Bedside ultrasonography is highly accurate in evaluating hypotension, even if performed by nonradiologist. Here we report three cases presenting with hypotension to the trauma room. In the first case, limited bedside ultrasonography demonstrated dilatation of the inferior vena cava and loss of respiratory variation in diameter. In further evaluation, dilated aortic root, massive pericardial effusion, collapse of right heart chambers, and a dissection flap at the anterior wall of base of ascending aorta were detected. With these findings, the patient was sent to the operation room with a diagnosis of DeBakey type 2 aortic dissection in approximately 15 min. In the second case, bedside ultrasonography demonstrated absence of pleural movements and comet tail artifacts on the right lung region of the patient. Together with deterioration of the vital signs, the patient was diagnosed as right-sided pneumothorax and underwent the tube thoracostomy. In the third case, bedside ultrasonography revealed the presence of free fluid in Morrison's pouch and splenorenal space in a hypotensive patient with a blunt abdominal trauma. He was consulted with general surgery department and was sent to the operation room without further diagnostic evaluation. In these cases, we emphasized the key role of bedside ultrasonography in hypotensive patients.
Pneumothorax (PTX) is the presence of an excessive amount of air between the two layers of the pleura. The clinical results depend on the extent of lung collapse. Bedside lung ultrasonography (BLUS) is a valuable way to diagnose PTX in the emergency department. The lung point is a pathognomonic sign of PTX. Here, we present a previously healthy 17-year-old male with left shoulder pain for 2 days, who was referred to the emergency department (ED). He had no history of trauma. BLUS was performed by the emergency physician. The lung point was detected with BLUS, and he was diagnosed with primary spontaneous PTX. Needle aspiration was performed. The patient was followed up with BLUS. Evidence of PTX was absent in BLUS after 6 h, and the patient was discharged for follow-up by a respiratory physician. In this case, the lung point in BLUS helped us make an accurate diagnosis of primary spontaneous PTX and invasive management of disease was arranged accordingly.
Acute dyspnoea is one of the most common reasons patients present to the emergency department (ED). In most cases, the physical examination and bedside radiographs are inconclusive, resulting in the need for more sophisticated diagnostics. These diagnostics may delay treatment or expose the patient to unnecessary radiation. Here, we present the case of a dyspnoeic patient. The patient was diagnosed with pneumonia by bedside thoracic ultrasonography (TUS). TUS was performed by the emergency physician and revealed bilateral pleural effusion, which was more significant on the right side of the thorax. The right lower lung lobe was consolidated, and dynamic air bronchograms were present on TUS. Computerised tomography of the chest was ordered. Bilateral multilobar consolidations were clearly appreciated with bilateral pleural effusion. Because of the dynamic nature of the disease process, we were able to diagnose pathological changes in the lung. In conclusion, TUS may be used for diagnosing pneumonia in the ED because it has high accuracy, low cost and no radiation exposure. Furthermore, it can be used bedside, and there is no need to transport an emergent patient to the radiology unit.
Authors:Erden Erol Ünlüer, Arif Karagöz and Pinar Yeşim Akyol
We present a case of an 84-year-old woman who presented with vague abdominal discomfort and syncope secondary to a type A acute aortic dissection. In pursuit of the diagnosis, multiple tests were ordered after the history and physical exam were complete. When the D-dimer levels were reported to be high, a bedside transthoracic ultrasound was performed which showed dilated aortic root and pericardial tamponade, leading us to order a computerized tomography to confirm the diagnosis of acute aortic dissection. A diagnostic testing algorithm being used in our institution using D-dimer, ultrasound, and other tests are provided in patients presenting with possible acute aortic dissection. In this case, bedside ultrasound helped us to rapidly make the diagnosis of acute aortic dissection and arrange for further inpatient care.
Authors:Erden Erol Unluer, Togay Evrin, Burak Katipoglu and Serdar Bayata
Fluid therapy is one of the main issues for hemodynamic resuscitation. Tissue Doppler imaging (TDI) of the right ventricle (RV) with bedside ultrasound (BUS) technique is a new dynamic method to identify fluid responsiveness in patients with hypotension. Here, we present the case of a hypotensive patient monitored with TDI measurements of RV. A 75-year-old male patient was admitted to the emergency department (ED) with the complaint of diarrhea. He was in severe hypovolemia, with hypotension, tachycardia, and tachypnea. His laboratory results were normal. BUS was performed on the patient by the ED physician. The velocity of the excursion of the tricuspid valve measured at presentation was 14.47 cm/s and, together with collapsed inferior vena cava (IVC), this finding led to the decision to begin fluid therapy immediately. The patient underwent 2 L of fluid therapy with 0.9% NaCl in a 2-h period. Control BUS after fluid therapy revealed decreased TDI velocity of tricuspid annulus to 11.81 cm/s and dilated IVC not collapsing sufficiently with respiration. The patient received his maintenance therapy after admission to the internal medicine department and was discharged from the service after 3 days. TDI in fluid responsiveness may find a clinical role in the future by the clinical studies.
Authors:Erden Erol Ünlüer, Seran Ünlüer, Yusuf Şahin, Kemal Erdinç Kamer, Arif Karagöz and Gözde Canan Tan
Mesenteric cysts are benign cystic lesions. Here, we present the case of a patient with abdominal pain, which was diagnosed as mesenteric cyst.
A 28-year-old male patient was admitted to the emergency department (ED) with abdominal pain and distention. Abdominal palpation revealed a smooth-surfaced mass palpable in the left upper quadrant. Ultrasonography depicted a hypoechoic heterogeneous mass-like structure with a size of 15 × 12 cm. Computerized tomography (CT) showed a well-defined cystic structure with a size of 12 × 12.5 cm near to the duodenum and pancreas. The patient was admitted, and the cystic structure was drained with a percutaneous drainage catheter; then, sclerotherapy was performed using ethyl alcohol with the aid of ultrasonography. The material was sent to the pathology lab and revealed negative results for malignant cell and mucin. The patient underwent a control CT with contrast, which revealed the catheter at the site of the operation and no cystic lesion after procedure. He was discharged 1 week after the procedure.
Mesenteric cysts are extremely rare benign lesions of the abdomen, and emergency physicians must consider this disease in the differential diagnosis of abdominal pain. The percutaneous drainage technique performed on our patient is a safe technique for the treatment of selected patients.
Authors:Erden Erol Ünlüer, Yusuf Şahin, Orhan Oyar, Gözde Canan Tan, Arif Karagöz and Celaleddin Turan
Emphysematous pyelonephritis (EP) is a rare form of necrotizing pyelonephritis. It is a life-threatening condition that usually affects patients with diabetes, and a small percentage may be due to urinary tract obstruction. Here, we present the case of an EP caused by urinary tract obstruction without diabetes. A 45-year-old woman presented to the emergency department with fever, chills, and abdominal pain. There was no significant past history. Physical examination depicted bilateral lower abdominal and right flank knocking tenderness. Laboratory exams revealed leukocytosis, neutrophilia, a high C-reactive protein level, and pyuria. Abdominal computerized tomography (CT) showed diffuse gas in the right renal collecting system and dilatation of the right renal pelvis compared to the right side, in addition to multiple millimetric stones located in the right kidney and right ureter. After emergent placement of a percutaneous nephrostomy, she was admitted. Control abdominal CT without contrast revealed the absence of gas, hydronephrosis of the right renal pelvis, and the presence of nephrolithiasis. The patient was discharged 10 days of post-procedure with instructions for follow-up. Emergency physicians need to remain alert about this life-threatening disease and the typical CT findings of this disease to make a timely diagnosis and navigate management.