US Applications. Case Based Wrap-Up 1. Case 1 E-FAST. Case presentations E-FAST Abdominal. Pearls for each indication

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1 Case Based Wrap-Up 1 Stephanie J. Doniger MD RDMS FAAP FACEP Associate Director, Pediatric Emergency Ultrasound Stanford University Medical Center US Applications Case presentations E-FAST Abdominal Aorta Renal Hepatobiliary Pearls for each indication Case 1 E-FAST 39 yo M w history of alcoholism; BIBA found down, still altered T37.6 HR 135 BP 110/84 100% O2 Exam: no external signs of trauma, moderate abdominal distension Initial E-FAST reported as slightly positive, but felt to be ascites

2 Case 1 Case 1 Case 2 Case 2 39 yo F, driver in high speed collision HR 112 BP 80/40 Exam: diaphoretic, seat-belt sign, JVD, muffled heart tones

3 Tamponade Clinical diagnosis: Beck s Triad Circumferential effusion RV scalloping Diastolic collapse Swinging heart CCW rotational movement Case 3 12 yo M restrained passenger, MVC HR 140 RR 62 Pulse ox 90% RA Exam: dyspneic, diaphoretic, seat-belt sign Case 3 E of E-FAST Ocean Waves Beach Seashore

4 E of E-FAST Case 4 Ocean No Waves No Beach 7 yo M auto vs. pedestrian In the ED, became apneic, lost pulses CPR initiated, multiple doses of epinephrine and atropine; difficult to assess pulses Stratosphere or bar-code sign Case 4 Cardiac Activity Sonographic asystole Absence of ventricular contraction, M- mode PEA evaluation *32% w/cardiac contractions No pts w/cardiac standstill had ROSC 73% w/contractions had ROSC Prognosis; stop resuscitative efforts? *Salen, et al. Can cardiac sonography and capnography be used independently and in combination to predict resuscitation outcomes? Acad Emerg Med 8: , 2001

5 Case 5 14 yo F, walked into ED Flipped over handlebars of her bicycle Case 5 Currently no complaints Exam: no bruising, no abdominal tenderness E-FAST Pearls Is there free fluid in the abdomen/pericardium? Is there a pneumothorax? Be sure to fan through region of interest Trendelenburg improves sensitivity Repeat E-FAST scans Act on positive scans RENAL

6 Case 6 Case 6 26 yo F w flank pain, fever, emesis, gross hematuria T 40 C HR 126 BP 190/86 Exam: uncomfortable, diaphoretic, R CVA tenderness Urolithiasis Case 7 16 yo F w recurrent LUQ abdominal pain PMH: Frequent urinary tract infections Exam: marked LUQ, L CVA tenderness

7 Case 7 Case 8 3 yo M with difficulty urinating, no urination for 8 hrs PMH: frequent urinary tract infections T 40 HR 130 BP unable to obtain Exam: uncomfortable, ill-appearing, palpable bladder on exam, diffuse abdominal tenderness Case 8 Other Unexpected Findings

8 Renal/Bladder Pearls Hydronephrosis Renal/Bladder Pearls vs. prominent pyramids vs. cysts (peripheral, cortex) Noble V. et al. Manual of Emergency and Critical Care Ultrasound. Cambridge Press NY, NY Renal/Bladder Pearls Is there hydronephrosis? Is the bladder distended? Include bladder with renal assessment Be sure to scan kidneys in 2 planes Often discover unexpected findings: refer or obtain additional studies appropriately Aorta

9 Case 9 Case 9 69 yo M with acute onset of lower back pain T 38 HR 122 BP 80/40 Pulse ox 89% RA Exam: diffuse abdominal & lower lumbar tenderness, no palpable masses Case yo M, smoker, history of hypertension Intermittent exertional R shoulder pain x 1 yr Now with anterior chest pain radiating to the back, nausea T37 HR 112 BP 180/100 Exam: diaphoretic, tachypneic, diffuse abdominal tenderness Case 10

10 Aortic Dissection Tear in the wall of the aorta Bleeding into & along wall of the aorta Visualization of the intimal flap by ultrasound SN 67-80%, SP % Preferred examinations: spiral CT, TEE, MRI (nonemergent) R.P. Roudaut et al., Accuracy of M-mode 2-D echocardiography in the diagnosis of aortic dissection: an experience with 128 cases, Clin Cardiol 1988: Aorta Pearls Is the abdominal aorta >3 cm diameter? Are the iliac arteries >1.5 cm diameter? Gentle pressure to push away bowel gas Keep probe perpendicular to patient Measurements (from outer walls) Proximal, mid, distal, iliacs Transverse & longitudinal views Be sure to follow entire length of aorta Case 11 Gallbladder 40 yo F with recurrent abdominal pain, emesis Obese, uncomfortable T 40.2 HR 114 BP 130/90 Exam: diffuse abdominal tenderness with maximal epigastric, RUQ regions

11 Case 11 Case yo M w recurrent, severe epigastric pain T 40 HR 126 BP 140/90 Exam: obese, diaphoretic, uncomfortable, mild abdominal distension, RUQ Case 12 Gallbladder Sludge Lumen filled with echogenic debris Calcium bilirubinate, calcium crystals Usually associated with biliary stasis and/or cholecystitis

12 Case 13 Case yo F with abdominal pain, emesis T 37.8 HR 82 BP 110/76 Exam: mild discomfort, epigastric and RUQ tenderness Case 14 Case yo M episodic, recurrent epigastric pain No fevers, vomiting T 37.9 HR 90 BP 100/70 Exam: minimal epigastric region, no Murphy s sign

13 Normal Variants of Gallbladder Junctional folds Kinking or folding of the GB on itself, posterior wall Phrygian cap GB folds on junction of the fundus with the body Septa: partial or complete Case yo F with abdominal pain, vomiting T 37.2 HR 100 BP 180/90 Exam: obese, diffuse tenderness, +Murphy s sign Case 15 WES Sign Wall-Echo-Shadow (WES) 1. Visualization of GB wall 2. Echo of gallstone within GB 3. Posterior acoustic shadow caused by stone Gallstones within a contracted GB

14 Gallbladder Pearls Are there gallstones? Is there a sonographic Murphy s sign? Measurements CBD <7 mm Anterior GB wall <4 mm Look for pericholecystic fluid, stones, sludge WES (wall echo shadowing) sign: GB filled with stones Gallbladder Pearls Patient positioning can improve visualization (left side) Be familiar with normal variants Be wary of duodenum mimicking stones Summary Questions? US is a great extension of your examination Answers yes/no questions Fan through region of interest Obtain scans in 2 planes When in doubt, repeat scan or obtain further imaging Practice, practice, practice! Thank You!