Depressed ejection fraction, image from The POCUS Atlas

An 44 year-old male with no reported medical history (though limited access to medical care) presents with lower extremity swelling. He states that the symptoms have been gradually worsening over the past 3 months. He notes occasional fatigue while at work but denies chest pain, shortness of breath, leg pain or changes in urination.

A point-of-care ultrasound is performed showing decreased left ventricular ejection fraction. The patient was admitted for further evaluation and management of new-onset congestive heart failure.

Algorithm for the Evaluation of Lower Extremity Edema with Ultrasound

Gallery

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.

• DVT
• Cirrhosis
• Soft Tissue

Nodular liver contour, ascites

Ascites

Cobblestoning

Cobblestoning

Longitudinal view of a ruptured Baker cyst

References

1. Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. Am Fam Physician. 2013;88(2):102-110.
2. Goyal A, Cusick AS, Bhutta BS. Peripheral Edema. [Updated 2022 Nov 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554452/
3. Smith, C. Clinical manifestations and evaluation of edema in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed 2/11/2023.

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A 63 year-old male with a history of hypertension, tobacco use, and nephrolithiasis presents with left-sided flank pain. He notes sudden-onset approximately 4 hours prior to presentation and describes radiation to his groin. Pain was associated with nausea, denies hematuria and states pain is different compared to prior kidney stones. On evaluation, vital signs are notable for tachycardia (114bpm), blood pressure measured at 112/65mmHg. The patient appears uncomfortable and examination is notable for a pulsatile abdominal mass above the umbilicus.

ED Course

Normal

Abdominal Aortic Aneurysm

A point-of-care ultrasound is performed which shows no hydronephrosis and an 8cm infrarenal abdominal aortic aneurysm. Vascular surgery was consulted and a CTA was performed revealing ruptured abdominal aortic aneurysm. Uncrossmatched blood products were administered en route to the operating room due to hypotension.

Algorithm for the Evaluation of Flank Pain with Ultrasound

Gallery

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.

• Aorta
• Lung
• Renal
• Gallbladder

Normal

Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm

Dissection Flap

  View Gallery

Normal

Subpleural Consolidation

Pleural Effusion

Pneumothorax

  View Gallery   View Algorithm

Normal

Mild Hydronephrosis

Moderate Hydronephrosis

Severe Hydronephrosis

  View Gallery

Gallstones

Many gallstones

Gallbladder wall thickening

Pericholecystic fluid

Choledocholithiasis

Common bile duct dilation

  View Gallery   View Algorithm

References

1. Moore CL, Daniels B, Singh D, Luty S, Molinaro A. Prevalence and clinical importance of alternative causes of symptoms using a renal colic computed tomography protocol in patients with flank or back pain and absence of pyuria. Acad Emerg Med. 2013;20(5):470-478.
2. ​​Prince L.A., & Johnson G.A. (2020). Aneurysmal disease. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.),Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.
3. Bueschen AJ. Flank Pain. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 182. Available from: https://www.ncbi.nlm.nih.gov/books/NBK292/
4. Carter MR, Green BR. Renal calculi: emergency department diagnosis and treatment. Emerg Med Pract. 2011;13(7):1-17;
5. https://wikem.org/wiki/Abdominal_aortic_aneurysm

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Infographic: CT Chest Interpretation Full Size 1775 downloads 2 MB

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Examples

• Sample
• Answer

Click to view slideshow.

Circulation: Dissection

Stanford type A aortic dissection. Flap extends cranially into the common trunk of the innominate/left common carotid arteries and proximal right subclavian artery. Caudally, extends to the abdominal aorta below the level of the superior mesenteric artery.

• Sample
• Answer

Click to view slideshow.

Circulation: Penetrating Atherosclerotic Ulcer

Penetrating atherosclerotic ulcer of the ascending aorta with mediastinal hematoma and compression of the pulmonary artery.
Case courtesy of Dr Jens Christian Fischer, Radiopaedia.org. From the case rID: 12810

• Sample
• Answer

Click to view slideshow.

Circulation: Intramural Hematoma

Intramural hematoma surrounding aortic root and ascending aorta with small hemopericardium.
Case courtesy of Dr David Preston, Radiopaedia.org. From the case rID: 27746

• Sample
• Answer

Click to view slideshow.

Circulation: Filling Defects

Extensive bilateral pulmonary emboli involving nearly all branches distal to left/right main pulmonary arteries.

• Sample
• Answer

Click to view slideshow.

Circulation: Complications

Saddle pulmonary embolism with pulmonary artery dilation and flattening of the interventricular septum suggestive of right ventricular strain.

• Sample
• Answer

Breathing: Pleura

Pneumothorax

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Infographic: CT Cervical Spine Interpretation PDF 925 downloads 15.30 MB

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Infographic: CT Cervical Spine Interpretation Full Size 669 downloads 5.27 MB

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Examples

• Sample
• Answer

Alignment

Note the sharp angle of the anterior vertebral line and associated asymmetric widening of the interspinous space.

• Sample
• Answer

Articulations: Craniocervical

Powers ratio >0.9, increased basion-dens interval (BDI). Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org. From the case rID: 87570

• Sample
• Answer

Articulations: Facets

Facet dislocation. Case courtesy of RMH Core Conditions, Radiopaedia.org. From the case rID: 33851

• Sample
• Answer

Fractures: Primary

Vertebral body height variance, posterior longitudinal ligament malalignment. Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 6150

• Sample
• Answer

Fractures: Secondary

Prevertebral edema

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A 45 year-old female with a history of ureterolithiasis s/p bilateral percutaneous nephrostomies, hypertension and diabetes presents to the emergency department with flank pain and dysuria for two days. She noted that output from her right nephrostomy had diminished. On evaluation, her vital signs are notable for fever and tachycardia but are otherwise normal. Examination demonstrates right costovertebral angle tenderness to percussion. Drain sites appeared normal, without overlying erythema. Urinalyses from both nephrostomy collection bags were submitted. Computed tomography of the abdomen and pelvis was obtained to evaluate for nephrostomy malposition.

Hospital Course

The patient was treated with parenteral antibiotics based on prior culture data and was admitted to the intensive care unit with urology consultation and plan for interventional radiology percutaneous drainage. The patient underwent uncomplicated perinephric drain placement and nephrostomy exchange and was discharged on hospital day five to complete a course of oral antibiotics.

An Algorithm for the Evaluation and Management of Emphysematous Urinary Tract Infections

References

1. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987;83(1):149-154.
2. Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology. 1996;198(2):433-438. doi:10.1148/radiology.198.2.8596845.
3. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology. 1997;49(3):343-346. doi:10.1016/S0090-4295(96)00501-8.
4. Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. JURO. 1997;157(5):1569-1573.
5. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;160(6):797-805.
6. Roy C, Pfleger DD, Tuchmann CM, Lang HH, Saussine CC, Jacqmin D. Emphysematous pyelitis: findings in five patients. Radiology. 2001;218(3):647-650. doi:10.1148/radiology.218.3.r01fe14647.
7. Park BS, Lee S-J, Kim YW, Huh JS, Kim JI, Chang S-G. Outcome of nephrectomy and kidney-preserving procedures for the treatment of emphysematous pyelonephritis. Scand J Urol Nephrol. 2006;40(4):332-338. doi:10.1080/00365590600794902.
8. Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore). 2007;86(1):47-53. doi:10.1097/MD.0b013e3180307c3a.
9. Mokabberi R, Ravakhah K. Emphysematous urinary tract infections: diagnosis, treatment and survival (case review series). Am J Med Sci. 2007;333(2):111-116.
10. Yao J, Gutierrez OM, Reiser J. Emphysematous pyelonephritis. Kidney Int. 2007;71(5):462-465. doi:10.1038/sj.ki.5002001.
11. Thomas AA, Lane BR, Thomas AZ, Remer EM, Campbell SC, Shoskes DA. Emphysematous cystitis: a review of 135 cases. BJU Int. 2007;100(1):17-20. doi:10.1111/j.1464-410X.2007.06930.x.
12. Falagas ME, Alexiou VG, Giannopoulou KP, Siempos II. Risk factors for mortality in patients with emphysematous pyelonephritis: a meta-analysis. JURO. 2007;178(3 Pt 1):880–5–quiz1129. doi:10.1016/j.juro.2007.05.017.
13. Somani BK, Nabi G, Thorpe P, et al. Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review. J Urol. 2008;179(5):1844-1849. doi:10.1016/j.juro.2008.01.019.
14. Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A. Emphysematous pyelonephritis: outcome of conservative management. Urology. 2008;71(6):1007-1009. doi:10.1016/j.urology.2007.12.095.
15. Kapoor R, Muruganandham K, Gulia AK, et al. Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis. BJU Int. 2010;105(7):986-989. doi:10.1111/j.1464-410X.2009.08930.x.
16. Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int. 2011;107(9):1474-1478. doi:10.1111/j.1464-410X.2010.09660.x.
17. Lu Y-C, Chiang B-J, Pong Y-H, et al. Predictors of failure of conservative treatment among patients with emphysematous pyelonephritis. BMC Infect Dis. 2014;14(1):418. doi:10.1186/1471-2334-14-418.

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CT Abdomen/Pelvis Infographic PDF 2560 downloads 7.04 MB

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Intraocular foreign body

A middle-aged male with no past medical history presents with blurred vision. He reported that he was hammering while at work approximately 3 days prior to presentation and felt something enter his left eye. He denies eye pain, has noted some eye redness and increased tearing. Denies prior eye surgery or procedures. Physical examination demonstrates normal visual acuity, minimal left nasal conjunctival injection sparing the limbus, and an irregular left pupil that is minimally reactive. A no-pressure ocular ultrasound was performed and demonstrated a hyperechoic structure in the globe suggestive of foreign body which was confirmed on computed tomography of the orbit. The patient was taken to the operating room for removal.

Imaging

Algorithm for the Evaluation of Visual Complaints with Ocular Ultrasonography

Gallery

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.

Orbital Abscess

Lens dislocation

Retinal detachment

Vitreous hemorrhage

Posterior vitreous detachment

ONSD (increased)

Central retinal artery flow (normal)

Central retinal artery occlusion

Applications^1,2

Useful for the evaluation of intraocular processes:

• Retinal detachment
• Vitreous hemorrhage/detachment
• Intraocular foreign body
• Lens dislocation
• Retroorbital hemorrhage/abscess
• Retinal vascular processes (CRAO)

Augmentation of physical examination when limited due to facial swelling or trauma:

• Pupil size and reactivity
• Extraocular movements

ONSD

• Normal <5mm adults (>15yo)
• Normal <4.5mm children (1-15yo)
• Normal <4mm infants (<1yo)
• By convention, measurements of the optic nerve sheath diameter are made 3-mm posterior to the globe

Technique

• Apply Tegaderm, ensuring no air bubbles trapped
• Apply copious ultrasound gel
• Use no-pressure technique, anchoring hand against the patient’s forehead, nasal bridge or maxilla
• Probe indicator to the patient’s right for transverse views
• Probe indicator to the patient’s head for longitudinal views
• Start with medium gain then increase to identify subtle findings

Test Characteristics

Prospective observational study evaluating patients presenting with ocular trauma or acute vision complaints underwent ocular ultrasound. Ultrasound findings agreed with the confirmatory test: ophthalmology consultation or advanced imaging (usually computed tomography) in 60 of 61 cases³.

Specific Findings ^4,5

Retinal Detachment^6-9

Appears as a highly reflective membrane floating in the substance of the vitreous body, moves within vitreous body with eye movement. Remains anchored at the optic nerve and ora serrata.

Posterior Vitreous Detachment¹⁰

Both retinal detachments and posterior vitreous detachments show a linear hyperechoic line in the posterior chamber. However, posterior vitreous detachments are not tethered to the optic nerve and will appear to cross midline.

Vitreous Hemorrhage

Seen more easily with high-gain, enhanced by eye movements which demonstrate hyperechoic particles swirling around in the vitreous body.

Retrobulbar Hematoma

Identified by the presence of a hypoechoic structure posterior to the globe. Should prompt a measurement of intra-ocular pressure if simultaneous globe rupture is not suspected.

Lens Dislocation

Usually secondary to blunt trauma, lens displaced from normal position and appears as an echogenic ovoid structure floating freely in the vitreous or over the retina.

Globe Rupture

If the diagnosis of globe rupture is obvious, ultrasound should be avoided. However, the “no-pressure” technique described above likely does not significantly impact intra-ocular pressure and should be safe^11,12. Globe rupture can be identified by scleral buckling, anterior chamber collapse, or globe collapse/irregularities.

Optic Nerve Evaluation^13-18

Though not a direct assessment of ocular pathology, evaluation of the optic nerve sheath diameter (ONSD) serves as a reliable surrogate for elevated intracranial pressure – emulating fundoscopy for papilledema. See normal measurements and image acquisition above.

Intraocular Foreign Body

The preferred imaging modality for evaluation of intraocular foreign body is orbital computed tomography. Ultrasonographically, foreign bodies are typically hyperechoic.

Central Retinal Artery Occlusion^19,20

A more advanced technique, the addition of color Doppler over the central retinal artery may reveal decreased systolic amplitude and diastolic flow in embolic or thrombotic occlusion.

References

1. Kimberly HH, Stone MB. Chapter E5 – Emergency Ultrasound. Ninth Edition. Elsevier Inc.; 2018:e49-e66. doi:10.1016/B978-0-323-35479-0.00204-X.
2. Knoop KJ, Dennis WR. Ophthalmologic, Otolaryngologic, and Dental Procedures. Seventh Edition. Elsevier Inc.; 2019:1295–1337.e2. doi:10.1016/B978-0-323-35478-3.00062-2.
3. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Academic Emergency Medicine. 2002;9(8):791-799.
4. Roque PJ, Hatch N, Barr L, Wu TS. Bedside ocular ultrasound. Crit Care Clin. 2014;30(2):227–41–v. doi:10.1016/j.ccc.2013.10.007.
5. Kilker BA, Holst JM, Hoffmann B. Bedside ocular ultrasound in the emergency department. European Journal of Emergency Medicine. 2014;21(4):246-253. doi:10.1097/MEJ.0000000000000070.
6. Yoonessi R, Hussain A, Jang TB. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med. 2010;17(9):913-917. doi:10.1111/j.1553-2712.2010.00809.x.
7. Shinar Z, Chan L, Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med. 2011;40(1):53-57. doi:10.1016/j.jemermed.2009.06.001.
8. Chu HC, Chan MY, Chau CWJ, Wong CP, Chan HH, Wong TW. The use of ocular ultrasound for the diagnosis of retinal detachment in a local accident and emergency department. Hong Kong Journal of Emergency Medicine. 2017;24(6):263-267. doi:10.1177/1024907917735085.
9. Vrablik ME, Snead GR, Minnigan HJ, Kirschner JM, Emmett TW, Seupaul RA. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Ann Emerg Med. 2015;65(2):199–203.e1. doi:10.1016/j.annemergmed.2014.02.020.
10. Schott ML, Pierog JE, Williams SR. Pitfalls in the Use of Ocular Ultrasound for Evaluation of Acute Vision Loss. J Emerg Med. 2013;44(6):1136-1139. doi:10.1016/j.jemermed.2012.11.079.
11. Chandra A, Mastrovitch T, Ladner H, Ting V, Radeos MS, Samudre S. The utility of bedside ultrasound in the detection of a ruptured globe in a porcine model. West J Emerg Med. 2009;10(4):263-266.
12. Berg C, Doniger SJ, Zaia B, Williams SR. Change in intraocular pressure during point-of-care ultrasound. West J Emerg Med. 2015;16(2):263-268. doi:10.5811/westjem.2015.1.24150.
13. Tsung JW, Blaivas M, Cooper A, Levick NR. A rapid noninvasive method of detecting elevated intracranial pressure using bedside ocular ultrasound: application to 3 cases of head trauma in the pediatric emergency department. Pediatr Emerg Care. 2005;21(2):94-98.
14. Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath diameter with direct measurement of intracranial pressure. Acad Emerg Med. 2008;15(2):201-204. doi:10.1111/j.1553-2712.2007.00031.x.
15. Blaivas M, Theodoro D, Sierzenski PR. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Academic Emergency Medicine. 2003;10(4):376-381.
16. Moretti R, Pizzi B. Optic Nerve Ultrasound for Detection of Intracranial Hypertension in Intracranial Hemorrhage Patients. Journal of Neurosurgical Anesthesiology. 2009;21(1):16-20. doi:10.1097/ANA.0b013e318185996a.
17. Rajajee V, Vanaman M, Fletcher JJ, Jacobs TL. Optic Nerve Ultrasound for the Detection of Raised Intracranial Pressure. Neurocrit Care. 2011;15(3):506-515. doi:10.1007/s12028-011-9606-8.
18. Major R, al-Salim W. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3. Ultrasound of optic nerve sheath to evaluate intracranial pressure. Emerg Med J. 2008;25(11):766-767. doi:10.1136/emj.2008.066845.
19. Riccardi A, Siniscalchi C, Lerza R. Embolic Central Retinal Artery Occlusion Detected with Point-of-care Ultrasonography in the Emergency Department. J Emerg Med. 2016;50(4):e183-e185. doi:10.1016/j.jemermed.2015.12.022.
20. Catalin J Dragos, Jianu S Nina, Munteanu M, Vlad D, Rosca C, Petrica L. Color Doppler imaging features in patients presenting central retinal artery occlusion with and without giant cell arteritis. VSP. 2016;73(4):397-401. doi:10.2298/VSP140814087C.

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A 43-year-old female with a history of hypertension, diabetes and obesity presents with right-upper quadrant abdominal pain for the past 1 week. The pain is characterized as burning, non-radiating, intermittent (with episodes lasting 10-30 minutes), resolving spontaneously and without apparent provoking features. She notes nausea but no vomiting, no changes in bowel or urinary habits. She similarly denies fevers, chest pain or shortness of breath. Vital signs were normal, and physical examination was notable only for right upper quadrant tenderness to palpation without rigidity or guarding.

An ECG demonstrates normal sinus rhythm, laboratory tests including liver function tests and lipase were normal and a bedside ultrasound of the right upper quadrant was performed demonstrating gallstones and a positive sonographic Murphy sign. The patient was diagnosed with acute cholecystitis, antibiotics were initiated, the patient was maintained NPO while general surgery was consulted.

Evaluation of Right-Upper Quadrant Abdominal Pain

The initial evaluation of a patient presenting with right-upper quadrant (or adjacent) abdominal pain typically includes laboratory tests such as a complete blood count, chemistry panel, liver function tests and serum lipase. In patients at risk for atypical presentations for an acute coronary syndrome or with other concerning symptoms, electrocardiography and cardiac enzymes may be indicated.

The differential diagnosis is broad. A systematic approach proceeds anatomically from superficial to deeper structures centered around the site of maximal pain.

Ultrasound in the Evaluation of Right Upper Quadrant Abdominal Pain

The diagnosis is unlikely to be made based on laboratory tests alone ¹. However, the addition of bedside ultrasound, particularly for the evaluation of gallbladder pathology, is both rapid and reliable ^2-8. The algorithm below provides a pathway for the incorporation of bedside ultrasound of the right upper quadrant in the evaluation of suspected gallbladder disease.

A normal-appearing gallbladder absent gallstones should prompt a traversal of the anatomic approach to the differential diagnosis detailed above. If gallstones are identified, the association with a positive sonographic Murphy sign is highly predictive of acute cholecystitis ^2,5,6,9. Acute cholecystitis may be associated with inflammatory gallbladder changes such as wall-thickening (>3mm) or pericholecystic fluid ^3,5,6,10-13. However, in the absence of cholelithiasis or a positive sonographic Murphy sign, these features are non-specific and may be the result of generalized edematous states such as congestive heart failure, renal failure, or hepatic failure and critically-ill patients may develop acalculous cholecystitis ^7,11,14. Finally, common bile duct dilation may be due to intra-luminal obstruction as in choledocholithiasis, luminal abnormalities such as strictures, or extra-luminal compression from masses or malignancy.  Dilation is generally described as a diameter >6mm – allowing an additional 1mm for every decade over 60 years-old as well as more vague accommodations for patients with prior cholecystectomy ^3,5,7,15.

Gallery

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.

Gallstones

Many gallstones

Gallbladder wall thickening

Pericholecystic fluid

Choledocholithiasis

Common bile duct dilation

References

1. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? JAMA. 2003;289(1):80-86.
2. Scruggs W, Fox JC, Potts B, et al. Accuracy of ED Bedside Ultrasound for Identification of gallstones: retrospective analysis of 575 studies. West J Emerg Med. 2008;9(1):1-5.
3. Ross M, Brown M, McLaughlin K, et al. Emergency physician-performed ultrasound to diagnose cholelithiasis: a systematic review. Acad Emerg Med. 2011;18(3):227-235. doi:10.1111/j.1553-2712.2011.01012.x.
4. Jang T, Chauhan V, Cundiff C, Kaji AH. Assessment of emergency physician-performed ultrasound in evaluating nonspecific abdominal pain. Am J Emerg Med. 2014;32(5):457-460. doi:10.1016/j.ajem.2014.01.004.
5. Kendall JL, Shimp RJ. Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg Med. 2001;21(1):7-13.
6. Summers SM, Scruggs W, Menchine MD, et al. A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med. 2010;56(2):114-122. doi:10.1016/j.annemergmed.2010.01.014.
7. Rubens DJ. Ultrasound Imaging of the Biliary Tract. Ultrasound Clinics. 2007;2(3):391-413. doi:10.1016/j.cult.2007.08.007.
8. Rosen CL, Brown DF, Chang Y, et al. Ultrasonography by emergency physicians in patients with suspected cholecystitis. American Journal of Emergency Medicine. 2001;19(1):32-36. doi:10.1053/ajem.2001.20028.
9. Shea JA. Revised Estimates of Diagnostic Test Sensitivity and Specificity in Suspected Biliary Tract Disease. Arch Intern Med. 1994;154(22):2573-2581. doi:10.1001/archinte.1994.00420220069008.
10. Miller AH, Pepe PE, Brockman CR, Delaney KA. ED ultrasound in hepatobiliary disease. J Emerg Med. 2006;30(1):69-74. doi:10.1016/j.jemermed.2005.03.017.
11. Shah K, Wolfe RE. Hepatobiliary ultrasound. Emergency Medicine Clinics of NA. 2004;22(3):661–73–viii. doi:10.1016/j.emc.2004.04.015.
12. Matcuk GR, Grant EG, Ralls PW. Ultrasound measurements of the bile ducts and gallbladder: normal ranges and effects of age, sex, cholecystectomy, and pathologic states. Ultrasound Q. 2014;30(1):41-48. doi:10.1097/RUQ.0b013e3182a80c98.
13. Engel JM, Deitch EA, Sikkema W. Gallbladder wall thickness: sonographic accuracy and relation to disease. American Journal of Roentgenology. 1980;134(5):907-909. doi:10.2214/ajr.134.5.907.
14. Gerstenmaier JF, Hoang KN, Gibson RN. Contrast-enhanced ultrasound in gallbladder disease: a pictorial review. Abdom Radiol (NY). 2016;41(8):1640-1652. doi:10.1007/s00261-016-0729-4.
15. Becker BA, Chin E, Mervis E, Anderson CL, Oshita MH, Fox JC. Emergency biliary sonography: utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis. J Emerg Med. 2014;46(1):54-60. doi:10.1016/j.jemermed.2013.03.024.

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A 27 year-old female is brought in by ambulance with syncope. Pre-hospital providers report that the patient developed pelvic pain, vaginal bleeding and lost consciousness. On their arrival, her blood pressure was 80mmHg systolic, point-of-care glucose was normal – a peripheral IV was started, fluids were administered and the patient was transported to the emergency department. On arrival, vital signs were notable for tachycardia and hypotension. The patient was lethargic, maintaining arousal only with constant verbal or noxious stimulation. Her abdomen was markedly tender throughout with rebound and involuntary guarding. Her last menstrual period was 5 weeks ago and she suspected that she was pregnant. Peripheral venous access was expanded and uncrossmatched blood products were rapidly transfused. Whole blood on a point-of-care pregnancy test was positive¹, and a bedside FAST demonstrated free intraperitoneal fluid in the hepatorenal recess with large free pelvic fluid. Gynecology was consulted for emergent operative management of suspected ruptured ectopic pregnancy with hemorrhagic shock and the patient was taken to the operating room.

Algorithm for the Evaluation of Suspected Ectopic Pregnancy

Gallery

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.

Ruptured Cornual Ectopic

Tubal Ectopic Pregnancy

Ectopic Pregnancy

Positive FAST in Ruptured Ectopic

The evaluation of suspected ectopic pregnancy, as with all complaints in the emergency department, begins with an assessment of patient stability: airway, breathing and circulation. The unstable patient requires immediate interventions to secure each critical component, all temporizing measures until the patient can be taken to the operating room for definitive management.

The evaluation and management algorithm for stable patients is dependent on findings of transabdominal & transvaginal ultrasonography, quantitative hCG level (relative to the institution-dependent discriminatory zone), and the identification of high risk historical and examination features that would prompt specialist consultation despite otherwise benign diagnostic tests.

If ultrasonography demonstrates a definite ectopic pregnancy (extrauterine live embryo,  adnexal mass containing yolk sac), gynecology consultation is warranted – the table below details candidates for attempts at pharmacologic therapy.

Requirements for methotrexate administration^2,3

Absolute

Hemodynamic stability

Ultrasound findings consistent with an ectopic pregnancy

Willingness of the patient to adhere to close follow-up

No existing organ dysfunction: hepatic, renal, pulmonary, hematologic, immune

Relative

Unruptured ectopic mass <3.5cm

No fetal cardiac activity detected

hCG <5000 mIU/L

If an intrauterine pregnancy is identified such as a live embryo or yolk sac, barring the presence of risk factors for heterotopic pregnancy (namely, the use of assisted fertilization methods ^{2, 4-6}), then an alternative cause for the patient’s symptoms should be sought.

If the ultrasound is non-diagnostic, patients should be stratified according to risk based on historical features, examination findings and quantitative hCG. If the hCG is above the institutional discriminatory zone, the absence of a definitive IUP is concerning, elevating suspicion for a non-visualized ectopic and warrants gynecology consultation. If the hCG is below the discriminatory zone, then certain features such as the presence of abdominal, adnexal or cervical motion tenderness, or high-risk ultrasonographic features including greater-than-moderate free pelvic fluid, complex fluid, or complex adnexal masses may be secondary features of ectopic pregnancy – again warranting consultation. If no high-risk features are present, close follow-up with repeat hCG and ultrasonography is reasonable.

Algorithm for the Evaluation of Vaginal Bleeding

References:

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