"Abscessed" with Bowel POCUS: Diverticulitis

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HPI: 42 yo male with no PMH presenting for abdominal pain x 2 days. His physical exam was significant for LLQ tenderness with guarding and rebound.

POCUS showed (see video):

We initially thought the outpouching connected to the abscess was a diverticulum but on further review, it’s more likely to be a loop of bowel given its size.

What a diverticulum should look like:


CT scan for reference:


Diagnosing Diverticulitis on POCUS

  • Use curvilinear vs linear probe

  • Start at maximal point of pain > lawnmower technique

  • #1: Find diverticula

    • Looks like outpouching attached to loop of bowel

  • Secondary findings:

    • Bowel wall diameter >5 mm

    • Prominent, fluid-filled bowel loops

    • Pericolic fluid collections

    • Increased pericolic fat (hyperechoic fat anterior to diverticula)

    • Intraabdominal abscesses

Case conclusion: CTAP showed perforated diverticulitis with multiple intraabdominal abscess. Patient was taken for IR drainage with feculent/purulent drainage noted. Patient is still doing well on surgical service.

References

  1. https://coreultrasound.com/diverticulitis/

  2. https://www.ultrasoundgel.org/posts/SFPsfN9yJ-9uSp640QlWtg

  3. https://www.ultrasoundcases.info/diverticulosis---diverticulitis-531/

VOTW: Interscalene Block for Shoulder Dislocation Reduction

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This week’s VOTW is brought to you by the US Team Drs. Jennie Xu and Laura Gonzalez and ED team Drs. Jennifer Wolin and Daniel Evans!

HPI: 45 year old male with no PMH presenting for left shoulder pain after falling off his scooter today. He was found to have an anterior shoulder dislocation and luckily the US team was available for an interscalene nerve block to help with pain control and an easier shoulder reduction!


Supplies you’ll need

Chlorhexidine

US probe cover

Echogenic needle

Sterile flush

10 mL of 1-2% lidocaine with or without epi (short acting anesthetic because it’s just for the shoulder reduction and has the potential to cause diaphragm paralysis- remember C3-5 innervates the diaphragm).

Place your linear probe at the medial/anterior neck at the level of the cricoid cartilage. Visualize the “stoplight” between the anterior and middle scalene muscles. The stoplight represents C5-7 in the brachial plexus.

Advance your echogenic needle through the prevertebral fascia and continue to bath the nerves (C5-7) with lidocaine. Use your saline flush to make sure you are in the right fascial plane prior to injecting your lidocaine.

Case conclusion: The ED team easily and quickly were able to reduce the patient’s shoulder dislocation!


Happy Scanning!

  • The US Team

References

  1. https://highlandultrasound.com/interscalene-block

Stop Giving Your Patients Oxygen!

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Stop giving oxygen.

You heard me.

Sometimes it seems like every patient in the emergency room is wearing a nasal cannula. Sometimes they're wearing it like a headband, or a necklace, or sometimes it's just spewing gas next to the stretcher. (Pause for laughter.)

But oxygen, for those who do not *need* it, may be harmful.

ACS

  • The folks at UpToDate suggest only giving oxygen if O2 is <90% on room air.

  • AHA also says only if room air sat <90%.

  • In the UK, oxygen is only recommended if the room air saturation is < 94%.

  • This amazing post from Dr. Salim Rezaie shows there is no convincing data that oxygen helps patients who aren't hypoxic, and there is some signal of harm with increased troponin/CK in patients given O2! Are we worsening their MIs?

STROKE

  • AHA says no oxygen unless saturation < 94%.

  • Journal Feed talked about this RCT of 8,000 patients, those getting supplemental O2 had no benefit.

ACUTE & CRITICAL CARE

So what's the ideal saturation?

In our critically ill patients, it's reasonable to aim for a sat of 94-98% based on a huge retrospective study in Chest.