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Emergency Ultrasound Section Newsletter - March 2013

circle_arrowTips and Tricks: FAST Exam Upper Quadrants, Part 1 - Emergency Ultrasound Section Newsletter, March 2013
circle_arrowUltrasound in the Dyspneic Patient - Emergency Ultrasound Section Newsletter, March 2013
circle_arrowWorkflow Solutions: Top - 10 Reasons You Needs One – Part 2 - Emergency Ultrasound Section Newsletter, March 2013
circle_arrowJournal Watch - Emergency Ultrasound Section Newsletter, March 2013
circle_arrowExpanding Emergency and Point of Care Ultrasound Beyond the ED - Emergency Ultrasound Section Newsletter, March 2013
circle_arrowCase Report: Rule in IUP to Rule Out EP - Emergency Ultrasound Section Newsletter, March 2013
circle_arrowInterested in Contributing? - Emergency Ultrasound Section Newsletter, March 2013

Tips and Tricks: FAST Exam Upper Quadrants, Part 1 - Emergency Ultrasound Section Newsletter, March 2013

Viveta Lobo, MD and Laleh Gharahbaghian, MD, FACEP

The focused assessment with sonography in trauma, or FAST exam, is undoubtedly the most widely used bedside ultrasound application in emergency medicine. With its incorporation into the ATLS trauma protocol, the FAST exam is performed immediately after the primary survey simultaneously with other resuscitative efforts. It is also a component of the RUSH protocol for patients with unexplained shock. Trauma patients often present with multiple injuries, and significant bleeding can occur without obvious changes in vitals signs. Medical patients can present intoxicated, altered, delirious, or demented all of which will limit the physical exam. The primary purpose of the FAST exam is to rapidly detect free fluid and hemorrhage in the peritoneal, pericardial and pleural spaces. There may be difficulties in obtaining adequate views, and we hope to discuss a few pearls to minimize them.

As with all ultrasound applications, familiarity with technique and patient anatomy, knowledge of common pitfalls, practice, and appreciating technical limitations are important errors to avoid. In general, the FAST exam is not “fast” – it can take up to 3-4 minutes to perform.1 The patient should be supine (or Trendelenberg) with low ambient light, with a low frequency probe used (the phased array probe provides the additional benefit of visualizing between the ribs and getting into the subxiphoid region more easily for the cardiac view). Even with the best technique, the FAST scan will only visualize 25 cc or more of thoracic free fluid and 500cc or more of intraperitoneal free fluid.2

The Right Upper Quadrant (RUQ)
RUQThe RUQ is the most sensitive region for free fluid in comparison to the other FAST views.3 The RUQ should be divided into 3 zones.
1. Above/Below the diaphragm,
2. Morrison’s pouch (hepato-renal recess)
3. Paracolic gutter: Around the left hepatic edge/inferior pole of kidney

The key is to know your landmarks, and STOP, STAY and widely FAN through each zone well, adjusting your depth as necessary to keep the area of interest centered on your screen. Click Here for a Video. Start high to stay and fan (anterior to posterior) around the diaphragm. Then, SLIDE down into another rib space, stop, stay and fan around the entire kidney. An additional rib space may be necessary to evaluate the paracolic gutter. 



Tips for RUQ Diaph2-TT Imagespineshadowragm View 

The liver may be easily seen, but the diaphragm can be more difficult, especially if it’s behind a rib shadow. Have the patient take in a deep breath. This lowers the diaphragm into your view and allows visualization of the thoracic cavity for hemothorax/pleural fluid as well as sub-diaphragmatic peritoneal fluid. Visualization of the spine shadow travelling in the lower part of the screen will normally stop at the diaphragm with a mirror image artifact illustrated in the thoracic cavity. 

3-TT Imagevline





However, if the spine is able to been seen above the diaphragm– this is pathognomonic of pleural fluid, and also known as the “V-line.”4Click Here for a Video.




4-TT ImageVine

Tips for RUQ Morrison’s Pouch (Hepato-Renal Recess) View

If rib shadows get in the way, using the same trick above of patient inspiration can help. There are also a few false positive “traps” here.

First, the double line sign, seen around the kidney capsule as hyperechoic double lines with hypoechoic material in between, can be mistaken for free fluid.5 However, free fluid will not be surrounded by hyperechoic lines and will not be in a contained structure.



  5-TT ImageRUQFFinMP

Second, edge artifact from the liver/kidney interface occurs due to ultrasound physics and sound wave transmission between structures of different densities. It is seen as a dark thin line tracing off the edge of this interface extending to the bottom of the screen. Click Here for a Video. This differentiates it from free fluid, which will not extend past the liver. Click Here for a Video.




Tips for RUQ Paracol6-TT ImageParaCOlicFFic Gutter view
This is where free fluid can be seen first amongst all the different zones of the RUQ view.6 The most important tip is to not forget to view this area. You will often have to slide your probe more inferior to obtain this view. Decrease the depth to look around the hepatic edge and inferior kidney pole, and evaluate the region with slow fanning. Click Here for a Video.





7-TT ImagestomachsabotageThe Left Upper Quadrant (LUQ)
The LUQ is less sensitive for free fluid than the RUQ for varying reasons. First, the LUQ is opposite the side of the sonographer, which can make it technically difficult to obtain an adequate view. Also, the spleen is smaller than the liver and, thus, the acoustic window is lessened. The stomach commonly obstructs the view as well. The LUQ should also be divided into 3 zones:
    1. Above/Below the diaphragm, 
    2. Spleno-Renal recess, 
    3. Paracolic gutter: Around the inferior pole of kidney





8-TT ImageLUQFFAboveTips for the LUQ view
In addition to the various RUQ view tips and tricks as stated above, the LUQ diaphragm view also requires tips to avoid “stomach sabotage”. There are two ways around this: oblique the probe to have the indicator angled toward the gurney and/or slide your probe to the posterior-axillary line away from the plane of the stomach.

Look out for Part 2 of FAST Tips and Tricks, in the next newsletter.





1.     Boulanger BR, McLellan BA, Brenneman FD, et al. Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma.
        J Trauma. Jun 1996;40(6):867-    874.
2.     Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma. Aug 1995;39(2):375-380.
3.     Chambers JA, Pilbrow WJ. Ultrasound in abdominal trauma: an alternative to peritoneal lavage. ArchEmerg Med. Mar 1988;5(1):26-33.
4.     Atkinson P, Milne J, Loubani O, et al. The V-line: a sonographic aid for the confirmation of pleural fluid. Crit Ultrasound J. 2012;4(1):19.
5.     Sierzenski PR, Schofer JM, Bauman MJ, et al.
        The double-line sign: A false positive finding on the focused assessment with sonography for trauma (FAST) examinationJ Emerg Med. 2011;40(2):188-189.
6.     Rozycki GS, Ochsner MG, Feliciano DV, et al. Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study.
        J Trauma. Nov 1998;45 (5):878-883.

Ultrasound in the Dyspneic Patient - Emergency Ultrasound Section Newsletter, March 2013

Michael D. Zwank, MD, FACEP, talks to the US Podcast’s Matthew S. Dawson, MD and Michael Mallin, MD

What is your approach to the acutely dyspneic patient in the emergency department? What role does physical exam play? What role does ultrasound play?

Dr. Mallin
:  The time when I really think ultrasound helps the most is in the undifferentiated dyspneic patient. In these particular patients, ultrasound can be invaluable. It's clear to me that undifferentiated hypotension and dyspnea are the two aspects of critical care when ultrasound is the most useful. I typically start with the lung exam, mostly because I think it gives you the most bang for your buck: pulmonary edema: bilateral B-lines, pneumothorax: no sliding and positive lung point, pneumonia: consolidation. The yes/no is so clear in this exam, there is just very little room for misinterpretation. I like that when the stakes are high. Next I'll move to the heart to help me confirm my suspicions: if there was evidence of pulmonary edema, I'll check for systolic or diastolic dysfunction; if the lungs looked normal, I'll look for a normal heart and confirm my suspicion of asthma, or look for right heart strain and thus PE or cor pulmonale. The great thing is that when patients present super sick with abnormal vitals and obvious pathology, these ultrasound findings are rarely subtle.

Dr. Dawson:  I approach the acutely dyspneic person with ABCU (airway, breathing, circulation, ultrasound). To me, there isn't anything much more important in the acutely dyspneic patient than the ultrasound. I get so much information so quickly that I think it's detrimental to the patient to delay it for much of anything other than immediate ABC issues. We've all heard the old adage that 90% of diagnoses can be made with history and physical, and I think that's probably true. However, if you're talking about critical patients where our decisions really matter, it would be nice to get that last 10% right. And even if your patient is in the 90% where you're correct on history and physical, there's certainly some value in "confirming" with ultrasound and feeling more confident in your treatment in these high stakes encounters.

The trick is to not let the ultrasound get in the way or delay critical interventions. If the patient is obviously wheezing in distress, don't delay an action such as nebulized albuterol while looking at 8 chest zones.

When you ask about the role of physical exam and ultrasound in the dyspneic patient some people will contrast the two, but I really think they're extremely complimentary. It's not "a choice." For me they blend together. I can't hear wheezes with an ultrasound and my accuracy for diagnosing pneumonia and pneumothorax are much lower by physical exam than with ultrasound. I don't feel comfortable taking care of a critically ill dyspneic patient without both.

Of all of the ultrasound applications that could be utilized in this particular patient, which one would you promote to novice users? And to more expert users?

Dr. Mallin
: Novice users should embrace the lungs. They can be tough because they are abstract.... looking for artifacts instead of actual anatomy..... but the return on investment is huge. A few signs.... B-lines, A-lines, Consolidation etc and you can tell a lot about an acutely dyspneic patient.

For the expert users, I think the heart is the place to concentrate. It's pretty complicated and can be confusing and difficult to get images, but the times when lung ultrasound can trip you up and push you in the wrong direction, the heart can redirect you. I remember a case of a young undifferentiated dyspneic women I saw a couple of years ago. I saw anterior B-lines bilaterally. I was putting my money on cardiomyopathy given her low sats, B-lines, and history of orthopnea and cough, but when I looked at her heart she had a banging EF and normal diastolic function. I ended up diagnosing her with bilateral pneumonia and sent an HIV panel. Turns out she had PCP pneumonia, one of the few pneumonias that is typically interstitial, causes fluid buildup in the interstitum and thus B-lines. Maybe that's not important for your everyday ultrasound exam, but nice to pull out when the rare case comes along.

Dr. Dawson:  For the novice user, the basic things we're all taught early in training are going to make the biggest difference for you. Pneumothorax, pericardial effusion, and global function are not hard to learn, and they can obviously make a big difference in guiding your treatment. It really only takes seeing a few of each of these to become pretty accurate.

For the more advanced user, there are nearly unlimited skills you could learn when it comes to echocardiography, and once you devote enough time to lung sonography we've seen that it's better than x-ray for pretty much every pathologic process of the lungs. As far as defining what's basic vs. advanced in the lungs, though, that's tough. People like Jim Tsung, MD, MPH, are redefining what is "advanced" with studies showing pretty good accuracy by novice users for things like pneumonia. I think frequently "basic" vs. "advanced" is defined more by what you're willing to try.

Workflow Solutions: Top - 10 Reasons You Needs One – Part 2 - Emergency Ultrasound Section Newsletter, March 2013

Mark W. Byrne, MD

By now, most people in emergency ultrasound have either heard of or thought about getting a commercial workflow solution product. But many still don’t understand all that they can do, thinking of them as mostly image archival tools. Surprisingly, even some who own these products aren’t using them to their full potential.

In this 2-part series, I wanted to highlight some of the best features of these products and the most compelling reasons why you should get one.

6. De-identifying images

 9-WF De-identifying images

I have not so fond memories of manually de-identifying large numbers of image sets to place in our teaching library or to include with QA feedback to sonographers. Clearly, there are better ways to spend our time than the various tedious and time-consuming methods most have used in the past. Special thanks to Ben Smith for sharing one very nice (free) solution to the ultrasound community – click here for the website link. Similarly, these workflow solutions products provide integrated functionality to completely automate the image and video de-identification process.

7.  Diagnostic vs. educational studies  

 10-wf Diagnostic vs educational studies
Most sites have some number of sonographers in training, from rotating medical students to interns and junior residents to attendings and staff physicians still in the process of becoming credentialed. We all know the ‘teaching’ scans that some of these learners perform may leave something to be desired in terms of image quality. Workflow solutions allow for the capability to store and provide QA over-reads for all scans, while clearly separating studies performed for educational purposes from those being used diagnostically for patient care decisions.

8. Teaching library  

11-wf teaching library

Education is an essential part of any well-run ultrasound program. As the ultrasound director, or anyone else involved in the QA process, invariably you will come across a number of exemplary scans you want to save for future use. These programs allow you to tag scans and assign them to any number of user-defined categories that can then be easily queried at some future date. This tagging function may be particularly appealing to academic sites engaged in research projects that require tracking of specific scan types and attributes.

9. Billing reports

12-billing reports

 While we pursued emergency ultrasound for the obvious benefits it provides to patient care, it also entails a lot of work, and, accordingly, we deserve compensation for our efforts. Most information required for billing can be included as part of your standard electronic worksheet templates. Additional fields corresponding to CPT billing codes can then be added on for your billable studies. Billing reports generated by the programs are typically exported to pre-defined folders on your network drive, which can then be easily accessed by your billing department. 

10. iOS support 


 13-wf ios support

One of the most intriguing implementations of these products is the ability to view images directly from your smartphone or tablet. UltraLinq is the clear innovator in this area, with very nicely designed iOS apps for both the iPhone (UltraLinq Lite) and iPad (Ultralinq Mobile) – click here  for a video demonstation. Web access to UltraLinq will also work on any device that supports HTML5 within its web browser. As smartphones and tablets become increasingly integrated into healthcare systems, one should expect apps from additional workflow solutions companies, as well as support for the Android and Windows 8 environments.  

Journal Watch - Emergency Ultrasound Section Newsletter, March 2013

Brian D. Euerle, MD, FACEP and Greg R. Bell, MD

Article: Weekes AJ, Reddy A, Lewis MR, et al. E-point septal separation compared to fractional shortening measurements of systolic function in emergency department patients. J Ultrasound Med. 2012;31(12):1891–1897.

Reviewer: Sam S. Hsu, MD

Objectives: E-point septal separation (EPSS) and fractional shortening (FS) are semi-quantitative measures that correlate to ejection fraction (EF). This study attempts to define the relationship between the two measures and to determine if EPSS as a continuous variable can predict FS.

Methods: This was a prospective study using a convenience sample of patients in whom the treating physician felt an evaluation of left ventricular function was indicated. Bedside ultrasound was performed by one of three people: a designated third-year emergency medicine resident, the emergency sonography fellow, or the emergency sonography fellowship director. Measurements were made on an M-mode tracing of a parasternal long-axis cardiac view. No other measures or estimates of left ventricular function were performed.

Results:  During the 3-month study period, 103 patients were enrolled in the study. EPPS and FS showed moderate correlation, with a Pearson coefficient of ‒0.59. Linear regression analysis yielded an R2 value of 0.35.

Discussion:  This study showed that EPSS has a moderate inverse correlation with FS but cannot predict FS as a continuous variable. In other words, EPSS and FS are not interchangeable measures. The study concludes that EPSS performs poorly as a continuous variable. Note that FS served as the “gold standard,” but both FS and EPSS are fallible predictors of EF. Separate sets of anatomic variations and abnormalities can profoundly affect their accuracies, which might account for their low R2 correlation. Since an EF gold standard was not used, this study is not conclusive on the question of whether EPSS is useful as a continuous variable in predicting EF. However, this study and current evidence supports using EPSS primarily as a categorical variable, with values >7 mm indicating a low EF. Finally, this study was not designed to determine whether FS or EPSS is the more accurate predictor of EF. The choice of which measure to use depends on the presence or absence of anatomic factors known to affect their accuracy and should be determined on an individual basis.

Article: Martindale JL, Noble VE, Liteplo A. Diagnosing pulmonary edema: lung ultrasound versus chest radiography. Eur J Emerg Med. 2012 Dec 20 [Epub ahead of print].

Reviewer: Adrea S. Lee, MD

Objective: Determining the underlying problem in patients presenting with dyspnea can be difficult. Lung ultrasound may be a useful tool to identify pulmonary edema in this population. The goal of this study was to determine how well physicians with minimal ultrasound training were able to recognize pulmonary edema on lung ultrasound compared with chest radiographs.

Methods: This was a prospective, blinded observational study. A convenience sample of 20 residents from each of the departments of emergency medicine (EM), internal medicine (IM), and radiology were enrolled and given a brief tutorial on identification of pulmonary edema on lung ultrasound images and chest radiographs. Residents then reviewed lung ultrasound images and chest radiographs from 20 patients who had presented with dyspnea, 10 of whom had been diagnosed with pulmonary edema as the cause of their symptoms, and 10 of whom had been given an alternative diagnosis. Cohen’s K (kappa) values were calculated to determine the agreement between resident and gold standard (attending) interpretations.

Results: Residents were more accurate at identifying pulmonary edema on lung ultrasound images (74% [K=0.51]) than on chest radiographs (58% [K=0.25]) (P<0.0001), despite having greater confidence in their chest radiograph interpretations (6.76 vs 6.30) (P<0.0001). Negative lung ultrasound images were interpreted more accurately than negative chest radiographs. Radiology residents were more accurate than EM and IM residents at interpreting chest radiographs (67% vs. 56% and 52%, respectively), while EM residents interpreted lung ultrasound images more accurately than IM residents (79% vs 69%).

Discussion: Patients presenting with dyspnea have a wide differential; lung ultrasound can assist in making the diagnosis. Previous studies investigating this topic, however, relied primarily on interpretations by highly trained sonographers. This study raised the question as to whether physicians of various specialties with just basic training are able to accurately interpret lung ultrasound images compared with the more traditional chest radiographs. The authors found that residents from different backgrounds can reliably recognize pulmonary edema on lung ultrasound and that they are able to more accurately interpret negative lung ultrasound images than negative chest radiographs. Residents had a tendency to over call pulmonary edema on chest radiographs. Not surprisingly, EM residents performed better than IM residents when evaluating lung ultrasound images, and radiology residents performed better than EM and IM residents when interpreting chest radiographs. The authors concluded that lung ultrasound has the potential to play a useful part in the evaluation of patients presenting with dyspnea, though more research will be essential in determining the precise role it will play.

Article: Thamburaj R, Sivitz A. Does the use of bedside pelvic ultrasound decrease length of stay in the emergency department?Pediatr Emerg Care. 2013;29(1):67‒70.

Reviewer: Brian D. Euerle, MD, FACEP

Objective: To compare the ED length of stay of two groups of pregnant patents: those having only bedside emergency physician performed ultrasound and those having only radiology department ultrasound.

Methods: This study was a retrospective chart review of pregnant patents between the ages of 13 and 21 years, who were seen in a large metropolitan urban emergency department. The patients had a positive pregnancy test and signs and symptoms suggestive of threatened abortion, such as abdominal pain or vaginal bleeding. Only patients with intrauterine pregnancy documented on ultrasound were included in the study. The 330 patients in the study were divided into two groups: 244 had only bedside pelvic ultrasound in the emergency department and 86 had only ultrasound performed in the radiology department. Emergency department ultrasound images were both transabdominal and transvaginal views and were obtained by emergency medicine attending physicians, fellows, and residents. Images obtained by residents were reviewed by a credentialed attending physician.

Results: Patients whose ultrasound images were obtained in emergency department had a length of stay of 142 minutes compared with 230 minutes for the group whose images were obtained in the radiology department.

Discussion: This study echoes what has been shown in several other reports: in many cases, pelvic ultrasonography performed at the bedside by emergency physicians can reduce the length of time that patients stay in the ED. While this is intuitive to practicing emergency physicians, it is nice to have another study that documents this observation and provides hard data. These researchers chose to look at a limited patient population—adolescents between the ages of 13 and 21 years—but there is no reason to think their findings would not apply to a broader age range. This study had a very focused research question and did not address the accuracy of emergency physicians’ interpretation of the ultrasound images, which has been studied by other investigators.

Expanding Emergency and Point of Care Ultrasound Beyond the ED - Emergency Ultrasound Section Newsletter, March 2013

Robert M. Bramante, MD interviews Gerardo C. Chiricolo, MD, FACEP, Past Chair ACEP Ultrasound Section; Chair, Division of Point of Care Ultrasound; Director, NY Methodist Hospital in Brooklyn, NY

I strongly believe that this is a perfect time for emergency physician ultrasound leaders to explore this exciting opportunity at their respective institutions. As point-of-care ultrasound becomes pervasive throughout the various different specialties, there becomes an obvious need for coordination and oversight in assuring appropriate use, continuing education, and quality assurance. We, as emergency ultrasound physicians, have demonstrated through our ACEP documents, our inter-organizational involvement, and growth in fellowships the ability to develop, manage, and lead such administrative endeavors. I encourage all in such positions to pursue this possibility.

The first step in such a path is to develop a strong presence in the emergency department. Establishing a strong division ensures confidence in your expertise, leadership qualities, and administrative experience. It also allows you to develop rapport and key relationships with hospital administrators and physicians of various medical specialties. It will become apparent which specialties and which faculty members will become your departmental ultrasound leaders and advocates. Another important part of this process is reassuring our radiology colleagues that we can co-exist and the relationship can be complimentary and collegial.

Once the division is well established, I advise meeting individually with the clinical chair of each department within the hospital. This meeting should be to ascertain the ultrasound needs and goals of the department as well as to garner support in moving forward. I actually developed specialty-specific ultrasound curricula together with each clinical chair as this encourages an inclusive approach. This conversation should comfort the department head mentioning that ultimate credentialing decisions would rest on him or her and that your role is in overseeing each physicians ultrasound education, experience, competency, and performing quality assurance on his or her scans. Your role will be to recommend or conversely not recommend credentialing in point-of-care ultrasound to him or her.

After you have gathered enough support, it is time to present the idea to the powers that be. This may be the vice president of clinical affairs, chief medical officer or whichever similar position you have at your institution. This might take some educating on your part. You might hear statements such as, “Wait-so you are telling me that a physician who is not a radiologist will be doing ultrasound!?” It might be a foreign concept. Be prepared to have literature and answers to the usual frequently asked questions. A big sticking point should be that most physicians in various specialties would be using point-of-care ultrasound, if not currently, then definitely in the near future. Setting up a division to give oversight and organization is a necessary safety measure and is good practice.

Lastly, you will need to present the idea to the executive committee or similar board who will ultimately decide the fate of the project. At this point however, you will have all the support you should need to get it through. Usually, most of the people you have already met with are the ones who will be voting. Don’t let your guard down and be prepared to take some tough questions regardless.

Case Report: Rule in IUP to Rule Out EP - Emergency Ultrasound Section Newsletter, March 2013

Bret W. Negro, MD and Samuel Lam, MD, FACEP 

Chief Complaint: “Pelvic pain and bleeding”

14-Case Presentation_2

1.     What anatomy and pathology are shown in the image and clips above? 
         a.     Click Here for the 1st Video
         b.     Click Here for the 2nd Video.
2.      What are the possible sonographic findings in patients with such condition?
3.      What risk factors should increase suspicion for this pathology?





Case Presentation
A previously healthy 24-year-old G2P1 female presented to the emergency department with right-sided abdominal pain, missed menstruation, and vaginal bleeding. On arrival, the patient had a pulse of 100 and blood pressure of 152/87 mmHg. Patient reported that pelvic pain had been following a fluctuating course for the past 11 days, and that on the day of arrival the pain had become acutely worse. Physical examination revealed tenderness to palpation throughout the lower abdomen, cervical motion tenderness, and a small amount of blood in the vaginal vault. Bedside urine pregnancy was positive. A bedside ultrasound was performed, which showed evidence of a ruptured ectopic pregnancy within the right adnexa. The obstetrics/gynecology service was emergently consulted, and a confirmation ultrasound was performed. The patient was taken to the operating room, where a ruptured right fallopian tube with approximately 300cc of hemoperitoneum was found. An emergent unilateral salpingectomy was performed. Pathology revealed chorionic villi. 

The Role of First Trimester Ultrasound in the Emergency Department
The primary goal of emergency sonography of the pelvis in patients who present with first trimester vaginal bleeding and/or abdominal pain is to identify an intrauterine pregnancy (IUP), and thereby exclude the diagnosis of ectopic pregnancy. For pregnant patients in whom no IUP is seen, the possibility of extrauterine implantation must be considered. Transvaginal sonography has been shown in various studies to have a high sensitivity and specificity (74-90.9% and 94-99.9%, respectively) for the detection of ectopic pregnancy. In our case, identification of this patient’s ectopic pregnancy on bedside ultrasound allowed for early obstetrics/gynecology consultation, thereby expediting initiation of treatment for this potentially life-threatening condition.

Answers to questions
1. The first image portrays a sagittal view of the uterine fundus. Of note is the absence of any evidence of intrauterine pregnancy (no gestational sac containing
    yolk sac or heart beat). A very small amount of free fluid is seen in the rectouterine pouch (of Douglas). The first video clip portrays the uterine fundus and
    right adnexa in the transverse plane. The right adnexa is notable for two heterogenous masses containing spherical, hypoechoic inclusions. The inferior mass 
    (at the top of the screen) is the right ovary containing a corpus luteum cyst. The more echogenic superior mass (at the bottom of the screen) contains a fetal 
    pole and yolk sac, thus revealing itself as an ectopic pregnancy. The second video clip demonstrates in greater detail the extrauterine gestational sac with its
    fetal pole and yolk sac. With closer inspection, fetal cardiac activity may be appreciated.
2. Ultrasound findings of ectopic pregnancy fall into 3 categories:
          a. Definite ectopic pregnancy: gestational sac with yolk sac and/or fetal pole outside the uterus.
          b. Highly suspicious for ectopic pregnancy: adnexal mass, tubal ring (gestational sac within the fallopian tube), pseudogestational sac (fluid collection in the
              endometrium without evidence of IUP), and/or large amount of free fluid in the pelvis and/or morison’s pouch in the setting of no definitive intrauterine
          c. Indeterminate scan: similar appearance as non-gravid uterus without free fluid or extrauterine masses. 
    One study showed that among patients diagnosed with ectopic pregnancy, the most common findings on transvaginal ultrasound besides extrauterine
    gestational sacs were complex adnexal masses (61%), large amount of echogenic fluid in the rectouterine pouch (21%), and tubal rings (16%).
3. Those at particularly high risk:
          a. Fallopian tube damage (previous tubal surgery including female sterilization and pelvic surgery including Caesarean section and ovarian cystectomy,
              previous abdominal surgery, and pelvic inflammatory disease). 
          b. Assisted reproductive technology 
          c. Endometriosis, unexplained infertility
          d. Pregnancy as a result of contraceptive failure (progesterone-only contraception, intrauterine contraceptive device)
          e. Cigarette smoking 
          f. Age >35 years
          g. Previous ectopic pregnancy
          h. Previous spontaneous abortion or induced abortion

Additional Reading:
1.     Hsu S, Euerle BD. Ultrasound in pregnancy. Emerg Med Clin North Am. 2012; 30(4): 849-867.
2.     Adhikari S, Blaivas M, Lyon M. Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience
        Am J Emerg Med. 2007; 25: 591-596.
3.     Sivalingam VN, Duncan CW, Kirk E, et al. Diagnosis and management of ectopic pregnancy. J Fam Plann Reprod Health Care. 2011; 37: 231-240.

Interested in Contributing? - Emergency Ultrasound Section Newsletter, March 2013

Many thanks to all section editors. If you want to contribute to the next newsletter, then just email John Bailitz, MD, FACEP, RDMS

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