st. john's riverside hospital hosted the 2023 bronx sonowars
Participants:
St. John’s Riverside Hospital
Columbia/NYP
St. Barnabas Hospital
Lincoln Hospital
Jacobi/Montefiore Hospital
Special thanks to EMPRESS Headquarters for hosting us, as well as Philips, Mindray, Sonosite, Abbvie/Dalvance, and Team Health for sponsoring this event!
Congratulations st. barnabas! – overall winners of the 2023 bronx sonowars
Congratulations to St. Barnabas Hospital for winning The 2023 Bronx SonoWars! St. Barnabas also won the first round question portion. And, congratulations to Lincoln (Team – Foreign Baddies) for winning the write up submission portion of the competition (There’s Smoke! Stop, Drop, and Sono – See below)!
Oh Snap, There's a Flap
Lincoln Hospital (Team 1)
Team: Scattered Reflections
Marimer Rivera, Yitzchok Kanter, Shayan Azizi, Jason Tromblee
A 39 year old male with disabling psychiatric illness presented with chest pain. History was limited except for new onset chest pain that woke him from sleep. Initial evaluation revealed a well-appearing male with normal chest X-ray, ECG without acute ischemic changes, and negative troponin.
Echocardiography was performed due to diagnostic uncertainty. A review of the parasternal long-axis view revealed a subtle intimal flap in the descending aorta suggestive of aortic dissection which was confirmed on suprasternal window. This finding expedited definitive management and CT Angio Chest imaging revealing a Stanford Type A (Debakey Type I) aortic dissection.
This case illustrates the utility of bedside echocardiography in identifying a fatal cause of chest pain in a patient from a vulnerable population who had no classic risk factors for aortic dissection. Providers should have a low-threshold for performing bedside echocardiography in vulnerable patient populations and for chest pain of uncertain etiology.
There's Smoke! Stop, Drop, and Sono!
Lincoln Hospital (Team 2)
Team: Foreign Baddies
Brendon Walker, Ryan Mischler, Giovanni Rodriguez-Diaz, Aram Durgerian
A 55-year old female presented with right shoulder pain for one week. She attributed her symptoms to lifting heavy boxes. However, physical examination was unusual revealing non-pitting facial edema and right-sided jugular venous distention (JVD).
Transthoracic echocardiography did not identify cardiac etiology of the JVD, thus sonographic evaluation of the neck vessels was performed. Examination of the right internal jugular vein (IJV) revealed the presence of a smoke-like swirling echogenic material within the blood vessel. This finding known as spontaneous echo contrast (SEC) is often associated with low flow state and hypercoagulability. In this case, the presence of SEC in the right IJV raised suspicion for hypercoagulable state and mechanical obstruction. CT imaging of the chest revealed right lung neoplasm with occlusion of the superior vena cava. Recognition of SEC may be a useful tool for identifying patients with hypercoagulable states or obstructive pathology.
Tearable Pain
St. John’s Riverside Hospital (Team 1)
Team: Waves of Gain
Dan Laub, Alina Mitina, Jennifer Goldston, Jazmin Sevilla
A 65-year-old male with a medical history of hypertension, Lemierre’s syndrome, and alcohol use disorder presented with sudden, severe chest pain that radiated to the back, accompanied by nausea and vomiting. The initial vital signs were normal, but the patient was in significant distress and writhing in pain during the physical examination. However, there were no abnormal findings during the exam. The EKG showed normal sinus rhythm with no acute ischemic changes. The chest x-ray revealed a questionably widened mediastinum. Point-of-Care Ultrasound (POCUS) of the proximal, mid, and distal aorta was performed, which revealed a dissection flap in the proximal and distal aorta that was not visible during the initial short-axis view. A CTA of the chest, abdomen, and pelvis was performed, which confirmed the presence of an aortic dissection extending from the ascending thoracic aorta through the distal abdominal aorta with a dissection flap extending into the major arch vessels proximally, and towards the right common iliac distally. Using ultrasound to diagnose AAA in the emergency room is valuable due to its low cost, availability at bedside, and high sensitivity and specificity.
Emphysematous Gallbladder
St. John’s Riverside Hospital (Team 2)
Team: Yonkers Ultrasound Team
Lisa Chan, Curtis Marino, Maria Tran, Joe O’Keefe
65yoM with PMH HTN, HLD, DM, who presents with diffuse abdominal pain. Initial vitals notable for fever, tachycardia. Physical exam notable for RUQ tenderness to palpation. Labs notable for leukocytosis, LFTs unremarkable, bilirubin within normal limits. Gallbladder ultrasound showed “Champagne sign” with multiple small, non-shadowing echogenic “bubbles” and dilated common bile duct. These echogenic “bubbles” represent gas that is formed due to wall necrosis in emphysematous cholecystitis. This gas migrates from a dependent to non-dependent position within the gallbladder with positional changes which resemble effervescing bubbles of champagne in a glass. Emphysematous cholecystitis can be complicated by gangrene or perforation. Mortality of emphysematous cholecystitis is around 15-25% (as compared to <5% in uncomplicated cholecystitis). Treatment is emergent surgical intervention.
References:
Kecler-Pietrzyk A, Bell D, El-Feky M, et al. Champagne sign (gallbladder). Reference article, Radiopaedia.org (Accessed on 11 Mar 2023) https://doi.org/10.53347/rID-73182
Radswiki T, Alhusseiny K, Omar Carrim Y, et al. Emphysematous cholecystitis. Reference article, Radiopaedia.org (Accessed on 11 Mar 2023) https://doi.org/10.53347/rID-15601
Safwan M, Penny SM. Emphysematous Cholecystitis: A Deadly Twist to a Common Disease. Journal of Diagnostic Medical Sonography. 2016;32(3):131-137. doi:10.1177/8756479316631535
Air and Jelly in the Belly
Jacobi/Montefiore (Team 1)
Team: Monte Team 1
Phil O’Donnell, Grace Ponchinka, Anjali Cherukuri, Caitlin Sershon
41M with past medical history of sarcoidosis (on daily methotrexate and steroids) presenting for right upper quadrant (RUQ) pain and vomiting x 2 months, increasing in severity x 1 day. Patient states that he has been having pain “every time” he eats, but that his pain improves without intervention within minutes. He presented to the ER today because he had an episode of this similar pain, but increased in severity in comparison to previous episodes with associated, bilious vomiting. Of note, he has been told he should receive a right upper quadrant ultrasound to evaluate, but he has been unable to see them due to scheduling issues. Labs were notable for ALT 80U/L, AST 157U/L. Alk Phos 203U/L. Total bilirubin 1.8mg/dL, direct bilirubin 0.8mg/dL. Lipase within normal limits. RUQ POCUS concerning for emphysematous cholecystitis, confirmed with CT.
Monster in the Belly
Jacobi/Montefiore Team 2
Team: Monte Team 2
Alexandra Lew, Noah Trump, Jason Siebert, Nora McNulty
86F with PMH of CVA, HTN, CAD, COPD presented to the ED from NH due to sudden, non-radiating, sharp left-sided abdominal pain that started yesterday afternoon. She was resting when the pain started and she has never had this pain before. Endorses one episode of NBNB emesis.. Denies, fevers, chills, dysuria, hematuria, numbness, tingling, loss of sensation.
A curvilinear probe was placed on the patient’s abdomen and flank to assess for nephrolithiasis, biliary pathology, and vascular competence when a pulsating enlarged Abdominal Aortic Aneurysm (AAA) concerning for rupture was identified (Figure 1, Figure 2). Vascular surgery was urgently consulted. Patient was hemodynamically stable and therefore CTA was performed (Figure 3). It was remarkable for 7.1 cm AAA with associated rupture. Patient was taken for emergent endovascular aneurysm repair for ruptured AAA with exclusion of right kidney.
B Mode Nematode
St. Barnabas Hospital Team 1
Team: B Mode Nematode
Jonathan Maik, Samuel Fransen, Somit Gedda, Om Pathak
A six year old female presented with her foster mother to the ED with abdominal pain. The patient awoke from sleep with periumbilical pain radiating to her right lower quadrant, associated with non bloody, non bilious vomiting. Social history included emigration from Honduras one month prior. No sick contacts, diarrhea, rhinorrhea, or fevers.
Physical Exam was positive for RLQ abdominal tenderness. Vital signs include a temperature of 39 C. Other vital signs were within normal limits. A point-of-care ultrasound of the abdomen was performed. The appendix was not visualized. A non-vascular, tubular structure was seen within the lumen of the small intestine, moving independently of intestinal peristalsis. Stool cultures were positive for Ascaris lumbricoides. The patient was treated with Albendazole and admitted for monitoring.
We present a case a of a child with undifferentiated abdominal pain. POCUS facilitated the diagnosis of a disease process rarely found in our region.
D-Bunked
St. Barnabas Hospital (Team 2)
Team: TAPSE Drivers
Aamir Bandage, Ocean Kwon, Harshit Terala, Teena Alex
This 51-year-old male was brought to the ER after being found collapsed and subsequently responsive to Narcan. The patient was found to be hyperkalemic, however refused further evaluation leading to the first of three cardiac arrests. Patient went into PEA arrest with ROSC, after which POCUS showed significant right ventricle dilation with positive D-sign. tPA was started for suspected PE, after which patient arrested again with ROSC. CTA of the chest showed an ascending aortic dissection with extrinsic compression of the pulmonary artery. Although TXA was given for tPA reversal, the patient arrested again without ROSC. We demonstrate here that D-sign is simply a symptom of increased right ventricular strain, not pathognomonic for PE. With POCUS as an adjunct, our job is to find the cause. In this case, extrinsic compression of the pulmonary artery led to increased right heart strain, mimicking the appearance of an acute pulmonary embolism.
Tie Fighters
Columbia Hospital
Team: RUSH HOUR
Tyler Wise, Tyler Wen, Guadalupe Jimenez, Shriman Balasubramnian
The patient is a 66 y/o female with CAD (on Eliquis), and HFrEF who presented to the ED with abdominal pain and concern for physical abuse at home. Physical exam revealed normotension, bradycardia, and diffuse abdominal distention. A FAST scan showed significant large volume ascites, most notably in the pelvic window (shown below).
Pelvic ascites in women can be identified by free fluid within the rectovaginal pouch, which can appear as a “TIE fighter sign” on transverse view—the uterus as the cockpit, and the uterine ligaments as wings. In our case, mixed echogeneity layering at the bottom (proton torpedoes?) can also be visualized, which is highly concerning for a new hemoperitoneum with clot burden instead of simple ascites.
Learning point: it is wise to FAST scan any elderly patient with a history of trauma and abdominal pain, and watch out for potentially deadly TIE fighters when examining the rectovaginal pouch.
