VOTW: “D”-oh! What a heart!

Hello all! This week’s VOTW is brought to you by myself.

Hospital course

30 y/o M presents to the ED after 2 syncopal episodes. He had 10 days of worsening dyspnea on exertion with chest pressure and palpitations. He flew to California 1 month ago and returned yesterday.  

In the parasternal short view of the heart above, we see two cardiac chambers, the right ventricle (RV) and the left ventricle (LV). We can see flattening of the interventricular septum towards the LV chamber, creating a “D”-shaped LV (labelled above).

View the attached clip to see the LV take on a shape of the letter “D” with each contraction! Also note that the RV is dilated and appears larger in size than the ”D”-shaped LV.

The clip above shows a parasternal short view of a normal heart. Notice that the left ventricle appears circular, and the right ventricle forms a smaller crescent-shape surrounding the left ventricle.

Case Conclusion

CT imaging showed pulmonary emboli within the bilateral pulmonary arteries and dilatation of the right atrium and right ventricle associated with right heart strain.

Thrombectomy was deferred because patient was hemodynamically stable. He was started on a heparin infusion in the ED and then admitted.   

Right heart strain

·       Pulmonary embolism can cause an acute increase in pulmonary pressures and right ventricular afterload that causes increased right heart strain. Focused ultrasound has been shown to be both highly sensitive and highly specific in detecting anatomical changes of the heart seen with right heart strain.

·       “D-sign” is a finding suggestive of right heart strain seen on the parasternal view of the heart. Increased right ventricular pressures cause bowing of the interventricular septum into the LV, causing the “D”-shaped LV to form.

·       Other findings suggestive of right heart strain include increased RV size, McConnell’s sign, and TAPSE.

Happy scanning!

Sono team

PS: just in case nobody gets it, the subject line pun is a Simpsons reference!

Resources to review:

·       https://www.thepocusatlas.com/right-ventricular-dysfunction/

·       https://everydayultrasound.com/blog/category/Right+Ventricular+Strain

·       https://www.acep.org/sonoguide/basic/cardiac

VOTW: Let’s put a knee-dle in that knee!

Hello all! This week’s VOTW is brought to you by myself.

Hospital course

50 y/o F presents to the ED with several weeks of lower back and left knee pain. Left knee is swollen and tender with palpation. She limps when ambulating due to the pain. Bedside ultrasound of the knee joint is shown below.

In the image above, the probe is placed over the suprapatellar space with a long-axis view. The femur is seen below, with a layer of dark anechoic effusion visible between the quadriceps tendon and the prefemoral fat pad.

Once the suprapatellar effusion was identified, the probe was rotated 90° into a transverse view of the knee, and the needle was inserted lateral to medial using an in-place approach. In the image above you can see the needle tip enter the effusion underneath the quadriceps tendon. The needle is the hyperechoic straight line in the left image, which is labelled with a white arrow in the right image.

In the clip above we can see this ultrasound-guided in-plane needle insertion with the needle tip entering the suprapatellar effusion.

In this clip, we can see the effusion shrink in size as the synovial fluid is actively aspirated through the needle!

Case Conclusion

The synovial fluid specimen was sent to the lab, and septic arthritis was ruled out. The patient’s left knee pain significantly improved after the arthrocentesis and she was discharged.

Ultrasound-guided knee arthrocentesis

·       While this procedure can be performed blind, the use of ultrasound improves accuracy, improves pain scores, and allows aspiration of more synovial fluid.

·       The patient should be positioned supine with the knee in 15-20° of flexion.

·       Begin by identifying a suprapatellar effusion by placing the linear probe superior to the patella with the marker oriented cephalad (long axis view of the knee). A joint effusion will look like an anechoic stripe within the joint space deep to the quadriceps tendon.

·       Once you identify a drainable effusion, rotate the probe 90° to obtain a transverse view (short axis view of the knee). A lateral to medial in-plane technique should be used to guide the needle tip into the joint effusion.

·       Remember to use a sterile ultrasound probe cover!

·       Ultrasound-guided arthrocentesis can be used to drain effusions from any joint, with commonly aspirated joints including knees, hips, shoulders, wrists, elbows, and ankles.

Happy scanning!

Sono team

Resources to review:

·       https://www.acep.org/sonoguide/procedures/arthrocentesis

·       https://mskultrasound.net/arthrocentesis-of-the-knee/

·       https://coreultrasound.com/knee-aspiration-and-injection/

VOTW: A real gut-wrenching situation!

Hello all! This week’s VOTW is brought to you by yours truly!

Hospital course

83 y/o F with PMH esophageal hernia presented to the ED with 2 days of abdominal fullness, nausea, and vomiting. Last bowel movement was 2 days ago. Bedside ultrasound was done.

This is small bowel. How do we know this? Note the small finger-like projections from the inner wall (yellow arrows). These are called plicae circulares, which are  mucosal folds of the small intestine. Also note that the bowel diameter is dilated up to 3.2 cm (blue arrow).

Note the transverse view of the small bowel below the stomach. The bowel wall appears thicker than normal, measuring 0.88 cm. Also note that the stomach itself appears very dilated!

In the clip above, we can see multiple loops of dilated small bowel. We can see hyperechoic specs of intestinal contents within the bowel making a “to-and-fro” motion instead of normal unidirectional peristalsis.

In the clip above, we can see dilated small bowel with no movement of the intestinal contents at all!

Case Conclusion

The patient was found to have a small bowel obstruction with an incarcerated femoral hernia on CT imaging. NG tube was placed in the ED and patient was admitted for surgical intervention.

Characteristic Findings of SBO

·       In normal small bowel, the regular bowel diameter is < 2.5 cm and we expect to see normal peristalsis with unidirectional flow.

·       A small bowel obstruction on ultrasound will show multiple loops of bowel with a diameter > 2.5 cm. The intestinal contents will appear to move back and forth with “to-and-fro” movement. Sometimes the distal obstruction will prevent the intestinal contents from moving at all!

·       A small bowel obstruction will also lead to bowel wall edema, which causes a wall thickness > 4 mm. The bowel wall edema and dilated diameter will make the intestinal folds or plicae circulares appear more prominent, leading to the “key board” sign seen in the image above.

Happy scanning!

Sono team

Resources to review:

·       https://coreultrasound.com/small-bowel-obstruction/

·       https://www.emdocs.net/us-probe-ultrasound-for-small-bowel-obstruction/

·       https://www.acep.org/sonoguide/advanced/gi---bowel-obstruction