Ultrasound For The Win! – 63M with an Erythematous Abdomen #US4TW

Welcome to another ultrasound-based case, part of the “Ultrasound For The Win!” (#US4TW) Case Series. In this case series, we focus on a real clinical case where bedside ultrasound changed the management or aided in the diagnosis. In this case, a 63-year-old man presents with a painful, warm, and erythematous area of his abdomen.

Case Presentation

A 63-year-old man with history of diabetes, hypertension, and hyperlipidemia presents with a painful area on his right lower abdomen. He states he noticed pain and redness today, and that it has been worsening over the course of the day. He denies any previous history of similar symptoms and denies trauma. On physical examination, he is a morbidly obese gentleman, in no acute distress. Examination of his abdomen reveals a 10 cm x 12 cm erythematous and tender area on the surface of the right side of his lower abdomen. The area is warm to touch without fluctuance or crepitus. Genitourinary examination is unremarkable.

Vitals

BP 173/82 mmHg
P 111 bpm
RR 23 breaths/min
O2 97% room air
T 37.9 C

Differential Diagnosis

  • Abscess
  • Cellulitis
  • Necrotizing Fasciitis

Laboratory Investigations

  • Total White Blood Cell count: 18 x mm3
  • C-Reactive Protein: 240 mg/L
  • Hemoglobin: 14.3 g/dL
  • Sodium: 139 mmol/L
  • Creatinine: 119 umol/L (or 1.35 mg/dL)
  • Glucose: 12 mmol/L (or 216 mg/dL)
  • Lactate: 4.1 mmol/L

POINT-OF-CARE ULTRASOUND was performed which showed the following:

Figure 1. Cobblestoning of subcutaneous soft tissue with fluid in the deeper fascial plane.
Figure 2. Another view of the cobblestoning of subcutaneous soft tissue and fluid in the deep fascial plane.
Figure 3. Cobblestoning of the subcutaneous tissue (#) and fluid in the deep fascial plane (arrow) is seen.

 

Ultrasound Image Quality Assurance

The ultrasound images were obtained using the high-frequency linear probe, which is beneficial when attempting to visualize superficial structures within a few centimeters from the surface. The images reveal cobblestoning of the subcutaneous tissue, a non-specific finding that can be seen with cellulitis [Fig. 1, Fig. 2]. Of note, the subcutaneous tissue is uniformly thickened; a comparison of a normal area (e.g. a contralateral limb) can be visualized to confirm abnormal thickening. Deep to the subcutaneous layer is the deep fascial plane, where abnormal fluid is seen in this case [Fig. 3]. These findings can be seen with necrotizing fasciitis. As the disease progresses, abnormal air, visualized as “dirty shadowing” on ultrasound, may be seen in late and more severe cases.

Disposition and Case Conclusion

Given the concerning history and physical examination along with the point-of-care ultrasound concerning for necrotizing fasciitis, empiric antibiotics (IV vancomycin and piperacillin/tazobactam) were given, and surgery was consulted.

The patient was taken to the operating room where a wash out and debridement was performed with a confirmed diagnosis of necrotizing fasciitis. The patient was monitored in the intensive care unit post-operatively and has since been discharged and is doing well.

Background on Necrotizing Fasciitis

Necrotizing fasciitis is rare (with an incidence of 4.3 infections per 100,000 in the United States), but severe soft tissue infection1,2. The most severe form of soft tissue infections, necrotizing fasciitis is a rapidly progressing infection of the subcutaneous tissue and fascia that is potentially limb and life threatening, with a mortality rate of up to 76%2,3. Bacterial enzymes cause tissue necrosis, leading to fluid that can be visualized in the deep fascial layer. The typical bacterial pathogens involved in necrotizing fasciitis include staphylococci, streptococci, and anaerobes, and antibiotic coverage should provide broad coverage for these organisms4. Definitive management requires operative debridement and potential fasciotomy.

The classic physical examination findings of necrotizing fasciitis, including a rapidly progressing area of erythema with ill-defined borders, are often indistinguishable from other soft tissue infections including cellulitis and abscess, especially early in the disease process. Thus, a high index of clinical suspicion is required in the Emergency Department2. While physical exam findings including blistering, hemorrhagic bullae, and crepitus can increase the suspicion of necrotizing fasciitis, these are often late findings seen only in severe and progressed cases2. While necrotizing fasciitis is considered a clinical diagnosis, there may be some utility for laboratory tests and point-of-care ultrasound to aid in risk-stratifying equivocal cases.

LRINEC Score

The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score utilizes 6 common laboratory tests to risk stratify patients with concern for possible necrotizing fasciitis (Table 1)3. A score of ≥6 should raise your suspicion of the diagnosis, while a score of ≥8 is strongly predictive of necrotizing fasciitis3. In this case, the LRINEC score is 6, which increases the suspicion of necrotizing fasciitis.

Table 1. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) Score

LRINEC Score > 6 should raise suspicion of necrotizing fasciitis. Score > 8 is strongly predictive of necrotizing fasciitis. (Modified from Wong et al.)
Lab, Units Score
C-Reactive Protein, mg/L
< 150 0
≥ 150 4
White cell count, per mm3
< 15 0
15 – 25 1
> 25 2
Hemoglobin, g/dL
> 13.5 0
11 – 13.5 1
< 11 2
Sodium, mmol/L
≥ 135 0
< 135 2
Creatinine
≤ 141 mmol/L or 1.6 mg/dl 0
> 141 mmol/L or 1.6 mg/dL 2
Glucose
≤ 10 mmol/L or 180 mg/dL 0
> 10 mmol/L or 180 mg/dL 1

Ultrasound Findings for Necrotizing Fasciitis

Ultrasound can also be used to identify patients with necrotizing fasciitis. While CT and MRI have been the more traditionally used imaging modalities, they are time consuming, costly, and delay the time to definitive operative management. The ultrasonographic findings of necrotizing fasciitis include diffuse thickening of the subcutaneous tissue when compared to the contralateral side or limb, and a layer of fluid seen more than 4 mm deep along the deep fascial layer1. Using these criteria, ultrasound has been shown to be 88.2% sensitive, 93.3% specific, and 91.9% accurate1. As the disease progresses, air within the fascial layer, seen as “dirty shadowing” may be seen. A useful mnemonic has been described in the literature as the STAFF exam (Subcutaneous Thickening, Air, and Fascial Fluid)2.

Necrotizing fasciitis remains a clinical diagnosis, and concern for the disease requires prompt surgical consultation. While laboratory tests (LRINEC score) and ultrasound are beneficial and can aid in the risk stratification and diagnosis of cases, they should not be used solely to rule out the disease.

Take Home Points

  1. Necrotizing fasciitis is a rare but potentially limb and life threatening infection, requiring a high index of clinical suspicion.
  2. While necrotizing fasciitis is a clinical diagnosis, the LRINEC score and point-of-care ultrasound can aid in the risk-stratification and early diagnosis of the disease.
  3. Ultrasonographic findings suggestive of necrotizing fasciitis include:
    • Fascial and subcutaneous thickening
    • Fluid in the deep fascial layer
    • Subcutaneous air

*Note: All identifying information and certain aspects of the case have been changed to maintain patient confidentiality and protected health information (PHI).

References

1.
Yen Z, Wang H, Ma H, Chen S, Chen W. Ultrasonographic screening of clinically-suspected necrotizing fasciitis. Acad Emerg Med. 2002;9(12):1448-1451.
2.
Castleberg E, Jenson N, Dinh V. Diagnosis of necrotizing faciitis with bedside ultrasound: the STAFF Exam. West J Emerg Med. 2014;15(1):111-113.
3.
Wong C, Khin L, Heng K, Tan K, Low C. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535-1541.
4.
Green R, Dafoe D, Raffin T. Necrotizing fasciitis. Chest. 1996;110(1):219-229.

Author information

Jeffrey Shih, MD, RDMS

Jeffrey Shih, MD, RDMS

Director, Emergency Ultrasound Fellowship Program,
The Scarborough Hospital
Lecturer,
University of Toronto
Assistant Editor, Ultrasound for the Win Series,
Academic Life in Emergency Medicine

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MEdIC Series: Case of the Terrible Code – Expert Review & Curated Commentary

Terrible code expert reviewThe Case of the Terrible Code outlined a scenario where a resident observed a resuscitation that was not going well. Should he intervene even though the code leader was an attending? How? This month the MEdIC team (Brent Thoma, Sarah Luckett-Gatopoulos, Tamara McColl, Eve Purdy, John Eicken, and Teresa Chan), hosted a discussion around these questions with insights from the ALiEM community. We are proud to present to you the Curated Community Commentary and our 3 expert opinions. Thank-you to all our participants for contributing to the very rich discussions last week.

MEdIC Series

This follow-up post includes:

  • Responses from our solicited experts (Joshua and Lainie collaborated on their response):
    • Chris Hicks, MD is an emergency physician and trauma team leader at St. Michael’s Hospital in Toronto as well as a Clinician Educator at the University of Toronto. His academic interests include simulation.
    • Lalena Yarris, MD is an EM Residency Director and Education Scholarship Fellowship Co-Director at Oregon Health and Science University. Her academic interests include education research methods, faculty development in education, feedback in medical education, and wellness in academic medicine.
    • Joshua Kornegay, MD is an emergency physician and Assistant Program Director at Oregon Health and Science University. His academic interests include resuscitation and simulation.
  • A summary of insights from the ALiEM community derived from the Twitter and blog discussions
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
Expert Response 1: Performing in High-Stakes, High-Stress Scenarios
Expert Response 2: Combating the Acute Stress Response
The Case of the Terrible Code: Curated from the Community

Case and Responses for Download

Click Here (or on the picture below) to download the case and responses as a PDF (354 kb).

3.8 Mini

Author information

Brent Thoma, MD MA

ALiEM Associate Editor
Emergency Medicine Research Director at the University of Saskatchewan
Editor/Author at CanadiEM.org

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10 Life and Work Tips for EM Residency Graduates

residency graduatesCongratulations to the Class of 2016 graduating class of emergency medicine residents! It is the end of a chapter and a beginning of another. For those of us practicing medicine for so many years, there are many things that we would have done differently… especially in that first year post-residency. In the following infographic, we present crowdsourced reflections and advice for residency graduates from the the UCSF Department of Emergency Medicine faculty.

Infographic: 10 Life and Work Tips for Residency Graduates

Tips for Graduates UCSF DIL

[Download infographic PDF (1.2 MB)]

Read more tips from the University of Maryland’s 15 tips to graduates.

Author information

Michelle Lin, MD

ALiEM Editor-in-Chief
Academy Endowed Chair of EM Education
Professor of Clinical Emergency Medicine
University of California, San Francisco

The post 10 Life and Work Tips for EM Residency Graduates appeared first on ALiEM.

Diagnose on Sight: Swollen Leg

Phlegmasia Cerulea Dolens_1 editedCase: A 58 year-old female presents with a one-day history of worsening right lower extremity pain and swelling, and an acute onset of dyspnea. Her past medical history consists of stage IV renal cell carcinoma diagnosed six months previously. Triage vitals are remarkable for a heart rate of 120 beats per minute and a blood pressure of 68/48 mmHg. What is the diagnosis?

 

Diagnose on Sight Poll

 

Answer

Master Clinician Bedside Pearls

Mark Reardon, MD FRCP  
Assistant Professor of Emergency Medicine
University of Ottawa

References

  1. Stallworth JM, Bradham GB, Kletke RR, Price RG, Jr. Phlegmasia Cerulea Dolens: a 10-Year Review. Ann Surg. 1965;161(5): 802-811 PMID: 14290003
  2. Chinsakchai K, Ten Duis K, Moll FL, de Borst GJ. Trends in management of phlegmasia cerulea dolens.Vasc Endovascular Surg. 2011 Jan. 45 (1):5-14 PMID: 21193462
  3. Onuoha CU. Phlegmasia Cerulea Dolens: A Rare Clinical Presentation. Am J Med. 2015 Sep;128(9):e27-8 PMID: 25910785
  4. Kearon C, Akl EA, Comerota AJ et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Dec;142(6):1698-1704 PMID: 22315268

Author information

Peter Reardon, MD

Peter Reardon, MD

Emergency Medicine Resident
University of Ottawa

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ALiEM Book Club: The Digital Doctor – Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age

digital doctor“Medicine is the most information-rich, knowledge-intensive human activity, probably ever.” — Matthew Burton in The Digital Doctor

Medicine is becoming an even more information-intensive field as we continue to make new medical discoveries. This, among many other reasons, has prompted increasing efforts over the past couple of decades to develop computerized systems in healthcare. Through this lens, Dr. Robert Wachter examines modern medicine – both the achievements and downfalls that have manifested.

Dr. Robert Wachter is an internist, interim chairman of the Department of Medicine and chief of the Division of Hospital Medicine at UCSF [UCSF Profile]. Through The Digital Doctor [Amazon link], he offers a thorough look into the digitization of healthcare, as well as its impact on the patient experience, doctor-patient relationship, and clinical safety. Initiatives are expanding rapidly to enhance and develop technologies that will diagnose, treat, and reach new levels of clinical acumen to partner with (and perhaps eventually supplant) physicians.

Summary

Wachter expounds on several major themes that expose how health information technology has fallen short since our government’s $30 billion investment in electronic healthcare programs:

1. Doctor-patient relationships

Technology arguably interferes with the doctor-patient relationship. Doctors are making less eye contact and forming less emotional connections with patients as we have transitioned into the computer age of healthcare. Wachter quotes physician-author Abraham Verghese, “We’re losing a ritual that I believe is transformative, transcendent, and at the heart of the patient-physician relationship. The ritual of one individual coming to another and telling him things that she would not tell her preacher or rabbi; and then, incredibly, on top of that, disrobing and allowing touch” (pg 27). At the heart of medicine is human connection, compassionate care, and empathic interaction with individuals who are vulnerable and ill.

2. Medical Errors

The technology that is designed to reduce medical errors and increase patient safety may actually cause harm. Wachter centers this theme around a narrative in Part 3: The Overdose. A 16–year-old boy named Pablo Garcia with NEMO syndrome was given 38 ½ tablets of the antibiotic Septra before his surgery. He didn’t make it to the surgery; he suffered a grand mal seizure and nearly died from the 39-fold overdose. Wachter explores the origin of such a mistake at one of the best hospitals in the country. The drug information was entered into the computer system, which was then passed through several checkpoints (including the technician, pharmacist, robot, and nurse) before the medication finally made its way to the patient. The poor interface design of the EMR software played a part in the pediatric resident’s mistake of putting the dosage information in an incorrect unit setting. She had overridden the warning that the dosage was much too high, likely because most alerts she encountered previously were unnecessary. Ironically, the checkpoint process and computerized alerts were developed to avoid mishaps like this, but alert fatigue and a fallible check system are concomitant with a fairly nascent digitized healthcare system. 

3. Deficit in Interoperability

One of the biggest issues facing the healthcare information technology field is the deficit in interoperability (connecting EHR systems used by different hospitals and clinics). Such an ease in communication would allow a smooth flow of patient information from one provider to another.

Wachter also broaches issues of big data (patient information databases), the productivity paradox (the idea that productivity has not increased but remained stagnant following the computerization of an industry) and, in a more positive light, he discusses the benefits of healthcare technology for the patient. In Chapter 20: OpenNotes, we learn about the history of patients gaining the right to view their medical records. Dr. Tom Delbanco, the founder of the Division of General Internal Medicine at Beth Israel Hospital, has been passionate about improving the doctor-patient relationship by advocating for the patient’s right to have access to his or her medical record. He created OpenNotes, a growing initiative to allow patients to view their doctor’s notes about their illness experience. Wachter quotes Delbanco, “Patients possess a body of knowledge about themselves that we can never hope to master, and we have a body of knowledge about medicine that they can never hope to master. Our job is to bring these two groups together so we can serve each other well” (pg 173).

Conclusion

The advances of technology may not ever reach a level of sophistication or clinical acumen that is sufficient enough to entirely replace a human physician. Among the many qualities that make a good doctor, there is one primary characteristic that a machine can never acquire: being able to emotionally connect and empathize with patients. Nonetheless, and despite the shortcomings we’ve discussed of healthcare information technology, we can be confident that great strides will be made to improve these drawbacks. Wachter, confident that we are moving in the right direction, expresses a deep optimism for the future as we continue to accommodate an increasing technological presence in clinical practice.

Discussion Questions

  1. Discuss the reasons why Pablo Garcia’s incorrect dosage information could have passed through several checkpoints but was still not corrected before reaching him. What are the ways in which this could have been avoided?
  2. Discuss some of the challenges that arise from patients having access to their medical records. What are the ways in which this improves the doctor-patient relationship? What are the ways in which it may harm it?
  3. Do you see us moving into an era where healthcare personnel will begin to share clinical spaces with technology with increasing harmony? What challenges might persist? Will there come a day when the computer will supplant the physician (or other healthcare professionals)?

 

* Disclaimer: We have no affiliations financial or otherwise with the authors, books, references, or hyperlinks listed. The Amazon links, however, are Amazon affiliate links.

Author information

Deborah Rose

NIH Post-baccalaureate Research Fellow
Rising M1
Loyola University Chicago Stritch School of Medicine

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