The textbook scan you never want to see

April 2, 2018

A woman attended with a tense, distended abdomen with a blood pressure of 50/30 and heart rate of 150. She had complained of left iliac fossa for the past 3 days, with no history of trauma. Needless to say a quick phone call was put out to the ITU team and the Gynae team – whilst this was happening we took a quick scan of the right upper quadrant.

Observations alone tell you that this patient is in need of attention, to put it lightly. The scan tells us that she needs surgery due to copious amounts of fluid in the abdominal cavity. Access was gained and after a quick gynae assessment she was rushed to theatres.

Exploratory surgery drained 3 litres of blood and fixed the problem of a ruptured ectopic. The patient made a full recovery and is doing well.

By Theo Muth

What is this?

February 5, 2018

A patient attended ED with a fever and excruciating abdominal pain. The patient had bruising lining the left side of their face, tracking down the left SCM and the sternum – a clear seatbelt bruise. A week ago the patient had been in a road traffic accident, the car was hit head-on and they were hurled toward the steering wheel.

After two days of dealing with whiplash the patient had started to feel abdominal pain- starting in the epigastric region and progressing throughout the abdomen. At the point when they had searing abdominal pain and had started to vomit, they attended the ED.

In shock, with a venous blood gas showing a haemoglobin of 70, their abdomen was peritonitic and palpation of any discernible mass was near-on impossible for the guarding. Despite the septic presentation with pyrexia of 38.5, the moment an RTC was mentioned I was half wheeling in the ultrasound machine, lubrication bottle in hand. Pressing lightly with the probe I found the following:

I took a while looking at the scans thinking ‘well that’s not normal’. I asked a colleague, ‘what do you think this is?’ Judging the origin of it in the upper right quadrant nestled in the liver, it made sense that it was the gall bladder. It looked sloughy, but in the context of trauma of low Hb and an aberrant cystic mass? Maybe a bleed somewhere, somehow – I wasn’t sure.

Regardless, I wasn’t qualified to make a clear classification. It wasn’t free fluid and it certainly wasn’t the aorta, which I had meticulously monitored from the top to its division around the umbilicus (three times minimum). We obtained a CT with fair clinical suspicion, showing thus:

The cyst was a gall bladder with a notable calcification around the entrance to the biliary duct. This patient had the inexplicable luck of having a car accident and a gangrenous gall bladder in a single week. Again, no previous training in identifying a grossly swollen gall bladder – but easily identifiable as something wrong on ultrasound. With the basics of anatomy we were able to make an educated guess, start the appropriate treatment and obtain a CT scan to confirm the diagnosis.

By Theo Muth

POCUS in cardiac arrest: Ventricular Standstill

January 17, 2018

A patient is brought in having collapsed at home. They were found to be in ventricular fibrillation, had been given 5 doses of adrenaline, amiodarone and put on the LUCAS.

The department team orchestrated a good crash call with further doses and shocks when possible.

After over 2 hours of downtime a blood gas showed a pH <6.1 and a lactate of >14. An echo scan was performed during rhythm checks:

Sub-xiphisternal view

This is demonstrative of ventricular standstill. The valves are moving due to ongoing blood flow but there is no ventricular movement driving that flow. From top to bottom we are looking at the right ventricle (thin walled) followed by the left (thick walled).

The literature indicates that ventricular standstill is not a definitive indicator of mortality. In a systematic review published in Academic Emergency Medicine (1), the authors concluded that an absence of cardiac activity reveals a 'significantly lower (but not zero)' chance of the patient gaining ROSC. It goes on to highlight how it should be used in conjunction with clinical findings to help predict patient outcome.

Having said this, a narrower study from 2001 demonstrated that 100% of one hundred and thirty six patients who were found to be initially in ventricular standstill went on to die in ED despite resuscitation efforts (2). It does however acknowledge the limitations of being a small study.

In the context of our patient with a long downtime, no identified reversible cause and an ominous blood gas, the image of their heart with no functional movement helped us to make a communal decision to cease further resuscitation attempts.

1) Academic Emergency Medicine. 2012 Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Blyth et al. Oct;19(10):1119-26

2) Academic Emergency Medicine. 2001 Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram. Blaivas, M. Fox, J. 10.1111/j.1553-2712.2001.tb00174.x

A good summary of uses of echo in emergencies can be found here:

https://lifeinthefastlane.com/own-the-echo/

By Theo Muth

The Uncertain X-ray

December 28, 2017

Ultrasound in the emergency department need not always be classified into official sounding bites such as FAST, ECHO or US-CVA. The following case hopefully shows how, when in doubt, the use of ultrasound with basics of image interpretation can be used to aid diagnosis, much in the way our stethoscopes will aid our decision to order further investigations.

A young lady presented to the ED having recently been admitted for a post-surgical complication. She was discharged on cefalexin and metronidazole for cover. After a couple of days she re-presented, tired, clammy and with a productive cough. Her initial observations showed a tachycardia, stable blood pressure and a significant pyrexia, with saturations within range. Examination revealed some crackles at the bases, more so on the right than the left. Triggering the sepsis pathway she was started on empirical antibiotic cover.

She had no other previous medical history of note apart from the recent treatment and was sent for a chest x-ray on account of the clinical findings:

Thoughts so far? I’m sure that some of you will have noted the abnormality immediately but even among our department there were some questions about whether there was a notable abnormality on the plain film.

Roll-on the ultrasound. A quick scan of the thorax showed the images below. The training I had previously received in thoracic ultrasound was limited to quickly identifying ‘lung’ or ‘no lung’ – principally in the context of traumatic pneumothorax. We can see here that in the upper right lobe, there is a relatively normal appearance, but as we look at the right lower lobes, there is an absence of the pleural markings. However, in comparison to a pneumothorax, there is a nice window of fluid (black) which we can see through to the lung beneath it.

Looking more carefully at the x-ray, it is easier to see the collection on the right lower thorax. Whereas before this could have been confused for a scapula line or an artefact, in addition to the ultrasound findings we can be more certain of a clear pathology. Incidentally the patient later went for a CT PA that confirmed a collection on the right side.

CTPA showing collection at right base. No PE was identified

Finding a pleural collection was not part of the normal trauma training. Even with no official ultrasound qualification it's easy to identify the difference between tissues ('there's grey lines separated by a big black segment') - which will help us arrive at a diagnosis with little time or inconvenience to the patient.

By Theo Muth