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
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.
Nodular liver contour, ascites
Longitudinal view of a ruptured Baker cyst
- Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. Am Fam Physician. 2013;88(2):102-110.
- 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/
- 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.
This algorithm was developed by Dr. Huakang Huang. Huakang is an emergency medicine resident at UTHealth Houston.
A 28 year-old female with a history of systemic lupus erythematosus and end-stage renal disease without access to scheduled hemodialysis presents to the emergency department with 1 week of worsening dyspnea, fatigue and leg swelling. Her symptoms are reminiscent of prior episodes resolving with hemodialysis. On evaluation, vital signs are normal and laboratory tests demonstrate microcytic anemia (Hb 5.9g/dL) but no hyperkalemia. A plain chest radiograph is normal and the patient ambulates without hypoxia.
The patient was deemed to not meet any requirements for emergent hemodialysis. One unit of packed red blood cells was ordered for transfusion for symptomatic anemia. During transfusion, the patient developed worsening dyspnea and was found to be hypertensive and hypoxic. A chest radiograph was obtained and is shown below.
Pulmonary vascular congestion and bilateral pleural effusions.
The transfusion was discontinued, the patient was placed on non-invasive positive pressure ventilation, and emergent hemodialysis was initiated with subsequent resolution of presumed transfusion associated circulatory overload.
Algorithm for the Evaluation and Management of Transfusion Reactions
This algorithm was developed by Dr. Eric Madden, chief resident in emergency medicine at McGovern Med EM.
- Carson JL, Triulzi DJ, Ness PM. Indications for and Adverse Effects of Red-Cell Transfusion. N Engl J Med. 2017;377(13):1261-1272. doi:10.1056/NEJMra1612789.
- Delaney M, Wendel S, Bercovitz RS, et al. Transfusion reactions: prevention, diagnosis, and treatment. Lancet. 2016;388(10061):2825-2836. doi:10.1016/S0140-6736(15)01313-6.
- Goel R, Tobian AAR, Shaz BH. Noninfectious transfusion-associated adverse events and their mitigation strategies. Blood. 2019;133(17):1831-1839. doi:10.1182/blood-2018-10-833988.
- Osterman JL, Arora S. Blood product transfusions and reactions. Emerg Med Clin North Am. 2014;32(3):727-738. doi:10.1016/j.emc.2014.04.012.
- Silvergleid AJ. Approach to the patient with a suspected acute transfusion reaction. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on September 01, 2019.)
- Suddock JT, Crookston KP. Transfusion Reactions. January 2019.
51 year-old male with a history of HTN, DM and chronic alcohol abuse presenting with lower extremity swelling. He notes one month of progressive, bilateral lower extremity swelling, in the past two weeks associated with increasing pain and redness and is now no longer able to ambulate due to pain. He denies fevers/chills, chest pain or shortness of breath. He also denies orthopnea and paroxysmal nocturnal dyspnea. He states that he has not had these symptoms prior to one month ago. On review of systems he denies nausea/vomiting, abdominal pain, and changes in bowel or urinary habits. He has a history of GI bleeding (unknown treatment) but denies hematemesis, hematochezia or melena. He has previously experienced alcohol withdrawal, which manifested as tremors, but no hallucinations or seizures.
- Chronic EtOH abuse
- Drinks 1-2 pints of alcohol daily, last drink this morning.
- Denies current tobacco or drug abuse, no prior IVDA.
||Adult, non-obese male, lying in bed. Tremors noted in upper extremities.
||PERRL, EOMI, no scleral icterus. Mucous membranes moist.
||RRR, normal S1/S2, no additional heart sounds, JVP 3cm above sternal angle at 30°.
||CTAB, no crackles.
||Soft, non-distended, with normoactive bowel sounds. Liver edge palpated 1cm below costal margin at mid-clavicular line, non-tender. No rebound/guarding.
||Warm, well-perfused with 2+ distal pulses (PT, DP). 3+ pitting edema symmetric in bilateral lower extremities to knee. Erythema and warmth bilaterally extending from ankles to mid-shin. Mild tenderness to palpation. No pain with passive dorsiflexion. 3x3cm shallow ulceration below medial malleolus on right lower extremity without underlying fluctuance or expression of purulent material. No venous varicosities noted. Decreased sensation to light touch below knee bilaterally.
||Normal rectal tone, brown stool, guaiac negative.
||Alert and oriented, CN II-XII intact, gait intact, normal FTN/RAM.
- CBC: 7.4/13.1/39/180
- Creatinine: 0.84
- Albumin: 4.3
- BNP: 28
Venous Lower Extremity Ultrasound
- No DVT.
- Pulsatile flow in bilateral EIV (external iliac veins) suggestive of elevated right heart pressure.
51M with HTN, DM, EtOH abuse presenting with lower extremity edema. Chronic bilateral lower extremity edema likely secondary to chronic venous insufficiency perhaps related to OSA given ultrasound findings of pulsatile flow in EIV’s. Doubt systemic cause: no evidence of heart failure on exam and normal BNP, no stigmata of cirrhosis and normal albumin, normal creatinine. Also, no evidence of DVT on ultrasound though bilateral DVT unlikely. Bilateral cellulitis also unlikely as the patient is afebrile without leukocytosis, however the patient was started on antibiotics including ceftriaxone and TMP/SMX given erythema, warmth and tenderness to palpation. The patient received benzodiazepines which eased withdrawal symptoms and he was admitted for continued treatment.
Mechanisms of Lower Extremity Edema: 1
Differential Diagnosis of Lower Extremity Edema: 1,2
- Duration: acute (<72h) vs. chronic
- Pain: DVT, CRPS, less severe in venous insufficiency
- Systemic Disease
- Cardiac: orthopnea, PND
- Renal: proteinuria
- Hepatic: jaundice, ascites
- Malignancy: lymphedema
- Improvement with elevation/recumbency: venous insufficiency
- OSA: snoring, daytime somnolence
- Medications: B-blocker, CCB, hormones, NSAID’s
Physical Exam 1,2
- Distribution: unilateral, bilateral, generalized
- Quality: pitting, non-pitting
- TTP: DVT, cellulitis
- Varicose veins: venous insufficiency
- Kaposi-Stemmer: inability to pinch dorsum of foot at base of 2nd toe (lymphedema)
- Systemic Disease
- Cardiac: JVD, crackles
- Hepatic: ascites, scleral icterus, spider angiomas
- Brawny, medial maleolar involvement: venous insufficiency
Key Features Distinguishing Cellulitis: 3
- Typically unilateral and acute
- Often with systemic symptoms (fever, leukocytosis)
- Risk Factors: immunosuppression, previous episodes, DM, PVD
- Trayes, K. P., Studdiford, J. S., Pickle, S., & Tully, A. S. (2013). Edema: diagnosis and management. American family physician, 88(2), 102–110.
- Ely, J. W., Osheroff, J. A., Chambliss, M. L., & Ebell, M. H. (2006). Approach to leg edema of unclear etiology. Journal of the American Board of Family Medicine : JABFM, 19(2), 148–160.
- Keller, E. C., Tomecki, K. J., & Alraies, M. C. (2012). Distinguishing cellulitis from its mimics. Cleveland Clinic journal of medicine, 79(8), 547–552. doi:10.3949/ccjm.79a.11121
- WikEM: Pedal edema