Critical Ultrasound Journal - Latest Articles

Transcranial ultrasound analysis of cerebral blood flow during induced hypertension in acute ischemic stroke - a case series

Jonathan List — 2013-04-08T00:00:00Z

Background: Current recommendations of stroke treatment favour a moderately elevated blood pressure in the acute phase, based on the concept of an improved cerebral perfusion. Here, cerebral blood flow was assessed in a case series of patients with acute hemodynamic stroke by means of transcranial colour-coded sonography (TCCS) to study the effects of pharmacologically induced hypertension.FindingsWe investigated six patients with acute hemodynamic stroke and blood pressure-dependent clinical fluctuation of neurological symptoms. TCCS was performed during the initiation phase of catecholamine-induced controlled hypertension. A blood pressure-dependent increase of flow velocity in the ipsilesional middle and the posterior cerebral artery was found in all patients (mean increase 0.80% and 0.65% per mmHg, respectively). Conclusions: Catecholamine-induced hypertension in severe hemodynamic stroke leads to an ultrasound-detectable rise of cerebral blood flow. This finding gives ‘proof-of-principle’ evidence, supporting active blood pressure management in this selected group of stroke patients. Outcome-related questions of target blood pressure, treatment duration or applicability to other forms of stroke, however, remain to be studied. In this, transcranial ultrasound may be a valuable tool for patient selection and subsequent bedside monitoring.

Emergency department diagnosis of a quadriceps intramuscular loculated abscess/pyomyositis using dynamic compression bedside ultrasonography

Aleksandr Tichter — 2013-02-13T00:00:00Z

IntroductionA 73-year-old man with a past medical history of myelodysplastic syndrome and recent chemotherapy presented to the emergency department with a 1-week history of progressively increasing left thigh pain and swelling. His physical examination revealed left anterolateral diffuse thigh swelling with no erythema or warmth to palpation. The anterolateral quadriceps was markedly tender to palpation. Emergency department bedside dynamic compression ultrasonography that was performed on the left anterolateral thigh revealed a quadriceps intramuscular abscess with loculated yet movable pus. Conclusion: Bedside dynamic compression ultrasonography can assist the emergency or critical care physician in the diagnosis of quadriceps intramuscular abscess or pyomyositis.

Emergency department diagnosis of supraspinatus tendon calcification and shoulder impingement syndrome using bedside ultrasonography

David Riley — 2013-02-11T00:00:00Z

A 45-year-old woman presented to the emergency department with a 2-day history of severe left shoulder pain made worse with movement. Emergency department (ED) bedside point-of-care static and dynamic ultrasound examination of the supraspinatus tendon revealed supraspinatus tendon calcification with impingement syndrome, and the patient was urgently referred to orthopedics after ED pain control was achieved. Bedside shoulder and supraspinatus tendon evaluation with static and dynamic ultrasonography can assist in the rapid diagnosis of supraspinatus tendon calcification and supraspinatus tendon impingement syndrome in the emergency department.

Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound

Dina Seif — 2013-02-11T00:00:00Z

Infective endocarditis is a challenging diagnosis that is rarely made in the emergency department. As the use of focused emergency ultrasound expands into more applications, including advanced echocardiography, the diagnosis of infective endocarditis may be made earlier, potentially leading to more timely treatment. We report a case of an ill-appearing patient presenting to the emergency department with an indwelling central venous catheter, a cardiac murmur, and necrotic toes, who was diagnosed with a large tricuspid vegetation and prominent tricuspid regurgitation on bedside emergency ultrasound. A cardiologist-performed echocardiogram confirmed these findings during the patient's hospital admission.

Accuracy of emergency department bedside ultrasound in determining gestational age in first trimester pregnancy

Turandot Saul — 2012-12-06T00:00:00Z

Background: Patient reported menstrual history, physician clinical evaluation, and ultrasonography are used to determine gestational age in the pregnant female. Previous studies have shown that pregnancy dating by last menstrual period (LMP) and physical examination findings can be inaccurate. An ultrasound performed in the radiology department is considered the standard for determining an accurate gestational age. The aim of this study is to determine the accuracy of emergency physician performed bedside ultrasound as an estimation of gestational age (EDUGA) as compared to the radiology department standard. Methods: A prospective convenience sample of ED patients presenting in the first trimester of pregnancy (based upon self-reported LMP) regardless of their presenting complaint were enrolled. EDUGA was compared to gestational age estimated by ultrasound performed in the department of radiology (RGA) as the gold standard. Pearson’s product moment correlation coefficient was used to determine the correlation between EDUGA compared to RGA. Results: Sixty-eight pregnant patients presumed to be in the 1st trimester of pregnancy based upon self-reported LMP consented to enrollment. When excluding the cases with no fetal pole, the median discrepancy of EDUGA versus RGA was 2 days (interquartile range (IQR) 1 to 3.25). The correlation coefficient of EDUGA with RGA was 0.978. When including the six cases without a fetal pole in the data analysis, the median discrepancy of EDUGA compared with RGA was 3 days (IQR 1 to 4). The correlation coefficient of EDUGA with RGA was 0.945. Conclusion: Based on our comparison of EDUGA to RGA in patients presenting to the ED in the first trimester of pregnancy, we conclude that emergency physicians are capable of accurately performing this measurement. Emergency physicians should consider using ultrasound to estimate gestational age as it may be useful for the future care of that pregnant patient.

Focused assessment with sonography for HIV-associated tuberculosis (FASH): a short protocol and a pictorial review

Tom Heller — 2012-11-21T00:00:00Z

Background: Ultrasound can rapidly identify abnormal signs, which in high prevalence settings, are highly suggestive of extra-pulmonary tuberculosis (EPTB). Unfortunately experienced sonographers are often scarce in these settings. Methods: A protocol for focused assessment with sonography for HIV-associated tuberculosis (FASH) which can be used by physicians who are relatively inexperienced in ultrasound was developed. Results: The technique as well as normal and pathological findings are described and the diagnostic and possible therapeutic reasoning explained. The protocol is intended for settings where the prevalence of HIV/TB co-infected patients is high. Conclusion: FASH is suitable for more rapid identification of EPTB even at the peripheral hospital level where other imaging modalities are scarce and most of the HIV and TB care will be delivered in the future.

Sonographic cervical motion tenderness: a case report of an ultrasound sign found in a patient with pelvic inflammatory disease

Resa Lewiss — 2012-09-18T00:00:00Z

No single historical, physical, laboratory, or imaging finding is both sensitive and specific for the diagnosis of pelvic inflammatory disease (PID). Cervical motion tenderness (CMT), when present, is classically found on bimanual examination of the cervix and uterus. CMT is often associated with PID but can be present in other disease entities. We present a case report of a patient who was ultimately diagnosed with acute PID. The evaluating physician performed a trans-vaginal bedside ultrasound, and the operator appreciated ‘sonographic CMT’. In cases where the physical examination is equivocal or in patients where the exact location of tenderness is difficult to discern, performing a trans-vaginal bedside ultrasound examination can increase the physician's confidence that CMT is present as the cervix is being directly visualized as pressure is applied with the probe. Bedside ultrasound and specifically sonographic CMT may prove useful in diagnosing PID in patients with equivocal or unclear physical examination findings.

The V-line: a sonographic aid for the confirmation of pleural fluid

Paul Atkinson — 2012-08-24T00:00:00Z

Background: Ultrasound is being used increasingly to diagnose pathological free fluid accumulation at the bedside. In addition to the detection of peritoneal and pericardial fluid, point-of-care ultrasound allows rapid bedside diagnosis of pleural fluid.FindingsIn this short report, we describe the sonographic observation of the vertebral or ‘V-line’ to help confirm the presence of pleural fluid in the supine patient. The V-line sign is a result of the fluid acting as an acoustic window to enable visualization of vertebral bodies and posterior thoracic wall, thus confirming the presence of pleural fluid. Conclusions: The V-line is a useful sonographic sign to aid the diagnosis of pleural free fluid.

Inferior vena cava displacement during respirophasic ultrasound imaging

David Blehar — 2012-08-06T00:00:00Z

Background: Ultrasound measurement of dynamic changes in inferior vena cava (IVC) diameter can be used to assess intravascular volume status in critically ill patients, but published studies vary in accuracy as well as recommended diagnostic cutoffs. Part of this variability may be related to movements of the vessel relative to the transducer during the respiratory cycle which results in unintended comparison of different points of the IVC at end expiration and inspiration, possibly introducing error related to variations in normal anatomy. The objective of this study was to quantify both craniocaudal and mediolateral movements of the IVC as well as the vessel's axis of collapse during respirophasic ultrasound imaging. Methods: Patients were enrolled from a single urban academic emergency department with ultrasound examinations performed by sonographers experienced in IVC ultrasound. The IVC was imaged from the level of the diaphragm along its entire course to its bifurcation with diameter measurements and respiratory collapse measured at a single point inferior to the confluence of the hepatic veins. While imaging the vessel in its long axis, movement in a craniocaudal direction during respiration was measured by tracking the movement of a fixed point across the field of view. Likewise, imaging the short axis of the IVC allowed for measurement of mediolateral displacement as well as the vessel's angle of collapse relative to vertical. Results: Seventy patients were enrolled over a 6-month period. The average diameter of the IVC was 13.8 mm (95% CI 8.41 to 19.2 mm), with a mean respiratory collapse of 34.8% (95% CI 19.5% to 50.2%). Movement of the vessel relative to the transducer occurred in both mediolateral and craniocaudal directions. Movement was greater in the craniocaudal direction at 21.7 mm compared to the mediolateral movement at 3.9 mm (p < 0.001). Angle of collapse assessed in the transverse plane averaged 115° (95% CI 112° to 118°). Conclusions: Movement of the IVC occurs in both mediolateral and craniocaudal directions during respirophasic ultrasound imaging. Further, collapse of the vessel occurs not at true vertical (90°) but 25° off this axis. Technical approach to IVC assessment needs to be tailored to account for these factors.

Point-of-care ultrasound used to exclude penile fracture

Adam Ash — 2012-07-13T00:00:00Z

This is a case report of a superficial penile hematoma that was difficult to distinguish clinically from a penile fracture. Such cases occur with relative frequency, and because definitive treatment is an urgent surgery, timely diagnosis is essential to avoid complications. Typical imaging modalities such as cavernosonography and magnetic resonance imaging can be invasive (cavernosonography) or time consuming (magnetic resonance imaging) and may not be readily available. Ultrasound has been used successfully in such cases, and, in this case, we used point-of-care ultrasound combined with a brief period of observation to exclude penile fracture.