Morrison’s Pouch V 2.2

morrisons-pouch-redo2

Case Presented by: Dr. Meredith Hill

CC: “My Stomach Hurts”

HPI: 18-year-old man presents to the emergency department complaining of abdominal pain.  He states last night his older brother who weights 400 lbs jumped on his back driving his knee into his left upper chest.  This took place around 11 pm.  At that time he did not feel significant pain but since then he has had pain in his left upper quadrant of his abdomen.  He feels there is a “bump” which is growing in size and is also painful to the touch.

ROS: unremarkable

PMH/PSH: asthma

Medications: none

Family History: CAD Allergies: none

Social history: +tobacco, denies alcohol and drug use

VS: Temp: 36.7  BP: 137/67 HR: 64 RR: 20

General: Patient is resting in bed.  He appears to be in some pain.

Head: Normocephalic, atraumatic

Eyes: Pupils are equal, round and reactive to light and accomidation. Extraoccular movements are intact bilaterally, no conjunctiva pallor, no sclera icterus    

Throat: Moist oral mucosa without intraoral lesions. No tonsilar exudate.

Neck: Supple, no lymphadenopathy. Trachea midline.

Lungs: Breath sounds clear to auscultation bilaterally without rhonchi, wheezes or rales.

Cardiovascular: Regular rate and rhythm, S1 and S2 auscultated. No murmur, rubs or gallops to auscultation. No peripheral edema, radial and dp pulses present and equal bilaterally

Abdomen: The abdomen is tender in the left upper quadrant just below the costal margin. Patient also has tenderness to palpation of the ribs on left anterior chest.  Appears to be rib 8 or 9. There is a slight amount of swelling here.  There is no rebound of the abdomen appreciated. Normal bowel sounds.

Extremity: Normal muscle strength and tone.  Full range of motion of upper and lower extremities.

Neurologic: Awake, alert and oriented to person, place and time.

Let’s review the information: 18-year-old male with history of trauma complaining of abdominal pain. +LUQ tenderness and pain as well as point tenderness over left anterior ribs with some swelling. Although patient’s mechanism of injury was from behind, he may have sustained either a significant abdominal injury as well as possible a skeletal injury.  With concern for a splenic injury a FAST exam was performed which was negative. A trauma panel was sent and chest x-ray was obtained. Patient was given pain medication.

Chest Radiograph

It was read as normal by radiology. An abdominal series was also obtained which did not show evidence of free air. There was still concern for bony injury versus possible splenic injury. Surgery was consulted.

A musculoskeletal ultrasound was performed to evaluate for rib fracture and a FAST exam repeated which was still negative. The ultrasound of patient’s ribs on his left anterior lower chest is pictured below.

There is an obvious cortical disruption. This is rib 9 on the left anterior chest toward the auxiliary line. Because of this finding, a CT abdomen was ordered to rule out splenic injury as patient continued to complain of pain. There was, however, no change in his abdominal exam. He did not have peritoneal signs. The Surgical team was able to view the ultrasound in real time and agreed with the plan to CT. A member of the on call surgical team also placed a rib block, which significantly improved patient’s pain.

CT scan read as negative for splenic injury. No acute intra-abdominal process was noted.

In this case, ultrasound was key in identifying patient’s diagnosis. Ultrasound has long been known as a more sensitive modality for identifying rib fractures as compared to a standard chest X-ray.  The exam is easy to learn and not painful for the patient. It can also be used in conjunction with the initial FAST exam.

Musculoskeletal Scan for Rib Fracture

This is a limited exam. You start by asking the patient where the point of maximal tenderness is located. Using the linear probe, place the transducer on the patient’s thorax with the indicator facing caudally. Locate the rib you want to scan and then turn the probe 90 degrees so the indicator is to the patients right or operators’ left.  Keeping the prop perpendicular to the long axis of the rib (see below) scan the rib for signs of cortical disruption. Remember that the rib will curve along the back so you will want to pay attention that you stay on the same rib. It does take some practice but ultrasound was found to be 78-80% sensitive as compared with X-ray, which is only 12-23% sensitive. In the case above, both X-ray and CT scan were read as normal.

A Few Pearls You Want to Remember:

–   The area will be tender, so use a copious amount of gel to avoid placing pressure over a painful area.

–   Keep the probe perpendicular to the rib and remember the angle of the rib will require you to angle the probe as you move from anterior to posterior.

–   Scan multiple ribs around the point of maximal tenderness to look for other fractures.

Below is a video showing how to scan for rib fractures using ultrasound. This video uses a slightly different technique. The initial scan over the point of maximal tenderness is done in the transverse plane then rotated 90 degrees when a cortical disruption is visualized.

Ultrasound Use in the Diagnosis of Rib Fracture from HQMedEd on Vimeo.

Sources

Sonoguide.com

Vimeo.com

Morrison’s Pouch V2.1

morrisons-pouch-redo2

Case Presented by: Dr. Meredith Hill

CC: “I can’t breath”

70-year-old man with a PMH of HTN who presents with shortness of breath. He states that he is increasingly short of breath over the last 3 weeks, and is significantly worse today. The patient complains of orthopnea and new bilateral lower extremity edema. He states he takes multiple medication, but ran out of them a few days ago. The patient denies chest pain, nausea, vomiting and abdominal pain. He denies fever and chills. Patient has a history of smoking, but quit several years ago.

Physical Exam:

VS: BP 182/104, HR 95, RR 22, Temp 36.1, Pulse ox 97 % on room air

General: Acute respiratory distress

Consitutional: Well-developed, well-nourished, pt in mild respiratory distress and can speak about 4-5 words at a time.

Respiratory: Decreased air entry at the bases, bilaterally. Accessory muscle use. No wheezing, but  faint crackles heard bilaterally.

Cardiovascular: Regular rate and rhythm. Normal heart sounds – S1/S2 positive, no murmurs, rubs, or gallops. Good peripheral pulses felt in bilateral upper extremities, capillary refill is less than two seconds. 3+ pitting edema bilaterally.  No JVD appreciated

DDX

Heart failure

COPD exacerbation

Pneumonia

Pneumothorax

Pulmonary Embolism

Acute coronary syndrome

Question:

How can we use ultrasound to differentiate causes of this patient’s acute dyspnea?

Discussion:

The BLUE protocol can be used to assess this patient’s dyspnea. The linear array probe is used to assess 3 lung zones on each hemithorax. Make sure the probe indicator goes toward the patient’s head. You are looking for a view between 2 ribs.  Maximizing the depth will also help.

1

2

You begin by ruling out pneumothorax. This is achieved by identifying lung sliding and assessing for A and B lines (Figure B and C).

A-lines (Figure B) are parallel to the lung pleura and B-lines (Figure C) are perpendicular.  B-lines indicate subpleural interstitial edema. If a dyspneic patient has A lines in bilateral lung fields then pneumonia and pulmonary edema can be ruled out. If you identify bilateral B lines, then pulmonary edema may be the cause of the dyspnea. Identification of both A and B line may represent pneumonia.  If you see the right lung with predominate A lines and the left with B lines (or vice versa) there is an increased likelihood for pneumonia.

3

4

You cannot really appreciate the sliding of the pleura in these still images but if you wanted to switch to M mode (Figure D) to assess for the “seashore” sign you could also use this to r/o PTX.

To evaluate for pulmonary embolism, a quick way to reduce the likelihood of the diagnosis is to evaluate for a DVT since most PEs originate from lower extremity DVTs.  Begin the scan by placing gel to the groin and medial thigh at a distance about 10 centimeters distal to the inguinal crease and identify the common femoral vein. Check for compressibility. Scan distally and check for compressibility at the junction of the superficial femoral vein and deep femoral vein.  Subsequently, move down to the popliteal vein, starting 2 cm proximal to the knee, compressing 3 separate times until you see the trifercation of the the popliteal vein into the anterior tibial vein, the posterior tibial vein, and the peroneal vein. If you confirm the presence of a DVT and identified an A-line on chest ultrasound, your suspicion for pulmonary embolism should increase.

http://www.youtube.com/watch?v=FHerMNhCR54

In the case above, the bedside US revealed B lines in all lung fields and negative DVT scan.  The patient was diagnosed with an acute exacerbation of heart failure.

Source: Lichtenstein et al. Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure: The BLUE Protocol. CHEST July 2008 vol. 134 no. 1 117-125.

5

case 1.2 answer

morrisons-pouch-redo2

Presented by Dr. Debia Kim

NICE JOB

Dan Seitz

Kyle Perry

Richard Gordon

47 y/o woman presents with pain and swelling in her right underarm for the past few days.  She says she first noticed an itchy “bug bite” in her armpit which gradually became larger but never “came to a head.”  She has not tried anything at home to relieve the pain, and her strength and range of motion are unaffected by the swelling.  No fevers/chills.  The patient has a history of DM2 and is a cigarette smoker.

Her physical exam reveals normal vital signs, and a 6cm x 4cm very tender, raised erythematous area of induration in the R axilla.  Peripheral pulses and neuro exam are normal.  No fluctuance.  You decide to do an ultrasound examination of the right (abnormal) underarm and also the left (normal) for comparison.

Image 1

Image 2

Image 3

Image 4

Questions:

  1. What is the diagnosis?
  2. Which images show pathology?
  3. What are the structures highlighted in the color-flow images?case

Answers:

  1. Celluitis and abscess
  2. Images 1 and 3
  3. Lymph nodes

This case prepared by Dr Debia Kim, PGY-1 Emergency Medicine Resident, Detroit Receiving Hospital

“Morrison’s Pouch” is an educational module that utilizes ultrasound video clips from case presentations in the Emergency Department.

Case 1.2

morrisons-pouch-redo2

Presented by Dr. Debia Kim

47 y/o woman presents with pain and swelling in her right underarm for the past few days.  She says she first noticed an itchy “bug bite” in her armpit which gradually became larger but never “came to a head.”  She has not tried anything at home to relieve the pain, and her strength and range of motion are unaffected by the swelling.  No fevers/chills.  The patient has a history of DM2 and is a cigarette smoker.

Her physical exam reveals normal vital signs, and a 6cm x 4cm very tender, raised erythematous area of induration in the R axilla.  Peripheral pulses and neuro exam are normal.  No fluctuance.  You decide to do an ultrasound examination of the right (abnormal) underarm and also the left (normal) for comparison.

Image 1

Image 2

Image 3

Image 4

Questions:

  1. What is the diagnosis?
  2. Which images show pathology?
  3. What are the structures highlighted in the color-flow images?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

This case prepared by Dr Debia Kim, PGY-1 Emergency Medicine Resident, Detroit Receiving Hospital

“Morrison’s Pouch” is an educational module that utilizes ultrasound video clips from case presentations in the Emergency Department.

Morrison’s Pouch: Answer 1.1

morrisons-pouch-redo1

Although we had many submissions – there were NO WINNERS this week

A 75-year-old woman presents with left lower extremity swelling and pain behind the knee for the past few days.  She has been taking ibuprofen and was referred from her PMD, who was concerned that she may have a DVT.  The patient has a history of hypertension and diabetes.  She smokes cigarettes daily.   Her vital signs are within normal limits.  On physical exam, her legs are symmetric in size, her dorsalis pedis pulses are 2+ and symmetric, there is no erythema, but she is tender to palpation in the popliteal fossa.

Questions:

1.  What is the diagnosis?
2. Which veins of the lower extremity are visualized in the DVT examination?
3. Name a finding seen on ultrasound exam that is consistent with the diagnosis of DVT?

Answers:
1.  Baker’s cyst
2. from the exam includes the veins from the iliofemoral junction to the popliteal fossa.
3. Veins that are not completely compressable are indicative for a DVT.

This patient’s leg veins were fully compressible, so a DVT was ruled out.  The ultrasound exam demonstrated a Baker’s cyst, which explains the pain she is having behing her knee.  The patient was discharged with pain medications and instructions to follow-up with her PMD for a repeat ultrasound in 1-week.

baker2-labelled

pop2-labelled4 saph2-labeled4 split2-labeled3

Discussion:
As ED physicians, we are using ultrasound with increasing frequency to evaluate the lower extremity for DVT, Baker’s cyst, and abscesses.  A Baker cyst is a synovial cyst that is located posterior to the medial femoral condyle, between the tendons of the medial head of the gastrocnemius and semimembranous muscles. It usually communicates with the joint by way of a slitlike opening at the posteromedial aspect of the knee capsule just superior to the joint line. An extension of the knee joint, a Baker cyst is lined with a true synovium.  The common symptoms of baker cysts include localized swelling and pain, and decreased range of motion of the extremity. Baker cysts commonly resolve following rest; analgesics and extremity elevation help to reduce swelling and pain. If symptoms persist, an orthopedic surgeon can excise the cyst.

Over the past decade, emergency ultrasound is well established in its use to detect lower extremity DVT.  The exam is traditionally performed by ultrasounding from the iliofemoral vein junction to the popliteal vein. After identifying these vessels, the vein is followed and compressed at 1-centimeter intervals. Full collapse indicates that no DVT is present, while partial or incomplete collapse is diagnostic of DVT.
Several studies have shown that ED ultrasound interpertation is equivalent to formal ultrasound studies. A 2000 study showed ED ultrasound exams and formal ultrasound studies agreeing in 110 of 112 cases of possible DVT. Of the two discrepancies, one was a false positive ED reading. The other was an ED-positive exam that was initially read as negative by formal ultrasound but later shown to be DVT-positive by venography. Another study done in 2004 showed that 154 of 156 DVTs were diagnosed by ED ultrasound, the remaining two being false positive results.

In addition, the ED evaluation of DVT saves time in correctly diagnosing the presence or absence of DVT, prevents a potentially unstable patient from having to leave the ED department for a study, and ensures the timely diagnosis even when an ultrasound technician is unavailable.

This case prepared by Dr Sam Lee, PGY-1 Emergency Medicine Resident, Detroit Receiving Hospital

Bibliography

  1. Blaivas, Lambert, Harwood, Wod, Konicki. Lower-extremity Doppler for Deep Vein Thrombosis – can emergency physicians be accurate and fast? Academic Emergency Medicine. Feb 2000. Vol. 7, number2. pgs. 120-1262.
  2. Stephen A. Shiver MD and Michael Blaivas. Acute Lower extremity pain in an adult patient secondary to bilateral popliteal cysts. Journal of EM: Volume 34, issue 3, April 2008. pgs 315-3183.
  3. Theodoro, Blaivas, Duggal, Snyder, Lucas. Real-time B-mode Ultrasound in the emergency department saves time in the diagnosis of Deep Vein Thrombosis American Journal of EM Vol 22, no. 3, may 2004. pgs. 197-200

“Morrison’s Pouch” is an educational module that utilizes ultrasound video clips from case presentations in the Emergency Department.  The section is hosted by Dr. Daniel Morrison, Director of Emergency Medicine Ultrasound for Detroit Medical Center, and case presentations are submitted by the EM residents of Detroit Receving Hospital.

Morrison’s Pouch: case 1.1

morrisons-pouch-redo2A 75-year-old woman presents with left lower extremity swelling and pain behind the knee for the past few days.  She has been taking ibuprofen and was referred from her PMD, who was concerned that she may have a DVT.  The patient has a history of hypertension and diabetes.  She smokes cigarettes daily.   Her vital signs are within normal limits.  On physical exam, her legs are symmetric in size, her dorsalis pedis pulses are 2+ and symmetric, there is no erythema, but she is tender to palpation in the popliteal fossa.

You decide to ultrasound her lower extremity and obtain the following images.

Ultrasound 1

Ultrasound 2

Questions:

1.  What is the diagnosis?

2. Which veins of the lower extremity are visualized in the DVT examination?

3. Name a fiding seen on ultrasound exam that is consistent with the diagnosis of DVT?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

This case prepared by Dr Sam Lee, PGY-1 Emergency Medicine Resident, Detroit Receiving Hospital

“Morrison’s Pouch” is an educational module that utilizes ultrasound video clips from case presentations in the Emergency Department.  The section is hosted by Dr. Daniel Morrison, Director of Emergency Medicine Ultrasound for Detroit Medical Center, and case presentations are submitted by the EM residents of Detroit Receving Hospital.

Answer VizD 1.2

VizD Winners:

Brian Kern                Marjan Siadat         Dave Mishkin

Scott Ottolini            Rob Klever

Devon Moore            Hong Chong

Richard Gordon        Allison Loynd

Answer to Case 1:2

A 35-year-old man presents to your ED after cutting his finger on the back of a refrigerator that he was moving for a friend.  He washed the finger and placed a bandage over it.  However, upon waking up this morning, he noticed increased redness and swelling as seen in the image below.

Questions:

1. What is the diagnosis?

2. What are Kanavel’s 4 cardinal signs?

3. What is the ED disposition?

Answers:

1. Pyogenic Flexor Tenosynovitis – inflammation of the tendon and the surrounding synovial sheath, typically results from a puncture wound

2. Kanavel’s Four Cardinal Signs of Flexor Tenosynovitis

  • finger held in slight flexion
  • symmetric swelling of the finger (sausage digit)
  • tenderness along the flexor tenon sheath
  • pain with passive extension of the finger

3. I.V. antibiotics, immoblization, elevation.  Hand surgeon consultation within 24-hours for incision and drainage

**if there is no history of trauma in a sexually active adult, consider disseminated GC and treat empirically with ceftriaxone until culture results are available**

_____________________________________________

“Morrison’s Pouch”

Please welcome our newest contributor to Receiving…Dr. Daniel Morrison, Director of Emergency Medicine Ultrasound for Detroit Medical Center.  Dr. Morrison is going to be leading the Ultrasound Section of Receiving.

If Dr Morrison cared for the patient in the clinical scenario above, an ultrasound of the finger would have been obtained to confirm the diagnosis of flexor tenosynovitis.  Included in the differential diagnosis is cellulitis and abscess of the digit without tendon involvement. (click on images to enlarge)

Normal Tendon

Finger Abscess Without Involvement of Tendon

Flexor Tenosynovitis (Fluid around tendon sheath)

Thank you to everyone who submitted their answer.  Stay tuned for next week’s VizD

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.