Ultrasound

Using Point-of-Care Ultrasound to Expedite Diagnosis of Necrotizing Fasciitis: A Case Report

Romero Kupai, MD^*, Ashkan Morim, MD^*, Lucas Friedman, MD^{*^} and Eva Tovar Hirashima, MD, MPH^{*^}

DOI: https://doi.org/10.21980/J85051 Issue 6:2 No ratings yet.

A consultative scrotal ultrasound was performed, which was read as showing a small right hydrocele, small bilateral scrotal pearls, and normal-appearing testes. Although present, there was no mention of subcutaneous air suggestive of NF, seen in figure 1 as punctate hyperechoic foci (arrowhead) with ring-down artifact known as dirty shadowing (arrow). Also, subcutaneous thickening (asterisk) and free fluid (arrow) were seen as shown in figure 2, although their clinical relevance was not recognized in the radiologist's final report. Figure 3 shows an abdominal and pelvic CT that re-demonstrates subcutaneous air in the scrotum and lower abdomen (arrow) as well as fascial thickening of the perineum and free intra-abdominal air. After these images, the patient was transferred to our hospital for further management. Almost immediately after the patient's arrival, POCUS was employed. As seen in figures 4, we were able to identify in just a few minutes extensive subcutaneous air accompanied by dirty shadowing, as well as re-demonstration of subcutaneous thickening, fluid collections, and a right hydrocele. Even without the outside hospital's CT, the sonographic findings were highly suggestive for the diagnosis of NF of the perineum, also known as Fournier’s gangrene.

Infectious Disease Visual EM

A Case Report on Detecting Porcelain Gallbladder form Wall-Echo-Shadow Sign on Point-of-Care Ultrasound

Fares Al-Khouja, MS^*, Proma Mazumder^{^}, John Moeller, MD^† and Shadi Lahham, MD, MS^†

DOI: https://doi.org/10.21980/J8164G Issue 6:2 No ratings yet.

Point-of-care ultrasound (POCUS) was performed by the emergency physician. Gallbladder ultrasound (US) should be performed using a curvilinear probe. If the patient’s body habitus does not allow for the use of a curvilinear probe, a phased array probe may be used. To find the gallbladder with ultrasonography, two approaches are commonly used. Many physicians prefer the “subcostal sweep” in which the probe is placed on the xiphoid process in a sagittal plane and swept along the inferior costal margin until the gallbladder is visualized. If this does not adequately locate the gallbladder, the “X minus 7” approach may be used. In this approach, the probe is placed on the xiphoid (X) process in a transverse view and moved 7 centimeters (minus 7) to the patient’s right. This technique is useful for patients with a larger body habitus. If the gallbladder is still not visualized, placing the patient in left lateral decubitus position or asking them to take a deep breath and hold may help the ultrasonographer locate the gallbladder. The US revealed mild hepatic biliary duct dilation with cholelithiasis and sludge, but no additional evidence to suggest cholecystitis. The US image showed a dilated common bile duct at 0.94 cm and calcifications. Visualization of the gallbladder wall is essential in differentiating between a positive wall-echo-shadow (WES) sign and a porcelain gallbladder. While a hypoechoic gallbladder wall is indicative of a WES sign, a hyperechoic wall layer will indicate a calcified gallbladder wall, suggesting a porcelain gallbladder. In image 1, the hyperechoic gallbladder wall can be visualized (white arrow), suggesting the presence of porcelain gallbladder and distinguishing it from a positive WES sign.

Abdominal/Gastroenterology Ultrasound Visual EM

Bladder Diverticulum – A Case Report

Savannah Tan, BS^* and Sangeeta Sakaria, MD, MPH, MST^*

DOI: https://doi.org/10.21980/J8635C Issue 5:4 No ratings yet.

On examination, the patient was alert and oriented but in mild distress. Suprapubic fullness was noted upon abdominal palpation. Point of care ultrasound of the bladder showed two enlarged “bladders” with a central communication. Bedside total bladder volume was measured to be 1288 cm3 (the top “bladder” was measured to be 1011 cm3, while the bottom “diverticulum” was measured to be 277 cm3) by ultrasound. The POCUS stills of the patient’s bladder demonstrated the bladder (red arrow) and bladder diverticulum (yellow arrow) with a central communication (blue arrow) in the transverse and sagittal views.

Renal/Electrolytes Ultrasound Visual EM

Ascending Thoracic Aortic Dissection: A Case Report of Rapid Detection Via Emergency Echocardiography with Suprasternal Notch Views

Brandon Backlund, MD^*, Anastasia Kendrick-Adey, MD^*, Rachel Harper, MD^* and Martin Makela, MD^*

DOI: https://doi.org/10.21980/J8WW6WIssue 5:2 No ratings yet.

Video of parasternal long-axis bedside transthoracic echocardiogram: The initial images showed grossly normal left ventricular function, and no pericardial effusion or evidence of cardiac tamponade. However, the proximal aorta beyond the aortic valve was poorly-visualized in this window.

Cardiology/Vascular Ultrasound Visual EM

Hemorrhagic Renal Cyst

Mary Rometti, MD^*, Christopher Bryczkowski, MD^*and Michael Rohinton Mirza, MD^*

DOI: https://doi.org/10.21980/J8C92V Issue 5:1 No ratings yet.

Bedside renal ultrasound demonstrated a right renal cyst with echogenic debris consistent with a hemorrhagic cyst (red arrow). In addition, a computed tomography (CT) scan of the abdomen and pelvis revealed a 4mm non-obstructing right renal stone and bilateral renal cysts. The CT also confirmed the ultrasound finding of a right renal cyst with mild perinephric stranding possibly consistent with a hemorrhagic cyst.

Renal/Electrolytes Abdominal/Gastroenterology Visual EM

Bilateral Common Iliac Artery Aneurysm

Laura Kolster, DO^*, Danielle Biggs, MD^*, Amy Patwa, DO^* and Michael Gerardi, MD^*

DOI: https://doi.org/10.21980/J83S73 Issue 5:1 No ratings yet.

A bedside ultrasound of the aorta was performed. The proximal, middle, and distal aorta appeared normal in caliber, as demonstrated by the images; however there seemed to be some enlargement at the bifurcation. The bifurcation into the iliac arteries, as highlighted by the yellow arrow, demonstrates a slightly enlarged iliac artery on the left. The aorta was followed below the bifurcation as it divided into the iliac arteries, as shown in the video clip. The ultrasound demonstrated a left iliac artery aneurysm measuring 5.99 cm, as highlighted by the orange circle. There were aneurysms to the bilateral common and internal iliac arteries.

Cardiology/Vascular Abdominal/Gastroenterology Visual EM

Atypical Presentation of Abdominal Aortic Aneurysm

Michael Rohinton Mirza, MD^* and Christopher Bryczkowski, MD^*

DOI: https://doi.org/10.21980/J82W6F Issue 4:4 No ratings yet.

Bedside ultrasound revealed an abdominal aortic aneurysm (AAA) with concern for dissection vs thrombus/hematoma due to an area of echogenicity within the lumen of the vessel, since normal blood vessels (including the aorta) have lumens that are uniformly anechoic. An intimal flap concerning for dissection appears as a hyperechoic stripe within the lumen of the vessel on ultrasound, often with a hypoechoic and/or anechoic area appreciated underneath the flap, indicating a separate area of blood flow. If this visualized area is of significant size, color doppler can be used to confirm blood flow on both sides of the flap. Given his bedside ultrasound findings, the patient underwent emergent computed tomography scan and was found to have an enlarged infrarenal abdominal aortic aneurysm, with acute intramural hematoma, extending into bilateral common iliac arteries.

Cardiology/Vascular Visual EM

Thoracic Aortic Aneurysm Measured by Point of Care Ultrasound Suprasternal Notch View

Hamid Ehsani-Nia, DO^* and Christopher Bryczkowski, MD^*

DOI: https://doi.org/10.21980/J8Z64V Issue 4:4 No ratings yet.

Point-of-care cardiac echocardiogram demonstrated a dilated ascending aorta (illustrated in red) measuring approximately 4 cm in the parasternal long axis (PLAX). A dilated aortic arch (illustrated in green) also measuring approximately 4 cm was appreciated using the suprasternal notch view (SSNV). A follow-up computed tomography angiogram (CTA) was performed, validating bedside ultrasound measurements.

Uncategorized Cardiology/Vascular Visual EM

Ultrasonographic Findings of Acute Achilles Tendon Rupture

Charles Craig Rudy, MD^{*^}, John A Thompson, MD^* and Rachel R Bengtzen, MD^{*^}

DOI: https://doi.org/10.21980/J8063S Issue 4:4 No ratings yet.

The ultrasound video clip shows a longitudinal view of the AT during a dynamic exam. While the patient’s foot is gently passively dorsi/plantar flexed, the video demonstrates first a normal Achilles tendon (from the unaffected extremity) without disruption (highlighted by a yellow bracket on screen left). Then it shows an abnormal tendon (the patient’s affected side) with disruption of the typical linear tendon fibers (red arrow identifies area of rupture). Dynamic testing shows the movement of the distal stump of the AT is evident adjacent to hypoechoic fluid that is reactive edema or blood from the acute rupture.

Orthopedics Visual EM

FAST Exam to Diagnose Subcapsular Renal Hematoma

Michelle Sofia Bakardjiev, MD^* and Amanda Esposito, MD^{^}

DOI: https://doi.org/10.21980/J8NP8DIssue 4:4 No ratings yet.

A bedside point of care ultrasound FAST exam was performed revealing a left subcapsular renal hematoma. The hematoma was a non-compressing hematoma, evidenced by preserved renal contour with the hematoma labeled with a red H and the normal renal contour labeled with a green K. Additionally, cortical necrosis and ischemia can be characterized by a dark, hypoechogenic renal cortex on ultrasonography with a decrease in flow to the cortex on color doppler which was not seen on this patient, providing further evidence that the hematoma was non-compressing. The hematoma was concluded to be an acute process due to its hypoechoic appearance with some mixed ultrasonographic echoes caused by the early deposit of fibrin.

Renal/Electrolytes Visual EM