{"id":2030,"date":"2014-12-28T20:19:07","date_gmt":"2014-12-29T01:19:07","guid":{"rendered":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/?page_id=2030"},"modified":"2016-02-05T14:40:03","modified_gmt":"2016-02-05T19:40:03","slug":"usom-dec-14-case","status":"publish","type":"page","link":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/program-welcome\/ultrasound\/ultrasound-of-the-month\/usom-dec-14-case\/","title":{"rendered":"USOM II"},"content":{"rendered":"<p>Case 1: A 32 y\/o M motorcyclist struck the side of a moving motor vehicle at high speed, was thrown 15 feet, and transiently lost consciousness per bystanders. \u00a0Prehospital vital signs were as follows: P: 120, BP: 100\/palpitation, SpO2: 95%, RR: 25, GCS 9\/15. \u00a0In the Emergency Department, the patient was A&amp;Ox3\u00a0with a GCS of 15 and labored respirations. \u00a0The patient reported left shoulder pain and shortness of breath.\u00a0 Initial ED vitals: HR 125, RR 25-30, SpO2 97% RA, blood pressure nonpalp by automated cuff, with no radial pulses and faint femoral pulses. \u00a0The patient&#8217;s airway was intact and b\/l breath sounds were present. \u00a0Providers noted mild anterior chest tenderness without ecchymosis or deformity. \u00a0A left shoulder joint dislocation was noted. \u00a0US performed:<\/p>\n<p><iframe loading=\"lazy\" width=\"500\" height=\"281\" src=\"\/\/player.vimeo.com\/video\/115067044?title=0&amp;byline=0&amp;portrait=0\" frameborder=\"0\" webkitallowfullscreen=\"webkitallowfullscreen\" mozallowfullscreen=\"mozallowfullscreen\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>What ultrasound exam was performed above and what are the significant findings?<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">Answer<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<p>The video demonstrates an eFAST (Expanded Focused Assessment with Sonography in Trauma). \u00a0This study incorporates both the abdominal FAST exam with a thoracic exam to evaluate for hemo- or pneumothorax. \u00a0The FAST in this case reveals hypoechoic fluid in the RUQ view (Morrison&#8217;s Pouch), which is the most sensitive view in a FAST to identify intraperitoneal fluid (#1).<br \/>\n<a href=\"\/emergencymedicine\/files\/2016\/01\/Fast2.png\"><img loading=\"lazy\" src=\"\/emergencymedicine\/files\/2016\/01\/Fast2.png\" alt=\"+Fast\" width=\"528\" height=\"455\" class=\"alignnone size-full wp-image-3638\" \/><\/a><\/p>\n<p><\/div>\n<\/div>\n<\/p>\n<p>How effective is the FAST exam? \u00a0What is the sensitivity and specificity?<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">Answer<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<p>The FAST is an integral component of a trauma evaluation and per ATLS protocol should be performed after the completion of the primary survey. \u00a0The FAST has variable sensitivities for the detection of intraperitoneal fluid (63-100%), but excellent specificity (95-100%). \u00a0Approximately ~500-600 cc of fluid is necessary to yield a positive exam (#2, #3).<\/p>\n<p>In the setting of blunt trauma, a positive FAST should elicit high suspicion for intraperitoneal bleeding. \u00a0If the FAST is negative, but the patient remains hypotensive or unstable, additional investigation is indicated (i.e. computed tomography or exploratory laparotomy).<\/p>\n<p><\/div>\n<\/div>\n<\/p>\n<p>Case 2: The same patient above presents to your trauma bay:<\/p>\n<p><iframe loading=\"lazy\" width=\"500\" height=\"281\" src=\"\/\/player.vimeo.com\/video\/115072893?title=0&amp;byline=0&amp;portrait=0\" frameborder=\"0\" webkitallowfullscreen=\"webkitallowfullscreen\" mozallowfullscreen=\"mozallowfullscreen\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>What is the finding on this EFAST? \u00a0How effective is ultrasound in detecting this pathology? <div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">Answer<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<p>This patient has a pneumothorax. \u00a0The hyperechoic linear line between the two rib shadows represents the pleura. \u00a0In the previous case, one observes sliding between the visceral and parietal pleuras, a normal finding. \u00a0The absence of lung sliding between pleural layers in this case reflects extrapulmonic air in the thorax, which is a pneumothorax. \u00a0Ultrasound has a higher sensitivity than CXR in detecting pneumothorax (98.1% vs. 75.5%; #4).<\/p>\n<p><a href=\"\/emergencymedicine\/files\/2016\/02\/PTX1.png\"><img loading=\"lazy\" src=\"\/emergencymedicine\/files\/2016\/02\/PTX1.png\" alt=\"PTX\" width=\"365\" height=\"489\" class=\"alignnone size-full wp-image-3662\" \/><\/a><\/p>\n<p><\/div>\n<\/div>\n<\/p>\n<p>Case 3: Same motorcycle patient presents and the following ultrasound is performed:<\/p>\n<p><iframe loading=\"lazy\" width=\"500\" height=\"281\" src=\"\/\/player.vimeo.com\/video\/115076635?title=0&amp;byline=0&amp;portrait=0\" frameborder=\"0\" webkitallowfullscreen=\"webkitallowfullscreen\" mozallowfullscreen=\"mozallowfullscreen\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>What condition is seen on this eFAST?<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">Answer<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<p>Pericardial effusion with evidence of both clot and fresh hemopericardium.<br \/>\n<a href=\"\/emergencymedicine\/files\/2016\/01\/Fast1.png\"><img loading=\"lazy\" src=\"\/emergencymedicine\/files\/2016\/01\/Fast1.png\" alt=\"+Fast\" width=\"535\" height=\"432\" class=\"alignnone size-full wp-image-3636\" \/><\/a><\/p>\n<p><\/div>\n<\/div>\n<\/p>\n<p>What&#8217;s the epidemiology and mechanism of this type of injury?<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">Answer<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<p>Hemopericardium in blunt trauma is relatively rare and is generally due to rupture of a free wall of the heart (right atrium 8-65%, right ventricle 17-32%, left atrium 8-15%, left ventricle 0-31%; #5). \u00a0This injury carries a high mortality and only 5% of patients with blunt cardiac injury and hemodynamic instability survive to hospital admission (#6). \u00a0This injury typically results from massive anterior thoracic forces, such as those in a motor vehicle collision. \u00a0The injury mechanism often leads to a multi-system trauma in these patients and one may also observe other associated thoracic injuries such as sternal or rib fractures, pneumothorax, hemothorax, and pulmonary or cardiac contusions.<\/p>\n<p><\/div>\n<\/div>\n<\/p>\n<p>What is the sensitivity and specificity of transthoracic ultrasound in the detection of hemopericardium?\u00a0<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">Answer<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<p>Sensitivity = 96% and specificity = 98% (#7).<br \/>\n<\/div>\n<\/div>\n<\/p>\n<p>What is the management of the patient above?\u00a0<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">Answer<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<p>The patient presents with tamponade physiology and his injuries require immediate intervention. \u00a0A stable patient with this injury should be taken directly to the OR for thoracotomy and definitive repair of the cardiac wall rupture. \u00a0If the patient becomes hemodynamically unstable, then an ED thoracotomy may be considered. \u00a0In patients with this injury who are hemodynamically stable (including low but stable blood pressure values), a pericardiocentesis may be considered. \u00a0The drainage catheter would drain extra-cardiac volume and relieve the tamponade until more definitive care is possible.<br \/>\n<\/div>\n<\/div>\n<\/p>\n<p>What&#8217;s your airway management for this patient?\u00a0<div class=\"bu_collapsible_container \" aria-live=\"polite\" data-customize-animation=\"false\"><h4 class=\"bu_collapsible\" aria-expanded=\"false\"tabindex=\"0\" role=\"button\">Answer<\/h4><div class=\"bu_collapsible_section\" style=\"display: none;\"><\/p>\n<p>If the patient should manifest distress or deteriorating mental status, endotracheal intubation may be indicated. \u00a0However, intubation could be dangerous for this patient, as positive intra-thoracic pressure (as occurs in mechanical ventilation) may severely reduce cardiac filling and lead to cardiovascular collapse. \u00a0As such, intubation should ideally occur in the controlled environment of the operating suite.<br \/>\n<\/div>\n<\/div>\n<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>References (<a href=\"#top\">back to top<\/a>)<\/p>\n<p>1) Rozycki, G.S.; Ochsner, M.G.; Feliciano, D.V.; et al. Early Detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study. J Trauma. 45(1998), pp. 878-883<br \/>\n2) Patel, Riherd. Focused assessment with sonography for trauma: methods, accuracy, and indications. Surg Clin N Am 91 (2011); 195-207.<br \/>\n<span style=\"line-height: 1.5;\">3) <\/span><a id=\"Ref2\" style=\"line-height: 1.5;\"><\/a><span style=\"line-height: 1.5;\">http:\/\/www.uptodate.com\/contents\/emergency-ultrasound-in-adults-with-abdominal-and-thoracic-trauma<br \/>\n<\/span><span style=\"line-height: 1.5;\">4)\u00a0<\/span><a id=\"Ref3\" style=\"line-height: 1.5;\"><\/a><span style=\"line-height: 1.5;\">Blaivas, Ml Lyon, M; Sandeep, D. Prospective comparison of supine chest radiography an bedside ultrasound for the diagnosis of traumatic pneumothorax. Academic Emergency Medicine. Vol 12, Issue 9, Sep 2005; 844-849<br \/>\n<\/span><span style=\"line-height: 1.5;\">5)\u00a0<\/span><a id=\"Ref4\" style=\"line-height: 1.5;\"><\/a><span style=\"line-height: 1.5;\">Schultz, J.M.; Trunkey, D.D. Blunt Cardiac Injury. Crit Care Clin. 2004; 20(1):57-70<br \/>\n<\/span><span style=\"line-height: 1.5;\">6)\u00a0<\/span><a id=\"Ref5\" style=\"line-height: 1.5;\"><\/a><span style=\"line-height: 1.5;\">Fedaker, et al. Fatal traumatic heart wounds: Review of 160 autopsy cases. Isr Med Assoc J. 2005;7 498-501<br \/>\n<\/span><span style=\"line-height: 1.5;\">7)\u00a0<\/span><a id=\"Ref6\" style=\"line-height: 1.5;\"><\/a><span style=\"line-height: 1.5;\">Mandavia D.P.; Hoffner R.J.; Mahaney K.; Henderson S.O. \u00a0Bedside echocardiography by Emergency Physicians. \u00a0Ann Emerg Med. 2001;38(4):377<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Case 1: A 32 y\/o M motorcyclist struck the side of a&hellip;<\/p>\n","protected":false},"author":9051,"featured_media":0,"parent":1585,"menu_order":3,"comment_status":"closed","ping_status":"open","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/wp-json\/wp\/v2\/pages\/2030"}],"collection":[{"href":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/wp-json\/wp\/v2\/users\/9051"}],"replies":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/wp-json\/wp\/v2\/comments?post=2030"}],"version-history":[{"count":50,"href":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/wp-json\/wp\/v2\/pages\/2030\/revisions"}],"predecessor-version":[{"id":3688,"href":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/wp-json\/wp\/v2\/pages\/2030\/revisions\/3688"}],"up":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/wp-json\/wp\/v2\/pages\/1585"}],"wp:attachment":[{"href":"https:\/\/www.bumc.bu.edu\/emergencymedicine\/wp-json\/wp\/v2\/media?parent=2030"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}