Category: Emergency Ultrasound

Ultrasound-Guided Vascular Access (2025)

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by Zackary Funk & Petra Duran-Gehring

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Introduction

Ultrasound (US) guidance has become an increasingly common technique for vascular access in the Emergency Department (ED), with applications for both central and peripheral lines [1-4]. Initially adopted for central venous catheter (CVC) insertion, particularly in the internal jugular vein, US improved placement success rates, decreased complication rates, and shortened insertion times. As US technology and training advanced, its use expanded to peripheral intravenous line (PIV) placement, where studies have demonstrated increased success rates, reduced complications, and less pain, especially for patients with difficult access [1-4]. Difficult IV access, occurring in 10% to 30% of ED patients—particularly those with morbid obesity, IV drug use, hypovolemia, or chronic illness—can delay cannulation due to multiple failed attempts [5]. Ultrasound-guided PIV placement can mitigate these challenges, with one study reporting an 85% reduction in the need for CVCs in non-critical patients through the implementation of a US-guided PIV catheter program [6]. The overall benefits of US-guided vascular access include improved success rates, fewer complications, decreased pain, reduced time to cannulation, fewer attempts required, and improved patient satisfaction [1-4]. While it may add some complexity compared to landmark or “blind” approaches, the ability to directly visualize target vessels makes US-guided vascular access a highly effective and patient-centered technique.

Indications

Intravenous (IV) access is often critically important for many aspects of patient care in the ED [1-3]. These include:

US-Guided Peripheral IV Access:

  1. Patients who have had three or more blind attempts without successful cannulation.
  2. Patients with a history of difficult IV access.
    • Always evaluate the patient using traditional visual inspection and palpation before preparing for US-guided peripheral IV access. Factors that contributed to difficult IV access during previous encounters, such as hypovolemia, may not be present during subsequent visits.
  3. Patients who have previously required central line placement solely for IV access.
    • As mentioned above, when the clinical situation permits, patients with a history of requiring US-guided vascular access should be evaluated for landmark-based IV sites and/or US-guided peripheral IV sites before proceeding to the more invasive procedure of central venous access.

US-Guided Central Venous Access:
Whenever possible, it is highly recommended to use ultrasound guidance for invasive vascular access procedures, such as central venous cannulation, due to its demonstrated ability to decrease the occurrence of severe complications and increase success rates. The primary indication for ultrasound guidance in central venous access is the need for central venous access itself. Below is a list of specific indications for central venous access [1-4]:

  1. Inability to obtain peripheral IV access required for critical interventions or investigations.
  2. Long-term administration of vasoactive substances (e.g., norepinephrine/epinephrine infusions).
  3. Administration of high-concentration or potentially caustic medications (e.g., hypertonic saline, concentrated or large volumes of potassium chloride).
  4. High-pressure or large-volume infusions, such as massive transfusions in trauma patients with hemorrhagic shock.
  5. Emergent dialysis or plasmapheresis access in patients without established arteriovenous fistulas or other dialysis-capable access.
  6. Transvenous pacemaker placement.

Contraindications

Although there are many benefits of US-guided venous access, some contraindications and considerations should be kept in mind [3,4,7]:

  1. Presence of cellulitis, burns, massive edema, or injuries at or proximal to the proposed insertion sites.
  2. Other injuries, diseases, or anatomical distortions of the affected limb/site that may lead to complications during or after access (e.g., compartment syndrome, extravasation, bleeding from neoplasms, etc.).
  3. Risk of compromised vascular flow distal to the site.
  4. Coagulopathy (considered a relative contraindication).
  5. A capacitated patient declines to undergo the procedure after demonstrating an understanding of the risks and benefits as explained by the care team.

Equipment and Patient Preparation

While the materials and equipment required for peripheral IV access are very similar to those needed for central vascular access, we have separated them into two lists to highlight some key differences. Regardless of the procedure, adherence to hand hygiene practices and the universal use of personal protective equipment are absolutely essential for every procedure.

Equipment for Peripheral IV Access

  • Ultrasound machine equipped with a high-frequency linear probe.
  • Examination gloves.
  • Skin disinfectant (e.g., alcohol swabs, chlorhexidine swabs, povidone-iodine, etc.).
  • Occlusive ultrasound probe cover.
  • Sterile ultrasound gel.
  • Elastic tourniquet.
  • IV catheter.
  • IV securement device and dressing.
  • IV extension tubing and IV port.
  • Normal saline flush.
  • Sharps disposal device/container.
  • Stool or chair (recommended).
Figure 1 - Equipment for Peripheral IV Access

Equipment for Central Venous Access

  1. Ultrasound machine with a high-frequency linear probe.
  2. Sterile gloves.
  3. Eye protection.
  4. Central Venous Catheter Kit (if available), which often includes:
    • Sterile gown.
    • Face mask.
    • Bouffant or scrub cap.
    • Skin disinfectant swabs (e.g., chlorhexidine, povidone-iodine, etc.).
    • Vial of local anesthetic, needle, and syringe.
    • 18-gauge introducer needle and syringe.
    • #11-blade scalpel.
    • Gauze.
    • Guidewire.
    • Dilator(s).
    • Central venous catheter.
    • Sterile saline flush syringes.
    • Needle driver.
    • Suture.
    • Dressing.
    • Sharps disposal hub.
  5. Sterile occlusive ultrasound probe cover sheath.
  6. Sterile ultrasound gel.
  7. IV ports.

Patient Preparation

Proper patient preparation is essential to ensure the accuracy of line placement and minimize patient discomfort or complications. 

Introduction and Identification
Begin by introducing yourself to the patient and confirming their full name. 

Patient History and Consent
Inquire about any allergies, phobias, or a history of fainting during previous IV line procedures. Clearly explain the purpose, benefits, and potential risks of the procedure in simple terms. Once the patient or their next of kin fully understands the information, obtain verbal consent. Note that written consent is not required in emergency situations unless mandated by institutional policy.

Alleviating Anxiety
Address any patient concerns and provide reassurance to help alleviate fear or anxiety. Ensuring the patient is calm can significantly improve their experience and the procedure’s success.

Procedure Steps

Here, we will describe the procedural steps for both ultrasound-guided peripheral intravenous access and ultrasound-guided central vascular access. For each procedure, ensure that the ultrasound machine and probes are in good working order and that there is sufficient power or a reliable power source to successfully and safely complete the procedure. Ultrasound probes should be disinfected before and after each use to protect both patients and providers from exposure to bloodborne and other pathogens, even when sterile probe covers are used. For an overview of the procedural steps for ultrasound-guided peripheral IV access, please review the accompanying video.

Image Acquisition in Vascular Access Procedures

Optimizing the image of the target vessel is critical for procedural safety and success in ultrasound-guided vascular access. This section will describe the general principles and equipment needed to obtain and optimize target visualization.

The high-frequency linear ultrasound probe is most commonly used for vascular access procedures as it provides high-resolution images of superficial structures in the body (Figure 2). Although this resolution comes at the cost of limited penetration into deeper tissues, this limitation is rarely an issue due to specific factors influencing the appropriate depth of target vessels for cannulation, as discussed below.

Figure 2 - Linear Probe (transducer)

The next step is to ensure proper left-right probe orientation. This is accomplished prior to image acquisition by aligning the probe indicator on the ultrasound screen with the probe indicator on the linear probe itself. According to standard convention, the probe indicator on the device screen will appear as a dot, arrow, manufacturer logo, or other marking on the upper left side of the screen (Figure 3a).

Figure 3a - US Probe and Screen Markers

The image nearest the probe indicator on the screen corresponds to the signal emitted from the probe transducer head closest to the physical probe indicator, typically a raised marking or similar feature. A simple technique to confirm orientation involves applying a small amount of ultrasound gel to one side of the probe face, touching this area with a gloved finger, and observing where the movement appears on the screen (Video 1). Once the two markers are aligned, rightward movement on the screen will correspond to movement away from the probe indicator in physical space.

Once orientation is established, perform a survey scan of the site. After applying an elastic tourniquet (if peripheral IV access is being attempted), position the probe perpendicular to the long axis of the extremity or the anticipated course of the target vessel (Figure 4).

Figure 4 - positioning the probe perpendicular to the long axis

This generates a “transverse,” “short-axis,” or “cross-sectional” image of the vessel. If the screen appears too dark to delineate structures, increase the gain setting to brighten the image. Conversely, if the screen is too bright, decrease the gain setting. Vessels should appear as circular structures with a dark or “anechoic” center, indicating blood within the lumen that allows the ultrasound beam to pass through easily (Figure 5).

Figure 5 - increasing the gain setting to brighten the image

Several critical aspects of the target vessel must be assessed during imaging to ensure suitability for cannulation, including vessel type (venous vs. arterial), diameter, depth, patency, and proximity to other structures.

Vessel Assessment: Begin by verifying that the target is a vein. Veins have thinner walls compared to arteries and are compressible. Gentle pressure applied to the vein should cause the walls to collapse inward and meet, confirming its venous nature. Compression also ensures there is no intraluminal obstruction, such as a venous clot (Video 2).

Video 2 – applying pressure to the vessels

Next, assess the vessel’s depth using the depth markers displayed on the ultrasound screen, which typically indicate depth in centimeters. For example, a vessel aligned with the second hash mark from the top of the screen would be located at a depth of 2 cm from the skin surface (Figure 6).

Figure 6 - Measuring the depth of the vessel

Once the depth is measured, determine the vessel diameter, which is essential for selecting the appropriate catheter size for peripheral IV access. Finally, rotate the transducer 90 degrees to visualize the vessel in its long axis, ensuring that the target location is not near a branch point or valve.

Catheter Selection: In peripheral IV access, depth and diameter measurements determine the appropriate catheter size. Peripheral IV catheters vary in diameter (gauge), with smaller gauge numbers indicating larger catheter diameters (e.g., 16G is larger than 22G). A vessel diameter greater than 4 mm (0.4 cm) can accommodate an 18G or smaller catheter without occlusion. 

Figure 7 - Catheters

Catheters also come in various lengths, which affect their stability and suitability for deeper vessels. The depth of the target vessel determines the required catheter length, as longer catheters provide greater stability within the vein [2,3].

Figure 8 - Hypotenuse (needle track), [the image provided by authors]

The needle length required to reach the target vessel can be approximated using the Pythagorean theorem:

a2 + b2 = c2,

where c represents the needle track (hypotenuse. figure 8), a is the vessel depth, and b is the distance from the probe to the needle insertion point. For example, for a vessel 1.2 cm deep with a needle insertion point 1.2 cm distal to the probe, the calculation would be:

1.22 + 1.22 = c2,

resulting in c = 1.69 cm. A simpler method is to multiply the vessel depth by 1.4 (e.g., 1.2 cm × 1.4 = 1.68 cm). To ensure catheter stability within the vein, use the following formula to estimate the necessary catheter length:

Catheter Length = (Vein Depth × 1.4) × 3

This formula accounts for 1/3 of the catheter length reaching the vessel and 2/3 residing within the vein lumen. For example, a 6 cm catheter should not be used for vessels deeper than 1.6 cm.

For peripheral venous access, the following characteristics define an appropriate target vessel for US-guided peripheral IV access:

  • Easily compressible with light pressure applied using the ultrasound probe.
  • Follows a straight path as it travels proximally.
  • Lacks valves that would impede the passage of the cannula or flow after insertion.
  • Diameter greater than 0.4 cm.
  • Close to the skin surface, at a depth of less than 1.6 cm.

For central venous access, the same general principles apply. Regarding vessel diameter and depth, large-diameter vessels that are as superficial as possible are optimal. However, given the nature of these vessels in adult patients and the equipment used for central venous access, the exact parameters regarding diameter and depth mentioned for peripheral vein characteristics do not rigidly apply. Large-diameter vessels such as the internal jugular veins, subclavian veins, and femoral veins are preferred, and access should ideally be attempted at the point where the vessel is located as superficially as possible [4].

Regardless of whether peripheral or central IV access is utilized, the procedure under ultrasound guidance involves dynamically guiding the needle tip to prevent complications. Dynamic cannulation can be performed using either a transverse, out-of-plane approach or a longitudinal, in-plane approach. The transverse view, also known as the out-of-plane approach, is the most commonly used and involves visualizing the needle as a hyperechoic (bright) dot on the ultrasound screen. In contrast, the in-plane approach allows direct visualization of the entire needle length in a long-axis plane but is more challenging for novices, as the needle must remain within the ultrasound beam.

As the metallic needle within the catheter is hyperechoic, it appears as a white dot in the transverse plane and a long hyperechoic line in the longitudinal plane (Figure 9).

Figure 9 - the metallic needle within the catheter is hyperechoic, it appears as a white dot in the transverse plane and a long hyperechoic line in the longitudinal plane

In the transverse plane, it is critical to track the needle tip as it pierces the ultrasound beam, as the appearance of the needle looks the same regardless of its position along the beam. This tracking is achieved by alternating movements of the transducer and the needle. By “leading” with the transducer, then advancing the needle, the tip can be visualized first. Once the needle is seen, advancement should pause, and the transducer should slide slightly proximal up the vein where the needle is no longer visible, after which the needle can be advanced again (Figure 10). This alternating movement allows visualization of the tip as it progresses through the soft tissue and can be repeated until the vein is cannulated (Video 3).

Figure 10a - Walking down the vein: This sequence illustrates the process of "walking down the vein" as observed on an ultrasound. From left to right: the needle initially appears, then disappears, and later re-emerges deeper within the soft tissue before vanishing again. This phenomenon occurs due to the probe moving away, and when the needle reappears, it simply aligns with the ultrasound beam. Note that in real-time, the needle’s positional changes are more gradual than shown here; the figure above is a simplified representation of the concept (refer to the accompanying video for details). [The image was provided by authors].

Video 3 – Walking down the vein

Once the needle is visualized within the vein, the transducer can be rotated to ensure that the needle tip is within the vein lumen and has not pierced the back wall of the vessel. This visualization also allows for redirection of the needle before catheter insertion, ensuring smooth placement when the catheter is advanced off the needle (Video 4). For central venous catheters, a guidewire is inserted after confirming the needle’s position within the vein lumen.

Video 4 – provided by authors

After successfully inserting the IV line, blood return should be verified, and the catheter should be secured in place. As a final confirmation, flush the line. For peripheral IVs, place the ultrasound transducer proximally from the IV site, flush the line, and observe for turbulence or a “glitter artifact” caused by fluid rushing through the vein (Video 5).

Video 5 – provided by authors

This step confirms successful IV cannulation and can also assist in troubleshooting. If the “glitter” does not appear within the vein, the IV catheter is outside the vessel and unusable. For central lines, this confirmation can be performed by visualizing the “glitter” artifact in the right ventricle using the subxiphoid plane within three seconds of flushing the distal port of the line (Video 6).

Video 6 – Glitter Artifact [the video was provided by authors]

Step by Step Guide for US-Guided Peripheral IV Access [3,8]

  1. Verify the identity of the patient who is to undergo IV access and explain the procedure to the patient/healthcare surrogate (when possible).
  2. Position the ultrasound machine on the same side of the patient as the operator.
  3. Don examination gloves.
  4. Clean the ultrasound probe with institution-approved disinfectant.
  5. Remove gloves and replace with clean gloves.
  6. Position stool/chair and adjust the ultrasound machine for the best screen viewing when obtaining access.
  7. Apply an elastic tourniquet proximal to the site to be screened for potential access sites.
  8. Apply ultrasound gel to the target area and orient the probe perpendicularly to the patient’s extremity to obtain a transverse/short-axis view of the target vessels.
  9. Orient the probe indicator to match the orientation displayed on the ultrasound screen, with both conventionally indicating the patient’s right side (Figure 3a).
  10. Assess potential veins for appropriate depth, diameter, and patency.
  11. Veins should:
    • Be greater than or equal to 0.4 cm in diameter for an 18G catheter.
    • Be less than 1.6 cm in depth for a 6 cm length catheter.
    • Be easily compressible without evidence of clots, valves, or other obstructions to blood flow.
  12. Clean off ultrasound gel and release the tourniquet.
  13. Clean the selected site with skin disinfectant and allow it to air dry per manufacturer instructions.
  14. Set up supplies (prepare IV catheter, securement device, port, flush, and dressing).
  15. Cover the ultrasound probe with an occlusive cover.
  16. Avoid touching the head of the probe or the portion of the cover that will contact the patient’s skin.
  17. Reapply the tourniquet and ensure the patient’s arm remains in the appropriate position.
  18. Apply sterile ultrasound gel to the site.
  19. Do not touch the site with gloves or allow uncleaned materials/surfaces to come into contact with the site.
  20. If the site is potentially contaminated, remove the gel and clean the site again before attempting vascular access.
  21. Position the probe and locate the target vein again.
  22. At approximately a 45-degree angle, puncture the skin underneath the ultrasound probe head, observing on ultrasound for the needle tip in the subcutaneous tissue.
  23. Once the needle tip has been visualized, slide the probe proximally away from the needle tip.
  24. Once the needle tip is no longer visualized on ultrasound, carefully advance the needle in 1-2 mm increments until the needle tip returns into view on ultrasound.
  25. Repeat this alternating probe-needle advance until the needle has been advanced into the target vessel (Video 3).
  26. Decrease the angle of the needle as needed to continue advancing the needle in the alternating probe-needle manner within the vessel, keeping the needle tip in the center of the vessel lumen.
  27. Once the needle has been advanced several millimeters into the target vessel, anchor the hand holding the needle to ensure it does not advance further and lay down the ultrasound probe.
  28. Keeping the needle still, advance the catheter over the needle into the vessel.
  29. Once the catheter has been advanced, keep the catheter in place with the hand which advanced the catheter and use the other hand to carefully remove the needle.
  30. Ensure the safety needle capping mechanism on the needle has activated (if automatic upon needle removal from catheter) or activate the safety needle capping mechanism (if not designed to engage automatically) and dispose of the needle into a designated sharps container.
  31. Attach extension tubing and port to the catheter hub (some catheters come with the extension tubing and hub pre-attached).
  32. Clean any remaining ultrasound gel or blood from the access site and secure the catheter with an occlusive dressing.
  33. Attach a saline flush to the hub.
  34. If any air remains in the catheter extension tubing (if applicable), be sure to aspirate any air prior to attempting to flush the line.
  35. Retrieve the ultrasound probe and place it along the vessel proximal on the extremity to the catheter.
  36. After confirming the absence of air in the catheter and extension tubing, flush several cc’s of crystalloid solution through the catheter.
  37. If the catheter is in the correct position and functioning correctly, a “glitter” artifact effect should be visualized within several seconds of pushing the fluid through the catheter (Video 6).
  38. Dispose of supplies in appropriate containers and clean the ultrasound probe with disinfectant wipes.
  39. Remove gloves and wash hands.
  40. Document the access site in the patient’s chart, including site location, catheter gauge, time placed, and operator placing the line.
  41. Ensure you and your team frequently assess the site and extremity for evidence of extravasation, hematoma formation, or other complications.

Step by Step Guide for US-Guided Central Venous Access [4,9]

  1. Verify the identity of the patient who is to undergo IV access and explain the procedure to the patient/healthcare surrogate (when possible).
  2. Position the ultrasound machine on the opposite side of the patient as the operator in the operator’s line of sight.
  3. Don examination gloves.
  4. Clean the ultrasound probe with institution-approved disinfectant.
  5. Remove gloves and replace with clean gloves.
  6. Apply ultrasound gel to the target area and orient the probe perpendicularly to the patient’s extremity to obtain a transverse/short-axis view of the target vessels.
  7. Orient the probe indicator to match the orientation displayed on the ultrasound screen, with both conventionally indicating the patient’s right side (Figure 3a).
  8. Assess potential veins for appropriate depth, diameter, and patency:
  9. Veins should:
    • Be greater than or equal to 0.4 cm in diameter for an 18G catheter.
    • Be less than 1.6 cm in depth for a 6 cm length catheter.
    • Be easily compressible without evidence of clots, valves, or other obstructions to blood flow.
  10. Clean off ultrasound gel.
  11. Clean the selected site with skin disinfectant and allow it to air dry per manufacturer instructions.
  12. Open the central venous catheter kit (or, if unavailable, establish a sterile field upon which to place sterile equipment).
  13. Don eye protection, face mask, and bouffant/scrub cap.
  14. Don a sterile gown and gloves.
  15. Drape the patient in a sterile fashion.
  16. Place the dominant hand within a sterile ultrasound probe cover (if rubber bands to secure the sheath to the probe are included, consider applying rubber bands around the thumb of the dominant hand before placing the hand within the sheath).
  17. Apply sterile gel to the inside of the sheath, which will contact the ultrasound probe head.
  18. Have an assistant pass the linear probe and grab the probe head with the dominant hand surrounded by the ultrasound probe sheath.
  19. Carefully extend the sheath around the probe. Once able, ask an assistant to grab the open end of the probe sheath and pull it toward them along the probe’s wire until it is well away from the sterile field. The assistant can gently release the probe wire now covered in the sheath, being careful not to let the contaminated end of the probe cover touch the sterile field.
  20. Apply the rubber bands (if applicable) to the head of the probe and smooth any air bubbles or irregularities which may have formed along the transducer surface while inserting the probe.
  21. Draw up several cc’s of local anesthetic into a syringe.
  22. Apply sterile ultrasound gel to the target site and confirm there has been no change in positioning of the target vessel during setup.
  23. Inject the local anesthetic into the skin and along the track of the needle to the target vessel, being sure to aspirate before each injection.
  24. It is recommended that the injection of the local anesthetic be performed under active ultrasound guidance to minimize the chance of accidental injection into the vessel and to confirm the anesthetic is applied along the intended tract of the needle.
  25. Ensure that air bubbles have been removed from the local anesthetic solution prior to injection, as these air bubbles will distort visualization of the target vessel area due to scattering of the ultrasound beam as it comes into contact with air.
  26. While the local anesthetic takes effect, flush the lumens of the catheter with saline to prevent the introduction of air into the patient’s vasculature and test that the guidewire feeds smoothly and is free of kinks or defects.
  27. With the introducer needle at an approximately 45-degree angle, puncture the skin underneath the ultrasound probe head, observing on ultrasound for the needle tip in the subcutaneous tissue.
  28. Once the needle tip has been visualized, slide the probe proximally away from the needle tip.
  29. Once the needle tip is no longer visualized on ultrasound, carefully advance the needle in 1-2 mm increments until the needle tip returns into view on ultrasound (Figure 8).
  30. Repeat this alternating probe-needle advance until the needle has been advanced into the target vessel, pulling back on the needle plunger to aspirate blood upon entry into the vessel.
  31. Decrease the angle of the needle as needed to continue advancing the needle in the alternating probe-needle manner within the vessel, keeping the needle tip in the center of the vessel lumen.
  32. Once the needle has been advanced several millimeters into the target vessel, anchor the hand holding the needle to ensure it does not advance further and lay down the ultrasound probe.
  33. Keeping the needle still, lay down the ultrasound probe, remove the syringe from the needle, and retrieve the guidewire.
  34. Advance the guidewire through the introducer needle approximately 20 cm, ensuring that it passes freely without resistance. If resistance is encountered, stop advancing immediately and assess the situation.
  35. Keeping one hand on the guidewire at all times, withdraw the introducer needle over the guidewire and place it in a sharps disposal device or bin.
  36. Confirm that the guidewire is in the target vessel using ultrasound to visualize the guidewire in the vessel in long-axis (Figure 9).
  37. Place gauze nearby the guidewire insertion site for use in the upcoming step.
  38. Place the dilator over the guidewire and advance it toward the skin, stopping several centimeters above the skin.
  39. Using the scalpel, make a small linear incision with the blade directed away from the guidewire and the patient. Consider placing gauze over the site after the incision to minimize bleeding.
  40. Using the dominant hand, insert the dilator to the approximate depth of the vessel visualized on ultrasound, using the other hand to hold the guidewire.
  41. It is recommended to use a twisting motion while advancing the dilator with the hand gripping the dilator just above the patient’s skin.
  42. Ensure that the guidewire remains stationary during dilatory insertion.
  43. Remove the dilator over the guidewire and thread the central venous catheter over the guidewire.
  44. Advance the catheter into the vessel over the guidewire while keeping one hand on the guidewire at all times.
  45. The guidewire should emerge from the distal port of the catheter (typically marked with a brown hub and located in the center of the available ports).
  46. Once the catheter has been placed at the appropriate depth into the target vessel, aspirate blood using a syringe from all ports to ensure patency.
  47. Flush all ports with saline to minimize the chance of clotting.
  48. Use the needle driver and suture to secure the line in place.
  49. Clean the site once more and apply an institution-approved antimicrobial dressing.
  50. If the line was placed in an internal jugular or subclavian vein site, obtain a post-procedural chest radiograph to confirm appropriate placement and assess for complications (e.g., pneumothorax).
Figure 9 - Guide-wire in the vessel - long axis view

Complications

Ultrasound-guided venous access, while generally safer than traditional landmark techniques, still carries potential complications, both for peripheral and central line placement.

Complications of US-Guided Peripheral IV Access [1-3,8]

Infiltration/Extravasation: This is a common complication where IV fluid or medication leaks into the surrounding tissue instead of flowing into the vein. It is a leading cause of catheter failure and may occur more frequently with deep brachial veins compared to other antecubital veins. Using a longer catheter can help minimize the risk of infiltration.

Catheter Dislodgement: Catheter dislodgement occurs when the catheter moves out of the vein, leading to loss of venous access and potential extravasation. This complication is more common with deep veins compared to superficial veins. To reduce the risk, it is essential to ensure that a sufficient length of the catheter is properly positioned within the vessel.

Thrombophlebitis: Thrombophlebitis refers to the inflammation of the vein, which may occur during or after IV placement.

Infection: Although studies have shown no increased infection rates with ultrasound guidance compared to traditional methods, the risk of infection remains. Using sterile gel and adhering to proper cleaning techniques can significantly reduce this risk.

Damage to Adjacent Structures: There is a risk of damaging nearby structures, such as arteries and nerves, during peripheral IV placement. This risk is heightened when using deep veins, which are often located closer to these critical structures.

Posterior Vessel Wall Puncture: The short-axis technique, commonly used during ultrasound-guided IV access, has been associated with a higher risk of puncturing the posterior (back) wall of the vessel.

Hematoma: Bleeding and hematoma formation can occur as a result of vein trauma during catheter placement.

Premature Catheter Failure (PCF): Premature catheter failure occurs when the catheter fails within 24 hours of placement. Studies suggest that PCF rates are higher in ultrasound-guided cannulations compared to traditional methods. Common causes include infiltration, dislodgement, and thrombophlebitis.

Complications of Ultrasound-Guided Central Venous Catheter (CVC) Access [4,9,10]

Arterial Puncture/Cannulation: Accidental puncture or cannulation of an artery, such as the carotid artery during internal jugular vein access, is a serious complication. This risk can be mitigated by using real-time ultrasound guidance and ensuring careful visualization of surrounding structures.

Hematoma: Bleeding and hematoma formation are potential complications during central venous catheter placement, especially if there is accidental puncture of surrounding tissues.

Pneumothorax: A collapsed lung (pneumothorax) is a known complication, particularly during subclavian vein access. Ensuring proper technique and real-time imaging can help reduce this risk.

Hemothorax: Bleeding into the pleural space (hemothorax) may occur during central venous access, especially if there is inadvertent damage to vascular structures near the pleural cavity.

Infection: Catheter-related bloodstream infections are a significant risk associated with central lines. Adherence to strict aseptic technique, including the use of sterile drapes, gloves, and probe covers, is essential to minimize this risk.

Thrombosis: Deep vein thrombosis and catheter-related bloodstream infections can occur as a result of CVC placement. Proper placement, routine monitoring, and prompt intervention are critical in reducing this risk.

Nerve Injury: There is a risk of nerve damage, such as brachial plexus injury, during internal jugular vein catheterization. Careful visualization of anatomical landmarks using ultrasound is critical to avoid this complication.

Catheter Malposition: The catheter may be unintentionally placed in an incorrect location, leading to functional and clinical complications. Real-time imaging during and after placement can ensure proper positioning of the catheter.

Air embolism: It is a rare but serious complication associated with both peripheral and central vein catheterization, which can cause significant neurological deficits and seizures if not promptly diagnosed and treated. The pathophysiology involves air entering the venous system due to a pressure gradient between the atmosphere and the veins, which can occur during catheter insertion, maintenance, or removal. The risk of air embolism is heightened by improper patient positioning. In cases of massive air embolism, immediate interventions such as resuscitation, positioning the patient in the left lateral decubitus and Trendelenburg position, and using hyperbaric oxygen therapy or extracorporeal membrane oxygenation can be life-saving.

Hints and Pitfalls

Universal safety precautions are critical for every procedure. This includes the consistent use of personal protective equipment (PPE) and cleaning all equipment before and after use. These practices are essential to protect both the operator and the patient from harm, including the risk of infections or cross-contamination.

Preparation is paramount to ensuring procedural success and minimizing complications. Proper assessment of the target vessel, including its depth, diameter, and patency, along with setting up the necessary equipment in advance, significantly increases the chances of success during cannulation. Needle tip visualization is also crucial throughout the procedure to prevent iatrogenic injuries caused by inadvertently advancing the needle tip into non-target structures near the vessel.

If a cannulation attempt fails or if the intravenous (IV) line fails due to infiltration, subsequent attempts should ideally be made at a different site to avoid cumulative damage to the same area. If a new site cannot be used, attempts should occur proximal to the initial site.

Strategies to Reduce Complications [1-3, 7-10]

Adequate training is a cornerstone of safe and successful ultrasound-guided venous access. Providers must be proficient in real-time ultrasound guidance techniques, which allow precise needle advancement and proper placement. Additionally, sterile technique is essential during all stages of the procedure, including the use of sterile gel and probe covers to minimize infection risk.

Choosing the appropriate vein for cannulation is another key strategy to reduce complications. This decision should be based on careful vein selection, including evaluating its accessibility and suitability for the intended catheter size. Proper catheter length and size selection are equally important, with tools like the Pythagorean theorem aiding in determining the optimal catheter length for stable placement within the vessel.

Visualization of the needle tip during insertion is vital to avoid injury to surrounding structures. The long-axis approach can provide continuous visualization of the needle tip, ensuring accurate placement within the vessel lumen. After catheter placement, ultrasound can confirm the catheter’s position and patency, reducing the risk of complications such as malposition or infiltration.

Post-procedural monitoring is just as important as the procedure itself. Regular assessment of the insertion site is necessary to detect early signs of infection, thrombophlebitis, or other complications, allowing for timely intervention if needed.

Special Patient Groups

Pediatrics

US-guided venous access in pediatric patients has been shown to significantly enhance the success rates and reduce complications associated with vascular access procedures. A retrospective analysis of 1028 US-guided central vascular access procedures in children demonstrated a high success rate of 97.2%, with the left brachiocephalic vein showing a higher success rate than the right [11]. The integration of ultrasound guidance in pediatric venous access procedures is associated with improved outcomes, emphasizing its role as a preferred method in clinical practice.

Geriatrics

US-guided venous access in geriatric patients has been shown to be a highly effective and safe method for catheter placement. The use of ultrasound guidance significantly reduces failure (success rate of 96.36%) and complication rates (7.27%) [12]. US-guided peripherally inserted central catheter insertion in elderly patients also reported high success rate, with minimal complications [13]. The use of ultrasound guidance for internal jugular vein catheterization further supports its efficacy in reducing failure and complication rates for central venous port placement [14]. Overall, the integration of ultrasound guidance in venous access procedures for geriatric patients enhances safety, reliability, and patient outcomes, making it a valuable tool in the management of this vulnerable population [12-14].

Pregnant patients

US-guided venous access provides significant benefits for pregnant patients, particularly by reducing complications and improving procedural success. Real-time ultrasonographic imaging enables clear visualization of target vessels, which is especially critical in cases of challenging anatomy during pregnancy [15]. This approach aligns with the growing adoption of point-of-care ultrasound (POCUS) to enhance success rates in both peripheral and central venous catheterization. By improving patient safety and minimizing complications, ultrasound guidance has become an essential tool for optimizing venous access procedures and ensuring safer care for pregnant patients [16].

Authors

Picture of Zackary Funk

Zackary Funk

Picture of Petra Duran-Gehring

Petra Duran-Gehring

Petra Duran-Gehring M.D., graduated from medical school at LSU Health Sciences Center in New Orleans, and completed her residency in emergency medicine at the University of Florida College of Medicine – Jacksonville. She achieved certification through the American Registry of Diagnostic Medical Sonographers and founded the emergency ultrasound program for the department of emergency Medicine at UFCOMJ. She is a nationally recognized leader in emergency ultrasound education and research, including serving as co-director of the ACEP Ultrasound Management Course, and director for the SEMPA Ultrasound Course. She has lectured throughout the country, and has received numerous teaching awards. When not teaching ultrasound, she loves spending time with her husband and three young sons.

Listen to the chapter

References

  1. Duran-Gehring P. Ultrasound-Guided IV Access. The Essential Emergency Ultrasound Course; 2019. Accessed August 5, 2023.
  2. Duran-Gehring P, Bryant L, Reynolds JA, Aldridge P, Kalynych CJ, Guirgis FW. Ultrasound-Guided Peripheral Intravenous Catheter Training Results in Physician-Level Success for Emergency Department Technicians. J Ultrasound Med. 2016;35(11):2343-2352. doi:10.7863/ultra.15.11059
  3. Gottlieb M, Sundaram T, Holladay D, Nakitende D. Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of Evidence-based Best Practices. West J Emerg Med. 2017;18(6):1047-1054. doi:10.5811/westjem.2017.7.34610
  4. Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006;48(5):540-547. doi:10.1016/j.annemergmed.2006.01.011
  5. Jacobson AF, Winslow EH. Variables influencing intravenous catheter insertion difficulty and failure: an analysis of 339 intravenous catheter insertions. Heart Lung. 2005;34(5):345-359. doi:10.1016/j.hrtlng.2005.04.002
  6. Au AK, Rotte MJ, Grzybowski RJ, Ku BS, Fields JM. Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters. Am J Emerg Med. 2012;30(9):1950-1954. doi:10.1016/j.ajem.2012.04.016
  7. Shokoohi H, Armstrong P, Tansek R. Emergency department ultrasound probe infection control: challenges and solutions. Open Access Emerg Med. 2015;7:1-9. Published 2015 Jan 5. doi:10.2147/OAEM.S50360
  8. Blanco P. Ultrasound-guided peripheral venous cannulation in critically ill patients: a practical guideline. Ultrasound J. 2019;11(1):27. Published 2019 Oct 17. doi:10.1186/s13089-019-0144-5
  9. Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017;21(1):225. Published 2017 Aug 28. doi:10.1186/s13054-017-1814-y
  10. Parienti JJ, Mongardon N, Mégarbane B, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med. 2015;373(13):1220-1229. doi:10.1056/NEJMoa1500964
  11. D’Alessandro P, Siffredi JI, Redondo Pertuz E, et al. Retrospective analysis of 1028 ultrasound-guided central vascular access in neonates and children. J Vasc Access. Published online September 26, 2024. Doi:10.1177/11297298241278385
  12. Sun X, Zhang Y, Yang C, et al. Ultrasound-guided totally implantable venous access device through the right innominate vein in older patients is safe and reliable. Geriatr Gerontol Int. 2019;19(3):218-221. doi:10.1111/ggi.13611
  13. Nakano Y, Kondo T, Murohara T, Yamauchi K. Option of Using Peripherally Inserted Central Catheters in Elderly Patients With Dementia: An Observational Study. Gerontol Geriatr Med. 2020;6:2333721420906922. Published 2020 Feb 18. doi:10.1177/2333721420906922
  14. Canfora A, Mauriello C, Ferronetti A, et al. Efficacy and safety of ultrasound-guided placement of central venous port systems via the right internal jugular vein in elderly oncologic patients: our single-center experience and protocol. Aging Clin Exp Res. 2017;29(Suppl 1):127-130. doi:10.1007/s40520-016-0680-9

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Chest Pain (2024)

~ iEM Education Project Team ~ Leave a comment

by Khaled Alaboud Alkheder & Muneer Al Marzooqi

Authors
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You Have A New Patient!

A 67-year-old woman presents to the ED with acute chest pain. The pain is sharp and stabbing in nature. She feels nauseated and short of breath. The patient has a history of hypertension, type 1 diabetes mellitus, medullary thyroid cancer, coronary artery disease, and gastroesophageal reflux disease. She smoked half a pack of cigarettes daily for 19 years but quit 18 years ago. Her current medications include Lisinopril, Insulin Glargine, Insulin Aspart, Sertraline, Aspirin, and Ranitidine.

The image was produced by using ideogram 2.0.

She appears anxious and diaphoretic. Her temperature is 37.2°C, pulse is 62/min, respirations are 19/min, and blood pressure is 142/81 mmHg. The lungs are clear to auscultation. The chest wall and abdomen are non-tender. There is 5/5 strength in all extremities. The remainder of the examination shows no abnormalities.

How would you proceed, and what is the next step in management?

What Do You Need To Know?

Chest pain in the emergency department is reported to be the second most common complaint, comprising approximately 5% of all emergency department visits. It can indicate various underlying causes, and patients present with many signs and symptoms. The potential causes of chest pain include diseases affecting the heart, aorta, lungs, esophagus, stomach, mediastinum, pleura, and abdominal viscera.

Patients usually describe visceral pain as a squeezing, pressure-like, or dull type of pain. If the pain is visceral, it may also refer to other locations due to the nerves coursing through somatic nerve fibers as they reach the spinal cord. For example, ischemic heart pain may refer to the left or right shoulder, jaw, or left arm.

Clinicians in the ED focus on promptly identifying and ruling out life-threatening causes of chest pain. Patients with serious causes of chest pain may not exhibit any vital sign or physical examination abnormalities and may appear healthy [1,2].

Initial Assessment and Stabilization (ABCDE Approach)

The ABCDE approach is universally recognized as the safest and most efficient method for the initial assessment of patients in the Emergency Department (ED), particularly those presenting with chest pain [3]. This systematic approach ensures rapid identification and management of life-threatening conditions. It prioritizes the immediate stabilization of the patient while facilitating a structured evaluation process.

A – Airway: The first step involves assessing the airway for any signs of obstruction. Key indicators include the patient’s ability to speak without distress and the presence of paradoxical chest movements. Obstructions may result from conditions such as tongue swelling, lip swelling, or other factors impeding spontaneous breathing. Ensuring a patent airway is critical, as it serves as the foundation for effective oxygenation and ventilation.

B – Breathing: Next, the breathing assessment evaluates respiratory effectiveness by observing the patient’s respiratory rate (normal range: 10-20 breaths per minute), inspecting for signs of respiratory distress, and auscultating lung sounds. Findings such as basal crackles may indicate pulmonary edema, diminished breath sounds could suggest pneumothorax or pleural effusion. Each of these conditions requires prompt recognition and intervention.

C – Circulation: The circulation step focuses on identifying signs of cardiovascular compromise or shock. Clinical signs include abnormal extremity coloration (blue, pale, pink, or mottled), prolonged capillary refill time (normal is ≤2 seconds), and abnormal heart rates. Auscultation of the heart should confirm normal S1 and S2 sounds without murmurs or gallops. These findings guide the clinician in diagnosing conditions such as hypoperfusion or cardiac dysfunction. Muffled heart sounds may point toward pericardial tamponade. 

D – Disability: Assessment of the patient’s neurological status is crucial, including evaluating their level of alertness, Glasgow Coma Scale (GCS) score, and glucose levels. Any abnormalities here could indicate underlying conditions such as hypoglycemia, traumatic brain injury, or other causes of altered mental status.

E – Exposure: The final step involves fully exposing the patient to detect visible signs such as rashes, discoloration, or gross abnormalities. This step ensures that no critical findings, such as trauma or skin infections, are overlooked.

Once the primary assessment is complete, interventions should focus on managing hemodynamic instability, such as shock or hypertension. Simultaneously, secondary assessments and investigations are initiated, including obtaining IV access, performing a 12-lead ECG, and ordering relevant diagnostic tests to confirm the underlying cause of the presentation.

Medical History

When assessing a patient presenting with chest pain in the Emergency Department (ED), obtaining a thorough history is critical after ensuring the patient’s stability. Key aspects of the history should include [3,4]:

  • Onset of Pain: Determining whether the pain started abruptly or developed gradually provides valuable diagnostic clues.
  • Site of Pain: The location of the pain (e.g., substernal, localized, diffuse, chest wall, or back) can guide the identification of the underlying cause.
  • Character of Pain: Descriptions such as sharp, squeezing, or pleuritic help differentiate between cardiac, pulmonary, and musculoskeletal etiologies.
  • Radiation: Pain radiating to areas like the jaw, back, shoulder, or arm can indicate cardiac involvement.
  • Associated Symptoms: Symptoms such as diaphoresis, palpitations, dyspnea, nausea, or vomiting are important to document.
  • Timing: The pattern of the pain, whether constant or episodic, its duration, and the time of onset can help in distinguishing between various causes.
  • Exacerbating/Relieving Factors: Identifying activities or factors that provoke or alleviate the pain aids in narrowing down the diagnosis.

Pain Descriptions and Differential Diagnosis: The nature of the chest pain provides critical diagnostic insights:

  • Cardiac Origin: Pain described as “squeezing,” “crushing,” or “pressure-like” suggests cardiac ischemia or acute coronary syndrome (ACS). Pain during exertion is typical of stable angina, whereas progressive pain at rest suggests unstable angina or myocardial infarction (MI).
  • Aortic Dissection: “Tearing” pain radiating to the back is a hallmark of aortic dissection.
  • Pulmonary or Musculoskeletal Causes: “Sharp” or “stabbing” pain is often associated with pulmonary embolism, pneumothorax, or musculoskeletal disorders.
  • Gastrointestinal Causes: “Burning” or “indigestion-like” pain may originate from the gastrointestinal tract but could also signify visceral chest pain. Pain triggered by meals is more likely gastrointestinal in origin.
  • Acute Conditions: Sudden onset pain suggests conditions like aortic dissection, pulmonary embolism, or pneumothorax.

Medical Background and Risk Factors: A comprehensive medical history is essential to assess the risk for specific conditions:

  • Risk Factors for Acute Coronary Syndrome (ACS):
    • Male sex
    • Age over 55 years
    • Family history of coronary artery disease
    • Diabetes mellitus
    • Hypercholesterolemia
    • Hypertension
    • Tobacco use
  • Risk Factors for Pulmonary Embolism: Patients are at an increased risk if they have:
    • Prolonged immobilization (e.g., long-distance travel)
    • Recent surgery, especially orthopedic procedures lasting over 30 minutes
    • Central venous catheterization
    • Trauma
    • Pregnancy
    • Cancer
    • Lung or chronic heart disease
    • A personal or family history of hypercoagulability
    • Use of hormonal contraceptives or chemotherapeutic agents that increase estrogen and progestin levels

This detailed and systematic approach to history-taking allows for accurate and timely diagnosis, ensuring that critical conditions are addressed without delay.

Physical Examination

After obtaining a detailed history, a focused physical examination is crucial to identify any signs that may guide the clinician toward an accurate diagnosis. This examination combines general and systemic assessments, prioritizing findings that can point to life-threatening conditions [5,6].

General Examination and Vital Signs:

The initial step involves assessing vital signs, which often provide significant diagnostic clues:

  • Hypotension may indicate conditions such as tension pneumothorax, pulmonary embolism (PE), or acute myocardial infarction (MI).
  • Tachycardia is a nonspecific finding but is frequently seen in acute MI, PE, aortic dissection, or tension pneumothorax.
  • Hypoxemia suggests pulmonary conditions such as PE, tension pneumothorax, or simple pneumothorax.
  • Fever can be indicative of inflammatory or infectious processes, including PE, pericarditis, myocarditis, or even extrapulmonary causes like cholecystitis.

Cardiovascular Examination:

A detailed cardiovascular assessment should focus on specific findings that may narrow the differential diagnosis:

  • Significant blood pressure differences between upper extremities are a hallmark of aortic dissection.
  • Pericardial rub is a characteristic sign of pericarditis.
  • Jugular venous distension (JVD) may indicate tension pneumothorax, PE, or pericarditis with effusion.
  • Narrow pulse pressure can be associated with pericarditis with effusion, reflecting compromised cardiac output.
  • Pulsus paradoxus, an exaggerated drop in systolic blood pressure during inspiration, is a critical finding in cardiac tamponade and constrictive pericarditis.

Pulmonary Examination:

The pulmonary evaluation should focus on auscultation and observation:

  • Unilateral diminished or absent breath sounds point to tension pneumothorax or simple pneumothorax.
  • Pleural rub, a coarse grating sound, may be heard in PE, indicating pleural irritation.
  • Basal crackles (rales), particularly when bilateral, are often associated with acute MI or pulmonary edema, reflecting fluid overload or cardiac dysfunction.

Integration of Findings:

These physical examination findings must be interpreted in the context of the patient’s history and associated risk factors. For example:

  • A patient presenting with hypoxemia, tachycardia, and JVD warrants an immediate evaluation for PE.
  • Tension pneumothorax should be suspected in cases with hypotension, unilateral absent breath sounds, and JVD.
  • Signs of basal crackles and a pericardial rub may point to a combination of acute MI and pericarditis, necessitating rapid interventions.

By systematically combining history with these focused examination findings, clinicians can efficiently narrow their differential diagnosis and prioritize further investigations and treatments. This structured approach ensures that life-threatening conditions are promptly identified and managed.

When To Ask for Senior Help

Remember that senior residents and attendings supervise you when working in the emergency department. It is important to ask for their help when needed, especially when a patient with chest pain arrives [6]. The following are situations when you need to call for help immediately in a patient with chest pain:

  • Patients clenching their chest with ongoing chest pain and diaphoresis.
  • Chest pain with severe shortness of breath and evidence of pulmonary edema.
  • Chest pain with hypotension.
  • Chest pain with severe bradycardia or tachycardia.
  • Chest pain followed by unresponsiveness.

These examples exhibit life-threatening features of chest pain that can be lethal within minutes. You must call for help, and the team will be assembled to care for the patient and administer lifesaving interventions.

Alternative Diagnoses

Chest pain is a common presentation in the Emergency Department (ED) and requires a systematic and thorough approach to rule out life-threatening conditions. These diagnoses must be prioritized in the differential diagnosis as they carry significant morbidity and mortality if not identified and managed promptly [1,6].

Life-Threatening Diagnoses:

  1. Acute Coronary Syndrome (ACS): ACS encompasses conditions such as unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). These result from ischemia due to decreased myocardial oxygen supply, often caused by atherosclerotic plaque rupture. Rapid identification through ECG and biomarkers is critical to initiate timely treatment.

  2. Acute Aortic Dissection: This condition arises when a tear in the intimal layer of the aorta allows blood to flow between the layers, creating a false lumen. Patients often present with severe, tearing chest or back pain and may have a significant difference in blood pressure between the upper extremities. Early diagnosis via imaging such as CT angiography is essential to prevent fatal rupture.

  3. Pulmonary Embolism (PE): PE results from the occlusion of pulmonary arteries by thromboemboli, often originating from deep vein thrombosis (DVT). Symptoms include sudden onset dyspnea, chest pain, and hypoxemia. Clinical suspicion should be high in patients with risk factors like prolonged immobilization, recent surgery, or hypercoagulable states.

  4. Tension Pneumothorax: This is a critical condition where air accumulates in the pleural space under pressure, compressing the lungs and mediastinum. Patients may present with hypotension, respiratory distress, and absent breath sounds on the affected side. Immediate needle decompression is lifesaving.

  5. Pericardial Tamponade: This occurs when fluid accumulates in the pericardial sac, impairing cardiac filling and output. Classic findings include hypotension, jugular venous distension, and muffled heart sounds (Beck’s triad). Pulsus paradoxus is another critical clue. Echocardiography confirms the diagnosis, and pericardiocentesis is the treatment.

  6. Esophageal Rupture with Mediastinitis: Esophageal rupture, also known as Boerhaave syndrome, can lead to mediastinitis due to leakage of gastric contents into the mediastinum. Patients typically present with severe chest pain following vomiting, subcutaneous emphysema, and signs of sepsis. Prompt surgical intervention is required.

Other Diagnoses to Consider:

  1. Simple Pneumothorax: Unlike tension pneumothorax, simple pneumothorax lacks hemodynamic compromise but still requires prompt recognition. Patients may present with pleuritic chest pain and diminished breath sounds on the affected side. Treatment typically involves observation or chest tube placement, depending on severity.

  2. Pericarditis: This inflammatory condition of the pericardium often presents with sharp, pleuritic chest pain that is relieved by sitting up and leaning forward. A pericardial rub is the hallmark auscultatory finding. ECG changes, including diffuse ST elevation, aid in the diagnosis. Most cases are viral and self-limiting, though complications like effusion and tamponade must be monitored.

Acing Diagnostic Testing

To accurately diagnose the cause of chest pain, a combination of bedside tests and advanced investigations are essential. These tests provide critical information that can guide immediate management, particularly in identifying life-threatening conditions [1,2].

Bedside Tests

Electrocardiogram (ECG):

The 12-lead ECG is a cornerstone of chest pain evaluation and must be performed within 10 minutes of the patient’s presentation or EMS arrival. It aids in identifying acute coronary syndromes (ACS), including ST-elevation myocardial infarction (STEMI).

STEMI Criteria:
  • General Criteria: At least 1 mm of ST elevation in two contiguous leads, excluding V2 and V3.
  • Specific Criteria for V2 and V3 ST Elevation:
    • Women: ≥1.5 mm elevation.
    • Men <40 years: ≥2.5 mm elevation.
    • Men ≥40 years: ≥2 mm elevation.
Source: Hernandez JM, Glembocki MM, McCoy MA. Increasing Nursing Knowledge of ST-Elevated Myocardial Infarction Recognition on 12-Lead Electrocardiograms to Improve Patient Outcomes. The Journal of Continuing Education in Nursing. 2019;50(10):475-480. doi:10.3928/00220124-20190917-10
Inferior ST segment elevations with anterior and lateral reciprocal changes. Inferior MI, so the right side of the heart should be evaluated with right side chest leads. V2 ST depression is very prominent, therefore, posterior leads should be applied form V7 to V12 for the left side.
43 years-old patients with left sided chest pain. Courtesy of Khaled Alaboud Alkheder and Muneer Al Marzooqi
Clinical Interpretation of the ECG above:
  • For instance, an ECG from a 43-year-old male presenting with severe left-sided chest pain showed ST elevation in anteroseptal leads (V1-V4) with J point elevation >2 mm and reciprocal ST depression in inferior leads, indicative of an acute anterior STEMI. This finding underscores the importance of identifying patterns such as J point elevation, which marks the transition between the QRS complex and the ST segment.

ECG Limitations and Additional Considerations:

  • While some patients exhibit a classic STEMI pattern, many may present with a normal or non-diagnostic ECG. A normal ECG at admission cannot rule out ACS or other conditions, necessitating further testing if clinical suspicion remains high.
  • If the initial ECG is inconclusive, it should be repeated after a 10-minute interval, especially if chest pain recurs.
  • Additional leads should be utilized when clinical suspicion exists for specific myocardial infarctions:
    • Posterior leads (V7-V9): For suspected posterior MI.
    • Right-sided leads (V3R and V4R): For patients with acute inferior MI, to assess for right ventricular involvement.
  • In suspected pulmonary embolism (PE), the S1Q3T3 pattern (prominent S wave in lead I, Q wave in lead III, and inverted T wave in lead III) may suggest right heart strain, though it is neither sensitive nor specific for PE [5].
S1Q3T3 - Courtesy of Khaled Alaboud Alkheder and Muneer Al Marzooqi
ECG 54-yo male chest pain for the last 3 days. S1 Q3 T3, Tachycardia, minor ST depressions on lateral leads (V5-6)

The ECG is a highly valuable tool for ruling in STEMI or other acute conditions. However, its limitations in ruling out conditions underscore the necessity of adjunct investigations and clinical correlation. For example, repeated ECGs, additional lead placements, and further imaging or lab tests (such as cardiac biomarkers or D-dimer for PE suspicion) ensure comprehensive evaluation and timely intervention.

By systematically incorporating these investigative steps into the diagnostic process, clinicians can optimize patient outcomes and address the underlying etiology of chest pain effectively.

Laboratory Tests

In the assessment of patients presenting with chest pain, laboratory investigations play a crucial role in diagnosing life-threatening conditions such as acute myocardial infarction (AMI) and pulmonary embolism (PE). Among the most valuable tests are cardiac troponins and D-dimer levels, each serving distinct purposes based on clinical suspicion and patient presentation.

Cardiac Troponins:

  • Utility in AMI Diagnosis:
    Cardiac troponins, specifically high-sensitivity troponin I and T, are the preferred laboratory markers for diagnosing AMI. These biomarkers can reliably detect myocardial injury within 3 hours of symptom onset. Their high sensitivity and specificity make them the gold standard in confirming myocardial infarction (MI).

  • Role in Ruling Out MI:
    While cardiac troponins are essential for diagnosing AMI, a single set of negative cardiac enzyme results is insufficient to rule out MI, especially in early presentations. However, in patients presenting with chest pain lasting over 2 hours, a single undetectable troponin T level can help exclude MI in certain cases [1].

  • Detection of Unstable Angina:
    High-sensitivity troponin assays can also detect subtle elevations associated with unstable angina, aiding in the identification of patients at risk for adverse cardiac events. However, serial testing may be required to observe trends and confirm the diagnosis.

D-Dimer:

  • Screening for Pulmonary Embolism (PE):
    D-dimer testing is particularly valuable in patients with suspected PE. In low-risk patients, a negative D-dimer test effectively rules out PE, eliminating the need for further imaging.

  • High-Risk Patients:
    Patients identified as high-risk based on clinical assessment or pretest probability should proceed directly to diagnostic imaging, such as computed tomography pulmonary angiography (CTPA). Similarly, patients with an intermediate or high pretest probability should not rely solely on D-dimer results but instead undergo confirmatory imaging [5].

These laboratory investigations provide critical insights when integrated with clinical findings and other diagnostic tools. For example:

  • In patients presenting with prolonged chest pain and an elevated troponin level, AMI is highly likely, warranting immediate intervention.
  • Conversely, in patients with a low-risk Wells score for PE and a negative D-dimer, further imaging can be safely avoided, reducing unnecessary radiation exposure and costs.

Imaging

In the assessment of chest pain, imaging plays a pivotal role in identifying life-threatening conditions and narrowing the differential diagnosis. A combination of imaging techniques can provide vital insights into both cardiac and non-cardiac causes of chest pain.

Chest X-Ray

  • Role in Emergency Evaluations:
    Chest X-rays are widely used in emergency departments as an initial imaging modality. They are particularly useful for identifying acute and life-threatening conditions, including pericardial effusion, acute aortic dissection, pulmonary embolism (PE), pneumothorax, and pneumonia.

    • Timeliness: In cases of high clinical suspicion, a chest X-ray should be performed and interpreted within 30 minutes to avoid delays in diagnosis and treatment.

  • Limitations:
    While chest X-rays are a valuable starting point, their sensitivity and specificity may be limited for certain conditions, necessitating further imaging in many cases.

Significant dilation and tortuosity of the aortic arch and descending aorta, exerting a mass effect on the trachea, causing rightward displacement and mild narrowing. Despite the patient's rightward rotation, a degree of mediastinal shift toward the left is observed. There are increased interstitial markings throughout both lungs, along with left apical pleural capping. - Source: Hacking C Large thoracic aortic aneurysm. Case study, Radiopaedia.org (Accessed on 31 Dec 2024) https://doi.org/10.53347/rID-73356
Pneumothorax on the left side (courtesy of Mohd Mokhtar and Raja Ahmad)
Ultrasonography

  • Advantages of POCUS:
    Point-of-care ultrasound has become an indispensable tool in emergency settings due to its rapid and dynamic assessment capabilities. It can evaluate both cardiac and non-cardiac causes of chest pain with high accuracy.

  • Cardiac Applications:

    • Detection of pericardial effusion and cardiac tamponade is a primary use of POCUS.

    • Example: A significant pericardial effusion may appear as a fluid collection around the heart, as visualized in Figure 5.

  • Pulmonary Applications:

    • POCUS has a higher sensitivity and specificity than chest X-rays for detecting pleural effusion and pneumothorax.

    • Pneumothorax Findings: The absence of the seashore sign (lung sliding) and the presence of the barcode sign on M-mode ultrasound strongly suggest pneumothorax.

    • Acute Heart Failure Findings: In cases of acute ischemic chest pain, lung B-lines detected on ultrasound indicate pulmonary edema due to heart failure.

Subxiphoid 4 Chambers View. PE = Pericardial Effusion, RV = Right Ventricle, LV = Left Ventricle
CT Pulmonary Angiography (CTPA)

  • Gold Standard for PE Diagnosis:
    CT pulmonary angiography (CTPA) is the imaging modality of choice for diagnosing acute pulmonary embolism (PE). Its high sensitivity and specificity make it invaluable for confirming or excluding PE in patients with high clinical suspicion.

  • Additional Findings:
    Beyond diagnosing PE, CTPA can reveal other significant pathologies, including [3,5]:

    • Pneumonia
    • Pericardial abnormalities
    • Musculoskeletal injuries
Pulmonary Embolism - Bilateral thrombus in main pulmonary arteries

Management

Patients presenting with typical chest pain are at a high risk of having Acute Coronary Syndrome. Empiric and symptomatic treatment is paramount in the ED to help control the situation and alleviate the patient’s pain. A common mnemonic used is (MONA), where patients can be given Morphine, which is an opiate, to help relieve the pain. Oxygen supplementation is recommended, but studies have shown that hyperoxygenation and hyperoxia are harmful and can lead to oxygen radicals; therefore, patients are maintained with oxygen saturation between 94–96% [2,6].

As a sublingual administration, Nitroglycerin is used to overcome coronary vasospasm and helps with vasodilation of the coronary vessels to improve blood flow to the myocardium and relieve ischemic chest pain. Finally, Aspirin, as an antiplatelet agent, is used empirically to prevent further clot formation and is one of the mainstay treatments when Acute Coronary Syndrome is suspected.

Aspirin

Dose: 162 to 325 mg in cases of acute coronary syndrome (ACS).
Frequency: Single dose.
Maximum Dose: 4 grams in 24 hours.
Category in Pregnancy: Category C.
Cautions/Comments: Prior to administration, check for allergies, bleeding disorders, or a history of bleeding gastrointestinal (GI) ulcers, as these conditions contraindicate the use of aspirin.

Nitroglycerin (Sublingual or Puffs)

Dose: For sublingual tablets, 0.4 mg per dose. For metered spray, 400 mcg of nitroglycerin per puff.
Frequency: For sublingual administration, up to 3 doses; for puffs, administer every 5 minutes with no more than 3 sprays in a 15-minute period.
Maximum Dose: Up to 3 doses (sublingual) or sprays (puffs) within a 15-minute period.
Category in Pregnancy: Category C.
Cautions/Comments: Nitroglycerin may cause hypotension, particularly with an upright posture. It is contraindicated in patients using phosphodiesterase inhibitors (e.g., for erectile dysfunction).

Morphine

Dose: 4 to 10 mg.
Frequency: Administer 2.5 to 5 mg every 3-4 hours as needed (PRN) or infused over 4-5 minutes.
Maximum Dose: 0.1 to 0.2 mg/kg.
Category in Pregnancy: Classified as Category CFR (consult further resources for more information).
Cautions/Comments: Monitor patients for respiratory depression. Co-ingestion with alcohol increases the risk of a fatal overdose and should be avoided.

Special Patient Groups

Pediatrics

Chest pain in children presenting to the emergency department can be a challenging clinical scenario, as it often raises concerns about serious underlying conditions, including cardiac issues, although they are relatively rare in this population. The differential diagnosis for pediatric chest pain includes musculoskeletal pain, respiratory conditions, gastrointestinal issues, and, less commonly, cardiac abnormalities such as myocarditis or pericarditis [7]. A thorough history and physical examination are essential to differentiate between these causes, considering factors such as the nature of the pain, associated symptoms, and the child’s medical history [8]. While most cases of chest pain in children are benign, it is crucial for healthcare providers to maintain a high index of suspicion and to utilize appropriate diagnostic tools, such as electrocardiograms and imaging studies, when indicated [9].

Pregnant Patients

Aortic dissection in pregnant patients is a rare but critical condition that necessitates swift recognition and management in the emergency department. Pregnancy itself can act as an independent risk factor for aortic dissection, particularly in women with preexisting connective tissue disorders, Turner’s syndrome, or a bicuspid aortic valve [35]. The physiological changes during pregnancy, such as increased blood volume and hormonal influences, may exacerbate underlying vascular conditions, leading to dissection [36]. Upon diagnosis, immediate treatment is crucial; intravenous nitroprusside and a β-blocker should be initiated to control blood pressure and reduce shear stress on the aorta [37]. Surgical intervention is mandatory for type A dissections, which pose a higher risk of mortality [38]. Furthermore, obstetric management must be tailored to the patient’s condition, with specific recommendations for cesarean delivery and gestational age based on the size of the aortic root [39]. Close collaboration with an obstetrician/gynecologist is essential for ongoing care and monitoring throughout the pregnancy [40,41].

Geriatrics

Older adults often experience less classic symptoms of myocardial infarction, such as chest pressure or pain, and may instead report vague symptoms like fatigue, shortness of breath, or confusion, which can complicate diagnosis [14]. Additionally, the presence of multiple chronic conditions may lead to an increased risk of complications and poorer outcomes [15]. Timely and accurate assessment is critical, as delays in diagnosis can significantly impact morbidity and mortality rates in this population [16]. Therefore, a high index of suspicion and thorough evaluation, including appropriate imaging and laboratory tests, are essential in managing chest pain in geriatric patients effectively [17].

When To Admit This Patient

Disposition decisions for patients presenting with chest pain in the emergency department (ED) are critical for ensuring appropriate care and minimizing the risk of adverse cardiovascular events. According to guidelines established by the American College of Cardiology and the American Heart Association (ACC/AHA), patients exhibiting high-risk features, such as ST-segment elevation on an electrocardiogram (ECG), hemodynamic instability, or signs of heart failure, should generally be admitted to the hospital for further evaluation and management [18]. Additionally, those presenting with intermediate-risk features—such as abnormal ECG readings, elevated cardiac biomarkers like troponin, or a history of coronary artery disease—also warrant hospitalization [19]. Conversely, low-risk patients, characterized by a normal ECG and negative cardiac biomarkers, may be safely discharged based on clinical judgment and validated risk stratification tools [19]. Ultimately, the decision to admit a patient with chest pain hinges on a comprehensive assessment of their symptoms, medical history, and individual risk factors for serious cardiovascular events, ensuring that high-risk patients receive the necessary care while minimizing unnecessary hospitalizations for those at lower risk [20].

Risk Stratification

The HEART Score is a clinical tool used to evaluate the risk of major adverse cardiac events (MACE) in patients presenting with chest pain. It assesses five key components: history, ECG findings, age, risk factors, and troponin levels, with each category assigned a score ranging from 0 to 2 points. The total score determines the level of risk and guides subsequent management.

History is assessed based on clinical suspicion. A highly suspicious history earns 2 points, a moderately suspicious history scores 1 point, and a slightly or non-suspicious history scores 0 points. This subjective component emphasizes the importance of a thorough clinical evaluation.

ECG findings are evaluated next. Significant ST-depression earns 2 points, nonspecific repolarization changes score 1 point, and a normal ECG scores 0 points. This category highlights the significance of electrocardiographic abnormalities in cardiac risk stratification.

Age is another important factor. Patients aged 65 years or older receive 2 points, those aged between 45 and 65 years earn 1 point, and patients 45 years or younger score 0 points, reflecting the age-related risk of cardiac events.

Risk factors are categorized based on their number and severity. Patients with three or more risk factors or a history of coronary artery disease (CAD) receive 2 points. Those with one or two risk factors score 1 point, while individuals with no risk factors score 0 points. Risk factors include diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLP), smoking (current or recent), obesity, and a family history of CAD.

Troponin levels are also considered. Levels three or more times the normal limit score 2 points, levels one to three times the normal limit earn 1 point, and normal troponin levels score 0 points. This biomarker is critical in identifying myocardial injury.

The total HEART Score helps categorize patients into low, moderate, or high risk for MACE over the next six weeks. A score of 0-3 corresponds to a 2.5% risk and suggests discharge home. A score of 4-6 indicates a 20.3% risk, warranting clinical observation. Scores of 7-10 reflect a 72.7% risk, prompting early invasive strategies. This systematic approach helps clinicians make evidence-based decisions for managing patients with chest pain.

Each variable is scored from 0 to 2, allowing for a comprehensive assessment of the patient’s risk profile. For instance, the patient’s history is examined for indicators of coronary artery disease (CAD), while the ECG is scrutinized for signs of ischemia, such as ST-segment depression [21]. Age is considered a significant risk factor, as older patients are at higher risk for CAD, and the presence of additional risk factors like hypertension, hyperlipidemia, smoking, and diabetes further elevates this risk [22]. Elevated troponin levels serve as a critical marker for myocardial ischemia or infarction. The total HEART score, ranging from 0 to 10, categorizes patients into different risk levels, guiding management decisions regarding further testing, hospitalization, or early discharge [23]. However, it is essential to use the HEART score in conjunction with clinical judgment, as it should not be the sole determinant in decision-making processes [24].

Revisiting Your Patient

The patient had presented with complaints of chest pain, shortness of breath, diaphoresis, and nausea, raising the suspicion of Acute Coronary Syndrome and possible Myocardial Infarction. This suspicion had been supported by her significant risk factors, which included insulin-dependent diabetes mellitus, hypertension, a 12-pack-year smoking history, and a history of ischemic heart disease.

Initial stabilization measures had been promptly undertaken. The patient had been placed in a monitored bed and connected to a cardiac monitor. The ABCDE approach had been followed, and it had been noted that she was vitally stable. A quick history had been obtained, which revealed a sudden onset of central chest pain, described as sharp and stabbing, accompanied by diaphoresis and nausea. On physical examination, equal air entry had been observed with no wheeze or crackles on chest auscultation. A cardiovascular examination had also been planned.

Based on the initial presentation and clinical findings, a cardiac workup had been deemed necessary. This included ordering Troponin T and I tests, performing a 12-lead ECG, and obtaining a portable chest X-ray to rule out potential complications such as congestive heart failure, pneumonia, or pneumothorax.

Therapeutic interventions had been initiated promptly. The patient had been started on supplemental oxygen via a nasal cannula or face mask. Analgesics had been administered while ensuring no contraindications or allergies were present. These included IV paracetamol, IV opioids such as morphine or fentanyl, and sublingual nitroglycerin, either as a puff or tablet. These measures had been aimed at relieving the patient’s symptoms and stabilizing her condition.

Authors

Picture of Khaled Alaboud Alkheder

Khaled Alaboud Alkheder

Tawam Hospital Emergency Medicine Residency Program, United Arab Emirates

Picture of Muneer Abdulla Al Marzooqi

Muneer Abdulla Al Marzooqi

Dr. Muneer is a Consultant Emergency Medicine Physician from the UAE. He completed his EM residency at Tawam Hospital in 2017 and has served as an attending physician and educator there since. He is the Program Director of the Emergency Medicine Residency Program at Tawam Hospital, focusing on medical education, peer development, EM Resuscitation, Simulation, and POCUS. Dr. Muneer has organized and lectured at various seminars and workshops in the MENA region for medical students, residents, and healthcare professionals, including Basic Ultrasound, POCUS, Airway, Suturing, ENT Emergencies Workshops, and the Chief Resident Leadership Program.

Listen to the chapter

References

  1. Stepinska J, Lettino M, Ahrens I, et al. Diagnosis and risk stratification of chest pain patients in the emergency department: focus on acute coronary syndromes. Eur Heart J Acute Cardiovasc Care. 2020;9(1):76-89. doi:10.1177/2048872619885346.
  2. Hollander JE, Chase M. Evaluation of the adult with chest pain in the emergency department. In: Post TW, ed. UpToDate. UpToDate; 2022. Accessed April 26, 2023. www.uptodate.com.
  3. Malik MB, Gopal S. Cardiac Exam. In: StatPearls. StatPearls Publishing; 2021. Accessed April 26, 2023. https://www.ncbi.nlm.nih.gov/books/NBK553078/
  4. Resuscitation Council UK. The ABCDE approach. Resuscitation Council UK. Published 2021. Accessed April 26, 2023. https://www.resus.org.uk/library/abcde-approach
  5. Thompson BT, Kabrhel C, Pena C. Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism. In: Post TW, ed. UpToDate. UpToDate; 2022. Accessed April 26, 2023. www.uptodate.com.
  6. Brown JE. Chest Pain. In: Walls R, Hockberger R, Gausche-Hill M, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Elsevier; 2022:202-210.
  7. Ravindranath S, et al. Chest Pain in Children: A Review. Pediatrics. 2017;140(3):e20173032.
  8. Baker R, et al. Pediatric Chest Pain: A Review of the Literature. J Emerg Med. 2020;58(5):738-746.
  9. Glickstein JS, et al. Evaluating Chest Pain in the Pediatric Emergency Department. Pediatr Emerg Care. 2019;35(4):233-238.
  10. Hoffman MK, et al. Chest Pain in Pregnancy: A Review. Am J Obstet Gynecol. 2020;222(5):453-460.
  11. Hernandez AF, et al. Acute Coronary Syndrome in Pregnancy: A Comprehensive Review. Circulation. 2021;143(6):545-558.
  12. Miller JM, et al. Noninvasive Cardiac Imaging in Pregnancy: Safety and Efficacy. J Am Coll Cardiol. 2019;73(2):234-243.
  13. Bennett KJ, et al. Collaborative Care Models in Managing Cardiovascular Disease in Pregnant Women. Obstet Gynecol. 2022;139(4):678-689.
  14. Hernandez AF, et al. Atypical Presentations of Myocardial Infarction in Older Adults. J Geriatr Cardiol. 2022.
  15. McCarthy MJ, et al. Comorbidities and Outcomes in Elderly Patients with Chest Pain. Emerg Med J. 2023.
  16. Huang WC, et al. Impact of Delayed Diagnosis on Outcomes of Chest Pain in Older Adults. Am J Emerg Med. 2021.
  17. Lee JH, et al. Evaluation and Management of Chest Pain in Geriatric Patients. Clin Geriatr. 2023.
  18. Amsterdam EA, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. Circulation. 2014;130(25):e344-e426.
  19. Morrow DA, et al. Acute Coronary Syndromes: A Review of Current Guidelines. J Am Coll Cardiol. 2013;62(12):1103-1110.
  20. Fihn SD, et al. 2014 ACC/AHA/ACP/PCNA/SCAI/STS Focused Update of the Guideline for the Management of Patients with Stable Ischemic Heart Disease. J Am Coll Cardiol. 2014;64(18):1929-1949.
  21. Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153-2158.
  22. Kahwati LC, Weber RP, Pan H, et al. Screening for Coronary Artery Disease: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2016;165(7):485-495.
  23. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol. 2013;12(3):121-126.
  24. Böhm M, Reil JC, Tschöpe C. The HEART score: a new tool for risk stratification in acute chest pain. Clin Res Cardiol. 2018;107(9):746-754.

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Out of Proportion: Acute Leg Pain

~ J. Austin Lee, USA ~ Leave a comment

Case Presentation

A 48-year-old male, with history of hypertension and diabetes and prior intravenous drug use (now on methadone) presents with acute onset right leg pain from his calf to the ankle, that woke him from sleep overnight. The pain has been constant, with no modifying or relieving factors. He hasn’t taken anything other than his daily dose of methadone. He hasn’t had any fevers or chills and denies any recent trauma or injuries.

Any thoughts on what else you might want to ask or know?

  • Any recent travel or prolonged immobilization?
  • Have you ever had a blood clot?
  • Are you on any blood thinners?
  • Have you used IV drugs recently?
  • Any numbness or weakness in your leg?
  • Any associated rash or color change?
  • Any back pain or abdominal pain? Any bowel or bladder incontinence?
  • Any recent antibiotics (or other medication changes)?
  • Have you ever had anything like this before?
[all of these are negative/normal]

Pause here -- what is your initial differential diagnosis looking like?

  • Deep vein thrombosis
  • Superficial vein thrombosis
  • Pyomyositis
  • Necrotizing fasciitis
  • Muscle sprain or tear
  • Arterial thromboembolism
  • Bakers cyst
  • Achilles tendonitis, Achilles tendon rupture

What are some key parts of your targeted physical exam?

  • VITAL SIGNS! [BP was slightly hypertensive, and he is slightly tachycardic, normothermic]
  • Neurologic exam of the affected extremity (motor and sensory)
  • Vascular exam of the affected extremity (femoral/popliteal/posterior tibialis/dorsalis pedis)
  • Musculoskeletal exam including ranging the hip, knee, ankle and palpating throughout the entire leg
  • Skin exam for signs of injury or rashes etc.
  • Consider a cardiopulmonary and abdominal exam, particularly the lower abdomen

On this patient’s exam, he was overall uncomfortable appearing and had slight tachycardia (110s, EKG shows normal sinus rhythm), normal cardiopulmonary exam, normal abdominal exam. He had a 2+ right femoral pulse and faintly palpable DP pulse that had a good biphasic waveform on doppler. His hip/knee/ankle all have painless range of motion. The compartments are soft in the upper and lower leg. He does have some diffuse calf tenderness and the medial aspect feels slightly cool compared to the contralateral side, but his foot is warm and well perfused. There isn’t any spot that is most tender. There is no rash, no crepitus, no bullae or bruising or other evidence of injury.

What diagnostic studies would you like to send?

  • CBC, BMP
  • CPK, lactate
  • DVT ultrasound?
  • Anything else?

What treatments would you like to provide?

  • Analgesia (mutli-modal)?
  • Maybe a bolus of IV fluids to help with the tachycardia?

The patient is having a lot of pain despite already getting NSAIDs, acetaminophen, and a dose of morphine. You decide to re-medicate the patient with more morphine and send him for DVT ultrasound. As soon as he gets back, he’s frustrated that you still haven’t treated his pain “at all” and he really does look uncomfortable and in a lot of pain.  You start to wonder if he’s faking it giving his history of IV drug use.

His DVT ultrasound comes back as normal. The lab work is also coming back and unrevealing. A normal CBC, metabolic panel, normal CPK, normal lactate. His pain is not really improving. You reexamine the leg, and the exam is unchanged. It really seems like his pain is out of proportion to the exam.

Pain is out of proportion to the exam should catch your attention every time. While we always need to keep malingering and less emergent causes for pain that seems to be more than expected in the back of our minds. But! Several emergent diagnoses have patients presenting in pain in a way that doesn’t fit what you can objectively identify as a cause. Diagnoses like compartment syndrome and mesenteric ischemia can be erroneously dismissed by emergency providers, and it is crucial you don’t just stop looking for the cause of pain out of proportion. In fact, it’s important you dig in deeper and rule out all potentially life and limb threatening causes.

In this case, the pain was recalcitrant to multiple doses of IV opiates and several other modes of treatment. The patient was getting so frustrated that he pulled out his IV and threatened to leave the ED. After talking with him further, he agreed to stay and a new IV was placed, more pain medication given, and a CTA with lower extremity run-off was performed, which showed the acute thrombus of the proximal popliteal artery, just below the level of the knee.

He was started on a heparin infusion and vascular surgery was consulted; the patient was admitted from the ED and taken for thrombectomy. No source of embolism was identified, and his occlusion was presumed to be thrombotic (most commonly from a ruptured atheromatous plaque leading to activation of the coagulation cascade), with particular attention to his history of diabetes and hypertension raising his risk for this. He had a fair amount of collateralization from other arteries around the occlusion, such that his foot wasn’t cold, and he had a doppler-able DP pulse. 

Remember

Go with your gut and don’t minimize pain that is out of proportion to the exam. Keep hunting for a reasonable explanation or you may miss a life or limb threatening cause of an atypical emergency presentation.

Further Reading

Deep Vein Thrombosis (DVT)

July 14, 2018 No Comments

by Elif Dilek Cakal Case Presentation An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2

Read More »

Acute Mesenteric Ischemia

July 1, 2018 No Comments

by Rabind Antony Charles Case Presentation A 75-year-old woman presents to your Emergency Department (ED) with diffuse abdominal pain for the past day, associated with

Read More »

Abdominal Pain

April 29, 2018 2 Comments

by Shaza Karrar Case Presentation A 39-year-old female presented to the emergency department (ED) complaining of right-lower-quadrant (RLQ) pain; pain duration was for 1-day, associated

Read More »
[cite]

Question Of The Day #17

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod17

Which of the following is the most likely cause for the patient’s elevated cardiac troponin level in the emergency department?

  • A) Atrial fibrillation with rapid rate
  • B) Patient age
  • C) Sepsis
  • D) Acute coronary syndrome

Elevated cardiac troponin levels, or troponinemia, are one sign that the myocardium may be infarcting or under some type of stressful condition. Cardiac troponin levels are assessed in conjunction with the clinical history, physical exam, EKG, and another laboratory testing in deciding if troponinemia is due to cardiac ischemia or another condition. Conditions associated with elevated cardiac troponin levels include cardiac ischemia (i.e. STEMI, NSTEMI), cardiac contusion, cardiac procedures, congestive heart failure, renal failure, aortic dissection, tachy- or bradyarrhythmias, rhabdomyolysis with cardiac injury, Takotsubo syndrome, pulmonary embolism, acute stroke, myocarditis, sepsis, severe burns, extreme exertion, and other conditions. It is unlikely that this patient had elevated troponin levels from Acute coronary syndrome (Choice D) as her cardiac catheterization results showed no significant occlusive lesions in the coronary arteries. D-Dimer levels do increase with patient age, but cardiac troponin levels do not increase with patient age (Choice B). Sepsis (Choice C) is a cause for elevated troponin levels, but this patient has no clinical signs or sepsis symptoms. Atrial fibrillation with a rapid rate (Choice A) is the most likely cause of this patient’s elevated troponin level. Correct Answer: A 

Want Another Question?

References

[cite]

You may want to read these

Acute Coronary Syndrome – https://iem-student.org/acute-coronary-syndome-acs/ 

Acute Management Of Supraventricular Tachycardias – https://iem-student.org/2020/01/10/acute-management-of-supraventricular-tachycardias/

Deadly ECG Patterns – 5 Can’t Miss ECG Findings – https://iem-student.org/2019/11/22/deadly-ecg-patterns-5-cant-miss-ecg-findings/

Cardiac Monitoring – https://iem-student.org/cardiac-monitoring/

Question Of The Day #16

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod16

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) Consult general surgery for exploratory laparotomy
  • B) Apply needle decompression of the chest
  • C) Apply Pericardiocentesis
  • D) Order CT scan of chest, abdomen, and pelvis

This patient sustained a penetrating traumatic injury to the left chest and presented to the emergency department with hemodynamic instability (tachycardic and hypotensive). Some differential diagnoses to consider on arrival include tension pneumothorax, cardiac tamponade, aortic injury, or aero-digestive tract injury. Prior to taking a detailed history on any trauma patient, a primary survey should be performed. The goal of the primary survey in a trauma patient is to identify and treat any life-threatening injuries as soon as possible. The primary survey is also known as the “ABCs.” Sometimes it is referred to as the “ABCDEFs.” This acronym stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (How to learn eFAST exam for free). Each letter is addressed and assessed in the order they exist in the alphabet. This creates a methodical, algorithmic approach to assist the practitioner in assessing the trauma patient for life-threatening injuries. The sonographic view shown in this question is the subxiphoid (cardiac) view and demonstrates the presence of free fluid. Free fluid on ultrasound appears black, or “anechoic” and is assumed to be blood in the setting of trauma. The free fluid is highlighted by red stars in the image below. The collapse of the right ventricle is shown by the yellow arrow in the below image.

cardiac tamponade - explained
SS Video 3 Pericardial Tamponade

In conjunction with hemodynamic instability and a history of penetrating chest trauma, this sonographic view strongly supports the diagnosis of cardiac tamponade. Consulting the general surgery team for exploratory laparotomy (Choice A) would be the correct course of action for a patient with hemodynamic instability and free fluid on the other abdominal views of the FAST exam. Needle decompression of the chest (Choice B) would be the correct initial treatment for a tension pneumothorax. The patient described in the case has clear bilateral lung sounds, no tracheal deviation mentioned, normal O2 saturation on room air, and sonographic demonstration of cardiac tamponade. A CT scan of the chest, abdomen, and pelvis (Choice D) would be indicated in this patient if he had normal vital signs and no free fluid on the FAST exam. A pericardiocentesis (Choice C) is the most appropriate next step in the management of this patient with cardiac tamponade to relieve signs of obstructive shock. It should be noted that this procedure has limitations and is not always effective. Pericardiocentesis is a temporizing treatment with pericardiotomy being the definitive therapy. Blood in an acute hemopericardium may clot and be unable to be aspirated with a large-bore needle. The procedure may injure surrounding organs, such as the liver, intestines, or heart itself. Ultrasound-guidance should be used whenever possible to avoid injury to surrounding organs. Emergent thoracotomy to relieve the cardiac tamponade should be performed on any patient with confirmed cardiac tamponade and cardiac arrest in the Emergency Department. Correct Answer: C

References

[cite]

You may want to read these

Pulmonary Embolism – https://iem-student.org/pulmonary-embolism/

Clinical Decision Rules – https://iem-student.org/clinical-decision-rules/

Question of The Day #6 – https://iem-student.org/2020/07/31/question-of-the-day-6/

Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol US Imaging – Illustrations

~ Murat Yazici, Turkey ~ Leave a comment

Patients with hypotension or shock have high mortality rates, and traditional physical exam techniques can be misleading. Diagnosis and initial care must be accurate and prompt to optimize patient care. Ultrasound is ideal for evaluating critically ill patients in shock, and ACEP guidelines now delineate a new category of ultrasound (US)– “resuscitative.” Bedside US allows for direct visualization of pathology and differentiation of shock states (1). The RUSH is one of the most commonly used protocols for this purpose.

The RUSH exam involves a 3-part bedside physiologic assessment simplified as “the pump,” “the tank,” and “the pipes” (2).

Rush steps and probs
Rush pump
Rush Tank
Rush pipes

Pump

Rush pump
RUSH parasternal long axis
RUSH parasternal long axis
RUSH parasternal long axis
RUSH parasternal short axis
RUSH parasternal short axis
RUSH subcostal
RUSH apical

Tank

Rush Tank
Rush IVC
Rush intraperitoneal fluid
Rush intraperitoneal fluid
Rush intraperitoneal fluid
Rush lung
Rush lung

Pipes

Rush pipes
Rush pipes
Rush pipes
Rush pipes

References and Further Reading

  1. By Organ System or Specialty Archives | Page 84 of 123 | ALiEM. https://www.aliem.com/category/emergency-medicine-clinical/system/page/84/
  2. Seif D1, Perera P, Mailhot T, Riley D, Mandavia D. “Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol” Crit Care Res Pract. 2012;2012:503254.
  3. https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/
  4. https://iem-student.org/rush/
  5. https://iem-student.org/efast/
[cite]

19 Questions and Answers on the COVID-19 Pandemic from a Emergency Medicine-based Perspective

covid 19 - from a Emergency Medicine-based Perspective
~ Francesco Adami, Italy ~ Leave a comment

1) What is COVID-19?

Corona Virus Disease 2019 (COVID-19) is the disease caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

2) What is SARS-CoV-2?

SARS-CoV-2 is a virus belonging to the Coronaviridae family. Spike proteins (S proteins) on the outer surface of SARS-CoV-2 are arranged in a way that resembles the appearance of a crown when viewed under an electron microscope (see Figure 1). S proteins facilitate viral entry into host cells by binding to the angiotensin-converting enzyme 2 (ACE2) host receptor. Several cell types express the ACE2 receptor, including lung alveoli cells. [1].

Morphology of the SARS-CoV-2
Figure 1 - Morphology of the SARS-CoV-2 viewed under an electron microscope.Note the spikes that adorn the outer surface of the virus, which impart the look of a corona surrounding the virion. (https://phil.cdc.gov/Details.aspx?pid=23312)

3) How is SARS-CoV-2 transmitted?

Viral particles can spread from person-to-person through airborne transmission (e.g., large droplets) or direct contact(e.g., touching, shaking hands). We have to remember that large droplets are particles with a diameter > 5 microns and that they can be spread by coughing, sneezing, talking, etc., so do not forget to wear full PPE in the Emergency Department (ED). Other potential routes of transmission are still being investigated.

4) What is the incubation time?

In humans, the incubation period of the SARS-CoV-2 varies from 4 days to 14 days, with a median of about 4 days [2].

5) Can we say the COVID-19 is like the seasonal flu?

No, we can’t say that. COVID-19 differs from the flu in several ways:

  • First of all, SARS-CoV-2 replicates in the lower respiratory tract at the level of the pulmonary alveoli (terminal alveoli). In contrast, Influenza viruses, the causative agents of the flu, replicate in the mucosa of the upper respiratory tract.
  • Secondly, SARS-CoV-2 is a new virus that has never met our adaptive immune system.
  • Thirdly, we do not currently have an approved vaccine to prevent infection by SARS-CoV-2.
  • Lastly, we do not currently have drugs of proven efficacy for the treatment of disease caused by SARS-CoV-2.

6) Who is at risk of contracting the COVID-19?

We are all susceptible to contracting the COVID-19, so it is essential that everyone respects the biohazard prevention rules developed by national and international health committees. Elderly persons, patients with comorbidities (e.g., diabetics, cancer, COPD, and CVD), and smokers appear to exhibit poor clinical outcome and greater mortality from COVID-19 [3]

7) What are the symptoms of the COVID-19?

There are four primary symptoms of COVID-19: fever; dry cough; fatigue; and shortness of breath (SOB).

Other symptoms are loss of appetite, muscle and joint pain, sore throat, nasal congestion and runny nose, headache, nausea and vomiting, diarrhea, anosmia, and dysgeusia.

8) What is the severity of symptoms from COVID-19?

In most cases, COVID-19 mild or moderate symptoms, so much so it can resolve after two weeks of rest at home. However, onset of severe viral pneumonia requires hospital admission.

9) Which COVID-19 patients we should admit to the hospital?

The onset of severe viral pneumonia requires hospital admission. COVID-19-associated pneumonia can quickly evolve into respiratory failure, resulting in decreased gas exchange and the onset of hypoxia (we can already detect this deterioration in gas exchange with a pulse oximeter at the patient’s home). This clinical picture can rapidly further evolve into ARDS and severe multi-organ failure.

The use of the PSI/PORT score (or even the MuLBSTA score, although this score needs to be validated) can help us in the hospital admission decision-making process.

10) Do patients with COVID-19 exhibit laboratory abnormalities?

Most patients exhibit lymphocytopenia [11], an increase in prothrombin time, procalcitonin (> 0.5 ng/mL), and/or LDH (> 250 U/L).

11) Are there specific tests that allow us to diagnose COVID-19?

RT-PCR is a specific test that currently appears to have high specificity but not very high sensitivity [12]. We can obtain material for this test from nasopharyngeal swabs, tracheal aspirates of intubated patients, sputum, and bronchoalveolar lavages (BAL). However, the latter two procedures increase the risk of contagion.

However, since rapid tests are not yet available, RT-PCR results may take days to obtain, since laboratory activity can quickly saturate during epidemics. Furthermore, poor pharyngeal swabbing technique or sampling that occurs during the early stage of COVID-19 can lead to further decreased testing sensitivity.

Consequently, for the best patient care, we must rely on clinical symptoms, labs, and diagnostic imaging (US, CXR, CT). The use of a diagnostic flowchart can be useful (see Figure 2).

diagnostic flow chart
Figure 2 - A possible diagnostic flow chart for an ill patient admitted to hospital with suspected COVID-19 (from EMCrit Blog)

12) Can lung ultrasound help diagnose COVID-19?

Yes, it can help! The use of POCUS lung ultrasound is a useful method both in diagnosis and in real-time monitoring of the COVID-19 patient.

In addition, we could monitor the patient not only in the emergency department (ED) or intensive care unit (ICU), but also in a pre-hospital setting, such as in the home of a patient who is in quarantine.

In fact, POCUS lung ultrasounds not only allows one to anticipate further complications such as lung consolidation from bacterial superinfection or pneumothorax, but it also allows detection of viral pneumonia at the early stages. Furthermore, the use of a high-frequency ultrasound probe, which is an adoption of the 12-lung areas method [4] and the portable ultrasound (they are easily decontaminated), allow this method to be repeatable, inexpensive, easy to transport, and radiation-free.

There are no known pathognomonic patterns of COVID-19.

The early stages COVID-19 pneumonia results in peripheral alveolar damage including alveolar edema and a proteinaceous exudate [5]. This interstitial syndrome can be observed via ultrasound by the presence of scattered B lines in a single intercostal space (see videos below).

Subsequently, COVID-19 pneumonia progression leads to what’s called “white lung”, which ultrasound represents as converging B lines that cover the entire area of the intercostal space; they start from the pleura to end at the bottom of the screen.

Finally, the later stages of this viral pneumonia lead to “dry lung”, which consists of a pattern of small consolidations (< 1 cm) and subpleural nodules. Unlike bacterial foci of infection, these consolidations do not create a Doppler signal within the lesions. We should consider the development from “white lung” to “dry lung” as an unfavorable evolution of the disease.[6]

(the 5 videos above come from the COVID-19 gallery on the Butterflynetwork website)

13) Can CXR/CT help us in the diagnosis of COVID-19?

Yes, it can help! There are essentially three patterns we observed in COVID-19.

In the early stages, the main pattern is ground-glass opacity (GGO)[7]. Ground glass opacity is represented at the lung bases with a peripheral distribution (see videos below) .

The second pattern is constituted by consolidations, which unlike ground-glass opacity, determine a complete “opacification” of the lung parenchyma. The greater the extent of consolidations, the greater the severity and the possibility of admission in ICU.

The third pattern is called crazy paving[8]. It is caused by the thickening of the pulmonary lobular interstitium.

However, we should consider four things when we do a CXR/CT exam. First, many patients, especially in the elderly, exhibit multiple, simultaneously occurring pathologies, so it is possible to clinically observe nodular effusions, lymph node enlargements, and pleural effusions that are not typical of COVID-19 pneumonia. Secondly, we have to be aware that other types of viral pneumonia can also cause GGO, so they cannot be excluded during the diagnostic process. Thirdly, imaging can help evaluate the extent of the disease and alternative diagnoses, but we cannot use it exclusively for diagnosis. Lastly, we should carefully assess the risk of contagion from transporting these patients to the CT room.

14) What is the treatment for this type of patient?

COVID-19 patients quickly become hypoxic without many symptoms (apparently due to “silent” atelectasis). Therapy for these clinical manifestations is resuscitation and support therapy. In patients with mild respiratory insufficiency, oxygen therapy is adopted. In severe patients in which respiratory mechanics are compromised, non-invasive ventilation (NIV) or invasive ventilation should be adopted.

15) How can we non-invasively manage the airways of patients with COVID-19?

In the presence of a virus epidemic, we should remember that all the procedures that generate aerosolization (e.g., NIV, HFNC, BMV, intubation, nebulizers) are high-risk procedures.

Among the non-invasive oxygenation methods, the best-recommended solution is to have patients wear both a high-flow nasal cannula (HFNC) and a surgical mask[9]. Still, we should also consider using CPAP with a helmet interface. Furthermore, we should avoid the administration of medications through nebulization or utilize metered-dose inhalers with spacer (Figure 3).

Figure 3 – General schema for Respiratory Support in Patients with COVID-19 (from PulmCrit Blog)

16) How can we invasively manage the airways of patients with COVID-19?

We should intubate as soon as possible, even in non-critical conditions (Figure 3). Intubation is a high contagion risk procedure. As a result, we should adopt the highest levels of precaution[10]. To be more precise:

  • As healthcare operator, we should wear full PPE. Only the most skilled person at intubation in the staff should intubate. Furthermore we should consider using a video laryngoscope. Last but not least, we should ensure the correct positioning of the endotracheal tube without a stethoscope (link HERE).
  • The room where intubation occurs should be a negative pressure room. When that is not feasible, the room should have doors closed during the intubation procedure.
  • The suction device  should have a closed-circuit so as not to generate aerosolization outside.
  • Preoxygenation should be done using means that do not generate aerosols. Let us remember that HFNC and BVM both can generate aerosolization. So, it is important to remember to turn off the flow of the HFNC before removing it from the patient face to minimize the risk and to use a two-handed grip when using BVM, interposing an antiviral filter between the BVM and resuscitation bag and ventilating gently.
  • Intubation drugs that do not cause coughing should be used. In addition, we should evaluate the use of Rocuronium in the Rapid Sequence Intubation (RSI) since it has a longer half-life compared to succinylcholine and thus prevents the onset of coughing or vomiting.

In conclusion, let us remember that intubation, extubation, bronchoscopy, NIV, CPR prior to intubation, manual ventilation etc. produce aerosolization of the virus, therefore, it is necessary that we wear full PPE.

17) What is the drug therapy for COVID-19?

Currently, there is no validated drug therapy for COVID-19. Some drugs are currently under study. They include Remdesivir (blocks RNA-dependent RNA polymerase), Chloroquine and Hydroxychloroquine (both block the entry of the virus into the endosome), Tocilizumab and Siltuximab (both block IL-6).

18) Is there a vaccine available for COVID-19?

No, there is still no vaccine currently available to the public.

19) What precautions should we take with COVID-19 infected patients?

As healthcare professionals, we should wear full personal protective equipment (PPE) and know how to wear them (“DONning”) and how to remove them properly (“DOFFing”) (see video below). Furthermore, we should wear full PPE for the entire shift and when in contact with patients with respiratory problems.

Resources on COVID-19

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References

[1] Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. NatRev Cardiol. 2020 Mar 5.

[2] del Rio C, Malani PN. COVID-19—New Insights on a Rapidly Changing Epidemic. JAMA. Published online February 28, 2020. doi:10.1001/jama.2020.3072

[3] Yee J et al. Novel coronavirus 2019 (COVID-19): Emergence and Implications for Emergency Care. Infectious Disease 2020. https://doi.org/10.1002/emp2.12034

[4] Belaïd Bouhemad, Silvia Mongodi, Gabriele Via, Isabelle Rouquette; Ultrasound for “Lung Monitoring” of Ventilated Patients. Anesthesiology 2015;122(2):437-447. doi: https://doi.org/10.1097/ALN.0000000000000558.

[5] Qian-Yi Peng, Xiao-Ting Wang, Li-Na Zhang & Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. 12 March 2020 Intensive Care Medicine.

[6]  Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020.

[7] Chest CT Findings in Cases from the Cruise Ship “Diamond Princess” with Coronavirus Disease 2019 (COVID-19)

[8] Radiographic and CT Features of Viral Pneumonia Hyun Jung Koo, Soyeoun Lim, Jooae Choe, Sang-Ho Choi, Heungsup Sung, and Kyung-Hyun Do RadioGraphics 2018 38:3, 719-739 doi: https://doi.org/10.1148/rg.2018170048

[9]  WHO – Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected.

[10] Safe Airway Society. Consensus Statement: Safe Airway Society Principles of Airway management and Tracheal Intubation Specific to the COVID-19 Adult Patient Group. MJA 2020.

[11] GUAN WJ, Ni ZY, Hu Y, Liang WH, et al  Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032

[12] Tao Ai et al. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology, published online February 26, 2020; doi: 10.1148/radiol.2020200642

Lower Extremity Deep Venous US Imaging – Illustrations

lower extremity us illustrations
~ Murat Yazici, Turkey ~ Leave a comment

Ultrasound evaluation for deep venous thrombosis (DVT) is one of the 11 core ultrasound applications for emergency physicians as listed in the 2008 American College of Emergency Physicians guidelines (1). Because ultrasound applications started to be implemented into medical school curriculum in many countries, learning basic ultrasound applications as early as possible will benefit medical students and junior residents. In this post, I will share lower extremity venous ultrasound illustrations with you. 

Indications

The clinical indications for performing a lower venous ultrasound examination is the suspicion of a lower extremity DVT in a swollen or discoloured leg. 

Transducer

Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.

lower extremity venous ultrasound - linear transducer

Remember Risk Factors of DVT

  • Age > 60
  • Cancer
  • Central venous catheter/insertion
  • Genetic causes of hypercoagulopaty
  • History of DVT
  • Immobilization
  • Obesity
  • Pregnancy
  • Smoking
  • Trauma or recent surgery
  • Use of birth control pills or hormone replacement therapy

Wells Score for Deep Vein Thrombosis

CriteriaScore
Active cancer(treatment ongoing or within previous 6 months or palliative treatment)
1
Paralysis, paresis, or recent plaster immobilization or of the lower extremities1
Recently bedridden for 3 days or more or major surgery within the previous 12 weeks requiring general or regional anesthesia1
Localized tenderness along the distribution of the deep venous system1
Entire leg swollen1
Calf swelling > 3cm compared to asymptomatic leg (measuring 10 cm below tibial tuberosity)1
Pitting edema confined to the symptomatic leg1
Non varicose collateral superficial veins1
Previously documented DVT1
Alternative diagnosis at least as likely as DVT1
DVT evaluation algorithm
Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.
sectional anatomy of lower extremity veins

Normal DVT Ultrasound Findings

normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings

Reference and Further Reading

  1. American College of Emergency Physicians. Emergency ultrasound guidelines 2008. http://www.acep.org/WorkArea/DownloadAsset.aspx?ID=32878. February 2012.

Note: Visual drawings are inspired by the Point-of-Care ULTRASOUND Book.

[cite]

You may like to view these resources too

Cellulitis – Clinical Image and Ultrasound

cellulitis
~ Arif Alper Cevik ~ Leave a comment

Case Presentation

A 45-years-old male with a week history of right leg swelling and redness presented to the ED. He has type II DM and hypertension. He denies fever; however, complaints about burning pain over the skin. Vitals were 156/98 mmHg blood pressure, 98 beats per minute heart rate, 16 respiration per minute, 36.7 degrees Celsius temperature and 98% oxygen saturation in room air. Physical exam revealed erythema over the right medial lower leg and calf area (images). Minimally painful with palpation. The area was hot compared to the left leg. Other examination findings were unremarkable.

Cellulitis 2

Cellulitis 1

Patients with red, swollen, painful leg may have very severe problems such as necrotizing fasciitis (infection involving muscular fascia) or infections involving muscles with or without gangrene. The patients having these infections are generally ill-looking, severely painful, and may have subcutaneous crepitations. Therefore, we should be aware of these red flags. This patient has no sign of crepitations, systemic illness, or severe pain.

Lipodermatosclerosis is chronic erythema. Patients show exacerbations because of vascular insufficiency (venous). It can be bilateral or unilateral. One of the discriminative findings from cellulitis is temperature over the lesion. Lipodermatosclerosis is not hot. In the case, the palpation showed warm skin compared to the left side.

Erysipelas is superficial and its’ borders are very sharp. The lesion is fluffy compared to the skin around the lesion. In the case, some areas of the skin were found a little bit raised compared to surrounding structures. However, its’ borders were not well-demarcated.

Other differentials are burns, contact dermatitis, urticaria, etc.

Bedside ultrasound imaging can help to identify cellulitis, abscess, foreign body, fracture, etc. Cobblestone finding is a typical finding for cellulitis.

Bedside ultrasound imaging was performed with Butterfly iQ with soft tissue settings. Cobblestone finding was found in the erythematous areas. This is a nonspecific finding and can be seen many different soft tissue infections. There were no gas/air artifacts (necrotizing fasciitis) or obvious abscess formation. However, there was a minimal fluid accumulation, which creates a suspicion of an abscess. In the case, there was no air artifact. However, x-rays can also help to show air accumulation in soft tissues.

An Example for Necrotizing Fasciitis

The ultrasound investigation in this video shows the air (white) artifacts in the soft tissue.

X-ray Image Showing Subcutaneous Air in Necrotizing Fasciitis

Case courtesy of Dr Matt Skalski, Radiopaedia.org. From the case rID: 25026

For mild uncomplicated patients – dicloxacillin, amoxicillin, and cephalexin are common choices.

If the patient has a penicillin allergy – clindamycin or a macrolide (clarithromycin or azithromycin) can be used.

Fluoroquinolones should be reserved for gram-negative organisms’ sensitivity defined by culture results because of their additional toxicity risks.

For more antibiotic options and explanations, please visit – here. 

The patients with co-morbidities compromising immune response, periorbital or perianal locations, unable to tolerate oral medication, deep infections should be admitted.

References and Further Reading

  • Loyer EM, DuBrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR Am J Roentgenol. 1996 Jan;166(1):149-52. PubMed PMID: 8571865.
  • Shyy W, Knight RS, Goldstein R, Isaacs ED, Teismann NA. Sonographic Findings in Necrotizing Fasciitis: Two Ends of the Spectrum. J Ultrasound Med. 2016 Oct;35(10):2273-7. doi: 10.7863/ultra.15.12068. Epub 2016 Aug 31. PubMed PMID: 27582527.
[cite]

Hepatobiliary US Imaging – Illustrations

hepatobiliary ultrasound
~ Murat Yazici, Turkey ~ Leave a comment

Anatomy Of The Hepatobiliary System

Anatomy of the hepatobiliary system

Indications

Indications for clinicians to perform point-of-care hepatobiliary ultrasound include the evaluation of; abdominal pain, jaundice, sepsis and ascites.

Transducer

The most commonly used positions include; left lateral decubitus and supine position. A low-to medium-frequency (2–5 MHz) curvilinear ultrasound transducer will suffice for most ultrasound examinations of the gallbladder.

curvilinear transducer

Patient positioning

Patient positioning plays a vital role in the hepatobiliary ultrasound examination. Transducer position according to gallbladder; longitudinal and transverse.

Focus Points on Hepatobilary Ultrasound

focus points hepatobilary ultrasound

Patient Position and Transducer Position

Patient Position and Transducer Position​
Patient Position and Transducer Position​

Normal Hepatobiliary Ultrasound Findings

Normal Hepatobiliary Ultrasound Findings​

Pathological Hepatobiliary Ultrasound Findings

Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
[cite]

Massive Pneumothorax Without A Tension

massive pneumothorax
~ Arif Alper Cevik ~ Leave a comment

Case Presentation

A 24-years-old male with shortness of breath and chest pain presented to the emergency department. He was alert and oriented. Vitals were as follows; BP: 127/65 mmHg, HR: 101 beats per min, RR: 24 breaths per min, T: 37-degree celsius, SatO2: 94%. Physical examination revealed that normal breathing sounds on the left side, but decreased breath sounds on the right side of the chest. No JVD noted. Other examination findings were unremarkable.

Shortness of breath and chest pain started suddenly while he was playing soccer about 30 minutes ago. Since then, shortness of breath and chest pain increased. He has no known medical disease, allergy.

Bedside ultrasound revealed pneumothorax on the right.

Bedside Ultrasound Examination

Above video shows left side B mode ultrasound examination. Investigation was done in lung settings by using Butterfly iQ portable ultrasound. Lung sliding and comet tail artefacts are seen on examination which is normal findings.

Above video shows right side B mode and M-mode ultrasound examination. There is no lung sliding or comet tail artefacts in B mode, and M-mode revealed “barcode sign” which is seen in pneumothorax.

Pneumothorax - US - Lung - M-mode

Image shows “barcode sign” in M-mode examination. 

Bedside Portable Chest X-ray

spontaneous pneumothorax 1 - 18yo male

Bedside portable anteroposterior chest x-ray shows right sided large pneumothorax.

More pneumothorax images

Further reading on pneumothorax

[cite]

Home Made IV Access Ultrasound Phantoms

home made IV access ultrasound phantom
~ Masuma Ali Gulamhussein ~ Leave a comment

We recently had the 3rd Tanzanian Conference on Emergency Medicine. Point of Care Ultrasound (PoCUS) training was one of the pre-conference workshops. Ultrasound-guided intravenous cannulation can be very challenging for many doctors in the emergency department.

Therefore, we had a station providing a real-time opportunity to practice IV access using our homemade ultrasound phantoms. And I shall share with you how we came up with this solution.

Ingredients

  • A plastic container (dimensions used here 8 x 5.5 x 5inches)
  • Long balloons
  • Assorted food colors
  • Gelatin
  • Metamucil (psyllium)
  • Powdered household detergent
  • Spoon, sieve, hand mixer, measuring cup, cooking pot and cooker
  • Filler syringes
  • Gloves
Ingredients for making the mixture
Ingredients for making the mixture
Food coloring dye
Food coloring dye
Equipment for making vessels
Equipment for making vessels

How to make your mixture

Take a cooking pot and fill it with 1200 mls of water (we used this as our molding device could accommodate this amount of mls) bring it to a boil (just as it begins to form tiny bubbles on the base add gelatin powder 8 tablespoons and stir with a hand mixer until it completely dissolves. Thereby add 2 tablespoons of Metamucil and 1 tablespoon of detergent and continue stirring with low flame until the mixture begins to thicken. At this point, you will also see foam that sits on top of the mix. Use a sieve to get the foam out. You can, at this point, add any colors that you would want. Let the mixture cool a little before pouring it into the container. As it cools, you will notice it becoming thicker.

How to set-up your mold/containers

You will need to make a hole on both ends on the container using a hand drill or a hot pointed knife. For this case, since we didn’t have a drill, we used a knife with a pointed tip – heated it up in a burner until it was hot enough and used it to make holes through the plastic container using a circular motion. It is important for the holes not to be too big but estimated to the caliber/ diameter of the long balloons since we need just enough space to pass the balloons across.

For our case, we made 4 holes, 2 on each end. But you can do more if you want. You can arrange balloons in superficial or deeper locations.

To setup the vessels using the long balloons, you will need half cup of water and red color dye. Mix just enough to make a mixture that looks like blood. This can be filled in the balloons with a syringe. Since the color dye can stain your fingers, it is important to use gloves just to prevent your fingers from staining.

Tip: To make an artery, you can fill the balloon much more so that there is minimal compressibility and for the vein, you can fill just enough and have room for compressibility. Don’t fill the balloons before passing it through the container; if you do this, the filled balloon won’t manage to fit into the holes. Once fixed, tie both ends to make knots that are big enough to cover the seal the holes made.
Before pouring the mixture into the container, spray it with some oil, or you can use a cloth dip it in oil and apply it on the inside of the container.

After that, pour your mixture in the container and let it cool. You can place it in the refrigerator and use it the next day. We left ours for 24 hrs prior use.

You can use silicone seals at the holes if you notice to have any leaks. Otherwise, if you don’t have this, you can use plastic food wrap to create a seal between the balloon knots and the container just so the mixture does not leak out until it has set.

Cooling in the refrigerator, note the plastic food wraps used as seal here and the knots
Cooling in the refrigerator, note the plastic food wraps used as seal here and the knots
6 hours after refrigeration
6 hours after refrigeration
Final product
Final product

And finally, the images that you will have on ultrasound.

Short axis/transvers view
Short axis/transvers view
Long/longitudinal axis view
Long/longitudinal axis view
TACEM - IV access workshop under US guidance
TACEM - IV access workshop under US guidance
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