As part of our new ultrasound curriculum, interns undergo an anesthesia/ultrasound rotation that consists of intubations in the OR in the morning followed by ultrasounds in the ED in the afternoon. During this four week rotation, some residents log over 250 ultrasound exams! We will be sharing some interesting cases diagnosed with ultrasound by our fantastic interns, starting with Dr. Tyler Scaff. Take a look at his images and video clips!
- Shyam Murali, Chief Editor
By Tyler Scaff, MD, PGY-1
Happy New Year! And what better way to start off the new year than to walk through some cool scans I picked up on my rotation in the emergency department. For each scan below, take a second to read the HPI, note the location of the scan, and observe the finding. Then see below for a couple of teaching points on the case.
Case 1
A 67-year-old man, who has not seen a doctor in over ten years, presents to the emergency department after a cardiac arrest. The patient was intubated and ROSC was obtained in the field. Medical history is unknown. While performing the RUSH exam, I noted this finding on ultrasound of the abdomen.
This is a profoundly enlarged aorta (aneurysm) measuring 5.6 cm x 7.3 cm. You can also see a component of dissection in the video clip. Note the heterogenous echogenicity, suggesting clot and debris in the true and false lumen. As I performed this scan, I could feel the pulse of the aorta bouncing my probe up and down. An aorta like this is well above the margin for emergency surgery as it is also dissected. On CT scan, the patient had multiple areas of aneurysmal dilatation of the aorta between the diaphragm and bifurcation. There were also findings concerning for impending rupture. However, this patient had multiple other problems and could not tolerate surgery. Sadly, he ended up passing away the next day.
Case 2
A 36-year-old man with history of alcohol abuse presents to the ED for epigastric abdominal pain and a 2-day history of worsening nausea and vomiting. On ultrasound of his epigastrium, I noted this finding.
Peripancreatic fluid is challenging to see and obtaining an ultrasound image of this is difficult for the patient to tolerate as it requires a significant amount of pressure on the epigastrium usually. This patient had other findings concerning for pancreatitis (specifically interstitial/edematous pancreatitis), and the CT abdomen demonstrated the same fluid noted above.
Case 3
A 62-year-old male with hepatic cirrhosis comes in to the emergency department requesting an evaluation of his distended, tender belly. On ultrasound of the right flank I observed this finding.
This is a small pleural effusion. As the patient breathes, you can see the tail of the lung move up and down freely in the fluid. Unfortunately, it is too shallow of a scan to observe the classic spine sign. For reference, this next scan is of the patient’s left flank, and is a normal study. Observe the pleural line moving up and down with motion of the diaphragm, as one contiguous unit.
Case 4
A 33-year-old G3P1010 female presents at approximately 13 weeks gestation with a chief complaint of vaginal bleeding. Prior to the pelvic exam, I performed a sagittal-plane transabdominal ultrasound of the uterus and note this finding.
Heterogenous material in the uterus with absence of a fetal pole in the setting of vaginal bleeding and a history of confirmed IUP is diagnostic for spontaneous abortion. The key here for me was to get my bearings in the field and fan back and forth several times to ensure that I was, in fact, looking at the uterus and I did not see a viable pregnancy. Pelvic examination demonstrated an open cervix with blood and debris in the vaginal vault.
Case 5
A 45-year-old man presents to the ED after a fall. His workup and imaging so far have been negative for injury. While scanning this patient’s Morrison's pouch, a medical student with a handheld ultrasound device began to scan over the patient’s umbilicus. We subsequently observed this finding:
This is a double-probe comet tail artifact I observed completely quite by accident. At right angles to each other, each probe caused the other’s image to shimmer as above. When parallel or pointing directly through the patient at each other, this finding was not observed. I was using a typical piezoelectric abdominal probe, and the medical student was using a tablet-operated universal probe (Butterfly Ultrasound). I found very limited information online about this artifact; here is one article that delves into this subject. The article specifically mentions pulsed wave doppler as worsening the artifact, producing profoundly noisy images.
References
Amir S, Chowdhry BS, Hashmani M, Hasan M. The Analysis of the Artifacts due to the Simultaneous Use of Two Ultrasound Probes with Different/Similar Operating Frequencies. Comput Math Methods Med. 2013;2013:890170. doi: 10.1155/2013/890170. Epub 2013 Mar 31.