29yo female presented yesterday with epigastric pain of 2/7 and vomitting. Her only PMHx was intussusception as a child for which she had had surgery.
She had opened her bowels yesterday. She stated she hadn't passed flatus today.
OE she was tachycardic HR 100, but otherwise stable and afebrile. Her abdomen wasn't distended and she was tender epigastrically without guarding.
BHCG was negative.
High on the differential was SBO.
On US, her GB and pancreas were normal. Aorta was 2 cm, nil flap.
However she became very tender on examination of the pelvis:
RIF: dilated loop of SI (note place circulars in video below); free fluid around the loop. Loop is dilated (>3cm) and completely filled with fluid.
No peristalsis in this dilated loop of bowel
LIF showed further distended loops of bowel with faecalised (grainy and faeces like: ie has been in the bowel a while) content and significant free fluid.
two videos showing washing machine (to and fro) movement of content due to bowel obstruction
CT showing the same as the US.
Important to note in this case: the patient had been seen the previous evening with vomiting and epigastric pain. Her ED US was deemed normal due to a normal GB, normal CBD and lack of hydronephrosis. Remember to keep an open mind if the ED US is negative and go searching for other pathology with US or perform a different diagnostic test if concerned.
Signs of bowel obstruction on US:
dilated loops of SI: >2.5cm
ineffective to and fro movement of contents
features suggestive of bowel ischaemia:
hyper echoic gas within the bowel wall with reverberation artefact (dirty shadowing)
absence of peristalsis
thick bowel wall >3mm
In a case of bowel obstruction always check for herniae
hyperechoic gas in within thickened bowel wall
Incidentally we had an elderly patient last night with vomitting and distended abdomen. This was her AXR (I don't know why we do these anymore)
On ED US, she had dilated SI loops, washing machining and free fluid. I know many of you would go straight to CT in this patient, but if you want extra reassurance before calling EGS, ordering the CT and booking a bed: have a look with US: it's really EASY!
Yigal had a 70yo patient who was sent in by the GP with central abdominal pain and a pulsatile mass in the epigastrium.
ED US was performed upon arrival and revealed:
transverse view of the aorta with a dissection flap undulating in its lumen
Longitudinal view of the aorta
A dissection flap is hyper echoic and undulates independent of aortic pulse. There may also be hypo echoic thrombus in the false lumen.Seeing a flap in the aorta is highly specific and sensitive for dissection. However, sometimes slice thickness artefact can lead to flap like lines in the aortic lumen. Just remember that a flap will be thick and seen in trans and long. An artefact will usually be thin, disappear in a different angle or view and can be linked to an adjacent structure like the IVC.
40yo male came into ED with severe RUQ pain 2 hours duration. Similar previous episodes, nil US, but this time the pain had woken him from sleep.
RUQ tender, but no guarding.
He was afebrile with normal obs
WCC normal, normal LFTs and lipase.
ED US revealed: not dilated, a thick walled GB with a several mobile stones but one stone impacted in the neck of the GB
Gb long. hyper echoic stone near the neck. The GB wall is thick and has a hypo echoic middle layer which could be GB wall oedema.
On sitting the patient up, the larger stones fall to the funds, but the stones at the neck remain (impacted)
The patient also had a positive sonographic murphey's.
The patient was admitted to EGS and scanned by radiology in the morning. The subsequent scan showed a severely dilated GB with perforation.
Without US, this patient may have been dc home...
Ali and Sarah had a patient post cardiac arrest after hanging. She had 25 mins of CPR in the field. On arrival, she was tachycardic 110, BP 110/, sats 100% on FiO2 1. Jana did a quick lung and cardiac US. Cardiac US was unremarkable, but the lung US showed a pneumothorax on the R. Jana didn't save any images (!!!!). But it would have looked like this:
M mode of R anterior lung showing barcode or stratosphere sign
CXR done while preparing for R chest tube.
This was an excellent pick as the patient had sats of 100% and equal air entry clinically. US helped expedite chest tube insertion.
The patient deteriorated haemodynamically en route to CT. An inotropic infusion was started assuming cariogenic shock.
CT revealed a large liver laceration and intraperitoneal free fluid. (This and the tension pneumothorax likely secondary to rib fractures from CPR.)
Given the amount of free fluid: FAST exam would likely have been positive.
CT abdo showing FF fluid around the liver and spleen
We all use US in ED to answer a specific question: is there a pneumothorax, is there hydronephrosis etc. But when the answer is negative, sometimes we forget to look for an alternate cause.
I'll check for hydronephrosis in a renal colic patient and then forget to look at the aorta.
We are so sophisticated with US now, we can look at multiple organ systems and make pertinent diagnoses. US can help differentiate the undifferentiated patient.
FAST for free fluid is part of the RUSH exam for undifferentiated shock.
None of us would think to do a FAST on cardiac arrest patients with no trauma. However, remember this case the next time you have an undifferentiated shock and look at the pipes and the tank as well as the pump to determine the cause.
Emcit RUSH https://emcrit.org/rush-exam/
Nama saw a 55yo female who presented with CP. She was treated with aspirin and GTN by MAS. Her obs were stable and she looked well. She had undergone a stress MIBI 2 years previously: NAD.
On examination, she had no murmurs, a clear chest and normal ECG.
However, she had RUQ tenderness and a positive Murphey's sign.
Does she have cardiac CP or biliary colic?
trop came back normal.
but so did WCC and CRP <2
But this is why we have US.
Nama did a beautiful GB US
Benign looking GB with hyper echoic stone and shadowing
Another view of the GB shows a stone in the GB neck and pericholecystic fluid.
The patient was fasted and admitted under EGS. She had a cholecystectomy for acute cholecystitis the next day.
The presence of gall stones and a positive sonographic Murphey's are two of the key features to look for with suspected acute cholecystitis in ED.
Other supportive features are
1. dilated GB >5cm (trans) >10cm (long)
2. thickened GB wall >4mm, fluid in GB wall, gas in GB wall
3. pericholecystic fluid
4. dilated CBD >6mm (with this need to consider ascending cholangitis).
Gordon had an elderly patient who presented via MAS sats 70%, diaphoretic, altered conscious state, HR 90. He had a hx of COPD, HT and CCF. No further hx.
Listening to his chest he had a few scattered crackles only.
CXR was not very helpful (see below)
Gordon did a lung US and echo which clarified the diagnosis of APO, R sided pleural effusion and cardiomyopathy.
Multiple coalescing B lines (vertical) seen anteriorly R and L.
Normal lung with horizontal A lines for comparison
R pleural effusion with collapsed lung.
dilated CM on PLAx
The patient had prompt and appropriate management for APO and responded well.
Bilateral multiple B lines anteriorly in a hypoxic patient is typically due to APO. However, other differentials could be:
1. bilateral pneumonia (would also have thickened pleural line)
2. pulmonary fibrosis (PHx and thickened pleural line)
3. ARDs (patchy, there will be skip areas, abnormal pleural line)
Cardiac US can also help with differentiation.
Ilya saw a patient last week with ongoing headaches post MVA in January. Headaches were worst in the morning with nausea and vomitting.
Ilya did the following optic nerve US to confirm bilateral papilloedema.
Images of the optic nerve entering into the globe posterior of the left and right eyes (labelling!! Ilya!!) show optic nerve sheath diameter (ONSD) >5mm indicating elevated ICP. Note that Ilya appropriately measured the nerve diameter 3mm posterior to the retina.
Studies vary from 4.8-6.5mm in the cut off diameter for ONSD on US. This may be due to inconsistencies in insinuating angle and measurement, as well as individual variation. However, a diameter >5mm is usually used as the cut off suggestive of ICP >20mmHg. BMJ is currently conducting a systematic review on ONSD US for elevated ICP (1).
It can be tricky to find the optic nerve due to its oblique entry into the globe. Holding the probe transverse and moving the probe laterally and fanning superiorly and inferiorly usually helps. Shrestha et al showed that the learning curve for accurate measurement requires at least 20 scans(2).
Nevertheless, getting good at this beats having to look for papilloedema with the ophthalmoscope!!
Ilya's patient went on to have an LP: opening pressure >34cmH2O.
1. Koziarz A, Sne N, Kegel F et al Optic nerve sheath diameter sonography for the diagnosis of increased intracranial pressure: a systematic review and meta-analysis protocol.BMJ Open. 2017 Aug 11;7(8):e016194.
2. Shrestha GS, Upadhyay B, Shahi A et al Sonographic Measurement of Optic Nerve Sheath Diameter: How Steep is the Learning Curve for a Novice Operator? Indian J Crit Care Med. 2018 Sep;22(9):646-649.
73 yo male with a PHx of HT represented to ED.
He was seen the night before with a swollen L calf following an international flight. He had no chest symptoms and was otherwise well and so he was discharged home with an US booked for the morning to investigate for DVT.
He presented the next morning: hypotensive (SBP 70/) tachycardic (Hr110-130 SR), sweaty and hypoxic (sats 85-90%), afebrile. He still had a swollen L calf. On close inspection there were 2 blisters posteriorly and bruising anteriorly. His chest had basal crackles.
If we are thinking DVT complicated by PE, this patient qualified for thrombolysis in the ED.
this is his ED cardiac ultrasound
PLAX: tachycardic, dilated LV and RV, poor LV contractility. No obvious RV>LV, no septal bowing to left: ie no features of massive PE
PSAx showing global decreased LV contractility. (note: slight D shape to LV was due to off axis view)
Other cardiac views were similar. The echo seemed to have moderate LV and RV dysfunction
associated with tachycardia. He didn't have any previous echoes for comparison. His IVC was small and collapsing >50%. None of this fit with a massive PE (which should have dilated RV>LV, septal bowing to L, dilated non collapsing IVC).
His L leg US showed a lot of subcutaneous oedema and cobblestoning with no evidence of DVT.
Cobblestoning is the presence of fluid between subcutaneous fat. It is usually seen in cellulitis or peripheral oedema. But it is not a specific sign. It can also be seen in patients with DVT if there is significant venous insufficiency.
Given all this, we went down the path of sepsis as a cause of hypotension and resuscitated him with fluids and inotropes and started broad spectrum antibiotics.
His lung US didn't show consolidation; just a few b blines bilateral bases.
The leg was further assessed for evidence of subcutaneous gas. None was palpable, seen on XR or US. However he was acutely sensitive to palpation.
If gas is present, it can be easily seen with US and is shown to be a good rule in sign of nec fasc (sens and spec 88% and 93% respectively(1))
Given the leg was the only source of sepsis, his presentation and a positive response to fluids and inotropes, he was rapidly referred to plastics with a presumptive diagnosis of necrotising fascitis.
He was taken to theatre and his leg was debrided to mid thigh.
PLAx 2 hours after presentation: worsening LV function (likely due to cardiomyopathy of sepsis). Note now a dilated LA. IVC was also now dilated and non collapsing.
Further fluid resuscitation (post 1.5L) was stopped at this point due to the risk of pulmonary oedema
Annabel and I did an EFAST on a trauma patient with LUQ pain.
Here are the images
Surely this looks like splenic lac with haematoma surrounding it!
But CT revealed this was stomach containing food!
The following clip does look a bit like the hyperechoic area is seperate from the spleen, but really, did she have to make it that hard?
Usually stomach is imaged when the probe is held too anteriorly on the chest. Sliding inferiorly in the LUQ so that your hand is almost touching the bed usually eliminated artifact from stomach gas.
68yo man presented to ED with a tight swollen left calf.
He had a history of thrombophilia and takes clexane on long haul flights. This presentation had no obvious precipitant,
On examination, there was obvious asymmetry in calf size and venous engorgement on the left. HR 90 regular, sats 100, BP 145/80. He stated he had no respiratory Sx or CP and felt otherwise well.
While waiting for formal US we did an ED one.
CFV in transverse: mobile non occlusive thrombus seen in the lumen (annotated below)
Longitudinal view of FV with floating thrombus: pt's cough caused vein to dilate demonstrating just how mobile the thrombus was!!!!!!!
The patient was started on an anticoagulant dose of clexane and further questioning (more like suggestive questioning) led to a hx of maybe SOB, maybe feeling like he was coming down with a cold.
CTPA revealed bilateral proximal emboli.
He was kept in bed until transferred to the ward.
I know we often feel as if ED DVT US doesn't make a difference because we get a formal US anyway: so what's the point. But I think it is still useful to know if the patient has a very proximal thrombus like this. In this man's case it changed his management from sitting in the WR waiting for an US which could take hours to full anticoagulation, further investigation and admission to the ward within minutes.