Phillips Perera

Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol.

Assessment of hemodynamic status in a shock state remains a challenging issue in Emergency Medicine and Critical Care. As the use of invasive hemodynamic monitoring declines, bedside-focused ultrasound has become a valuable tool in the evaluation and management of patients in shock. No longer a means to simply evaluate organ anatomy, ultrasound has expanded to become a rapid and noninvasive method for the assessment of patient physiology. Clinicians caring for critical patients should strongly consider integrating ultrasound into their resuscitation pathways.

Caval Sonography in Shock A Noninvasive Method for Evaluating Intravascular Volume in Critically Ill Patients

onography has traditionally been used to assess anatomic abnormalities. However, its value in evaluating physiologic characteristics has recently been recognized, particularly in the care of patients in shock. As the use of point-of-care sonography grows in critical care and emergency medicine, noninvasive assessment of intravascular volume status is increasingly being used to guide therapy of the critically ill. Although intravenous fluid is often the initial treatment in hypotensive patients, aggressive volume resuscitation may be detrimental in some patients and in certain types of shock. Accurate diagnosis of shock state can be challenging because physical findings of hypovolemic, distributive, cardiogenic, and obstructive shock often overlap. Pulmonary artery and central venous pressure catheters, which provide physiologic data such as cardiac output and right atrial pressure, are time-consuming, invasive, and carry considerable risks. Central venous pressure has long been used to guide fluid management; however, data suggest that in critically ill patients, central venous pressure may not correlate with the effective intravascular volume. 1 Furthermore, invasive hemodynamic monitoring has not been shown to benefit patients. 2 Given the importance of determining intravascular volume in shock, a rapid bedside sonographic examination can be instrumental in guiding medical management of critically ill patients. Multiple sonographic protocols now exist for the evaluation of shock, dyspnea, and cardiac arrest. 3,4 This article will describe the use of sonography of the inferior vena cava (IVC) in the evaluation of patients in shock.

Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound.

Infective endocarditis is a challenging diagnosis that is rarely made in the emergency department. As the use of focused emergency ultrasound expands into more applications, including advanced echocardiography, the diagnosis of infective endocarditis may be made earlier, potentially leading to more timely treatment. We report a case of an ill-appearing patient presenting to the emergency department with an indwelling central venous catheter, a cardiac murmur, and necrotic toes, who was diagnosed with a large tricuspid vegetation and prominent tricuspid regurgitation on bedside emergency ultrasound. A cardiologist-performed echocardiogram confirmed these findings during the patients hospital admission.

Point-of-Care Ultrasound in Diagnosing Pyomyositis: A Report of Three Cases

BACKGROUND Pyomyositis is a bacterial infection of skeletal muscle that often results in deep intramuscular abscesses. The absence of external dermatologic manifestations in the early stages of pyomyositis makes this a challenging diagnosis. In addition, physical examination findings can be difficult to distinguish from more common processes, such as soft-tissue cellulitis. Clinicians can fail to diagnose this serious disease in a timely manner, resulting in delayed treatment and potential clinical deterioration from sepsis. Although advanced imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI) provide excellent detail, ultrasound (US) can also be used to detect this disease. US can be performed expeditiously at the bedside and is less expensive than CT or MRI. It allows the clinician to examine the deeper tissue planes of muscle, in which purulent fluid collections will develop as pyomyositis advances. CASE REPORT Three patients presenting with leg pain were evaluated with point-of-care (POC) US and diagnosed with pyomyositis. The early diagnosis of this condition prompted rapid treatment with administration of appropriate antibiotics and involvement of orthopedic surgery. Aspiration of fluid allowed for detailed fluid analysis and bacterial cultures. Additional diagnostic imaging was performed, confirming the initial US diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POC US can be helpful in identifying and further delineating intramuscular abscesses and can subsequently lead to expedited and appropriate care in patients who present with extremity pain, but lack significant dermatologic changes.

Ultrasound for the Detection of Pleural Effusions and Guidance of the Thoracentesis Procedure

Objective. To review the use of ultrasound for the detection of pleural effusions and guidance of the thoracentesis procedure. Methods. Two clinical cases will be presented in which ultrasound proved beneficial in guiding the diagnosis and management of patients with pleural effusions and respiratory distress. The ultrasound techniques for the evaluation of pleural effusions and performance of the thoracentesis procedure are discussed. A review of the most current literature follows to present the known diagnostic and safety benefits of ultrasound guidance for thoracentesis. Conclusions. Ultrasound improves the diagnostic accuracy for the detection of pleural effusions over standard chest radiographs. Ultrasound can also diagnose a complicated pleural effusion that may be at higher risk for an adverse outcome during a thoracentesis. Optimally, thoracentesis should be performed under direct ultrasound guidance to decrease the complication rate and improve patient safety.

Spontaneous Pneumomediastinum on Bedside Ultrasound: Case Report and Review of the Literature

Spontaneous pneumomediastinum is a rare disease process with no clear etiology, although it is thought to be related to changes in intrathoracic pressure causing chest pain and dyspnea. We present a case of a 17-year-old male with acute chest pain evaluated initially by bedside ultrasound, which showed normal lung sliding but poor visualization of the parasternal and apical cardiac views due to significant air artifact, representing air in the thoracic cavity. The diagnosis was later verified by chest radiograph. We present a case report on ultrasound-diagnosed pneumomediastinum, and we review the diagnostic modalities to date.

Diagnosis of Pneumoperitoneum with Bedside Ultrasound

An 86-year-old female was brought in by ambulance for severe abdominal and back pain. She was hypotensive en route and appeared to be in distress upon arrival to the emergency department. Her abdomen was tense and distended with diffuse tenderness to palpation present. A bedside abdominal ultrasound (US) was done immediately, which raised concern for free air. A portable upright chest x-ray was obtained, which confirmed the diagnosis of pneumoperitoneum (Video). Video Pneumoperitoneum. Pneumoperitoneum due to perforated viscus is an emergent diagnosis that requires immediate surgical consultation and intervention. US is a useful tool that can be done at the bedside to rapidly make the diagnosis. Both low- and high-frequency transducers may be used to detect intraperitoneal free air. With the patient in a supine position, the perihepatic space should be evaluated. The patient may also be turned to the left lateral decubitus position to facilitate the rise of free air to the RUQ.1 Findings may also be seen from the anterior abdominal wall when the patient is supine. Pneumoperitoneum can be detected on US by the enhanced peritoneal stripe sign (EPSS) in conjunction with reverberation artifacts, which have the appearance of repeating linear lines extending at equidistant distances posteriorly from the peritoneal lining.2 Comet tail artifact may also be appreciated from the peritoneal stripe. The “scissors maneuver” can increase sensitivity of US in detecting intraperitoneal free air.3 Indirect signs may also be seen on US, including thickened bowel loops or air bubbles in peritoneal free fluid.4 US has been shown to have a sensitivity of 85% and a specificity of 100% for pneumoperitoneum. It has been shown by some to have a higher sensitivity for this diagnosis as compared to plain radiography.5 Although computed tomography imaging is still the gold standard for pneumoperitoneum, US is a helpful initial diagnostic tool that can be done rapidly at the bedside.

Bedside Ultrasound in a Case of Blunt Scrotal Trauma

This case study describes a patient who suffered blunt force trauma to the scrotum. Use of bedside emergency ultrasound facilitated early diagnosis of a ruptured testicle and allowed for prompt urological consultation and timely surgical repair. The utility of bedside emergency ultrasound in the evaluation of testicular trauma, as well as the outcome of our case, is discussed here.

Emergency Ultrasound Identification of a Cornual Ectopic Pregnancy

CASE A 26-year-old female presented with complaints of vaginal bleeding. Her history was significant for fetal loss during her only prior pregnancy. Her last menstrual period was 6 weeks prior. The urine pregnancy test result was positive. She had visited an outside hospital the day before and was diagnosed with a threatened abortion. The patient reported that her ultrasound results at the time had revealed a ‘‘normal early pregnancy.’’ Bedside transvaginal ultrasonography was performed (see video, online only) and a bicornuate uterus was identified. A pregnancy with gestational sac, yolk sac, and small fetal pole was identified high in the right cornual limb. The endo-myometrial mantle or EMM (the distance from the outer part of the gestational sac to the uterine wall) was found to be 5.6 mm. No free fluid was identified.

Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam.

Introduction The focused assessment with sonography in trauma (FAST) exam is a critical diagnostic test for intraperitoneal free fluid (FF). Current teaching is that fluid accumulates first in Morison’s pouch. The goal of this study was to evaluate the “sub-quadrants” of traditional FAST views to determine the most sensitive areas for FF accumulation. Methods We analyzed a retrospective cohort of all adult trauma patients who had a recorded FAST exam by emergency physicians at a Level I trauma center from January 2012 – June 2013. Ultrasound fellowship-trained faculty with three emergency medicine residents reviewed all FAST exams. We excluded studies if they were incomplete, of poor image quality, or with incorrect medical record information. Positive studies were assessed for FF localization, comparing the traditional abdominal views and on a sub-quadrant basis: right upper quadrant (RUQ)1 - hepato-diaphragmatic; RUQ2 - Morison’s pouch; RUQ3 - caudal liver edge and superior paracolic gutter; left upper quadrant (LUQ)1 - splenic-diaphragmatic; LUQ2 - spleno-renal; LUQ3 – around inferior pole of kidney; suprapubic area (SP)1 - bilateral to bladder; SP2 - posterior to bladder; SP3 – posterior to uterus (females). FAST results were confirmed by chart review of computed tomography results or operative findings. Results Of the included 1,008 scans, 48 (4.8%) were positive. The RUQ was the most positive view with 32/48 (66.7%) positive. In the RUQ sub-quadrant analysis, the most positive view was the RUQ3 with 30/32 (93.8%) positive. Conclusion The RUQ is most sensitive for FF assessment, with the superior paracolic gutter area around the caudal liver edge (RUQ3) being the most positive sub-quadrant within the RUQ.