Ultrasound

Point-Of-Care Ultrasound for the Diagnosis of Extensor Tenosynovitis

James A Frank, MD^*, Joshua Lupton, MD^* and Bryson Hicks, MD^*

DOI: https://doi.org/10.21980/J8Q050Issue 4:3 No ratings yet.

Point-of-care ultrasound of the dorsal aspect of the left hand reveals a heterogenous hypoechoic fluid collection surrounding the extensor tendons (axial view) within the retinaculum consistent with edema. Longitudinal view shows anechoic fluid within the tenosynovium which is located between the anisotropic extensor tendon and linear hyperechoic synovial sheath. Longitudinal view also shows some cobblestoning, or tissue edema, superficial to the anisotropic extensor tendon. The patient’s contralateral right dorsal hand was scanned in a longitudinal view and shows no cobblestoning or hypoechoic fluid under the synovial sheath. The patient was diagnosed with tenosynovitis, and started on intravenous antibiotics.

Point-of-care Ultrasound in the Diagnosis and Monitoring of Bladder Hematoma vs. Hemorrhage

Esther Kim, BS^* and Shadi Lahham, MD, MS^*

DOI: https://doi.org/10.21980/J8092FIssue 4:3 No ratings yet.

Bladder POCUS demonstrated 500mL of post void residual fluid, indicative of retention. Half of the volume is hyperechoic (red circle); this is likely the bladder wall hematoma. Could also consider sonographic artifact, bladder mass, or cystitis.1-2

Genitourinary Ultrasound Visual EM

Point-of-Care Ultrasound to Evaluate Intrahepatic Biliary Stent Function

Michael Louthan, BS^* and Shadi Lahham, MD, MS^*

DOI: https://doi.org/10.21980/J86S6N Issue 4:3 No ratings yet.

The ultrasound image demonstrates severe intrahepatic biliary ductal dilatation without an obvious intrahepatic obstructive lesion, as pointed out by the white arrows. The hepatic vasculature is well-distinguished from the biliary tree via color flow doppler, as seen by the white arrowheads.

Abdominal/Gastroenterology Ultrasound Visual EM

Diagnosis and Treatment of an Anterior Shoulder Dislocation with Bedside Ultrasound

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

DOI: https://doi.org/10.21980/J8Z924Issue 4:3 No ratings yet.

Bedside ultrasound with the transducer placed on the posterior right shoulder revealed an anterior dislocation of the right humerus. This is evident by displacement of the humeral head further away from the posteriorly placed ultrasound transducer, and appears deep to the glenoid cavity. In a posterior shoulder dislocation, the humeral head would appear closer to the transducer (and the near field of the ultrasound image) than the glenoid. Note that a hypoechoic, heterogeneous fluid collection is within the joint space, compatible with a hematoma. A right shoulder X-ray confirmed the anterior dislocation with no evidence of fracture. Under direct ultrasound guidance the glenohumeral joint space was injected with 10 mL of 2% lidocaine as an intraarticular anesthetic block. The right shoulder was reduced using continual traction. Post-reduction ultrasound demonstrated a successful shoulder reduction, depicted by the humeral head being relocated to its anatomical location, adjacent to the glenoid cavity, as noted on the ultrasound image. A hematoma remains present within the joint space. Successful shoulder reduction was further confirmed by X-ray. The patient’s arm was placed in a sling and she was discharged home with orthopedics follow-up.

Orthopedics Visual EM

Right Atrial Thrombus

Michael Berkenbush, MD, NRP^*, Mei-Yung Chan, MD^* and Amanda Esposito, MD^*

DOI: https://doi.org/10.21980/J8F93V Issue 4:3 No ratings yet.

History of present illness: A 77-year-old male presented to the emergency department with shortness of breath. Symptoms progressively worsened over the last 4-5 days, and on arrival was associated with chest tightness. He denied any medical conditions, smoking, or pertinent family history. He has not seen a primary care physician in “many years.” Upon arrival he was in mild

Cardiology/Vascular Visual EM

Posterior Vitreous Detachment

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

DOI: https://doi.org/10.21980/J89K9N Issue 4:3 No ratings yet.

Ocular ultrasound was performed and demonstrated a thin, slightly echogenic strand (blue arrow) extending from the posterior eye into the vitreous humor (yellow arrow) which was hyperkinetic with extraocular motion. These findings are consistent with a posterior vitreous detachment (PVD).

Ophthalmology Visual EM

Macula-Off Retinal Detachment Identified on Bedside Ultrasound

Colin Prather, MD^* and Bryson Hicks, MD^*

DOI: https://doi.org/10.21980/J8WP8KIssue 4:2 No ratings yet.

Point-of-care ultrasound was performed, demonstratinga free-floating, serpiginous, hyperechoic membrane (R) tethered at the optic nerve (ON) and ora serrata (OS), but detached at the macula (M) lateral to the optic nerve. This is diagnostic for macula-off retinal detachment. It can be differentiated from macula-on retinal detachment, in which the hyperechoic retina would appear attached posteriorly at the location of the macula just lateral to the optic nerve. Ophthalmology was consulted, agreed with the diagnosis of macula-off retinal detachment, and took the patient to the OR for laser photocoagulation.

Ophthalmology Visual EM

Point-of-Care Ultrasound for the Diagnosis of Systolic Heart Failure

Amal Shafi, BS^*, Maili Alexandria Drachman, MD^{^}, Michelle Bui, BS^* and Tushank Chadha, BS^*

DOI: https://doi.org/10.21980/J8HD1R Issue 4:2 No ratings yet.

Bedside ultrasound with the phased array probe was used to obtain a parasternal long axis view which demonstrated poor contractility and a severely decreased ejection fraction (EF). M-mode was placed over the anterior leaflet of the mitral valve to create a tracing depicting both the E-wave of early diastole (green arrow) and the A-wave from the atrial kick (blue arrow). The shortest distance between the septum and the mitral valve on the M-mode tracing gives the patient’s E-Point Septal Separation (EPSS) (pink arrow). EF can be estimated using the formula EF=75.5-2.5 x EPSS (in mm). This patient’s EPSS was measured to be 20mm which estimates that she had an EF of 25.5%.

Visual EM Cardiology/Vascular

Bedside Ultrasound for the Rapid Diagnosis of Fournier’s Gangrene

Patrick Penalosa, BS^*, Maili Alexandria Drachman, MD^{^} and Vy Han, MD^*

DOI: https://doi.org/10.21980/J8CP99Issue 4:2 No ratings yet.

Point of care ultrasound (POCUS) utilizing a high-frequency linear probe revealed heterogeneous debris with subcutaneous air within the scrotal wall extending into the perineum consistent with necrotizing fasciitis of the perineum or Fournier’s gangrene (FG). The video shows multiple foci of gas that appear as echogenic dots with “dirty shadows” posteriorly from reverberation artifact arising from gas within the soft tissue.

Infectious Disease Genitourinary Visual EM

Saddle Pulmonary Embolus

Colin Therriault, MD^*, Daniel Natkiel, DO^* and Megan Stobart-Gallagher, DO^{^}

DOI: https://doi.org/10.21980/J8N63P Issue 4:2 No ratings yet.

An electrocardiogram (ECG) showed evidence of right heart strain with an incomplete right bundle branch block, S1Q3T3 (see red arrow [S1], blue arrow [Q3], and black arrow [T3]), and ST-segment elevation in the septal leads (green arrows). Bedside echocardiography showed a dilated right ventricle with ventricular wall akinesis (red arrow) sparing the apex (purple arrow), which is known as McConnell’s Sign. It also showed a mobile hyperechoic mass (yellow arrow). These ultrasound findings were concerning for pulmonary embolism (PE), so computed tomography (CT) angiogram of the chest was ordered and confirmed massive bilateral obstructive filling defects (red arrows) consistent with saddle pulmonary embolism. Additionally, noted is flattening of the interventricular septum (blue arrow) consistent with right heart strain. Laboratory studies were notable for a troponin-I of 0.29 ng/mL, a B-type natriuretic peptide of 792.3 pg/mL, lactic acid of 5.30 mmol/L, and a creatinine of 2.0 mg/dL, consistent with end organ dysfunction. All other lab work was within normal limits.

Visual EM Cardiology/Vascular Respiratory