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Case Series

Using Point-of-care Ultrasonography to Diagnose Traumatic Arthrotomy of the Knee: A Case Series

Introduction: Accurate diagnosis of traumatic arthrotomy of the knee (TAK) is critical for patients presenting to the emergency department (ED) to ensure timely treatment. Current diagnostic modalities including plain radiography, computed tomography (CT), and the saline load test (SLT) have advantages and disadvantages. Point-of-care-ultrasonography (POCUS) offers a possible timely, low-cost, and efficient alternative method of diagnosing TAK. In this case series we present three cases where POCUS was used to diagnose TAK in the ED.

Case Series: Three patients in their early 20s presented to the ED complaining of knee trauma with wounds in proximity to the joint. Mechanisms of injury included a gunshot wound in one case and blunt trauma (motor vehicle collision and bicycle crash) in two cases. In all three cases TAK was suggested on POCUS examinations by the presence of intra-articular hyperechoic foci consistent with air artifact. All three cases had TAK confirmed by orthopedic evaluation.

Discussion: Ultrasound may have utility in the evaluation of patients presenting with knee trauma where TAK is a concern. The SLT is generally considered the gold standard test for diagnosis of TAK, but it is invasive and has a wide range of diagnostic accuracy. Intra-articular air has been found to be a sensitive marker for TAK in CT studies. Thus, additional investigations into the diagnostic accuracy of POCUS for this finding should be undertaken.

  • 1 supplemental video

Case Reports

Acute Abdominal Pain and a Whirlpool Sign on Computerized Tomography: A Case Report

Introduction: Mesenteric volvulus is a rare cause of abdominal pain and bowel obstruction in elderly patients. When a mesenteric volvulus occurs in adult patients, the symptoms are often non-specific, which contributes to delays in diagnosis.

Case Report: We present a case of a 75-year-old female who presented with non-specific abdominal pain. The rare whirlpool sign on computed tomography identified a mesenteric volvulus as the cause of small bowel obstruction. She was taken to the operating room and, after successful resection of the small bowel, she recovered and ultimately was discharged home.

Conclusion: Early identification of a whirlpool sign and early surgical consultation are key to providing the best chance for salvage of ischemic small bowel due to mesenteric volvulus and to prevent a fatal outcome.

  • 1 supplemental video

Transcatheter Arterial Embolization for Atraumatic Splenic Rupture in TEE-negative Endocarditis: A Case Report

Introduction: Spontaneous splenic rupture is an extremely rare complication of infective endocarditis.

Case Report: We present a case of a 56-year-old immunocompetent female with porcine bioprosthetic mitral valve replacement, automated implanted cardioverter-defibrillator, and atrial fibrillation on apixaban who was found to have in-hospital atraumatic splenic rupture complicating infective endocarditis with Haemophilus parainfluenza. The rupture was treated successfully by endovascular embolization. Usual treatment with six weeks of antibiotics provided durable cure without further complication, and no surgical intervention was needed for either the valve or spleen.

Conclusion: Transcatheter arterial embolization should be considered early in atraumatic splenic rupture. Relevant abdominal and cerebral imaging should be considered in all cases of suspected or confirmed infective endocarditis where unexplained symptoms are present.

Diabetic Ketoalkalosis: A Case Report

Introduction: Diabetic ketoacidosis (DKA) is a common diagnosis in the emergency department (ED). However, one must consider other causes for acid-base disturbances when the pattern is not consistent with typical presentation.

Case Report: A 52-year-old female with a history of insulin-dependent diabetes mellitus type 2 presented to the ED with abdominal pain, nausea, and vomiting for three days. Her diagnostic workup revealed diabetic ketoacidosis but with concurrent metabolic alkalosis. Standard treatment for DKA was initiated, and there was improvement of her mentation and resolution of metabolic derangements.

Conclusion: Overlooking a diagnosis of DKA because of alkalosis on venous blood gas testing could lead to inappropriate treatment and, therefore, increased risk of morbidity and mortality in the affected patient.

Permissive Hypotension in a Patient with Severe Hypernatremia: A Case Report

Introduction: Severe hypernatremia is a critical situation, and when coupled with intravascular depletion and hypotension can create a treatment dilemma.

Case Report: We present the case of a medically complex patient who had gradually worsening alteration of mental status and mean arterial pressures in the 50s on presentation to the

emergency department.

Conclusion: Final diagnoses included severe hypernatremia and hypovolemic shock secondary to poor oral intake. We used judicious fluid repletion with gradual improvement in sodium levels and permissive hypotension to avoid rapid osmotic shifts. Balancing reperfusion and the risk for osmotic effects of aggressive fluid resuscitation can be a challenging situation for the multidisciplinary team.

Acute Focal Bacterial Nephritis in a Patient with Solitary Kidney: Case Report

Introduction: Acute focal bacterial nephritis is an underdiagnosed condition. It clinically resembles acute pyelonephritis. If unrecognized and undertreated, it may progress into complications (kidney abscess and scars). Contrast-enhanced computed tomography (CT) reveals specific images of the disease and is considered the gold standard to make the diagnosis. 

Case Report: A 63-year-old male patient with solitary kidney presented with symptoms compatible with acute pyelonephritis. Kidney ultrasound was not conclusive. Because of persisting high-grade fever not resolving after 48 hours of antibiotics, a contrast-enhanced CT was then performed, and the diagnosis of acute focal bacterial nephritis was made. A repeat CT after three weeks of intravenous (IV) antibiotics showed marked improvement of the intrarenal lesions, and a fourth week of IV antibiotics was dispensed.

Conclusion: Diagnosing acute focal bacterial nephritis is important (particularly in a patient with solitary kidney). This will dictate the therapy duration. Unlike acute pyelonephritis, acute focal bacterial nephritis requires at least three weeks duration of antibiotics to avoid progress into further complications. 

Emergency Department Point-of-care Ultrasound Identification of Suspected Lemierre’s Syndrome: A Case Report

Introduction: Lemierre’s syndrome is septic thrombophlebitis of the internal jugular vein, most commonly associated with head and neck infections. While central catheters are associated with venous thromboembolism and catheter-associated bacterial infections, cases of Lemierre’s syndrome caused by central catheters are extraordinarily rare.

Case Report: We detail a case of Lemierre’s syndrome resulting from a peripherally inserted central catheter in a pregnant female patient. Diagnosis of this rare and potentially life-threatening disease process was expedited using point-of-care ultrasound.  

Conclusion: Diagnosis of rare but potentially life- or limb-threatening pathologies is paramount to the successful practice of emergency medicine. Identifying these rare disease processes requires a high index of suspicion and a work-up strategy that includes consideration of medical history in combination with lab and imaging findings to determine appropriate interventions.