Ultrasound in Dyspnea

Brief H&P:

A 68 year-old male with a history of hypertension, diabetes, hyperlipidemia, chronic obstructive pulmonary disease and congestive heart failure (CHF) with depressed ejection fraction presents via ambulance with a chief complaint of shortness of breath. EMS reports that the patient was tachypneic and saturating 80% on ambient air on their arrival. En route, he received nebulized albuterol, nitroglycerin and was started on non-invasive positive pressure ventilation (NI-PPV).

On arrival, he remains uncomfortable-appearing with a respiratory rate of 35 breaths/min and accessory muscle use. His heart rate is 136bpm, blood pressure is 118/85mmHg, and he is saturating 95% on an FiO2 of 100%. Attempts to obtain a history are limited due to difficulty comprehending his responses with the PPV mask on, and prompt desaturation with it off. Lung auscultation is similarly challenging due to ambient and transmitted sounds, although basilar crackles and diffuse expiratory wheezing are appreciated. Cardiovascular examination reveals a rapid and irregularly irregular rhythm. Assessment of jugular venous distension is limited due to the patient’s body habitus and the presence of mask straps around the patient’s neck. Lower extremities demonstrate 2+ pitting edema, symmetric bilaterally. Intravenous access is established and laboratory tests are sent. The ECG technician and portable chest x-ray are called.

The case presentation above demonstrates a common emergency department scenario: a critically-ill patient with undifferentiated dyspnea. Specifically, the scenario reveals a situation where the physical examination is either obfuscated by technical challenges or otherwise indeterminate. The patient is at risk for deterioration and targeted intervention is mandatory. If a COPD exacerbation is assumed, additional nebulized breathing treatments are indicated – a potentially costly jolt of beta agonists if the patient’s atrial fibrillation and rapid ventricular response are the consequence of decompensated systolic heart failure. Take the route of decompensated CHF and prompt afterload reduction with diuresis would be next – if incorrect, not only would the primary cause go untreated, but his tenuously-maintained blood pressure may suffer.

Algorithm for the Use of Ultrasound in the Evaluation of Dyspnea

Algorithm for the Use of Ultrasound in the Evaluation of Dyspnea

1. Lung Ultrasound

An approach incorporating point-of-care ultrasonography may be useful. First, a thoracic ultrasound is performed where certain causative etiologies might be identified immediately – for example absent lung sliding suggesting pneumothorax, or signs of generalized or subpleural consolidation.

The POCUS Atlas
The ultrasound images and videos used in this post come from The POCUS Atlas, a collaborative collection focusing on rare, exotic and perfectly captured ultrasound images.
The POCUS Atlas

Pneumothorax

Hepatization

Shred Sign

Pleural Effusion

2. Cardiac Ultrasound

Other findings on lung ultrasound may point to causes that are not primarily pulmonary. For example, if diffuse B-lines are encountered a focused cardiac ultrasound can be performed to grossly evaluate ejection fraction and estimate right atrial pressure.

B-Lines

Depressed EF

Dilated IVC

3. Venous Ultrasound

Finally, if the lung ultrasound is largely unremarkable (A-lines), a sequence of ultrasonographic findings including right ventricular dilation and the presence of a deep venous thrombosis would point to pulmonary embolism as the diagnosis.

DVT

RV Dilation

All ultrasound graphics from the algorithm are available for free, licensed (along with all content on this site) under Creative Commons Attribution-ShareAlike 4.0 International Public License.

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References

  1. Lichtenstein DA, Mezière GA, Lagoueyte J-F, Biderman P, Goldstein I, Gepner A. A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Chest. 2009;136(4):1014-1020. doi:10.1378/chest.09-0001.
  2. Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound. 2008;6(1):16. doi:10.1186/1476-7120-6-16.
  3. Gallard E, Redonnet J-P, Bourcier J-E, et al. Diagnostic performance of cardiopulmonary ultrasound performed by the emergency physician in the management of acute dyspnea. Am J Emerg Med. 2015;33(3):352-358. doi:10.1016/j.ajem.2014.12.003.
  4. Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care. 2014;4(1):1. doi:10.1186/2110-5820-4-1.
  5. Zanobetti M, Scorpiniti M, Gigli C, et al. Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED. Chest. 2017;151(6):1295-1301. doi:10.1016/j.chest.2017.02.003.
  6. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. doi:10.1378/chest.07-2800.
  7. Images from The POCUS Atlas
  8. Special thanks to Dr. Timothy Jang, Director Emergency Ultrasound Program, Director Emergency Ultrasound Fellowship, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine at Harbor-UCLA

CT Interpretation: Head

The emergency physician should be adept at the interpretation of computed tomography of the head, particularly for life-threatening processes where awaiting a radiologist interpretation may unnecessarily delay care.

As with the approach detailed previously for imaging of the abdomen and pelvis, a similar structured method for interpretation of head imaging exists and follows the mnemonic “Blood Can Be Very Bad”.

Normal Neuroanatomy

Brainstem
Posterior Fossa
High Pons
Cisterns
Ventricles

Blood: Blood

Density
Acute: hyperdense (50-100HU)
1-2wks: isodense with brain
2-3wks: hypodense with brain

Types/Locations

Intraparenchymal Hemorrhage/Contusions
Sudden deceleration of the head causes the brain to impact on bony prominences (e.g., temporal, frontal, occipital poles).
Non-traumatic hemorrhagic lesions seen more frequently in elderly and located in basal ganglia.
Intraventricular Hemorrhage
White density in otherwise black ventricular spaces, can lead to obstructive hydrocephalus and elevated ICP.
Associated with worse prognosis in trauma.
Subarachnoid Hemorrhage
Hemorrhage into subarachnoid space usually filled with CSF (cistern, brain convexity).
Extracranial Hemorrhage
Presence of significant extracranial blood or soft-tissue swelling should point examiner to evaluation of underlying brain parenchyma, opposing brain parenchyma (for contrecoup injuries) and underlying bone for identification of fractures.

Can: Cisterns


Evaluating the cisterns is important for the identification of increased intracranial pressures (assessed by effacement of spaces) and presence of subarachnoid blood.

  • Circummesencephalic: CSF ring around midbrain and most sensitive marker for elevated ICP
  • Suprasellar: Star-shaped space above the sella
  • Quadrigeminal: W-shaped space at the top of the midbrain
  • Sylvian: Bilateral space between temporal/frontal lobes

Be: Brain

Evaluate the brain parenchyma, including an assessment of symmetry of the gyri/sulci pattern, midline shift, and a clear gray-white differentiation.

Very: Ventricles

Evaluate the ventricles for dilation or compression. Compare the ventricle size to the size of cisterns, large ventricles with normal/compressed cisterns and sulcal spaces suggests obstruction.

Bad: Bone

Switch to bone windows to evaluate for fracture. The identification of small, linear, non-depressed skull fractures may be difficult to identify as they are often confused with sutures – surrogates include pneumocephalus, and abnormal aeration of mastoid air cells and sinuses. The Presence of fractures increases the suspicion for intracranial injury, search adjacent and opposing parenchyma and extra-axial spaces.

Example #1

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CT Head Interpretation

  • Ill-defined lesion in right parietal white matter with a large amount of surrounding vasogenic edema with midline shift and right uncal herniation.
  • Acute on subacute right extra-axial subdural hematoma.
  • Effacement of basilar cisterns.

Example #2

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CT Head Interpretation

  • Bilateral subacute subdural hematomas, left larger than right and associated with rightward midline shift.
  • Left lateral ventricle is partially effaced.

Example #3

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CT Head Interpretation

Subdural hematoma with significant herniation

References

  1. Perron A. How to read a head CT scan. Emergency Medicine. 2008.
  2. Arhami Dolatabadi A, Baratloo A, Rouhipour A, et al. Interpretation of Computed Tomography of the Head: Emergency Physicians versus Radiologists. Trauma Mon. 2013;18(2):86–89. doi:10.5812/traumamon.12023.

CT Interpretation: Abdomen/Pelvis

As with the systematic approach preferred for the evaluation and management of other processes explored on this site, a similarly structured method for the interpretation of imaging commonly obtained in the emergency department may afford the same benefits – namely, the timely identification of pathology while avoiding costly missed diagnoses. In this post, I propose an approach to the interpretation of computed tomography of the abdomen and pelvis.

Aorta Down

Thoracic Aorta

Thoracic Aorta

Start with the descending thoracic aorta

Abdominal Aorta

Abdominal Aorta

Follow the abdominal aorta down including its branches (celiac, SMA, paired renal arteries, IMA)

Aortic Bifurcation

Aortic Bifurcation

Continue to the bifurcation of the abdominal aorta to the left and right common iliac arteries

Veins Up

Femoral Veins

Femoral Veins

Start with the left and right femoral veins

Inferior Vena Cava

Inferior Vena Cava

Follow the inferior vena cava up

Infrahepatic IVC

Infrahepatic IVC

The inferior vena cava gains contrast from the renal veins

Right Atrium

Right Atrium

The inferior vena cava empties into the right atrium

Solid Organs Down

Heart and Pericardium

Heart and Pericardium

Evaluate for the presence of a pericardial effusion or cardiomegaly

Spleen

Spleen

Heterogenous contrast-enhancement is normal

Pancreas

Pancreas

The tail of the pancreas lies in the hilum of the spleen

Liver

Liver

Evaluate the intrahepatic bile ducts for dilation or pneumobilia, portal venous system for gas, and liver parenchyma for vascular abnormalities or abscesses

Gallbladder

Gallbladder

Evaluate for radioopaque stones, pericholecystic fluid or surrounding fat stranding

Adrenal

Adrenal

A wishbone-shaped structure superior to the kidneys

Kidney and Ureter

Kidney and Ureter

Evaluate for hydronephrosis or hydroureter

Bladder

Bladder

Continue down into the pelvis; in a female patient the evaluation should include the uterus and adnexa

Rectum Up

Rectum

Rectum

Having reached the inferior-most portion of the image following solid organs, move upward again from the rectum

Sigmoid

Sigmoid

Evaluate the sigmoid colon for diverticulitis

Transverse

Transverse

Continue following the sigmoid colon up the descending colon to the transverse colon and the hepatic flexure

Cecum

Cecum

Continue down the ascending colon to the cecum

Appendix

Appendix

At the cecum, attempt to identify a small tubular structure (the appendix) - evaluate for periappendiceal fat stranding, perforation or abscess

Esophagus Down

Esophagus

Esophagus

Start at the esophagus, evaluate for perforation or hernia

Stomach

Stomach

Continue to the stomach and duodenum

Small Bowel

Small Bowel

Evaluate the small bowel for obstruction (dilation, air-fluid levels)

Tissue-specific Windows

Lung Window

Lung Window

Switch to lung window to evaluate the lung parenchyma and continue through the abdomen to identify intraperitoneal free air

Bone Window

Bone Window

Use the bone window to identify fractures or lytic lesions

Try It Yourself

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CT Abdomen/Pelvis Interpretation

  • Cystic lesion in the inferior right lobe of the liver most consistent with hepatic abscess.
  • Multiple calcified gallstones in the gallbladder.

Hypotension

Brief H&P:

A 50 year-old male with a history of colonic mucinous adenocarcinoma on chemotherapy presented with a chief complaint of “vomiting”. He was unwilling to provide further history, repeating that he had vomited blood prior to presentation. His initial vital signs were notable for tachycardia. Physical examination showed some dried vomitus, brown in color, at the nares and lips; left upper quadrant abdominal tenderness to palpation; and guaiac-positive stool. Point-of-care hemoglobin was 3g/dL below the most recent measure two months prior. As his evaluation progressed, he developed hypotension and was transfused two units of uncrossmatched blood with adequate blood pressure response – he was started empirically on broad-spectrum antibiotics for an intra-abdominal source. Notable laboratory findings included a normal hemoglobin/hematocrit, acute kidney injury, and elevated anion gap metabolic acidosis presumably attributable to serum lactate of 10.7mmol/L. Computed tomography of the abdomen and pelvis demonstrated pneumoperitoneum with complex ascites concerning for bowel perforation. The patient deteriorated, was intubated, started on vasopressors and admitted to the surgical intensive care unit. The initial operative report noted extensive adhesions and perforated small bowel with feculent peritonitis. He has since undergone multiple further abdominal surgeries and remains critically ill.

Imaging

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CT Abdomen/Pelvis

Free air is seen diffusely in the non-dependent portions of the abdomen: in the anterior abdomen and pelvis, inferior to the diaphragm, and in the perisplenic region. There is complex free fluid in the abdomen.

Algorithm for the Evaluation of Hypotension1

This process for the evaluation of hypotension in the emergency department was developed by Dr. Ravi Morchi. In the case above, a systematic approach to the evaluation of hypotension using ultrasonography and appropriately detailed physical examination may have expedited the patient’s care. The expertly-designed algorithm traverses the cardiovascular system, halting at evaluable checkpoints that may contribute to hypotension.

  1. The process begins with the cardiac conduction system to identify malignant dysrhythmias (bradycardia, or non-sinus tachycardia >170bpm), which, in unstable patients are managed with electricity.
  2. The next step assesses intravascular volume with physical examination or bedside ultrasonography of the inferior vena cava. Decreased right atrial pressure (whether due to hypovolemia, hemorrhage, or a distributive process) is evidenced by a small and collapsible IVC. If hemorrhage is suspected, further ultrasonography with FAST and evaluation of the abdominal aorta may identify intra- or retroperitoneal bleeding.
  3. If a normal or elevated right atrial pressure is identified, evaluate for dissociation between the RAP and left ventricular end-diastolic volume. This is typically caused by a pre- or intra-pulmonary obstructive process such as tension pneumothorax, cardiac tamponade, massive pulmonary embolism, pulmonary hypertension, or elevated intra-thoracic pressures secondary to air-trapping. Thoracic ultrasonography can identify pneumothorax, pericardial effusion, or signs of elevated right ventricular systolic pressures (RV:LV, septal flattening).
  4. Assuming adequate intra-vascular volume is arriving at the left ventricle, rapid echocardiography can be used to provide a gross estimate of cardiac contractility and point to a cardiogenic process. If there is no obvious pump failure, auscultation may reveal murmurs that would suggest systolic output is refluxing to lower-resistance routes (ex. mitral insufficiency, aortic insufficiency, or ventricular septal defect).
  5. Finally, if the heart rate is suitable, volume deficits are not grossly at fault, no obstructive process is suspected, and cardiac contractility is adequate and directed appropriately through the vascular tree, the cause may be distributive. Physical examination may reveal dilated capillary beds and low systemic vascular resistance.

Algorithm for the Evaluation of Hypotension

References

  1. Morchi R. Diagnosis Deconstructed: Solving Hypotension in 30 Seconds. Emergency Medicine News. 2015.

Aortic Dissection

Imaging

Prominent cardiomediastinal silhouette, which may be due to patient position.

Prominent cardiomediastinal silhouette, which may be due to patient position.

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CT Angiography Aorta

Highly complex type B aortic dissection originating at the distal arch (just distal to the left subclavian artery) and terminating at the level of diaphragm. The dissection contains multiple false lumens containing blood products of differing ages (thrombus and contrast-opacified blood). No apparent involvement of the left common carotid or left subclavian artery.

Mediastinum Anatomy

Mediastinal Masses

Anterior
Retrosternal goiter
Thymoma
Germ-cell tumor
Lymphadenopathy (lymphoma)
Middle
Aortic arch aneurysm
Dilated pulmonary artery
Tracheal lesion
Posterior
Esophageal lesions
Hiatal hernia
Descending aortic aneurysm
Paraspinal abscess

References:

  1. Faiz, O., & Moffat, D. (2002). Anatomy at a glance. Malden, MA: Blackwell Science.
  2. Whitten CR, Khan S, Munneke GJ, Grubnic S. A diagnostic approach to mediastinal abnormalities. Radiographics. 2007;27(3):657–671. doi:10.1148/rg.273065136.
  3. WikEM: Widened mediastinum

Ultrasound Gallery

Appendicitis

Appendicitis

Non-compressible tubular structure in the RLQ of a patient with focal abdominal tenderness. >6mm in diameter.

Common Bile Duct

Common Bile Duct

A tubular structure typically anterior to the portal vein without flow. Normally measures <4mm, increases by 1mm per decade after 40yrs.

Cellulitis

Cellulitis

"Cobblestone" appearance of soft tissue suggesting infection/edema.

Fetal Heart Rate

Fetal Heart Rate

Placing the M-Mode marker over the most visibly active portion of the fetal heart allows for measurement of the fetal heart rate.

Free Fluid

Free Fluid

Free fluid in the hepatorenal recess.

Hydronephrosis

Hydronephrosis

Severe hydronephrosis.

Thoracic Aorta Aneurysm

Thoracic Aorta Aneurysm

Subxiphoid view of thoracic aorta, markedly dilated (>3cm) with thrombus.

Pericardial Effusion

Pericardial Effusion

Mild pericardial effusion in a patient with pleuritic chest pain.

Inferior Vena Cava

Inferior Vena Cava

IVC without significant respiratory variation.

B-lines

B-lines

B-lines extending deep from pleura suggestive of interstitial fluid accumulation (pulmonary edema).

"Shred" sign

"Shred" sign

Irregular, "shredded" pleural line suggestive of consolidation.

Pneumothorax

Pneumothorax

Transition point with loss of lung sliding in a patient with a small spontaneous pneumothorax.

Volvulus


Swirling mesenteric vessels in mid-pelvis associated with narrowed segments of small bowel and fluid-filled proximal small bowel raises concern for volvulus and small bowel obstruction.

Head Trauma: Radiographic Evolution

CT Head (Initial)

CT Head (Initial)

- Noncontrast axial images through the head demonstrate no evidence of skull fracture.
- Large lentiform-shaped mixed density extra-axial acute epidural hematoma in the right parietal occipital
- Associated subdural hematoma tracking along right convexity toward the right temporal lobe.
- There is no evidence of midline shift.

CT Head (+8h)

CT Head (+8h)

- Significant interval increase in the size of the right hemispheric subdural hematoma
- There is now midline shift from right to left at the level of the septum pellucidum measuring 10 mm, partial effacement of the right lateral ventricle and subfalcial herniation.
- Scattered subarachnoid blood is redemonstrated.
- Comminuted fractures of the nasal bone are present and there is overlying and associated periorbital soft tissue swelling.

CT Head (+16h, s/p SDH evacuation)

CT Head (+16h, s/p SDH evacuation)

- Interval gross total evacuation of right hemispheric subdural hematoma.
- Moderate anterior bifrontal subdural and right epidural air is present.
- Small scattered subarachnoid and intraventricular blood is redemonstrated.

Elevated Hemidiaphragm

CXR - PA
CXR - Lateral

Causes of an Elevated Hemidiaphragm

Causes of an elevated hemidiaphragm

References:

  1. Lavender, JP, Potts DG (1959). Differential diagnosis of elevated right diaphragmatic dome. The British journal of radiology, 32(373), 56–60.
  2. Nason, L. K., Walker, C. M., McNeeley, M. F., Burivong, W., Fligner, C. L., & Godwin, J. D. (2012). Imaging of the diaphragm: anatomy and function. Radiographics : a review publication of the Radiological Society of North America, 32(2), E51–70. doi:10.1148/rg.322115127
  3. Prokesch, R. W., Schima, W., & Herold, C. J. (1999). Transient elevation of the hemidiaphragm. The British journal of radiology, 72(859), 723–724.
  4. Burgener, F., Kormano, M. & Pudas, T. (2008). Differential diagnosis in conventional radiology. Stuttgart New York: Thieme.