case illustrates how alternative findings can still impact clinical care and potentially avoid intubation. 

 

COVID +

On the same shift, numerous COVID-19 patients were also seen, with variable pre-test probability. ECHO for these patients would not reveal an alternative diagnosis (such as our CHF case). There were however some classic findings on ultrasound. Note below two patients with thoracic scans. There are scattered B-lines (unlike our CHF patient, who had diffuse B-lines). There is also pleural thickening and at times an irregular pleural border. 

COVID patient 1
thicker pleural lining

Author

Sukhdeep Singh, MD. Clinical Faculty, UCSD Department of Emergency Medicine. Director of POCUS, El Centro Regional Medical Center.

References

  1. DeRose et al, How to Perform Pediatric Lung Ultrasound Examinations in the Time of COVID‐19. Journal of Ultrasound in Medicine. 22 April 2020.
  2. The POCUS Atlas. http://www.thepocusatlas.com/covid19