UCONN Emergency Medicine Interest Group

Ultrasound Case #4

In RADIOLOGY on September 25, 2011 at 11:19 AM

Syndicated from the UCONN EM Residency website; credit to Dr. Russell and Dr. Kleinberg for cases and images.

CC: shortness of breath

HPI: 62 yo female with no significant pmh presents with shortness of breath worsening over the last 3 days with associated lest sided chest pain, low grade fever and non productive cough.

SH: 40 pack year smoking history, occasional alcohol.  Denies drug use.

FH: Lung cancer

PE: T 100.8 BP 110/90 HR 99 RR 24 SAT 90% ra. GEN: Uncomfortable, speaking in fragmented sentences.  CV: Regular rate and rhythm, no MRG.  PULM: Moderate respiratory distress.  Absent breath sounds in the base and midway up the back on the left.  Dullness to percussion on the left compared to the right.

EKG: Normal sinus rhythm with occasional PVCs.

Labs: WBC 12.5 with left shift, remainder of CBC, Chem7, PT/INR and cardiac enzymes grossly within normal limits.

Bedside U/S: see beginning of post for 1st still image; click for video.

What is the cause of the patient’s dyspnea? (click below to see the answer below the fold)

Answer: pleural effusion. Above image and video show anechoic fluid in the pleural space consistent with a moderate sized pleural effusion.  Lung is seen as hyperechoic tissue moving in the fluid.

Here is the CXR consistent with bedside ultrasound findings of a moderate sized left pleural effusion:

Plan: Diagnostic and therapeutic thoracentesis using bedside ultrasound.  Fluid sent for analysis. Pt admitted to medicine.

Teaching Points for Lung Ultrasound

Below image showing ultrasound of right upper quadrant.  The liver is seen in the middle of the image.  The hyperdense line to the left of the liver is the diaphragm.  Further to the left of the diaphragm is normal lung parenchyma.  Notice it is the same echogenicity as the liver.

Click to see a video showing normal lung sliding between two ribs.  This ultrasound is taken using the high frequency linear array probe. Compare to a second video with pleural fluid seen as the dark line between the lung parenchyma and chest wall.

Image below showing normal lung siding, resembling waves on a sandy beach.  This is seen using M Mode.

Compare this to a M Mode image with pleural effusion. You can no longer see the “waves on a sandy beach” appearance:

Loss of lung sliding could be due to a number of different causes including pneumothorax, consolidation, atelectasis, single lung intubation and pulmonary fibrosis.

References:

  • Blok BK. Thoracentesis. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia, Pa: Saunders Elsevier; 2009.
  • Koh, D.M., Burke, S., Davies, N, Padley, S.P.  Transthoracic ultrasound of the chest: clinical uses and applications. Radiographics. 2002; 22.
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