Critical Ultrasound Journal - Latest Articles

Case report and brief review of literature on sonographic detection of accidentally implanted wooden foreign body causing persistent sinus:

Bhaskar Borgohain — 2012-05-16T00:00:00Z

Despite advances in imaging techniques, detection of vegetative foreign bodies in soft tissues remains a difficult and sometimes even a challenging task. Clinical evaluation of such patient may present several months or even years after the initial injury and clinician may fail to elicit an antecedent skin puncture. X-ray examination will miss radiolucent foreign bodies. A 15 years old boy presented with a draining non-healing sinus at the lateral aspect of right thigh for 9 months. Musculoskeletal ultrasonography was ordered after ruling out chronic osteomyelitis to detect possible lesions around the thigh. High frequency linear ultrasonic probe readily detected an elongated foreign body within the vastus lateralis muscle. A long piece of wood was confirmed at surgery. Non-healing sinus with normal finding in radiograph following old trauma should raise the suspicion of implanted radiolucent foreign body/bodies. The role of diagnostic ultrasound as a valuable screening tool for detection of foreign body is briefly reviewed.Key words: Sinus, Implanted Foreign Body, Sonography

Bedside ultrasound diagnosis of atraumatic bladder rupture in an alcohol intoxicated patient

Michael Daignault — 2012-05-15T00:00:00Z

Most commonly, patients who present to the emergency department with a history and physical examination suggestive of urinary bladder rupture report a preceding traumatic event. Spontaneous atraumatic bladder rupture is relatively uncommon, but can occur in the context of a recent alcohol binge. The alcohol-intoxicated patient presents diagnostic and therapeutic challenges to the emergency physician (EP) that take on additional urgency given the high mortality of unrecognized bladder rupture. This case report reviews bladder anatomy, the unique physiological changes in the alcohol-intoxicated patient, and the high mortality rate of a ruptured urinary bladder. We review the historical diagnostic imaging options followed by a discussion of how bedside ultrasound could expedite diagnosis and management. We present the case of a patient with spontaneous atraumatic rupture of the urinary bladder after a recent alcohol binge. Bedside ultrasound was utilized by the EP to determine the need for emergent surgical consultation and intervention. We recommend that EPs consider bladder rupture in their initial evaluation of patients presenting with nonspecific abdominal pain in the context of recent alcohol intoxication. When using bedside ultrasound to evaluate the pelvis, the presence of anterior or posterior vesicular fluid collections, the loss of normal pelvic landmarks, or irregularities in the bladder wall may increase the EPs suspicion for this disease entity and expedite time-sensitive management.

Diastolic Dysfunction and Mortality in Early Severe Sepsis and Septic Shock: A Prospective, Observational Echocardiography Study

Samuel Brown — 2012-05-04T00:00:00Z

Background: Patients with severe sepsis or septic shock often exhibit significant cardiovascular dysfunction. We sought to determine whether severity of diastolic dysfunction assessed by transthoracic echocardiography (TTE) predicts 28-day mortality. Methods: In this prospective, observational study conducted in 2 intensive care units at a tertiary-care hospital, 78 patients (age 53.2 +/- 17.1; 51% Female; Mean APACHE II score 23.3 +/- 7.4) with severe sepsis or septic shock underwent TTE within 6 hours of intensive care unit (ICU) admission, after 18 to 32 hours, and after resolution of shock. LV diastolic dysfunction was defined according to modified American Society of Echocardiography 2009 guidelines, using E, A, and e' velocities; E/A and E/e'; and E deceleration time. Systolic dysfunction was defined as an ejection fraction (EF) < 45%. Results: Twenty-seven patients (36.5%) had diastolic dysfunction on initial echocardiogram, while 47 (61.8%) patients had diastolic dysfunction on at least one echocardiogram. Overall mortality was 16.5%. The highest mortality (37.5%) was observed among patients with grade I diastolic dysfunction, an effect that persisted after controlling for age and APACHE II score. At time of initial TTE central venous pressure (CVP) (11+/-5 mmHg) did not differ among grades 1-3, although patients with grade I received less intravenous fluid. Conclusions: LV diastolic dysfunction is common in septic patients. Grade I diastolic dysfunction, but not Grades II and III, was associated with increased mortality. This finding may reflect inadequate fluid resuscitation in early sepsis, despite an elevated CVP, suggesting a possible role for TTE in sepsis resuscitation.

Supporting the early use of echocardiography in blunt chest trauma

Scott Jennings — 2012-05-03T00:00:00Z

This case reports a very unusual mechanism of cardiac rupture following an episode of multiple blunt chest trauma. The patient, a professional jockey, was trampled by horses, and although shocked on hospital admission, he did not present with signs and symptoms that were consistent with cardiogenic shock. This case highlights the difficult and subjective nature of clinical examination in emergency situations when dealing with cases of acute cardiac tamponade. It further emphasises the lack of sensitivity of traditional trauma imaging and investigative approaches such as the standard anteroposterior chest X-ray and electrocardiogram. The diagnosis of acute cardiac tamponade was not made until tertiary-care-centre arrival, when ultrasound technology in the form of bedside echocardiography was used, facilitating emergency surgery to repair a ruptured left ventricle. It is hoped that the sharing of this case will alert fellow clinicians to this uncommon but possible mechanism of cardiac rupture and subsequent tamponade, encourage the early use of echocardiography at the bedside in hypotensive blunt chest trauma cases and reinforce the principles of the Advanced Trauma Life Support course in treating trauma victims.

Analysis of 777 cases with obstruction of ureter or extrahepatic bile duct by ultrasonography after normal saline retention enema

Chong Tang — 2012-04-17T00:00:00Z

Background: Conventional transabdominal ultrasound usually fails to visualize parts of the ureter or extrahepatic bile duct covered by bowel gas. In this study, we propose a new method for gaining acoustic access to the ureters and extrahepatic bile duct to help determine the nature of obstruction to these structures when conventional transabdominal ultrasound fails. Methods: The normal saline retention enema method, that is, using normal saline-filled colons to gain acoustic access to the bilateral ureters and extrahepatic bile duct and detecting the lesions with transabdominal ultrasonic diagnostic apparatus, was applied to 777 patients with obstructive lesions, including 603 with hydroureter and 174 with dilated common bile duct, which were not visualized by conventional ultrasonography. The follow-up data of all the patients were collected to verify the results obtained by this method. Results: Of the 755 patients who successfully finished the examination after normal saline retention enema (the success rate of the enema is about 98%), the nature of obstruction in 718 patients was determined (the visualizing rate is approximately 95%), including 533 with ureteral calculus, 23 with ureteral stricture, 129 with extrahepatic bile duct calculus, and 33 with common bile duct tumor. Conclusions: Colons filled fully with normal saline can surely give acoustic access to the bilateral ureters and extrahepatic bile duct so as to determine the nature of obstruction of these structures when conventional transabdominal ultrasound fails.

Comparison of computerized tomography and ultrasound for diagnosing soft tissue abscesses

Romolo Gaspari — 2012-04-17T00:00:00Z

Background: The diagnosis of a superficial abscess is usually obtained through history and physical exam but bedside ultrasound (US) and computerized tomography (CT) are sometimes used to assist in the diagnosis. It is unclear which imaging modality is superior for patients with superficial soft tissue infections. We compared the diagnostic accuracy of CT and US in patients with skin and soft tissue infections. Methods: Patients presenting with a suspected skin abscess that underwent both US and CT imaging were eligible for inclusion. Two physicians blinded to patient characteristics and other imaging results prospectively reviewed the CT and US images for pre-defined image elements, and in circumstances where there was disagreement between these interpretations, a third physician adjudicated the findings. The presence or absence of an abscess cavity was noted on imaging. Imaging detail was summarized using a pre-specified 4-point scale based on the degree of visible detail with higher numbers corresponding to greater detail. The clinical presence of an abscess was defined by surgical evacuation of purulence. Sensitivity and specificity for both CT and US were calculated using Chi square analysis. Comparison between imaging detail was performed using a Student's T-test. Data are presented with (95% confidence intervals) unless otherwise noted. Results: Over an 18 month period 612 patients received a soft tissue bedside ultrasound with 65 of those patients receiving a CT for the same complaint. 30 of these 65 patients had an abscess located in the head and neck (37%), buttock (17%), lower extremity (17%), upper extremity (13%), torso (13%), or hand (3%). US demonstrated a sensitivity and specificity for the diagnosis of abscess of 96.7% (87.0% to 99.4%) and 85.7% (77.4% to 88.0%) respectively. The overall sensitivity and specificity of CT for the diagnosis of an abscess was 76.7% (65.5% to 82.8%) and 91.4% (81.8% to 96.7%) respectively Overall image detail ratings were superior for US compared to CT (3.5 vs 2.3, p = 0.0001). Conclusion: US is more sensitive then CT, but CT is more specific for superficial soft tissue abscesses. US demonstrated more visible detail within the abscess cavity compared to CT.

Emergency department diagnosis of upper extremity deep venous thrombosis using bedside ultrasonography

Tony Rosen — 2012-04-16T00:00:00Z

A 27-year-old man presents to the emergency department with a 1-day history of severe right upper extremity pain and swelling. The patient's status is post open reduction internal fixation for a left tibial plateau fracture, which was complicated by methicillin-sensitive Staphylococcus aureus osteomyelitis. A peripherally inserted central catheter (PICC) line was subsequently placed for intravenous antibiotic therapy. Emergency department bedside ultrasound examination of both the right axillary vein and subclavian vein near the PICC line tip revealed deep venous thrombosis of both veins. Bedside upper extremity vascular ultrasonography can assist in the rapid diagnosis of upper extremity deep venous thrombosis in the emergency department.

Emergency department ultrasonography guided long-axis antecubital intravenous cannulation: How to do it

David Riley — 2012-04-16T00:00:00Z

An 85-year-old woman with a past medical history of severe peripheral vascular disease and right below knee amputation presented to the emergency department with a 1-day history of non-positional dizziness and weakness. The patient required intravenous access to work up her dizziness and weakness. The patient had multiple failed blind ED peripheral IV attempts performed in the past. Emergency department bedside ultrasonography with a high frequency linear array vascular probe was used to guide antecubital brachial vein cannulation on the first attempt using the long-axis approach.

Medical students benefit from the use of ultrasound when learning peripheral IV placement

Scott Osborn — 2012-03-06T00:00:00Z

Background: Recent studies support high success rates after a short learning period of ultrasound IV technique, and increased patient and provider satisfaction when using ultrasound as an adjunct to peripheral IV placement. No study to date has addressed the efficacy for instructing ultrasound-naive providers. We studied the introduction of ultrasound to the teaching technique of peripheral IV insertion on first- and second-year medical students. Methods: This was a prospective, randomized, and controlled trial. A total of 69 medical students were randomly assigned to the control group with a classic, landmark-based approach (n = 36) or the real-time ultrasound-guided group (n = 33). Both groups observed a 20-min tutorial on IV placement using both techniques and then attempted vein cannulation. Students were given a survey to report their results and observations by a 10-cm visual analog scale. The survey response rate was 100%. Results: In the two groups, 73.9% stated that they attempted an IV previously, and 63.7% of students had used an ultrasound machine prior to the study. None had used ultrasound for IV access prior to our session. The average number of attempts at cannulation was 1.42 in either group. There was no difference between the control and ultrasound groups in terms of number of attempts (p = 0.31). In both groups, 66.7% of learners were able to cannulate in one attempt, 21.7% in two attempts, and 11.6% in three attempts. The study group commented that they felt they gained more knowledge from the experience (p < 0.005) and that it was easier with ultrasound guidance (p < 0.005). Conclusion: Medical students feel they learn more when using ultrasound after a 20-min tutorial to place IVs and cannulation of the vein feels easier. Success rates are comparable between the traditional and ultrasound teaching approaches.

Bedside lung ultrasound in the critically ill patient with pulmonary pathology: different diagnoses with comparable chest X-ray opacification

Jacqueline Koeze — 2012-03-06T00:00:00Z

The differential diagnosis and treatment of opacifications on the chest X-ray in critically ill patients may be challenging. This holds in particular the patient that suffers from respiratory failure with hemodynamic instability. Opacification in the chest X-ray could be the result of hematothorax, pleural effusion, atelectasis, or consolidation. Physical examination of such patients may not always indicate what the cause of the opacification is and thus may not always help indicate the correct therapeutic approach. In such cases, bedside ultrasound may be very helpful. We present two cases with similar chest X-ray opacifications but different diagnoses established with the help of a bedside lung ultrasound. There is documented accuracy of ultrasound in differentiating pleural effusions from consolidation. Ultrasound is safe and may be an alternative for computed tomography scan in a hemodynamically or respiratory unstable intensive care patient.