An 8 week old male has poor feeding, weight loss and frequent, projectile, vomiting. A bedside ultrasound can easily make the diagnosis.
A 65 year old F with a history of ESRD on HD came in with severe abdominal pain and hypotension that began during her dialysis session.
On exam she was tender, hypotensive 70/40, but not particularly ill appearing. A bedside ultrasound of the RUQ showed the following:
A CT scan demonstrated “gas throughout the portal vein and the portal venous system in the liver” as well as “areas of pneumatosis involving the small bowel some of which demonstrate thickened wall” which were “findings concerning for small bowel ischemia.”
CTA of the abdomen showed no vascular explanation for small bowel ischemia. The patient went to the OR but was found not to have ischemic bowel.
The patient was admitted to the ICU and placed on pressor support, pain control and IVF hydration and was discharged a few days later.
The working theory is that she developed transient mesenteric ischemia secondary to hypovolemia due to fluid shifts related to her dialysis.
Our ultrasound case of the week is a 56y/o male who presented to the ED for a second time with abdominal pain. It was sharp but mild, located in the lower midline. He looked great and work-up was initially negative. However, a quick bedside ultrasound of the aorta showed the below clip.
Its not obvious, but there seemed to be an irregularity in the lumen. This prompted a CTA showing a small dissection.
This patient was admitted, medically managed, and discharged 2 days later.
This is a great example of how a bedside ultrasound cinched a potentially serious diagnosis when all else seemed normal.
A previously healthy 14 year old male came in with weakness and shortness of breath. He was running in high school gym class when he felt weak and dyspneic and had to lie down. He had had some diarrhea and vomiting for the past few days and a recent cold.
Exam and work-up:
HR 107, BP 82/61, O2 90%, RR 30, Oral Temp 97.6
Tachypneic, tachycardic, +bilateral rales with L > R, +Diaphoresis
WBCs: 15.8, Neutrophils 83%
Lactic Acid: 6.4
VBG pH 7.26 pCO2 50
Patient given Antibiotics, 1L NS, 6L Oxygen Non Breather, but began to decompensate, bradying down, altered and lethargic. Patient was intubated and had peri-intubation arrest with CPR and code epi, ROSC, and started on epi drip.
A bedside ultrasound was performed.
The bedside Echo showed global hypokinesis with plethoric IVC consistent with acute congestive heart failure. Note that if you thought this otherwise healthy pediatric patient was septic, his ECHO was not consistent with that diagnosis.
Troponin and BNP were resulted.
The patient was diagnosed with fulminant myocarditis and transferred to an appropriate referral center, where he was placed on ECMO for 3 days and made a full recovery.
On this week’s Case of the week, an 80y/o male with an indwelling foley presented to the ED without any urine output. Check out the video to see how ultrasound helped trouble shoot the problem and speed up the dispo.
The patient is a 60 year old man with history of HTN, HLD and pre-DM who presented with fevers, chills, night sweats and worsening scrotal and testicular pain.
A bedside testicular ultrasound was performed:
Note scrotal skin thickening, and dirty shadowing suggestive of subcutaneous air.
Diagnosis: Fournier’s gangrene.
OR report: extensive necrotizing fasciitis of entire right hemiscrotum, half of left hemiscrotum right pre-pubic area/base of penis and perineum with sparing of bilateral testicles.
Patient did well post-operatively. Cultures grew e. coli and bacteroides thetaiotaomicron and he was discharged on PO antibiotics four days later.
We have a cool clip this week compliments of Jessica Andrusaitis showing the reduction of an anterior shoulder dislocation in real-time. Check out the video for a brief review of shoulder anatomy as well!
A 70yo M p/w abdominal pain. A bedside ultrasound was performed:
Rare journal club away from the beach, pancakes with ultrasound gel. Did someone just actually publish a new FAST article?
Faculty and fellows (past and present) joined together to teach critical care ultrasound at ACEP18!
On Friday September 7th Ultrasound Fellowships from California, Arizona, Utah and Colorado came together to learn about topics on administration, career development, billing and to learn a little TEE on the side!