St. John’s Riverside Hospital
St. Barnabas Hospital
A 62-year-old male with no reported past medical history presented with worsening left foot swelling after cutting his toenail. On physical examination, his left foot was swollen, warm, erythematous, and tender to palpation. There was a poorly healing wound on the plantar surface of his left foot. Of note, crepitus was not felt. A point-of-care ultrasound (POCUS) of the left foot was performed which showed extensive cobblestoning without a discrete fluid collection, and deeper “dirty” shadowing suggestive of subcutaneous air (Figure 1). When gentle pressure was applied with the transducer, the subcutaneous air mobilized, confirming our suspicion that the “dirty” shadowing visualized was indeed subcutaneous air (Video 1). We call this novel sonographic finding “sonographic crepitus.” This dynamic visualization of subcutaneous air movement with transducer pressure application ultimately raised our suspicion for necrotizing fasciitis, in an otherwise equivocal physical examination of the wound. Prior studies have described sonographic findings consistent with necrotizing fasciitis such as subcutaneous thickening, air, and fascial fluid as well as an approach to early POCUS screening in these patients as delays in diagnosis and treatment have led to increased morbidity and mortality (1,2). In equivocal cases, POCUS may assist in diagnosis and has been shown to have a positive impact in expediting care (3), as it did in this patient. We hope that sonographic crepitus may be added to the continuum of sonographic findings associated with necrotizing fasciitis and further assist diagnosis in ambiguous cases.
Castleberg E, Jenson N, Dinh VA. Diagnosis of necrotizing fasciitis with bedside ultrasound: the STAFF Exam. West J Emerg Med. 2014;15(1):111-113. doi:10.5811/westjem.2013.8.18303
Nawijn, F., Smeeing, D.P.J., Houwert, R.M. et al. Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 15, 4 (2020). https://doi.org/10.1186/s13017-019-0286-6
Yen ZS, Wang HP, Ma HM, Chen SC, Chen WJ. Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med. 2002 Dec;9(12):1448-51. doi: 10.1111/j.1553-2712.2002.tb01619.x. PMID: 12460854.
A 58 year old male with lung cancer presents to the ED after a witnessed cardiac arrest at home. ROSC was achieved after one round of CPR. In the ED, the patient was hypotensive. A RUSH exam was performed revealing a large pericardial effusion with signs of tamponade. An emergent ultrasound guided pericardiocentesis was performed in the ED with resultant improved hemodynamics after aspiration of 50cc of fluid. Our subxiphoid view using the liver as a window shows the needle tip, as a hyperechoic structure with reverberation artifact, in the pericardium draining the effusion.
Cardiac tamponade is a potentially reversible etiology of hemodynamic instability and can be rapidly screened for with POCUS echo. Cardiac tamponade is a clinical diagnosis and evidence of tamponade on POCUS can be used to support the diagnosis of cardiac tamponade. Supporting signs include right atrial end systolic collapse, right ventricular diastolic collapse, and a plethoric IVC.
An 85 year-old female with a history of hypertension, hyperlipidemia, gastroesophageal reflux disease, laparoscopic cholecystectomy presented with abdominal pain starting earlier that morning. Her pain was located in the lower abdomen and was associated with constipation, belching, and multiple episodes of emesis. Physical examination revealed a distended, diffusely tender abdomen with tympany to percussion. Point-of-care ultrasound (POCUS) of the abdomen was performed using the “lawn mower” method, starting in the right lower quadrant and using graded compression, scanning all abdominal quadrants. Ultrasound images demonstrated dilated, small bowel loops containing air and fluid levels measuring up to 4.1 centimeters, localized free fluid between loops of bowel, and the “keyboard sign” (visualization of the plicae circularis). Computed tomography confirmed presence of a small bowel obstruction (SBO). POCUS demonstrates high sensitivity and specificity in diagnosis of SBO, allowing emergency medicine physicians to take early critical actions and allows for rapid management to improve patient care.
39M history of HCV, IV drug use presenting with body aches and fevers. Pt was tachycardic, tachypneic, afebrile, hypotensive, and lethargic on exam, concern was for septic vs cardiogenic shock given tachycardia and low blood pressure without fever. Utilization of the rapid ultrasound for shock and hypotension (RUSH) exam provided the answer. Massive vegetations were noted upon the tricuspid valve and in right atrium, right ventricle:left ventricle ratio was close to 1:1, with a mild to moderate pericardial effusion without signs of tamponade was visualized. Modified Dukes Criteria were positive based on signs and symptoms. The patient was ultimately diagnosed with infective endocarditis. This case not only highlighted the use of the Modified Dukes Criteria for diagnosing infective endocarditis, it also highlighted a key and important skill in determining the cause of undifferentiated hypotension and shock using the RUSH exam.
95 y/o Hispanic F with PMH of Dementia presents to ED for pain to RLE x1 day. The Patient’s family noticed that the patient normally ambulates on her own but since last night it has been painful, and today she could not tolerate standing therefore was brought in for evaluation. On examination, the patient was found to have a right lower extremity that was tender to touch and swollen compared to the left, as well as right 2nd-5th toe erythema with no palpable pedal pulse . This prompted concern for DVT vs Arterial occlusion. On POCUS, the DVT study showed a distal superficial femoral vein occlusion noted by loss of compressibility in the superficial femoral vein and popliteal vein with visible echogenic material.
Teaching point: Not all cold dead legs are the same. POCUS DVT studies are highlysensitive and specific in the hands of EM physicians and can aid in early bedside diagnosis.
Relevant information: 70 y.o male with a recent pacemaker placement 2 weeks ago presented to the ED with acute onset dyspnea and lightheadedness. Vital signs were notable for hypotension. EKG showed an AV paced rhythm without electrical alternans. POCUS echo showed a pericardial effusion and right ventricular collapse concerning for tamponade.
Tatarian, Liana, et al. “Late-Onset Acute Pericardial Effusion Following Pacemaker Implantation: A Case Report.” Chest, vol. 156, no. 4, 2019, https://doi.org/10.1016/j.chest.2019.08.1361.
68 year-old male denies PMH presents to the ED by his PMD for abnormal labs. Patient states he has been experiencing dyspnea on exertion, exertional chest pain, dizziness and bilateral pedal edema which has been worsening for about 6 months. Has been urinating normally without any difficulty. He also reports that he has not seen a doctor in many years. Therefore, he went to a primary care doctor for the first time in 3 years, 1 week ago, due to the symptoms described above who ordered basic labs. He was called today and was recommended to present to the ER today for Hgb of 5.0. Of note, the patient’s blood work was also significant for BUN 119, Cr 15.5, and K 5.7. He denies fever, chills, malaise, abdominal pain, rectal bleeding, black stool, syncope, palpitations, or hematemesis.
Teaching point: The importance of renal US in the evaluation of patients with renal failure.
A 32 year old female presents on postpartum day seven with an occipital headache that started four days ago. The patient described the headache as gradual in onset, heavy in quality, different from previous headaches, and initially intermittent with progression to a constant pain that had minimal relief with Ibuprofen. Her recent pregnancy was complicated by gestational diabetes and preeclampsia without severe features. Incidentally, she also received a tubal ligation during her postpartum admission. There was concern for Cerebral Sinus Venous Thrombosis (CSVT) given the quality and character of her headache, in addition to being both post-partum and with recent surgery, so the optic nerve sheath diameter (ONSD) was measured to establish if there was increased ICP. We noted a significantly elevated ONSD on the right and minimal elevation on the left, which correlated to her significant right sided clot burden on magnetic resonance venography.
Teaching point: ONSD is a non-invasive screening tool for elevated ICP and can increase your pre-test probability of occult pathology prior to imaging.
Figure 1: POCUS demonstrating acute cholecystitis: shadowing gallstones, and gallbladder wall thickening. The Patient also had a positive sonographic Murphy sign.
Figure 2: Repeat POCUS upon patient’s acutely worsening condition shows the duodenum, a common false positive for acute cholecystitis.
A middle aged female with a recent history significant for cholelithiasis presents with persistent, progressively worsening, epigastric pain for one week. She’s also experiencing fevers, chills, and had one espide of non-bloody, non-biliary emesis. Her vitals are blood pressure 196/102 mmHg, heart rate 127 beats per minute, respiratory rate 22 breaths per minute and temperature 100.4 °F. A point of care ultrasound (POCUS) biliary study is positive for acute cholecystitis demonstrating shadowing gallstones, a sonographic Murphy sign and anterior gallbladder wall thickening (first image/clip). After the initial POCUS exam, the patient complains of acutely worsening pain. A repeat POCUS is performed by the same clinician. The gallbladder now looks different, demonstrating an oblong structure, filled with heterogeneous material and surrounded by fluid. The clinician is concerned and seeks out a colleague questioning if it’s possible to progress to pericholecystic fluid (which was not present on the initial images) so quickly, or wonders aloud if it’s possible to perforate the gallbladder by pushing on it? These two POCUS biliary studies performed on the same patient demonstrate both a true positive acute cholecystitis (first image/clip) as well as one of the most common false positive biliary findings (second image/clip), the duodenum .
A common cause for false positive biliary scans is an air filled duodenum . It’s imperative that a biliary scan includes multiple views to avoid such false positives. It is estimated that over 20 million people in the United States have gallbladder disease. Of the patients who present to the Emergency Room (ER) with abdominal pain, 3-10% have acute cholecystitis . In the hands of ER providers, Point of Care Ultrasound (POCUS) has been proven to shorten ER visits .
Walas MK, Skoczylas K, Gierbliński I. Errors and mistakes in the ultrasound diagnostics of the liver, gallbladder and bile ducts. J Ultrason. 2012;12(51):446-462. doi:10.15557/JoU.2012.0032
Pinto, A., Reginelli, A., Cagini, L. et al. Accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis: review of the literature. Crit Ultrasound J 5, S11 (2013). https://doi.org/10.1186/2036-7902-5-S1-S11
Hilsden R, Leeper R, Koichopolos J, et al. Point-of-care biliary ultrasound in the emergency department (BUSED): implications for surgical referral and emergency department wait times. Trauma Surg Acute Care Open. 2018;3(1):e000164. Published 2018 Jul 30. doi:10.1136/tsaco-2018-000164