30 year old female is brought by EMS from an outpatient surgery center for evaluation of persistent hypotension and vaginal bleeding after an elective abortion and D&E at approximately 20 weeks gestation. Initial vitals on arrival were T 98.6 F, HR 99, BP 62/palp, RR 21, O2 100%. On exam, patient was pale and lethargic but mentation intact. There is scant vaginal bleeding on pelvic exam. A bedside FAST is performed and shown below. What is the interpretation of the FAST, and which views demonstrate free fluid if present?

Answer: Free Fluid in RUQ, LUQ, and Pelvis

The patient received 2 units of uncrossed pRBCs in addition to 1g TXA IV and was taken emergently to the OR with OBGYN for exploratory laparotomy. She was found to have 1500 ccs of hemoperitoneum from an actively bleeding R uterine artery laceration. She did well post-op and was discharged a few days later!

Focused Assessment with Sonography for Trauma

• High sensitivity and specificity for detecting intra-abdominal free fluid in hypotensive trauma patients.
• Four views: RUQ, LUQ, cardiac, and suprapubic
• Where you’ll find free fluid:
  • RUQ: 1. Subdiaphragmatic space, 2. Hepatorenal space (Morrison’s pouch), and 3. Caudal edge of the liver
    • Most sensitive area for intra-abdominal free fluid is the RUQ – more specifically, the caudal edge of the liver (contiguous with right paracolic gutter)
  • LUQ: 1. Subdiaphragmatic space, 2. Splenorenal space, and 3. Inferior pole of the left kidney
  • Cardiac: 1. pericardial effusion
  • Pelvis: 1. Between the bladder and uterus (in females), 2. Posterior to the uterus (in females), and 3. Posterolateral to the bladder
    • Fluid in the pelvis will first accumulate in the rectouterine pouch of Douglas in females, and the posterior bladder margin in males. Prostate may be confused with free fluid but is generally more hyperechoic and discrete in structure.

Key learning point for this case: clotted blood is more hyperechoic and can start to resemble tissue or other structures. Easy to miss if not looking closely.

References:

1. Lobo V, Hunter-Behrend M, Cullnan E, Higbee R, Phillips C, Williams S, Perera P, Gharahbaghian L. Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam. West J Emerg Med. 2017 Feb;18(2):270-280. doi: 10.5811/westjem.2016.11.30435. Epub 2017 Jan 19. PMID: 28210364; PMCID: PMC5305137.
2. Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med ​​. 2017 May;69(5):e27-e54. Doi: 10.1016/j.annemergmed.2016.08.457.
3. “Fundamentals.” Core Ultrasound Courses, courses.coreultrasound.com/courses/fundamentals. Accessed 2 May 2024.

A 31 yo male presents with left thumb pain after a dirt bike crash.  Patient is unable to move his left thumb and has tenderness at the base. An x-ray is shown below.  What’s the diagnosis?

Answer: Type I first metacarpal fracture (Bennett fracture)

• Most commonly occurs in young males from forceful axial load against a fixed object (sports, bicycle accident, punching), presents with pain and swelling at thenar eminence, decreased range of motion at MCP/CMC joints
• Diagnosis of first metacarpal fractures usually made by plain radiograph
• Management with reduction (may be accomplished with longitudinal traction, abduction and extension of first MC), thumb spica splint, and prompt orthopedic follow up.  May require percutaneous pin fixation or open reduction and internal fixation.

Classification of first metacarpal base fractures

1. Type I, Bennett fracture: intra-articular fracture-dislocation/subluxation at the CMC joint
2. Type II, Rolando fracture: a comminuted Bennett fracture
3. Type III, (no eponym): extra articular fracture
4. Type IV, (no eponym): extra-articular pediatric fracture involving the proximal physis

References:

Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.

75 y/o M PMHx of ESRD on HD, pulmonary HTN, HLD presents to the ED with 1 week of progressive fatigue and SOB. Pt on 2L NC home O2 but requiring 4L NC in the ED to maintain saturation > 95%. On exam, pt with increased WOB and RR > 20. Lungs are CTA. Cardiac exam shows RRR with mild JVD, abdominal distention and +1 pitting edema B/L. POCUS was performed and is shown below. What is the diagnosis? 

Answer: Right Heart Strain from Pulmonary Hypertension 

• Signs in POCUS that are indicative of R heart strain:
  • D-sign: septal flattening seen in the parasternal short orientation that is indicative of increased RV pressures 
  • McConnel’s Sign: seen in the apical 4 chamber view. R ventricular free wall akinesis with sparing of the apex (apical hyperkinesis) 
  • Increased RV:LV ratio, typically should be ⅓:⅔ 
  • Decreased TAPSE: measurement of the vertical motion of the tricuspid valve in the apical 4 chamber view (normal > 16 mm)
• Causes of R- Heart Strain:
  • Pulmonary Embolism
  • Pulmonary hypertension 
  • Biventricular failure
  • R sided heart failure 
  • Valvular dysfunction (Acute TR) 
• Pulmonary Hypertension:
  • Type 1: primary arterial pulmonary HTN 
  • Type 2: PH due to L heart failure
  • Type 3: PH due to lung disease 
  • Type 4: PH due to chronic thromboembolic disease 
  • Type 5: idiopathic PH 
• Acute Treatment for PH includes
  • Optimize RV preload- patients typically euvolemic or hypervolemic and do not respond well to rapid shifts in fluid status (usually avoid fluids). If hypovolemia/sepsis consider small 250 ml boluses with frequent reassessments 
  • Improve cardiac output: consider early ionotropes 
  • Reduce RV afterload: avoid hypoxia, acidosis, hypercapnia 
  • Treat arrhythmias: most common is SVT followed by afib/flutter 

Resources: 

https://courses.coreultrasound.com/courses/take/fundamentals/lessons/18316427-right-heart-strain-5minsono

The Crashing Pulmonary Hypertension Patient

A 39 y.o. woman who is G9P1 and currently 6 weeks pregnant presents to the ED with a chief complaint of vaginal bleeding that began in the morning with associated lower abdominal pain and lightheadedness. Physical exam demonstrates lower abdominal tenderness without peritonitis and a small amount of blood in the posterior vaginal fossa with a closed cervical os. You obtain a serum HCG which is 8,960 and perform a transvaginal ultrasound which demonstrates the following. What’s the diagnosis?

Answer: Ectopic Pregnancy

• When performing a pelvic US in the ED, the focused question is: “Is there an intrauterine pregnancy (IUP) or not?”
• To diagnose an IUP, one must visualize a gestational sac AND either a yolk sac or fetal pole within the uterus.
• In this patient, no gestational sac nor yolk sac are visualized within the uterus.
• The left adnexa demonstrates a tubal ring concerning for an ectopic pregnancy. OBGYN was consulted who took the patient Level 1 to the OR where the ectopic pregnancy was confirmed and removed along with a left salpingectomy.

Resources:

Heaton, Heather. “Chapter 98: Ectopic Pregnancy and Emergencies in the First 20 Weeks of Pregnancy.” Tintinalli’s Emergency Medicine A Comprehensive Study GUide, 9th ed., McGraw-Hill, 2020, pp. 615–623.

Pontius E. Ectopic Pregnancy & Heterotopic Pregnancy. In: Johnson W, Nordt S, Mattu A and Swadron S, eds. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/reci4t2X66l3qk1SX/Ectopic-Pregnancy-and-Heterotopic-Pregnancy#h.za15ev4ckcfv. Updated February 2, 2024. Accessed April 17, 2024.

25 year-old female presents following a fall from her horse 5 days ago. She complains of severe pain in the radial aspect of her right wrist and has no other injuries.  Plain films at an outside ED immediately following the injury were negative, and repeat plain films are shown here. What’s the diagnosis?

Answer: Non-displaced Scaphoid Waist Fracture

• The most common carpal bone fracture (60-70% of all carpal fractures). 10-30% of scaphoid fractures are not detected on the first set of plain films, but “scaphoid view” plain films (i.e., AP wrist with ulnar deviation) can improve the view of the scaphoid.
• If a scaphoid fracture is clinically suspected, the patient should be placed in a thumb spica splint and follow up in 7-10 days for repeat plain films and reexamination
• The most feared complication of a scaphoid fracture is avascular necrosis (AVN) of the proximal fracture segment. AVN is more likely in unstable scaphoid fractures, for example those that are proximal, oblique, displaced >1 mm, rotated, or comminuted. These require surgical consult and long arm thumb spica splint.
• Stable fractures can be splinted with a short arm thumb spica splint and patients should be instructed to follow up with orthopedics in 7-10 days

References:

Escarza, Robert et al. “Chapter 266. Wrist Injuries.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 7e.  Eds, Judith E. Tintinalli, et al.  New York, NY: McGraw-Hill, 2011.

DeAngelis, Michael A and David A Wald. “Wrist.” Simon’s Emergency Orthopedics, 7e.  Ed. Scott C Sherman.  New York, NY: McGraw-Hill, 2014

Jordanov, Martin I and Robert Warne Fitch. “Chapter 9 Upper Extremity.” The Atlas of Emergency Radiology. Eds. Jake Block et al.  New York, NY: McGraw-Hill, 2013

A 20 year old male presents to the emergency department via EMS for left knee pain. He was playing basketball when he jumped and felt a “pop” in his left knee and has been unable to walk on his left leg since. He denies falling. On exam, the left lower extremity is distally neurovascularly intact with normal strength, sensation, and a palpable pulse. There is slight bogginess and swelling with tenderness to palpation to the inferior knee. He is unable to extend at the knee. A point of care ultrasound of the bilateral knees is performed and shown below. What’s the diagnosis?

Answer: Left patellar tendon rupture

• Commonly occurs from forced quadriceps contraction or falling on a flexed knee.
• Associated with a high-riding patella also known as patella alta which can be appreciated on physical exam and lateral radiographs of the knee.
• There is emerging data demonstrating point of care ultrasound as a quick and effective method to diagnose tendon injuries in the emergency department compared to physical exam, x-ray imaging, and MRI.
• Treatment:
  • Incomplete tears with intact extensor mechanism can be immobilized and followed up outpatient with orthopedics.
  • Complete tears or loss of extensor mechanism should prompt orthopedic consultation in the ED as expedited surgical repair is often indicated.

References:

Bengtzen R. Knee Injuries. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.

Berg, K., Peck, J., Boulger, C., & Bahner, D. P. (2013). Patellar tendon rupture: an ultrasound case report. BMJ case reports, 2013, bcr2012008189. https://doi.org/10.1136/bcr-2012-008189

Wu TS, Roque PJ, Green J, et al. Bedside ultrasound evaluation of tendon injuries. Am J Emerg Med. 2012;30(8):1617-1621. doi:10.1016/j.ajem.2011.11.004

A 40 year old female presents to the emergency department via EMS for shortness of breath. Prior to arrival to the ED, the patient was hypoxic and in severe respiratory distress with absent left lung sounds prompting needle thoracostomy and rapid sequence intubation by EMS. Vital signs are BP 108/70, HR 102, Temp 98F, RR 16, SpO2 99% on 50% FiO2. A left sided chest tube is placed without complication. Chest x-ray confirms appropriate positioning of the endotracheal tube and chest tube with expansion of the left lung. Four hours later, the ventilator is alarming due to elevated peak and plateau pressures. SpO2 is 90%. There is no change with suctioning. A new chest x-ray is obtained and is shown below. What’s the diagnosis?

Answer: Reexpansion pulmonary edema

• Reexpansion pulmonary edema is a rare but potentially fatal complication following drainage of a pneumothorax or pleural effusion. The pathophysiology is poorly understood but is thought to involve an inflammatory response leading to increased pulmonary capillary permeability.
• Risk factors include large size pneumothorax, large volume pleural effusion, rapid reexpansion, and prolonged duration of symptoms (> 72 hours).
  • Prevention includes limiting drainage of pleural effusions to a maximum volume of 1.5 liters in one attempt.
• Imaging will demonstrate unilateral airspace opacities in portions of the lung that were previously collapsed.
• Treatment is supportive with supplemental oxygen and observation. Most patients recover without adverse outcomes.

References:

Nicks BA, Manthey DE. Pneumothorax. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.

Asciak R, Bedawi EO, Bhatnagar R, et al British Thoracic Society Clinical Statement on pleural procedures Thorax 2023;78:s43-s68.

Morioka H, Takada K, Matsumoto S, Kojima E, Iwata S, Okachi S. Re-expansion pulmonary edema: evaluation of risk factors in 173 episodes of spontaneous pneumothorax. Respir Investig. 2013;51(1):35-39. doi:10.1016/j.resinv.2012.09.003

https://radiopaedia.org/articles/re-expansion-pulmonary-oedema

A 50 year old male with a past medical history of Crohn disease with ileocolectomy presents via EMS for shortness of breath. Prior to arrival to ED, patient was found to be hypoxic and in acute respiratory distress prompting rapid sequence intubation by EMS. Vital signs are notable for hypotension and tachycardia. On exam, there are equal breath sounds bilaterally. His abdomen is distended with bruising on the left flank. GCS is 3T. A portable chest x-ray is obtained to confirm endotracheal tube placement and is shown below. What’s the diagnosis?

Answer: Pneumoperitoneum

• Most commonly caused by gastrointestinal perforation from etiologies such as peptic ulcer disease, traumatic injury, bowel obstruction, or infection.
• While CT is the gold standard for diagnosis, a chest x-ray may be utilized to quickly assess for presence of subdiaphragmatic air.
  • Sensitivity of upright chest x-ray to detect pneumoperitoenum varies across studies but is up to 80%.
  • Upright positioning for 10 minutes prior to radiograph or lateral upright positioning may increase sensitivity to over 90%.
  • Specificity is approximately 90%.
• Management includes emergent surgical consultation, broad spectrum antibiotics with anaerobic coverage, and gastric decompression.

References:

Bogle AM, Gratton MC. Peptic Ulcer Disease and Gastritis. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.

Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992;16:713–16.

Woodring JH, Heiser MJ. Detection of pneumoperitoneum on chest radiographs: comparison of upright lateral and posteroanterior projections. Am J Roentgenol 1995;165:45–7.

A 63 year old female is brought in by EMS after being found down. She has multiple ecchymoses on her chest and bilateral flanks. GCS is 6. After intubation, she is taken for CT head/cervical spine and a CT chest/abdomen/pelvis with contrast. Upon return from CT, x-rays are done (shown below) to further evaluate bruising and a laceration to her L elbow. What’s the diagnosis?

Answer: Contrast extravasation

• Predisposing factors for contrast extravasation
  • Small IV gauge (22G or less)
  • More distal access (hand)
  • Rapid injection of contrast
• Incidence: up to 1% of patient receiving IV contrast through peripheral IV
• Most common symptoms: local pain, swelling
• Complications occur in < 1 %  (more common with large volume and in patients with atherosclerosis, venous insufficiency, or impaired lymphatic drainage)
  • Compartment syndrome
  • Tissue necrosis
• Close monitoring required following extravasation
  • Compartment checks, vascular checks, and monitoring of overlying skin
  • Surgery consult for any signs of compartment syndrome or tissue injury
  • Elevate limb, warm compresses may be used
  • Patients rarely require more than conservative supportive treatment

References:

Sbitany, H., Koltz, P. F., Mays, C., Girotto, J. A., & Langstein, H. N. (2010). CT contrast extravasation in the upper extremity: Strategies for management. International Journal of Surgery, 8(5), 384-386. doi:10.1016/j.ijsu.2010.06.002

Sonis, J. D., et al (2018). Implications of iodinated contrast media extravasation in the emergency department. The American Journal of Emergency Medicine, 36(2), 294-296. doi:http://dx.doi.org/10.1016/j.ajem.2017.11.012

50-year-old with a history of T2DM, hypertension, hyperlipidemia, substance use, and asthma who presents with 4 weeks of progressive left index finger pain. The patient had some swelling from the fall, but now has had one week of swelling worsening, pain, redness. Physical exam reveals digit red, swollen, fusiform, very tender, and unable to flex or extend DIP and PIP. A POCUS is obtained and shown below. What’s the diagnosis?

Answer: Necrotizing Fasciitis

POCUS is very quick to evaluate for many of differentials but would be painful to press directly on the digit with gel. There is an excellent alternative here: waterbath technique.

Water is an excellent medium for ultrasound. In this instance, we submerged the patient’s hand in water, and we are able to submerge the probe and hover above the affect area without concern for the amount of gel we displace in assessing the area or the pressure we apply to get clear images. Also, the high transmissibility of ultrasound through water allows for excellent visibility of superficial structures of body parts like fingers when direct contouring with gel would be virtually impossible. With this technique, we can look for fractures, abscesses, air, and cobble-stoning quickly, easily and with a high degree of accuracy.

So, in this patient as it turns out, air and cellulitis are visible, likely being a necrotizing infection. POCUS with a waterbath was the quickest way to establish this diagnosis. This is extremely important because even with advances in antibiotics, time to surgical intervention is most important in decreasing morbidity and mortality in these patients.

Resources:

Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Am J Emerg Med. 2004 Nov;22(7):589-93. doi: 10.1016/j.ajem.2004.09.009. PMID: 15666267.

Shelhoss S C, Burgin C M (November 16, 2022) Maximizing Foreign Body Detection by Ultrasound With the Water Bath Technique Coupled With the Focal Zone Advantage: A Technical Report. Cureus 14(11): e31577. doi:10.7759/cureus.31577

Shrimal P, Bhoi S, Sinha TP, Murmu LR, Nayer J, Ekka M, Mishra P, Kumar A, Trikha V, Aggarwal P. Sensitivity and specificity of waterbath ultrasound technique in comparison to the conventional methods in diagnosing extremity fractures. Am J Emerg Med. 2022 Mar;53:118-121. doi: 10.1016/j.ajem.2021.12.067. Epub 2022 Jan 2. PMID: 35016093.

Bonne SL, Kadri SS. Evaluation and Management of Necrotizing Soft Tissue Infections. Infect Dis Clin North Am. 2017 Sep;31(3):497-511. doi: 10.1016/j.idc.2017.05.011. PMID: 28779832; PMCID: PMC5656282.