Adam Ash

Cervical ectopic pregnancy diagnosed by point-of-care emergency department ultrasound.

BACKGROUND Although rare, cervical ectopic pregnancy (EP) represents a potentially lethal variation of a common first-trimester disease entity. CASE REPORT We report a case of low abdominal pain and vaginal bleeding diagnosed as a cervical EP by point-of-care ultrasound. CONCLUSION Familiarity with cervical EP and its sonographic appearance is essential for emergency physicians because it can be easily mistaken for an intrauterine pregnancy or other obstetric/gynecologic pathology, such as an incomplete abortion or nabothian cyst. The management of each of these differs substantially, making accurate diagnosis crucial.

Eccentrically Located Intrauterine Pregnancy Misdiagnosed as Interstitial Ectopic Pregnancy

This is a case report of an eccentrically located intrauterine pregnancy initially diagnosed as an interstitial ectopic pregnancy. Although interstitial ectopic pregnancy represents a well-known pitfall in first-trimester sonography, the common error is to misidentify the ectopic pregnancy as intrauterine, not the reverse. Such an error is potentially catastrophic because it may lead to the inadvertent termination of a viable pregnancy. Although the role of ultrasonography for evaluation of ectopic pregnancy is well established, its diagnostic accuracy for interstitial ectopic pregnancy remains uncertain. Because of this, sonographic findings should be considered suggestive, but not diagnostic, in this setting.

Seldinger Technique for Placement of “Peripheral” Internal Jugular Line: Novel Approach for Emergent Vascular Access

This is a case report describing the ultrasound-guided placement of a peripheral intravenous catheter into the internal jugular vein of a patient with difficult vascular access. Although this technique has been described in the past, this case is novel in that the Seldinger technique was used to place the catheter. This allows for safer placement of a longer catheter (2.25″) without the need for venous dilation, which is potentially hazardous.

Ultrasound-guided drainage of peritonsillar abscess: shoot with your hockey-stick

Peritonsillar abscess (PTA) is a complication of pharyngitis and tonsillitis, and the most common deep space infection of the head and neck [1]. Often clinical examination alone cannot accurately distinguish between peritonsillar cellulitis and abscess. This can lead to inappropriate management, failed drainage attempts, and unnecessary complications. Some clinicians rely on computerized tomography (CT scans) or otolaryngologist consultation to confirm the diagnosis or assist in drainage. Point-of-care ultrasound is able to confirm the diagnosis of PTA, as well as differentiate PTA from cellulitis [1]. Ultrasound is also able to provide either static or dynamic guidance for drainage procedures [2]. Previous case studies report that intra-oral ultrasound has a sensitivity of 89 % and a specificity approaching 100 % for the diagnosis of PTA. A CT scan has a specificity of 75 % [3]. Typically, an endocavitary probe is used for the procedure [4]. Linear array probes have been used for transcutaneous imaging through the neck, but intraoral use has not been described [5]. This case report describes the diagnosis and drainage of PTA made with a linear array ‘‘hockeystick’’ probe intra-orally. This probe is unique in that it is shorter than typical endocavitary probes, and thinner than typical linear array probes, making it ideal for use within a confined space such as the oral cavity (Fig. 1a). We believe the novel use of this transducer provides better access to the oral cavity, is more comfortable for the patient, and provides superior imaging of the peritonsillar area compared with the endocavitary probe. A 23-year-old woman was presented to the Emergency Department (ED) complaining of severe throat pain for 2 days associated with fever, chills and odynophagia. The patient was tachycardiac and febrile on arrival. The head and neck examination revealed erythematous pharynx, swollen tonsils with bilateral white exudates, slight bulging of the right peritonsillar space without uvular deviation, some trismus, and right-sided anterior cervical lymphadenopathy. The patient was not drooling, had no audible stridor, and displayed no other signs of upper airway compromise. The remaining history and physical examinations were non-contributory. A PTA was suspected, and a focused ultrasound study of the painful area was performed to differentiate an abscess from simple pharyngitis or tonsillitis. After providing topical analgesia with Cetacaine spray, the patient’s pharyngeal cavity was examined via intra-oral ultrasound. It was determined that due to the patient’s trismus it would be difficult to insert an endocavitary transducer. Instead, we chose the L14-5sp linear array (aka ‘‘hockey-stick’’) transducer (ZONARE Medical Systems, Inc, Mountain View, CA). The probe was covered with a sterile barrier, and placed directly over the area of maximal swelling. A right-sided PTA was clearly visualized (Fig. 1b, c). The abscess was immediately drained at the bedside utilizing static ultrasound guidance. The patient was administered an initial dose of clindamycin in the ED, and was discharged home with oral antibiotic therapy and otolaryngology clinic follow-up. The diagnosis and drainage of PTA with an ultrasound study improves accuracy and decreases complications [1]. Not only is an ultrasound study able to identify the abscess & Adam Ash adamash4@hotmail.com

Lesser saphenous vein thrombosis diagnosed by point-of-care ultrasound in a patient presenting with pulmonary embolism.

In recent years, much controversy has surrounded the topic of anticoagulation use in cases of superficial venous thrombosis. There is increasing evidence to demonstrate that these clots can spread to the deep venous system and pulmonary vasculature if left untreated. The most common culprit is the greater saphenous vein [1]. Lesser saphenous vein clot is thought to have a much smaller likelihood of evolving into a deep venous thrombosis (DVT), although the exact occurrence rate is uncertain [1]. We describe a case of a patient presenting with lower extremity swelling that was ultimately diagnosed as being caused by lesser saphenous vein thrombosis. The diagnosis was made by point-of-care ultrasound, and the patient was also diagnosed with a concomitant pulmonary embolism. A 42-year-old woman presented to the emergency department (ED) complaining of right calf pain accompanied by mild swelling. She additionally experienced increasing exertional dyspnea since returning to the United States from Guatemala 11 days prior. She appeared comfortable with normal vital signs and an unremarkable physical examination, outside of the described edema. There were no additional risk factors for thromboembolic disease. An ECG revealed sinus bradycardia, and a chest X-ray study was normal. A focused ultrasound of the right lower extremity performed by the emergency physician showed a right lesser saphenous venous thrombosis extending near the right popliteal vein (Fig. 1). The patient was also diagnosed with a segmental pulmonary embolism extending from the bifurcation down into the right lower lobe via CT angiography that was completed shortly after the ultrasound study. Heparin therapy was initiated, and later transitioned to Xarelto 15 mg twice a day. The patient was discharged the following day in stable condition. Ultrasound evaluation for DVT of the lower extremity involves graded compression of the femoral and popliteal regions, classically utilizing a high frequency linear transducer. Findings of deep venous thrombosis include non-compressibility of the vein, direct visualization of thrombus in the vessel lumen, absence of phasic respiratory variation, and lack of Doppler augmentation with calf compression or ankle plantar/dorsi-flexion. A thrombus found within 3 cm of the saphenofemoral junction is treated as a deep venous thrombosis [1]. During a focused evaluation, the lesser saphenous vein and other superficial veins are typically visualized, and a superficial thrombophlebitis or thrombosis may be revealed as in the case with our patient by using the same graded compression technique mentioned above. In addition, a repeat ultrasound study following a negative study is always recommended in 5–7 days as propagation of a more subtle clot can occur. Thus, the location and proximity of superficial venous thromboses (SVT) plays an important role in whether or not the patient requires anticoagulation. Superficial venous thromboses are common, accounting for 30 % of documented venous thromboses or approximately 125,000 cases per year in the Unites States population [2, 3]. A study by Decousus et al. reports that 198/844 (23.4 %) patients with SVT have an associated DVT [1]. Of this group, 72.7 % of greater saphenous vein thromboses are associated with DVT while 26.3 % of lesser saphenous vein thromboses are associated with DVT. Superficial venous thrombosis usually presents with pain, swelling, and erythema, and historically were treated & Adam Ash adamash4@hotmail.com

Ureterocele found incidentally on focused assessment with sonography for trauma (FAST) exam

A 33-year-old man presented to the emergency department (ED) as a level one trauma after being struck by a car while changing a flat tire on the side of the highway. He complained of right hip pain, was unable to walk, but denied any other injuries. Physical examination revealed a distressed, but well appearing man with normal vital signs and tenderness to palpation over his right hip. Although his abdomen was non-tender, a FAST exam was performed due to the mechanism of injury, and revealed the following image of the bladder (Fig. 1a). No Foley catheter had been placed in this patient. Discussion