VOTW: A Heart-y Effusion

Case: A 62 yoF with a PMHx of CAD presented to the ED as a notification for shortness of breath. She began to worsen and was placed on BIPAP, pressors, and given IV fluids. Despite this, her BP dropped to 57/35 and her pulses became faint. Dr. Yu a bedside echo and saw a large pericardial effusion with tamponade (video 1). She then performed an emergent pericardiocentesis under US guidance and 75 ccs of bloody fluid was removed.

Video 1: subxiphoid view showing a large pericardial effusion with the heart swinging, right atrial, and right ventricular collapse.

Video 2/image 1: Needle tip at the top of the screen inside the pericardial effusion.

Case Conclusion: The patient’s BP immediately improved to 189/94 and she was weaned off of pressors before being admitted to MICU. Cardiothoracic surgery was consulted and the patient is scheduled for a pericardial window.

For more information on how to perform a pericardiocentesis in the subxiphoid approach: https://litfl.com/pericardiocentesis/

Happy scanning! 

Ariella Cohen 

VOTW: Uterus Didelphys

Case: 29 yoF G1P0 presented to the ED with vaginal bleeding and abdominal pain. A transabdominal ultrasound was performed that did not show a definitive IUP. Beta-HCG was elevated at ~30,000. The providers then performed a TVUS that showed a gestational sac without a clear yolk sac and a concerning second structure (video 1). OBGYN was consulted to rule out ectopic pregnancy and their repeat US showed an IUP. However, they also identified 2 uteruses and a vaginal septum, leading them to believe that the patient had uterus didelphys.

Video 1: Superficially you see a collapsed bladder. On the right side of the video, you see 1 uterine horn with a thickened endometrium and no gestational sac. On the left side of the video, towards the end of the clip, you can see an endometrium with a gestational sac. 

Uterus didelphys is a rare condition where a person develops 2 uteruses. It occurs when the Mullerian ducts do not fuse during embryologic development, resulting in 2 separate uteruses, each with its own fallopian tube and ovary (image 1). Some people also have 2 cervixes and 2 vaginal canals. This condition occurs in 0.3% of the population. Pregnancies in women who have uterus didelphys are considered high risk as there is less room for fetus to develop.

Case conclusion: the patient was counseled about risks and the need for close follow-up. She has a repeat ultrasound and appointment in the outpatient clinic this week.

Happy Scanning!

- Ariella Cohen, MD

References: https://my.clevelandclinic.org/health/diseases/23301-uterus-didelphys

VOTW: Do you know the muffin man?

Case: 57 yoF with PMHx of osteoarthritis presented to the ED with right knee pain. A bedside US was performed that showed bulging of the right medial meniscus with surrounding edema Image 1, videos 1&2), consistent with a tear in the medial meniscus.

Meniscal Tear

How to assess the meniscus:

1. Have the patient flex their knee slightly to 20-30 degrees (you can prop their knee up with a rolled towel) 

2. Use the linear probe and place it longitudinally along the medial aspect of the knee 

3. Identify the medial collateral ligament (MCL), which will appear as a hyperechoic and fibrillar structure, extending from the medial femoral condyle to the proximal tibia

4. The meniscus will appear as a triangular structure that sits between the femur and tibia, under the MCL

5. A meniscal tear is identified with a well-defined anechoic or hypoechoic area surrounding the meniscus. It can cause extrusion of the meniscus as a result of surrounding edema, described as a "muffin top". There may also be increased vascularity in the surrounding area when color flow doppler is applied

Note: The same process can be repeated on the lateral aspect of the knee to assess the lateral meniscus (image 3).

Case conclusion: While the patient had pain with flexion, she was able to ambulate independently. She was discharged with orthopedic follow-up and conservative measures.

Happy scanning! 

Ariella Cohen

References: 

https://theultrasoundsite.co.uk/ultrasound-case-studies/

https://ultrasoundpaedia.com/knee-normal/

https://www.nysora.com/ultrasound-of-the-musculoskeletal-system/chapter14-knee-preview/