VOTW: Hip, Hip hooray!

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

Hospital course

70 y/o F presented to the ED after a fall onto her left hip. XR imaging confirmed a left femoral neck fracture. Instead of using IV opioids, a PENG block was done to relieve the patient’s pain!

Ultrasound

Above we can see the important anatomical landmarks of the pericapsular nerve group (PENG) block. The femoral artery and veins (FA, FV) were identified using color doppler as shown. The bony land marks are the anterior inferior iliac spine (AIIS) and iliopubic eminence (IPE), with the ilium in between. The psoas tendon (PT) is seen along the groove created by the iliopsoas notch.

Here we can see the needle inserted under the psoas tendon with injection of local anesthetic which hydrodissects, or lifts, the psoas tendon off the bone. The spread of the local anesthetic is indicated by the dotted blue line.  

See the clips to see the needle insertion and hydrodissection in action!

Case Conclusion

The patient had excellent pain relief after the PENG block and the patient was taken to the OR later that day for surgical repair.

PENG (Pericapsular Nerve Group Block) block

·       This block targets the terminal sensory branches of the femoral, obturator, and accessory obturator nerves. It is ideal for pain control in the setting of intertrochanteric hip and femoral neck fractures, as well as acetabulum and pubic rami fractures. This block primarily targets sensory nerves, preserving motor function!

·       The probe should first be placed in transverse orientation over the proximal thigh, inferior to the inguinal ligament. After identifying the femoral head, the probe should be moved up until the AIIS and IPE of the ilium are visualized. Key anatomical landmarks to note are the femoral artery and psoas tendon which runs along the groove created by the iliopsoas notch. In general, the femoral nerve lies above the psoas tendon, lateral to the femoral artery.

·       The needle should be inserted in a lateral-to-medial approach until it contacts the ilium bone underneath the PT. Hydrodissection of local anesthetic should lift the PT off the ileum.

·       When inserting the needle take care to avoid going near the femoral nerve and femoral artery!

Happy scanning!                                                                              

Sono team

Resources to review:

·       https://nerveblock.app/nerve-blocks/peng/

·       https://www.acep.org/emultrasound/newsroom/apr2021/pericapsular-nerve-group-peng-block-for-patients-with-hip-or-pelvis-fractures-in-the-ed

·       https://www.nysora.com/education-news/the-hip-block-new-addition-to-nysoras-web-app/

·       https://www.acepnow.com/article/benefits-of-using-the-pericapsular-nerve-group-peng-block/

VOTW: The Effusion Fusion!

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

Hospital course

50 y/o F with PMH ESRD on HD, HTN, presented to the ED after a syncopal episode. The patient was intubated for respiratory failure but afterwards developed worsening hypotension and tachycardia. Bedside transthoracic echocardiogram was performed.

Ultrasound

In this parasternal long view of the heart, we can see an effusion within the pericardial sac (pericardial effusion). This is represented by anechoic fluid that tracks anterior to the descending aorta. However, note that there is also fluid POSTERIOR to the descending aorta – this is a pleural effusion!

In this apical-4 chamber view of the heart, again we can see a pericardial effusion. Note that the right atrial wall collapses during systole!

Case Conclusion

The echocardiogram confirmed the presence of a large pericardial effusion with signs of early tamponade as well as a pleural effusion. The patient was admitted to the MICU.   

Cardiac tamponade, pericardial effusions, and pleural effusions

·       It is important to be able to differentiate a pericardial effusion and a pleural effusion on the parasternal long view of the heart. Both look similar however there is one key differentiating factor. A pericardial effusion will be located ANTERIOR to the descending aorta, while a pleural effusion will be located POSTERIOR to the descending aorta.

·       The earliest sonographic finding of cardiac tamponade is right atrial collapse during early systole. As the pericardial effusion continues to grow, diastolic right ventricular collapse can also occur.

Happy scanning!                                                                              

Sono team

Resources to review:

·       https://www.acep.org/emultrasound/newsroom/may-2024/cardiac-tamponade

·       https://med.emory.edu/departments/emergency-medicine/sections/ultrasound/case-of-the-month/lung/pleural_pericardial_effusion.html

·       https://www.emdocs.net/us-probe-when-does-an-effusion-become-pericardial-tamponade/

VOTW: Not so FAST!

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

Hospital course

A 10 year old female presented with severe abdominal pain after hitting her abdomen on a metal pole. The patient was hypotensive and her abdomen was diffusely tender with guarding. A bedside FAST exam was done.

In this RUQ view, we can see free fluid located adjacent to the liver tip. See the attached clip to see this in real-time!

In this LUQ view, we can see free fluid between the diaphragm and the spleen. The diaphragm is highlighted with the dotted white line. Also note the abnormal spleen architecture; the spleen appears to have varying echo intensity with irregular borders and a hypoechoic rim. See the attached clip to see this in real-time!

In this sagittal view of the bladder, we can see free fluid between the bowel and bladder. See the attached clip to see this in real-time!

In this transverse view of the bladder, we can see free fluid above the bladder. See the attached clip to see this in real-time!

Without a doubt this was a positive FAST!

Case Conclusion

The patient was quickly stabilized with IV fluids and pRBC transfusion. CT imaging showed a grade 3 splenic laceration and confirmed moderate amount of hemorrhage in the abdomen and pelvis. The patient was admitted to the PICU for observation.

FAST exam & Splenic laceration

·       With every FAST exam it is extremely important to follow the liver until you have a good view of the liver tip, as fluid will likely collect there first.

·       Remember, free fluid fills potential spaces between structures, so will have characteristically sharp edges! Free fluid will NOT have smooth edges and walls like physiologic structures do.

·       In the LUQ view, any disruption of normal spleen architecture / echotexture could indicate a splenic injury. These include splenic lacerations, hematomas, and rupture.

Happy scanning!

Sono team

Resources to review:

·       https://www.thepocusatlas.com/trauma-atlas

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

·       https://www.ultrasoundcases.info/cases/abdomen-and-retroperitoneum/spleen/trauma-of-the-spleen/