• CASE #48…..24yo F with abdominal pain, N/V, constipation.
    Enter the name for this tabbed section: Case
    CASE: 24yoF presents with abdominal pain, nausea, vomiting, constipation x4 days. She has a history of SLE.

    Based on the following video, please answer these questions:

    Q1: Describe the renal findings on ultrasound.
    Q2: What is up with her LUQ view?
    Q3: What is the anechoic material on her abdominal views?
    Q4: Describe her bowels on ultrasound. What does this signify?

    Case is courtesy of Dr. Julia West and Dr. Iman Tamimi (MUSC Emergency Medicine).

    Enter the name for this tabbed section: Answer
    [For more “answers” see the video below]

    Q1: Describe the renal findings on ultrasound.

    => Normal pyramids with preserved vascular flow; moderate hydronephrosis.

    Q2: What is up with her LUQ view?

    => Large L pleural effusion; the round anechoic structure is her stomach—patient had just drank a large glass of water prior to imaging.

    Q3: What is the anechoic material on her abdominal views?

    => Free fluid; given her stable hemodynamics, most likely ascites rather than hemorrhage.

    Q4: Describe her bowels on ultrasound. What does this signify?

    => Her bowels are dilated, with thickened walls, and surrounded by free fluid, consistent with serositis versus enterocolitis.


    Click here to read more about GI manifestations of SLE.


    Case is courtesy of Dr. Julia West and Dr. Iman Tamimi (MUSC Emergency Medicine).

  • CASE #47…..36yo M with left thumb pain and swelling.
    Enter the name for this tabbed section: Case
    CASE: 36 year old male with left thumb pain and swelling. No known trauma.

    Based on the following video, please answer these questions:

    Q1: What pathology is noted on the ultrasound exam?
    Q2: What is the diagnosis?
    Q3: What physical exam findings are associated with this diagnosis?
    Enter the name for this tabbed section: Answer
    [For more “answers” see the video below]

    Q1: What pathology is noted on the ultrasound exam?

    HYPOECHOIC FLUID COLLECTION AND HYPEREMIA.

    Q2: What is the diagnosis?

    FLEXOR TENOSYNOVITIS.

    Q3: What physical exam findings are associated with this diagnosis?

    KANAVEL’S SIGNS:

    1) PAIN WITH PASSIVE EXTENSION
    2) FINGER HELD IN FLEXION
    3) FUSIFORM SWELLING
    4) TENDERNESS ALONG THE TENDON SHEATH


    Case courtesy of Dr. Nick Ashenburg, 3rd year EM resident, Maine Medical Center.
  • CASE #46….Superficial Cervical Plexus Block.
    CASE COURTESY OF DR. RYAN BARNES (MUSC EMERGENCY MEDICINE)
  • CASE #45….64yo M with right flank pain but LOOKS SICK.
    CASE COURTESY OF DR. RYAN BARNES (MUSC EMERGENCY MEDICINE)
  • CASE #44….Dyspnea in a patient with a history of pulmonary fibrosis.
    Enter the name for this tabbed section: Case
    CASE: 79 year old man with increased dyspnea. History of interstitial lung disease.

    QUESTION: What findings on ultrasound are suggestive of pulmonary fibrosis?
    Enter the name for this tabbed section: Answer
    [For more “answers” see the video below]

    QUESTION: What findings on ultrasound are suggestive of pulmonary fibrosis?

    ANSWER:

    1) Pleural line thickening
    2) Subpleural cysts

    Sperandeo et al. Transthoracic Ultrasound in the evaluation of pulmonary fibrosis: our experience. Ultrasound in Medicine and Biology 2009:723–729.

    Case courtesy of Neal Kinariwala, MD, Upstate EM.
  • CASE #43….Elderly patient, s/p OLT, with acute left wrist pain, no fever.
    CASE COURTESY OF DR. SUSAN WILCOX & DR. RYAN BARNES (MUSC EMERGENCY MEDICINE)
  • CASE #42….Knee pain and swelling. Looking for an effusion.
    CASE COURTESY OF DR. RYAN BARNES (MUSC EMERGENCY MEDICINE)
  • CASE #41….Finger injury in need of a procedure. Nerve block anyone?
    CASE COURTESY OF DR. LEANNE RADECKI (MUSC EMERGENCY MEDICINE)
  • CASE #40….79yo male with severe GU pain.
    Enter the name for this tabbed section: Case
    CASE: A 79yo male with BPH and dementia arrives with severe GU pain. He had a foley catheter placed by Urology the other day. There has been urine output in the foley bag, but less than usual.

    Watch the video below and simply answer the most pressing question:

    WHY DO THIS MAN’S NETHER-REGIONS HURT SO DARN BAD??
    Enter the name for this tabbed section: Answer
    [For more “answers” see the video below]

    QUESTION: Why is our patient in so much pain?

    ANSWER: Foley balloon is inflated in this poor gentleman’s prostate. OUCH.

    As a reminder, ultrasound is a pretty awesome way to evaluate for a whole range of GU pathology, especially concerns about urinary retention and/or aberrant foley placement.
  • CASE #39….50yo female with dyspnea and hypotension.
    Enter the name for this tabbed section: Case
    A 50 year-old female presents with dyspnea and hypotension. She has a history of DVT. Based on the cardiac ultrasound below, please answer the following questions:

    Q1: What findings on this US suggest increased right heart pressures?
    Q2: What is the
    specific sonographic pathology we see in the two clips?
    Q3: What is your plan for this patient?
    Enter the name for this tabbed section: Answer
    [For more “answers” see the video below]

    Q1: What findings on this US suggest increased right heart pressures?
    The RV is enlarged compared to the LV (remember RV : LV should typically be around 0.6).

    Q2: What is the
    specific sonographic pathology we see in the two clips? This is a clot-in-transit. What we call the “death worm” (not scientific).

    Q3: What is your plan for this patient? This patient deserves tPA or interventional IR (catheter-directed tPA).
  • CASE #38….83 yo male with hypothermia and AMS.
    Enter the name for this tabbed section: Case
    HPI: 83 year old male with CKD and HTN presents with AMS and hypothermia. On a bedside abdominal ultrasound, you see the following findings during sonography over the right lobe of the liver (and wherever else you image the abdomen).

    Based on the video below, attempt to answer the following questions:


    Question 1: What is the artifact you see?

    Question 2: What pathology does this likely represent?

    This case is courtesy of Dr. Terrill Huggins of the Division of Pulmonary and Critical Care Medicine at the Medical University of South Carolina.

    Enter the name for this tabbed section: Answer
    Question 1: What is the artifact you see? REVERBERATION ARTIFACT (analogous to the “A-lines” seen on thoracic scans)

    Question 2: What pathology does this likely represent?
    PNEUMOPERITONEUM

    Though US may be performed anywhere on the abdomen to assess for free air, consistent yield has been reported in the RUQ, overlying the right lobe of the liver. As free air moves to the least dependent area, the ideal position is supine with the head slightly elevated. A linear array (higher resolution) probe is recommended, though any probe may be used. Based on canine studies, it has been shown that intra-peritoneal air volumes as low as 0.2 mL can be consistently identified by US.
    [1] Other studies have shown comparable or improved US testing characteristics compared to AXR. In 2002, Chen et al reported a higher US sensitivity (92%) compared to AXR (78%) for pneumoperitoneum. [2]

    AUS’s limitations are due to operator-dependent image acquisition, non-pathologic air (i.e., intra-luminal air), and confounders such as obesity or subcutaneous emphysema. Also, perforation of retroperitoneal structures (e.g., second/third parts of the duodenum or ascending/descending colon) may result in abdominal catastrophe, producing retroperitoneal air.

    In this case, CT imaging confirmed pneumoperitoneum with a large air collection next to the 2nd portion of the duodenum. The patient’s age, declining status, multiple medical co-morbidities, hypoalbuminemia, and evolving hemodynamic stability were reasons that exploratory laparoscopy was not pursued. The patient’s course improved with medical management and surgery was not required. The cause of pneumoperitoneum was secondary to a perforated duodenal ulcer that spontaneously sealed.

    Click here for a great review of the role of ultrasound in detecting intraperitoneal free gas by Dr. Adrian Goudie of Western Australia.
  • CASE #37….49 yo female with diffuse abdominal pain, nausea, and vomiting.
    Enter the name for this tabbed section: Case
    HPI: This is a case of a 49 year old woman with PMHx of ESRD presents to the ED complaining of 2-3 days of diffuse abdominal pain, nausea, and vomiting. She has had multiple ED visits at multiple facilities for the same complaints. Previous laboratory workup was unremarkable. Abdominal US positive for cholelithiasis without cholecystitis; abdominal CT otherwise negative for acute process.

    On exam, she was noted to have diffuse abdominal tenderness and a positive Murphy’s sign. Based on this exam, it is suspected that acute cholecystitis/choledocolithiasis may be present. To further evaluate her abdomen, a bedside RUQ scan was performed with a curvilinear probe.

    Based on the video below, attempt to answer the following questions:


    Q1 – What are the sonographic signs consistent with acute cholecystitis?

    Q2 – What rule of thumb is used to determine abnormal common bile duct size?

    Q3 –What abnormal findings can be seen in this exam?

    Q4 – What maneuvers can assist in detecting stones/gravel/sludge in the gallbladder?

    Q5 – How would you manage this patient?

    This case is courtesy of Dr. Alex Monroe and Dr. Owen Stell from the Medical University of South Carolina.

    Enter the name for this tabbed section: Answer
    **Watch the video below for the case answers.

    Q1 – What are the sonographic signs consistent with acute cholecystitis?
    Distended gallbladder with stones or sludge, gallbladder wall thickening >3mm, +Sonographic Murphy’s sign, pericholecystic fluid. Common bile duct distention > 5mm can be seen with choledocholithiasis, but is not included in the sonographic definition of acute cholelithiasis.

    Q2 – What rule of thumb is used to determine abnormal common bile duct size? CBD is abnormal >5mm + 1mm for every decade over the age of 50. An easier way to remember this is to employ a single number: the CBD diameter is abnormal if it is >6mm.

    Q3 –What abnormal findings can be seen in this exam? Distended GB with fine gravel/sludge, GB wall thickening to approximately 6mm, common bile duct distention approximately 7mm.

    Q4 – What maneuvers can assist in detecting stones/gravel/sludge in the gallbladder? Attempt to turn the patient to left lateral decubutis evaluate for stone/gravel/sludge dependency with gravity

    Q5 – How would you manage this patient? Consult general surgery for evaluation for cholecystectomy. Consider ERCP/MRCP for further evaluation of choledocholithiasis.

    Pearl: Currently, there is debate over the utility of common bile duct measurements in RUQ evaluation with ultrasound. In Becker et al’s Emergency Biliary Sonography: Utility of Common Bile Duct Measurement in the Diagnosis of Cholecystitis and Choledocholithiasis, it was discovered that that isolated CBD dilatation in the absence of other ultrasonographic or laboratory findings was a rare occurrence.
  • CASE #36….A 21 year old female cuts her finger while slicing an avocado.
    Enter the name for this tabbed section: Case
    HPI: This is case of a 21 year old right hand dominant female with no significant past medical history who presents with a laceration to her left 2nd digit just below the PIP joint. Patient explains she is unable to flex her PIP or DIP. On exam there is a 3 cm laceration (see video below) on the volar surface of the left 2nd digit just inferior to the PIP. No active flexion of the PIP or DIP was noted but full range of motion of the MCP. Sensation was intact and capillary refill was less than 2 seconds.

    Based on exam, it was suspected that the laceration not only involved the skin and underlying soft tissue but possibly involved the tendon of both flexor digitorum profundus and flexor digitorum superficialis as well. To further evaluate the injury, the patient’s affected hand was submerged in a water bath and examined with the high frequency linear probe in a longitudinal orientation.


    Q1- What are the ultrasound findings of the normal finger?

    Q2- What are the pathologic findings of the affected finger?

    Q3- What maneuver can further investigate/clarify the injury?

    Q4- How do you manage this patient?

    This case is courtesy of Dr. Russ Allinder and Dr. Tony Congeni from the Medical University of South Carolina.

    Enter the name for this tabbed section: Answer
    Q1- What are the ultrasound findings of the normal finger?

    Ultrasound of the normal finger demonstrated appropriate striations and anisotropy of the tendon. There was continuity of the entire tendon on the volar aspect of the finger.


    Q2- What are the pathologic findings of the affected finger?

    The tendon is discontinuous with surrounding edema and a defect in the skin. No clearly defined, striated tendon is noted under the injured segment.


    Q3- What maneuver can further investigate/clarify the injury?

    Passive flexion and extension may further elucidate the injury. Attempted active flexion was not successful in this case due to the injury.


    Q4- How do you manage this patient?

    She is presumed to have a complete FDP and FDS laceration. Her finger was sutured and she was placed in a splint. She was scheduled for outpatient, elective surgery.


    There currently is little literature available concerning the role of ultrasound evaluation of flexor tendon injuries in the digits. In the literature that has been published, US has been found to be accurate, as well as cost and time efficient relative to MRI prior to surgery.
    The 2008 article in The Journal of Hand Surgery (European Volume) titled “The Role of Ultrasound in the Management of Flexor Tendon Injuries” by Jeyapalan et al discusses ultrasound management for flexor tendon injuries including past publications on the topic, in their retrospective study of 18 digit injuries.
  • CASE #35….Median nerve block under ultrasound guidance.
  • CASE #34….63 year old F with cirrhosis needs a paracentesis.
    63yo F with liver disease and cirrhosis. The patient requires a paracentesis. You have an ultrasound machine.

    Case by Dr. Drew Johnson.
  • CASE #33….21 year old M with chest pain - “The Whiner”
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    THE WHINER

    21 year old M with chest pain, exquisitely tender. 24 hours, hurts to move and breath. Better leaning forward. VS stable. EKG with antero-lateral ST elevation. But, again, his pain is better leaning forward and he is 21 freaking years old!! You do an US and determine the diagnosis.
    https://vimeo.com/128887623
  • CASE #32….18 year old M with pain and swelling in the private parts - “The Eggplant”
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    THE EGGPLANT

    Your patient has a tender, swollen “package.” You do an US, make the diagnosis, and provide US guidance to treat the problem.
    https://vimeo.com/124750572
  • CASE #31….67 year old M with left testicular pain.
    Enter the name for this tabbed section: Case
    HPI: 67-year-old male with a 10-year history of elevated PSA presents following TURP with a 10-day history of dysuria, testicular tenderness and fevers. Patient failed outpatient course of Bactrim. He reports that his left testicle has become red, warm, swollen and painful over the last 2 days. A testicular ultrasound was performed.

    Q1- What are the ultrasound findings?

    Q2- Describe the vascular ultrasound findings.

    Q3- What is the diagnosis?

    Q4- How do you manage this patient?

    This case is courtesy of Dania Daye from the Hospital of the University of Pennsylvania.

    Enter the name for this tabbed section: Answer
    Q1- What are the ultrasound findings?

    Ultrasound of the left testicle demonstrates testicular enlargement, heterogeneous echotexture and hyperemia. A reactive hydrocele is also appreciated. Also appreciated is a tiger striping pattern within the parenchyma of the left testicle suggestive of tissue edema.


    Q2- Describe the vascular ultrasound findings.

    Analysis of the spectral waveform demonstrates readily detectable venous flow. The resistive index of the arterial flow seems to be slightly less or in the vicinity of 0.5 (Normal >0.5). The resistive index (RI) is defined as RI = (peak systolic volume – end diastolic volume)/peak systolic volume. In the testicles, a normal RI ranges from 0.5-0.7. In testicular inflammation, flow during diastole is brisk resulting in resistive index< 0.5. A resistive index > 0.75 is suggestive of testicular torsion.

    With both arterial and venous flows present, no evidence of testicular torsion is appreciated.


    Q3- What is the diagnosis?

    The above findings are consistent with an inflammatory process, most likely epididymo-orchitis. The sensitivity of Doppler ultrasound in detecting testicular inflammation has been reported to be almost 100%. The presence of venous and arterial flow excludes the possibility of testicular torsion.


    Q4- How do you manage this patient?

    The patient was started on a course of antibiotics. Urology was consulted and patient was to follow-up with the urology clinic on an outpatient basis. Patient was discharged home on a course of cephalosporins with a scrotal sling. He was instructed to follow-up with the urology clinic.
  • CASE #30….23yo F with pelvic pain.
    Enter the name for this tabbed section: Case
    Case: A 23yo female presents with acute onset severe lower abdominal pain that woke her from sleep 5 hours prior to presentation. Pain is constant. No nausea or vomiting. No fevers. LMP 2-3 months prior.

    Q1: What findings suggest pregnancy, and more specifically, what findings ensure an intrauterine pregnancy?

    Q2: What do you see in these videos?

    This case is courtesy of the Hospital of the University of Pennsylvania.

    Enter the name for this tabbed section: Answer
    Q1: A double decidual sign can be an early sign of pregnancy but it can be confused with a pseudo-gestational sac. An intrauterine gestational sac must have a yolk sac, fetal pole, or intrauterine fetal heart beat to truly be an intrauterine pregnancy.

    Q2:
    A right adnexal ectopic is observed in the videos.
  • CASE #29….25yo M s/p GSW to back.
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    CLUB BULLET

    Alex as an ex-convict who got into a gun fight at a bar. See how ultrasound quickly established the right course of action. Run time is three minutes.
    http://vimeo.com/113416962
  • iCASE #28….54yo M with chest pain.
    SHOT TO THE HEART….

    54 year old male with chest pain. Says it feels like "I was shot in the chest."

    He is hypotensive.

    How can ultrasound help you diagnose and hopefully save this man?

    You may play the interactive case video in either HTML5 (compatible with an iPad, but gotta have a GREAT wireless) or SWF (Flash, not iPad compatible) formats. Old versions of Internet Explorer probably won't like these videos!
  • iCASE #27….9-month-old with shaking spells.
    SHAKE SHAKE SHAKE…..

    A 9 month old arrives with "shaking spells" and back-arching.

    How can ultrasound help you solve this mystery?

    You may play the interactive case video in either HTML5 (compatible with an iPad, but gotta have a GREAT wireless) or SWF (Flash, not iPad compatible) formats. Old versions of Internet Explorer probably won't like these videos!
  • CASE #26….23yo F with abdominal pain and constipation.
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    DEATH BY CONSTIPATION

    Miriam is miserable. She has not had a bowel movement for one week, and she feels if she can just have a good one, she will feel so much better. See how she almost dies right in front of us.

    This young woman comes in with constipation, but danger lurks in her abdomen.
    https://vimeo.com/102628954
  • CASE #25….45yo M with ankle pain while playing tennis.
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    BRAD PITT IN THE ED

    In 2004, Brad Pitt starred in the movie "Troy". He played the legendary warrior "Achilles" who is impervious to injury except for the tendon at the back of his ankle.

    Our patient suffered an Achilles Tendon rupture while playing tennis. He felt a pop in his ankle and noticed immediate swelling at the back of his lower leg. His ultrasound demonstrates this injury within minutes of seeing the patient.
    https://vimeo.com/76015708
  • CASE #24….55yo M with blurry vision and neck pain.
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    TICKING TIME-BOMB

    Rodney comes into the emergency department with a 10-minute episode of blurry vision and neck pain. If you miss the diagnosis, he will die. Click on the button below to see if you can keep from blowing him up.
    https://vimeo.com/90817656
  • CASE #23….43yo M with cough and fever.
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    THE WORTHLESS CXR

    Bob has been feeling lousy all week. He is coughing and thinks he has a fever. He is so weak now he can barely make it to the bathroom. His CXR is read as a possible infection (but this is not what is going to kill him).
    https://vimeo.com/100030931
  • CASE #22….45yo M with flashes of light in his right eye.
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    CAN ULTRASOUND BE USED FOR AN EYEBALL?

    Not many clinicians would think to use ultrasound to image the eye. However, an eyeball is basically a bag of water. And this makes it a perfect organ to image with ultrasound. In fact, ultrasound can help you with a lot of ocular emergencies that in the past have been very difficult to diagnose, in addition to convincing the on-call ophthalmologist to come in and manage the patient.

    HISTORY AND PHYSICAL EXAM

    Bob is watching TV when he starts to see flashes of light. The problem is they are not coming from the TV, but rather they seem to be in his right eye.

    His visual acuity is 20/30 in the left eye, and 20/200 in the right eye.
    You decide to use ultrasound to help you figure out the cause of his sudden loss of vision.
    https://vimeo.com/87398091
  • CASE #21….70yo M needs IV access, STAT.
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    MCGYVER IN THE ED

    Oscar is a very nice older man with multiple abdominal surgeries and many presentations to your ED for small bowel obstruction. Tonight he is miserable. He cannot stop vomiting, and he is in terrible pain. The nurses try a couple of times to get IV access, but soon throw up their hands and come to you for help. So you "MacGyver" a solution for this problem with two items in your ED and an ultrasound machine.
    https://vimeo.com/84360604
  • CASE #20….19yo F with sore throat.
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    MOUTH FULL OF PUS

    You encounter an 19yo woman with a "Hot Potato" voice and an angry ENT physician on-call. Click on the button below to see how you can make this case "easy" for you and the patient.
    https://vimeo.com/88264261
  • CASE #19….33yo F with radicular back pain.
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    THE FAKE-OUT

    Angela is a 33-year-old woman that returned to our emergency department with back pain radiating from her left flank to her left anterior thigh. On her first visit there were no significant findings on her physical examination. She had normal vital signs and was afebrile. A urinalysis and urine pregnancy test were negative, and she was sent home with a non-steriodal pain medication and told to follow up with her primary care physician.

    She returned ten days later complaining of the same pain without any relief. She had a hard time moving around and getting up to walk made it worse.

    VITAL SIGNS

    HR = 74, BP = 125/73, RR = 14, T = 98.0

    STUDIES AND EXAM

    A urine pregnancy test and urinalysis done in triage were normal.
    Her physical exam was remarkable for no tenderness in her flank. There was some very mild tenderness on the anterior aspect of her left thigh, but no swelling or mass. She had good femoral, popliteal, and dorsal pedal pulses in this extremity. There was no other abnormality of the left leg.
    Her cardiovascular and pulmonary exams were normal. Her abdomen was slightly tender in the left lower quadrant with no peritoneal signs.

    We thought her pain is related to either radicular nerve pain from vertebral disc disease or vascular disease such as a DVT. However, we decide to perform a pelvic exam and transvaginal ultrasound just to be sure we are not missing something.

    THE PELVIC

    Her speculum exam was remarkable for cervical discharge. During the transvaginal ultrasound examination she complained of a lot of tenderness.
    Find out what we saw by watching this video.
    https://vimeo.com/80027321
  • CASE #18….20yo F with dizziness.
    This case is presented with the permission of Thomas Cook from 3rd Rock Ultrasound, The Emergency Ultrasound Course.

    CASE

    Natasha is 20-year-old student studying communications at the local university. Over the past year she has also been working out hard to "get in shape". She felt that she gained too much weight from all the studying, so she changed her diet and starting running. On one hot day she was running around the campus at school and fainted. EMS brought her to our emergency department.

    On arrival she said she still felt a bit dizzy, but denied any specific chest pain, shortness or breath, or pain associated with trauma. She had no past medical problems and had never fainted before. Her last menstrual period was six weeks prior, but she often had irregular periods because she was using Norplant.

    VITAL SIGNS

    HR = 78, BP = 110/70, RR = 14
    Her physical exam including cardiovascular, pulmonary, gastrointestinal, and neurologic examinations were unremarkable. Orthostatic vital signs were normal.

    STUDIES

    Her ECG showed a normal sinus rhythm.
    Her CXR was normal.
    Her urine pregnancy test was negative.
    Her hemoglobin was 14.1 gm/dL.
    Her TSH, glucose, and serum electrolytes were normal.
    So JUST TO MAKE SURE nothing was missed, a cardiac ultrasound was performed.
    https://vimeo.com/77828908
  • CASE #17….55yo F with cough, SOB, and CP.
    Enter the name for this tabbed section: Case
    A 55yo F with h/o recurrent ovarian CA, PE, pleural effusions and ascites, presents with cough, SOB, and CP. VS: 131/79, 155, 99.1 20, 94% on 2L/NC. Point-of-care hemoglobin is 6.

    A bedside cardiac and pleural exam is performed.

    Based on the history and the U/S video below…..

    Q1. What is the pathology noted on the ultrasound?
    Q2. How would you describe the cardiac function?
    Q3. How would you manage this disease process?
    https://vimeo.com/79635009
    Enter the name for this tabbed section: Answer
    https://vimeo.com/79635481


    Q1. What is the pathology noted on the ultrasound?
    Tension hemothorax. A large pleural fluid collection is noted, with a homogenous echogenicity which suggests blood, as does the sudden drop in the patient's hemoglobin. The lung is seen to float in the fluid (blood) collection.

    Q2. How would you describe the cardiac function?
    The cardiac ultrasound suggests a hyperdynamic heart.

    Q3. How would you manage this disease process?
    The patient received PRBCs and an emergent tube thoracostomy.

  • CASE #16….65yo M with diffuse abdominal pain.
    Enter the name for this tabbed section: Case
    A 65-year-old male with a history of extensive tobacco use presents to the Emergency Department with two days of worsening abdominal pain. Over the past three weeks, he reports 10 pounds of unintended weight loss, a change to his bowel habits including constipation with frequent small volume liquid stools, and increased abdominal distention. His abdominal pain is localized over his epigastric and right and left upper quadrants. A right upper quadrant ultrasound is performed at the patient’s bedside to evaluate for possible causes of the patient’s symptoms.

    Based on the history and the U/S video below…..

    Q1. What abnormalities are observed in the liver parenchyma?
    Q2. What is the most appropriate management option for the emergency physician who discovers this on bedside ultrasound?

    https://vimeo.com/79623033
    Enter the name for this tabbed section: Answer
    https://vimeo.com/79623100


    Q1. What abnormalities are observed in the liver parenchyma?

    There is evidence of extensive hepatic parenchymal change. There are numerous lesions of varying echogenicity with poorly defined borders. These findings would be most concerning for evidence of intrinsic or metastatic liver cancer.

    Hepatic malignancies produce variable echogenic patterns. Their borders range from smooth to irregular in appearance, and their echogenicity can be decreased or increased as compared to surrounding “normal” hepatic tissue. Necrosis typically results in decreased echogenicity, while tumor hemorrhage can result in increased echogenicity depending on the time course of the bleeding.

    The most common benign tumors of the liver are hemangiomas, which are typically hyperechoic, with well-defined borders. Hepatic adenomas are also common benign tumors of the liver, and exhibit well-defined margins with variable echogenicity. The liver is a common metastatic destination for malignancies originating in the colon, breast, and pancreas.

    Of note, metastases to the liver on ultrasound usually take on one of the following appearances: (1) hypoechoic mass, (2) mixed echogenicity mass, (3) mass with target appearance, (4) uniformly echogenic mass, (5) cystic mass, or (6) heterogeneous or "coarse" echo texture without focal mass. Most metastases are solid and mainly hypoechoic relative to the background liver (though in this case are hyper echoic).


    Q2. What is the most appropriate management option for the emergency physician who discovers this on bedside ultrasound?


    The ability to delineate benign processes from malignant ones within liver parenchyma on bedside ultrasound is outside the scope of emergency bedside ultrasound. It is however, important to be able to recognize deviations from normal, and the possible causes of those differences. Upon detection, this should prompt the physician to consider additional imaging and providing appropriate follow-up.

    Following bedside ultrasound, the patient underwent an abdominal CT with oral and intravenous contrast that showed evidence of diffuse liver parenchymal changes consistent with metastasis from a likely sigmoid colon primary source. Follow up was arranged with an oncologist, and he has subsequently undergone an IR guided liver lesion biopsy, and further CT imaging to characterize the degree of metastasis. Pathology results are still pending.


    Sources:
    1. Ma OJ, Mateer JR (2008). Emergency Ultrasound (2nd Edition). New York, The McGraw-Hill Companies, Inc.
    2. Cosby KS, Kendall JL (2006). Practical Guide to Emergency Ultrasound. Philadelphia, Lippincott Williams & Wilkins.

    (This case is courtesy of Dr. Stephanie Bailey, MUSC)
  • CASE #15….69yo F with epigastric pain.
    Enter the name for this tabbed section: Case
    This is a 69yo F who presents with 24 hours of epigastric abdominal pain. History of a TAH for fibroids and a laparoscopic cholecystectomy. She complained of 10/10 abdominal pain. She did have a small bowel movement on the day of admission, but no longer can recall the last time she had flatus.

    Diffuse, moderate abdominal pain without guarding or rebound.

    BP markedly elevated, but VS otherwise normal.

    Her pain goes away with an oral dose of an anti-hypertensive. However, on re-exam, she has further paroxysms of pain and undergoes a bedside ultrasound.

    Refer to the U/S below.

    Click here for a still image.

    Based on the history and the U/S video/image…..

    Q1. How do I know whether this is large or small bowel?
    Q2. How does U/S compare to Xray in the evaluation of SBO? What are its test characteristics?
    Q3. What is the diagnosis in this case and why?
    https://vimeo.com/75888555
    Enter the name for this tabbed section: Answer
    https://vimeo.com/75891066

    Q1. How do I know whether this is large or small bowel?
    Look for the plica circulares. (In contrast from the haustra of the colon.) On ultrasound, AKA the “keyboard sign.” Click here for a marked image (arrows indicating the plica circulates).

    Q2. How does U/S compare to Xray in the evaluation of SBO? What are its test characteristics? The best article to answer this question is by Taylor et al in AEM. Overall, AXR are diagnostic in 30-70% of cases of SBO, with a specificity of 50%. Taylor’s systematic review noted +LR of 1.65 (95% CI = 1.07-2.52) and –LR 0.59 (0.43-0.82); in other words, not very useful. As for U/S, the formal U/S pooled results had a +LR of 14.1 (3.57-55.66) and a –LR of 0.13 (0.08-0.20). For bedside U/S, +LR 9.55 (2.16-42.21) and –LR 0.04 (0.1-0.13). In other words, U/S is more useful. Click here for the article by Taylor et al.

    Q3. What is the diagnosis in this case and why? Small bowel obstruction. This patient demonstrates dilated bowel loops and findings of “back-and-forth” peristalsis.

    Discusssion:

    To make the diagnosis of SBO by ultrasound, you may use a curved or linear array probe. Look for fluid-filled, dilated loops of bowel (>2.5cm), with back and forth movement of bowel contents due to dysfunctional peristalsis.

    According to the awesome
    “Ultrasound Podcast” of Mike Mallin and Matt Dawson:

    Only a few small studies have looked point of care ultrasound for the diagnosis of SBO in the ED. After a 10-minute training session and 5 practice scans residents at UCLA Olive View Medical Center (
    Jang et al) were able to detect CT proven SBO with a sensitivity of 91% and specificity of 84%. Small study with big confidence intervals, but the basic take home message is that trained ED providers with an ultrasound are about as good as plain films. Something to try next time you are waiting for further imaging studies.

    In our patient:

    CT scan (yes, our surgeons still wanted it): Findings consistent with small bowel obstruction with transition zone in the mid to right upper pelvis.

    Hospital course: The patient was admitted and started on IV fluids with an NG tube placed. Home medications were held at that time until she was tolerating PO. Her diet was slowly advanced as her bowel function returned, and her oral medications were restarted. She was discharged to home without complications (or surgery!).
  • CASE #14….58yo F with RLE pain, s/p fall.
    Enter the name for this tabbed section: Case
    The patient is a 58 y/o F who presented with right lower extremity pain after a fall at her job. She is a teacher and was walking down some steps at the school and had a mechanical fall on the stairs. She landed on her right knee and immediately felt pain. She was unable to lift her leg at that time. No bony tenderness, but increased swelling over right patella. She is neurovascularly intact distal to injury.

    Based on the history and the U/S below…..

    Q1. What abnormalities are seen on this ultrasound exam?
    Q2. What is your next step?

    https://vimeo.com/73332653
    Enter the name for this tabbed section: Answer
    https://vimeo.com/73332653

    Q1. What abnormalities are seen on this ultrasound exam?
    There is a joint effusion (almost certainly a hemarthrosis) and a patellar tendon rupture.

    Q2. What is your next step?
    Knee immobilizer and orthopedics referral.


    Discussion
    :

    Probe selection and application:

    1) High frequency linear transducer.

    2) Put probe with transducer pointed superiorly and drag the probe inferiorly from the quadriceps muscle to tendon, then over the patella, eventually over the patellar tendon and to the tibial tuberosity.

    3) Look for any disruption of tissue, tendon, or bone. Look for areas of effusion.

    There are three forms of rupture: complete, partial and tendinitis. In complete ruptures, tendons separate completely from the tibia resulting in inability to straighten leg. In partial ruptures the majority of the tendon is still attached to the soft tissue located at the posterior end of the patellar bone. The third form, patellar tendinitis, causes tendon to be torn in middle from over-use.

    The patient was placed in a knee immobilizer, given pain meds, and was referred to orthopedics. Patellar tendon ruptures require surgical repair. Partial tears can be managed non-operatively.


    (This case is courtesy of Dr. Blake Willis, MUSC)
  • CASE #13….10yo M with RUQ pain X 2 weeks.
    Enter the name for this tabbed section: Case 13
    A 10-year-old male, previously healthy, presented with right upper quadrant pain for 2 weeks without other symptoms. Initially, the pain was present only at night, and the patient described the initial pain as though "someone punched him." Pain progressed and became worse over the ensuing week. The patient denied fever, nausea, vomiting, diarrhea, constipation, hematemesis, or hematochezia. On questioning, the patient denies any fatigue, chills, diaphoresis, anorexia, or shortness of breath. He has had no change in his urine output. He also denies any hematuria or back pain. He has not reported any rash. Of note, the patient does live on a farm and drinks well-water. He also bathes in the well water. He has had no recent travel, sick contacts, or strange food consumption. The patient and his family have not appreciated any jaundice.

    His temp was 38.1 degrees Celsius. The patient had positive bowel sounds. Abdomen was soft, nondistended, mildly tender to palpation over the right upper quadrant with guarding. Liver border appreciated at the costal margin on deep palpation.

    WBC was 14.1 with 72% neutrophils. CRP was 9.5 and ESR was 40.

    Based on the history and the U/S below…..

    Q1. Describe what are you seeing on the U/S.
    Q2. What is your differential diagnosis?
    Q3. What do you do next?
    https://vimeo.com/73316681
    Enter the name for this tabbed section: Answer
    https://vimeo.com/73321784

    Q1. Describe what are you seeing on the U/S.
    There is a heterogeneous lesion in the right lobe of the liver which demonstrates peripheral hyperemia (increased blood flow).

    Q2. What is your differential diagnosis? Differential diagnosis: amebic hepatic abscess vs. pyogenic liver abscess vs. cystic tumor.

    Q3. What do you do next? Patient was admitted on broad-spectrum ABX. CT scan was performed and confirmed the U/S finding. Percutaneous aspiration was then performed of the liver abscess per ID recommendations via Interventional Radiology, fluid was able to be sent to pathology and microbiology for further evaluation.

    Diagnosis: Pyogenic liver abscess consistent with methicillin-susceptible Staphylococcus aureus.

    Treatment: The patient’s WBC and CRP improved after 1 week or IV Ancef and was discharged home with Keflex for 5 weeks with follow-up in 3 weeks.


    (This case is courtesy of Dr. Blake Willis, MUSC)
  • CASE #12….58yo F with flank pain.
    Enter the name for this tabbed section: Case 12
    A 58-year-old female with a history of kidney stones presents with acute onset of right-sided 8/10 flank pain and NB/NB vomiting 3 hours ago. Over the past 10 days she has experienced mild dysuria, intermittent hematuria, and right-sided flank “aching” that radiates to her ipsilateral labium. Her LMP was 5 years ago. She admits to chills but denies fever or a history of STIs.

    Watch the video below and answer the following questions:

    Q1. What are the sonographic differences between mild, moderate, and severe hydronephrosis?
    Q2. What abnormalities are observed in the right kidney?
    Q3. A more obvious demonstration of what pathologic artifact in the bladder view would make this diagnosis easier to call?
    Q4. Presence of what finding in the bladder would rule out a diagnosis of complete ureteral obstruction?
    Q5. Which 3 segments of the ureter are the most prone to obstruction and why?
    Q6. If hydronephrosis without visible stones were noted on emergency US in an older patient with hypertension, hypercholesterolemia, or a history of smoking, what US exam should be performed next?
    Q7. How can one differentiate normal renal pyramids from hydronephrosis?
    Q8. What can cause hydronephrosis other than ureteral stones? What about false negative exams?
    https://vimeo.com/66943850
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    https://vimeo.com/66943850
    Please see the reference video above.

    Q1. What are the sonographic differences between mild, moderate, and severe hydronephrosis?
    • Mild: any fluid in renal pelvis/ calyces
    • Moderate: confluent calyceal dilation with preserved renal parenchyma; “bear’s paw” appearance
    • Severe: extensive calyceal dilation with cortical effacement. Appears like a “balloon”
    • Note: hydronephrosis in all cases has no color flow unlike vessels

    Q2. What abnormalities are observed in the right kidney? Mild-moderate hydronephrosis with hydroureter without visible stones. A urinoma is also visible on the transverse view.

    What is a urinoma?
    • Extravasated urine found adjacent to the kidney or tracking elsewhere in the body
    • Develops secondary to leakage from the collecting system, most commonly blunt trauma, but can also develop in response to obstruction (cancer, stones), infection, pregnancy, or various congenital causes
    • Can cause pain and pressure symptoms, or even result in abscess formation, sepsis, and peritonitis
    • US or CT-guided needle drainage or treatment of the cause is recommended to both diagnose and treat urinomas
    • In the accompanying clips, the urinoma is not visible on the longitudinal view (likely due to suboptimal gain settings)

    Q3. A more obvious demonstration of what pathologic artifact in the bladder view would make this diagnosis easier to call? Shadowing of the kidney stone appreciated at the right UVJ. Stones are identified at the UVJ in 30–50% of cases of ureterolithiasis. The shadowing is difficult to appreciate in this study partly due to posterior acoustic enhancement and partly because the gain is too high. Both of these should be adjusted by the sonologist.

    Q4. Presence of what finding in the bladder would rule out a diagnosis of complete ureteral obstruction? Ureteral jets

    Q5. Which 3 segments of the ureter are the most prone to obstruction and why?
    • Ureteropelvic junction: this is where the renal pelvis narrows to become the ureter
    • Ureteral crossing over the iliac vessels: compression by the vessels and bending of the ureters
    • Ureterovesicular junction: narrowing where the ureter enters the bladder. This is the site of obstruction in our patient

    Q6. If hydronephrosis without visible stones were noted on emergency US in an older patient with hypertension, hypercholesterolemia, or a history of smoking, what ultrasound exam should be performed next? Examination of the aorta to rule out AAA. This exam would also be indicated with a normal renal ultrasound in an older patient complaining of abdominal or back pain.

    Q7. How can one differentiate normal renal pyramids from hydronephrosis? The pyramids are discrete anechoic or hypoechoic areas that do not connect to each other or the pelvis (unlike hydronephrosis). Traces of renal sinus fat can always be seen outside of hydronephrotic calyces, in contrast to pyramids, which are on the outside of the renal sinus. Pyramids are prominent in younger patients

    Q8. What can cause hydronephrosis other than ureteral stones (false positive exams)? What about false negative exams?
    • Positive:
    o Retroperitoneal masses or neoplasms
    o Pregnancy
    o Full bladder (overhydration, diuresis, bladder outlet obstruction, etc)
    o Around 6-9% of patients getting routine renal scanning have mild hydronephrosis
    o Note: renal sinus cysts should be distinguished from hydronephrosis.
    • False negative:
    o Dehydration (repeat scan after correcting patient’s fluid status)
    o Incomplete obstruction
    o Ultrasound has a 15-25% false negative rate for ureteral stones. Fortunately, the larger the stone the lower the false-negative rate. This is important because larger stones are less likely to pass and therefore more important to diagnose and manage

    Of Note:

    The
    clips and images demonstrate the following findings:
    • Right kidney: mild to moderate hydronephrosis and hydroureter with perinephric fluid consistent with urinoma
    • Bladder: strong left jet, absent right jet, possible stone at right UVJ with subtle shadowing

    A CT done shortly after US revealed a 4mm renal calculus at or just past the right ureterovesical junction. At least moderate right hydroureteronephrosis with an asymmetrically enlarged and edematous right kidney and associated perinephric and periureteral fluid were also noted.

    (This case is courtesy of Evan Suzuki, MD)
  • CASE #11….33yo M with chronic chest pain.
    Enter the name for this tabbed section: Case
    A 33yo male presents to the ED with c/o chest pain for 3 months. He is dyspneic but otherwise has normal VS. He states that he was told that "something was wrong with my left lung."

    The probe is oriented in a coronal plane along the left posterior axillary line.
    Alt image
    Stacks Image 14369
    Q1: What is the diagnosis?
    Q2: What are the common etiologies and appearances on US?
    Q3: What is the characteristic sonographic “sign” depicted in the clip?
    https://vimeo.com/65009526
    Enter the name for this tabbed section: Answer
    https://vimeo.com/65013788

    Q1: What is the diagnosis?
    Pleural Effusion. A pleural effusion typically appears as an anechoic or hypoechoic space on US. Fluid accumulates between the visceral and parietal layers of the pleura. It collects in the most dependent portions of the pleura, the costophrenic angles.

    PLEASE CLICK HERE FOR THE NARRATED CLIP EXPLAINING THE CASE.

    In the
    clip, pleural fluid is noted above the diaphragm, spleen and kidney. Lung tissue is normally not well visualized because of the large amount of air present. However, the pleural fluid provides a good acoustic window, and the normally aerated lung tissue has been compressed and appears hyperechoic.

    Q2: What are the common etiologies and appearances on US?
    Internal echoes may be present in the fluid and the echogenicity of the effusion can assist the clinician in determining the cause of the effusion. Click here for a table explaining the various sonographic findings.

    The patient had a thoracentesis during his hospitalization, which revealed frankly bloody fluid and clearly an exudate by the pleural fluid analysis. He had almost 2 L removed and had significant improvement in his chest and lung pain.


    Q3: What is the characteristic sign depicted in the clip?
    The Spine Sign (aka The V-line).

    • Typically you will not see the posterior thoracic cage (vertebral bodies and posterior ribs) superior to the diaphragm.

    • Normally, below the diaphragm, the spine is visible because sound waves are transmitted to the vertebral bodies by the acoustic windows of the liver/spleen and kidney.

    • Normally, above the diaphragm, the vertebral line ends abruptly as aerated lung does not permit transmission of sound waves to the posterior thoracic structures. Instead, a black acoustic shadow or “lung curtain” is seen and no posterior structures can be visualized.

    • However, when there is fluid in the thorax the spine (thoracic cage) is seen as an echogenic line extending superiorly from the diaphragm. This is due to transmission of ultrasound waves through fluid to the posterior thoracic cavity. This is known as the “
    spine sign.”


    References:

    1) Noble VE, Nelson BP (2007). Manual of Emergency and Critical Care Ultrasound (2nd Edition). New York, Cambridge University Press.
    2) Atkinson et al. The V-line: a sonographic aid for the confirmation of pleural fluid. Critical Ultrasound Journal 2012,4:19.

    (This case is courtesy of Rachel Scott, MD)
  • CASE #10….60yo F with right eye pain.
    Enter the name for this tabbed section: Case
    This is a 60 year old female with history of DM, HTN and GERD who presented with a two day history of right eye pain. She stated that she woke up with the pain, had an increase in floaters and blurry vision. She denied trauma to her affected eye. VA was 20/25 right eye and 20/50 left eye. EOMI were intact. A right eye ultrasound was obtained.

    Q1. Does this patient have increased intraocular pressure?
    Q2. What is her ocular ultrasound finding?
    https://vimeo.com/65014866
    Enter the name for this tabbed section: Answer
    https://vimeo.com/65016139
    Q1. Does this patient have increased intraocular pressure? No.

    Q2. What is her ocular ultrasound finding? Posterior vitreous hemorrhage/detachment. (Though I personally can't rule out a retinal detachment….a point of disagreement with Ophtho attending.)

    Discussion: Ocular emergencies account for about 3% of all visits to the ED. Pathology include globe penetration, foreign body retention, acute glaucoma, retrobulbar hematomas, lens disruption, retinal detachment and vitreous hemorrhages.
    When performing an ocular ultrasound, the following anatomy should be appreciated:

    1)
    Anterior chamber – Consists of the cornea, lens and the anechoic fluid between the two.
    2)
    Cornea – Thin, hyperechoic structure attached to sclera at periphery.
    2)
    Lens – hyperechoic structure that is concave at posterior of anterior chamber.
    3)
    Posterior chamber – large anechoic area posterior to the lens.
    4)
    Retina – varies from 0.56 mm near the optic disk to 0.1 mm anteriorly. Anterior surface contacts the vitreous body and posterior surface adherent to choroid.
    5)
    Optic sheath – Measure it at 3 mm posterior to the globe. Normal measurements are 5 mm or smaller in adults.

    Posterior vitreous hemorrhage - Web-like structure along the posterior of eye, as seen in the clip, can be appreciated. Sometimes the gain has to be turned up to see the strands of hemorrhage.

    Posterior vitreous detachment - Fine echodensities visible in the vitreous chamber. There is a swirling appearance (seen in the clip) when the patient moves his or her eyes, with underlying hemorrhage.

    Unlike
    retinal detachment, vitreous detachment: — occurs in front of the optic disc and does not remained anchored to it. — lacks a thickened hyperechogenic membrane.

    (This case is courtesy of Celia Cheung, MD)
  • CASE #9….93yo F with AMS and SOB.
    Enter the name for this tabbed section: Case
    93 year old female with history of hypertension, stage IV CKD, and dementia, presents to the ED brought by family for altered mental status and shortness of breath. She was found to by tachypneic and hypoxic on room air.

    Q1: What abnormality do you see?
    Q2: Is there qualitative evidence of tamponade?
    Q3: How can you quantitatively assess for tamponade?
    https://vimeo.com/104012790
    Enter the name for this tabbed section: Answer
    https://vimeo.com/104012792
    Referring to the marked ultrasound above.

    Q1: What abnormality do you see? Circumferential pericardial effusion.

    Q2: Is there qualitative evidence of tamponade? No RV diastolic collapse, no serpiginous motion of RV or RA free wall.

    Q3: How can you quantitatively assess for tamponade? Refer to this image. Assess for sonographic pulsus paradoxus. Visualize heart in apical 4 chamber view. Place Doppler over MV inflow track. Assess for variation in inflow velocity between inspiration and expiration. Variation >25% between minimum and maximum indicates pulsus paradoxus. This patient demonstrates no significant variation. Of note, the second inflow wave generated from the atrial kick is equal in magnitude to the first inflow wave, consistent with longstanding hypertension and diastolic heart failure.

    (This case is courtesy of Sam Bores at the University of Pennsylvania.)
  • CASE #8….26yo F with left-sided back/abdominal pain.
    Enter the name for this tabbed section: Case
    26 year old woman presents complaining of vague left-sided back and lower abdominal pain. She reports that the pain is “kinda” the same as her prior kidney stone. Senior resident “unimpressed” by her pain, diagnoses her with MSK strain. UA neg for pregnancy or blood. Astute intern decides to circumvent the senior resident and performs a renal ultrasound.

    What is your diagnosis?
    https://vimeo.com/55545170
    Enter the name for this tabbed section: Answer
    Hydro_marked
    In comparing the right (normal) and left (abnormal) kidneys, you can see dilation of the calyces (arrow) and the ureter (arrowheads) in the image to the right. While the actual stone was not visualized, the findings and clinical presentation in this case were consistent with acute ureteral colic. The patient was recommended to return in 3-4 days for recheck (UA, possible CT-IVP) if the pain persisted.

    As for ureteral stone identification, U/S unfortunately has very poor sensitivity. A great review of the topic appears in
    EMJ in 2012 (Dalziel and Noble); the authors note that only 2/3 of stones will be in the "field of view" for U/S identification. Of these, U/S is only 16% sensitive for stones <7mm and 75% sensitive for stones >7mm. As for the finding of hydronephrosis, bedside U/S sensitivity (compared to CT) has a range of sensitivities from various studies of 72-97% and specificities from 73-83%. False positives for hydronephrosis include pregnancy, an over distended bladder, rapid IV rehydration, etc. For this reason, it is always important to obtain imaging of both kidneys and the bladder before making the diagnosis of probable kidney stone.

  • CASE #7….78yo F s/p fall, knee pain.
    Enter the name for this tabbed section: Case
    A 78-year-old woman presented to the Emergency Department after falling during her Christmas shopping. She complains of severe pain in her right knee, but no other apparent injuries. On physical exam, the patella of her right knee appears to be situated well above the joint, though in the midline. The EM team is concerned for patellar tendon rupture. Before the X-ray tech arrives, the brilliant resident decides to evaluate the knee with ultrasound.

    In the movie below, the probe is oriented in a longitudinal (sagittal) plane over the lower leg. In the first clip of the movie, the probe moves from the tibia to the patella. The second clip involves the patella moving proximally. While viewing the movie, try to answer the following questions.


    Questions:

    1. Is there a patellar tendon rupture?
    2. How would you describe the patella?
    https://vimeo.com/56065069
    Enter the name for this tabbed section: Answer
    In the movie, the probe is dragged over the anterior aspect of the lower leg towards the distal thigh. In the first clip, the patellar tendon attaches to the proximal tibia (arrowheads on image). The tendon attaches to a fragment of bone, which ends abruptly. As the sonographer drags the probe proximally (second clip), another piece of bone is seen, which attaches to a tendon superiorly. This represents the proximal fragment of what is a patellar fracture (arrow marks fracture). In fact, there was no patellar tendon rupture, but instead a patellar fracture, a diagnosis which was confirmed on plain film.

    The patient was seen by orthopedics in the ED and given a knee immobilizer and crutches. As she was on anticoagulation at the time of her injury, the decision was made to delay surgery. She was discharged home with a scheduled ORIF of the patella after holding her meds for several days.

    1. Is there a patellar tendon rupture? No.
    2. How would you describe the patella? Fractured.


    References:

    2002 Dulchavsky et al. J Trauma. Extremity U/S is quick and accurate (94%) in identifying fractures. Better for midshaft fractures of the radius/ulna, humerus, femur, or tibia/fibula. Worse for hand/foot, tendon, and femur.

    Noble and Nelson. Manual of Emergency and Critical Care Ultrasound, 2nd ed. “Soft Tissue and Musculoskeletal Ultrasound”, 213-225.

  • CASE #6….47yo M with panic attack and cardiac arrest.
    Enter the name for this tabbed section: Case
    A 47 year old male presents after having a "panic attack" shortly after being discharged from the hospital. While the nurses were talking to him in the car, he loses pulses. The staff begins CPR in the parking lot and wheels the patient into the ED resuscitation bay. He was resuscitated according to ACLS algorithm. An ECHO performed at a rhythm check is shown below.

    Questions:
    1. What is this patient’s most likely diagnosis?
    2. How would you describe this patient’s LV function?
    https://vimeo.com/56498477
    Enter the name for this tabbed section: Answer
    On the PSLA view of the heart, you can see the Septum (S) bowed towards the direction of the Left Ventricle (LV). You also notice the size of the Right Ventricle (RV) compared to that of the . You also note in the video how the left ventricle is hyperdynamic and almost appears to collapse completely at the end of systole. These are all the result of a PE in this case.

    On the PSSA view, the Left Ventricular walls form a D shape as opposed to the classic round appearance in a normal heart. You again notice the enlarged size of the right ventricle when compared to the left ventricle.

    In normal hearts, the right ventricle is usually roughly 2/3 the size of the left ventricle when looking at the heart from an apical 4 chamber view. This patient's
    apical 4 chamber view is significant for an enlarged right ventricle, as well as paradoxical septal movement (bowing of the septum towards the left ventricle) especially noticeable in the video clip.

    While these findings may be seen with large pulmonary emboli, you will also see the enlarged RV and signs of right heart strain in patients with moderate to severe pulmonary hypertension. A more specific finding in acute pulmonary embolism is right ventricular free wall hypokinesis with preserved apical function. This is termed the McConnell sign.

    1. What is this patient’s most likely diagnosis? PE.

    2. How would you describe this patient’s LV function? Hyperdynamic LV.

    Multiple reports have shown that ultrasound in cardiac arrest is useful in narrowing your differential diagnosis and therefore guiding treatment. A
    review article by Hernandez covers the sonographic findings you would expect in some of the most common causes of PEA including tamponade, hypovolemia, pulmonary embolus, and tension pneumothorax.

    (This case is courtesy of Dr. Brad Presley)
  • CASE #5….18yo M with lower abdominal pain.
    Enter the name for this tabbed section: Case
    18yo male presents with 3 days of lower abdominal pain. Vital signs normal except for a pulse of 101. Has supra-pubic and right lower quadrant pain. He is guarding. The EM resident, Dr. Fulkerson, does an ultrasound.

    What is your diagnosis?
    https://vimeo.com/47756133
    Enter the name for this tabbed section: Answer
    Diagnosis: Appendicitis with perforation/free fluid.

    Ultrasound of the appendix is a well-accepted diagnostic study, though it is more commonly performed outside the U.S. Studies have demonstrated that it changes management, lowers CT utilization, and produces cost savings. Why hasn’t it caught on? Well, for one, it’s very operator dependent. And a normal appendix is often difficult (in my case, impossible) to visualize. Anatomically, the appendix is a blind-ended tubular structure that lies around 1-2 cm distal to the ileum. Sadly, the classic “McBurney’s point” location of an appendix only occurs in around 1/3 of patients. The normal diameter is < 6mm.

    The probe of choice is a high-frequency linear transducer, though others will suggest a curvilinear transducer. I spread the gel on the area of interest, and take a quick look to see if an inflamed appendix jumps into view. If not, I ask the patient to press the probe down at the point of maximal pain. I then use gradual, gentle compression which displaces pesky gas-filled loops of bowel. Once identified, the diameter of the appendix should be measured in transverse and longitudinal, outside wall to outside wall. A normal appendix undergoes peristalsis and easily collapse with compression. An inflamed appendix will appear as a “target” in transverse, with an anechoic lumen, echogenic ring of mucosa/submucosa, and an outer ring of hypoechoic muscularis externa (per Ma and Mateer). The diameter will be > 6mm, it will be non-compressible, and no peristalsis will occur (Siegel MJ. JAMA 1991;266(14):1987-9). Sensitivity and specificity are around 86% and 81%, respectively (Terasawa et al. Ann Intern Med 2004;141(7):537-46).

    For perforated appendicitis, as is seen in
    this case, there may be fluid around the inflamed appendix. In some cases, the targetoid appearance may disappear, though it is maintained in this patient. Literature suggests that the sensitivity of U/S for detection of an appy after perforation is quite low, though the pathology was pretty clear in this patient.

    So, for appy U/S, think:

    1. > 6mm
    2. Non-compressible
    3. No peristalsis


    The ultrasound in this case demonstrates a
    targetoid appearance in transverse. In longitudinal, there is no peristalsis, and no compressibility. The appendix is dilated when measured with calipers. When imaged with a curvilinear probe, the wall of the appendix appears to disappear (perforated, best seen in the close-up) and is surrounded by fluid.

    This patient went to the OR and had a perforated appendix. He was washed out and underwent an appendectomy, and had an otherwise uncomplicated post-operative course.
  • CASE #4….64yo F with N/V and abdominal pain.
    Enter the name for this tabbed section: Case
    64 year old female presents with crampy upper abdominal pain and nausea/vomiting. Similar episodes in the past.

    What the heck is going on with her?
    https://vimeo.com/46975602
    Enter the name for this tabbed section: Answer
    Diagnosis: Cholelithiasis with a dilated common bile duct (CBD), and intrahepatic ductal dilatation.

    Discussion: Anatomically, the intrahepatic ducts form in the liver and form the common hepatic duct (CHD) in the porta hepatis. The CHD combines with the cystic duct to form the CBD. No distinction is typically made between the CHD and CBD; some experts go on to divide the CBD into a proximal, mid, and distal portion. Most do not. Measurements are made from inner wall to inner wall. A normal CBD is <6mm in diameter, while 6-8 mm is considered equivocal, and >8mm is dilated. I use the formula of adding 1mm for every decade of life (60yo=6mm). That said, after a cholecystectomy, the CBD may commonly dilate to as much as 1cm in diameter.

    The intrahepatic ducts are more difficult to evaluate due to small diameter (<1mm in the periphery); they should always be <50% the size of the adjacent portal vessel. Dilated intrahepatic biliary ducts may show a classic “shotgun” appearance; “too many tubes”; “antler signs”. Look for a stone in the CBD, though with the understanding that U/S only has a sensitivity of 15-55% for detection of CBD stones.
    In this patient, cholelithiasis and a markedly dilated CBD were both noted on U/S. A CBD stone was suspected clinically, but not visible on U/S. She went on to have an MRCP, which showed multiple stones in the main bile duct. Biliary cannulation, sphincterotomy, and stone extraction were performed. The patient subsequently had a laparsoscopic cholecystectomy.
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  • CASE #3….How to check a FHR.
    Enter the name for this tabbed section: Case
    This is a TVUS image of an early pregnancy of a woman who comes to the ED complaining of lower pelvic pain. Fetal heart rate is calculated using M mode (FHR 98).

    What is wrong with this image?
    What is the normal range of FHR in early pregnancy?


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    Enter the name for this tabbed section: Answer
    Use M-mode (correctly) for fetal heart rate.

    M mode shows depth and tissue motion on the y-axis and time on the x-axis. Fetal heart rate (FHR) is measured in M mode in this image but you still have to place the calipers in the correct position for the FHR to be correctly measured. Arrows indicate where the calipers should have been placed along the x-axis in order to correctly determine the HR. When the crown rump length (CRL) is > 5mm the HR should be > 120bpm. Bradycardia is considered any HR < 90 bpm and correlates to an increased risk of fetal demise. A heart rate between 90-170 bpm can be normal.

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  • CASE #2….24yo pregnant F with cramping.
    Enter the name for this tabbed section: Case
    A 24 year-old female arrives with early pregnancy and pelvic cramping. She has never had an ultrasound to confirm IUP.

    Below is a transvaginal ultrasound (TVUS) image of a pregnancy. What would you do differently with regard to imaging this pregnant female?


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    Enter the name for this tabbed section: Answer
    Start with a transabdominal scan!!

    This is a good example of why we start with a transabdominal ultrasound (TAUS). This is a very large fetus and is probably late 2nd trimester. It is rarely necessary to perform a TVUS after you have confirmed a definitive IUP by TAUS. In this case, you would have obtained all the essential information by TAUS. No need to subject your patient to a more invasive TVUS.
  • CASE #1….37yo F with dyspnea.
    Enter the name for this tabbed section: Case
    37 year-old female presents with dyspnea and tachycardia. CXR shows cardiomegaly. Bedside echo is performed. From the videos below, please answer the following questions:

    Q1: Which cardiac view is this?
    Q2: What is the pathology?
    Q3: What are the sonographic findings that are consistent with this disease process?
    https://www.vimeo.com/8841737
    https://vimeo.com/8842333
    Enter the name for this tabbed section: Answer
    Question 1: Which cardiac view is this?

    tamponade
    This is a subxiphoid view.

    Note the liver edge adjacent to the RV, the LV more posteriorly, and the atria on the left side of the U/S screen.

    This view is obtained by placing the probe in the subxiphoid area with the indicator at 9 o’clock, the probe head angled slightly towards the patient’s left shoulder, and almost flattening your hand against the patient’s abdomen.


    A deep breath and “hold” will typically improve your view.

    Question 2: What is the pathology?

    There is a large pericardial effusion.

    There is RV collapse noted on the second video in particular.


    These findings are concerning for cardiac tamponade.

    Question 3: What are the sonographic findings that are consistent with this disease process?

    Pericardial effusion, RA or RV collapse, and lack of respiratory variation in the IVC (big, plethoric IVC).

    More discussion
    • This is a classic example of cardiac tamponade
    • Effusions tend to collect inferiorly and posteriorly, and are oftentimes best seen in the subxiphoid view (also great in the PSLA)
    • Small effusions may be confused with an epicardial fat pad, which is seen in the anterior precordial space (between the RV and liver on subxiphoid view)
    • Effusions are commonly termed small (< 1cm, localized), medium (1-1.5cm, circumferential), or large (> 1.5cm, circumferential)
    • Can see tamponade acutely with as little as 50mL of fluid
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