Cut to the case!
Emergency doctors discuss cases and how to manage tricky situations in the Emergency Department.
Cut to the case!
Severe abdominal Pain Sorted with Ultrasound
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Severe abdominal pain scanned and sorted with ultrasound! Emma Paterson joins Jonathan Papson on the cut to the case team to discuss a case of an acute abdomen where a timely ultrasound makes the diagnosis and facilitates treatment.
I had a 40-year-old female and she comes in and she's in terrible abdominal pain. She is really distressed. And about the only thing this poor lady could say was hernia. The bottom line is ultrasound actually saved the day. Hi, Jonathan.
SPEAKER_00Hi, Emma. And this is Cut to the Case.
SPEAKER_01And Emma, welcome to Cut to the Case. Thank you. It's very exciting. Emma's uh ultrasound expert, so no surprise, we're gonna be doing an ultrasound case. And we had a case, didn't we? I mean it was pretty dramatic, and I'll I'll take you through it because I found it pretty challenging, but I think the the bottom line is ultrasound actually saved the day. So and I was surprised at how useful it really was. So so let's get into it. Um we had I had a 40-year-old female and she comes in and she's in terrible abdominal pain. She is really distressed, she's holding her abdomen, she's really distressed, severe central abdominal pain, and so much so that I couldn't really get a history. Um nothing. It was really hard, and so we gave her analgesia, I examined her, you know, she wasn't really guarding, she was just sort of sore all over, uh all over the abdo. Her vital signs, her heart rate was 120, um, blood pressure was actually okay. She wasn't shocked, it was maybe 110 um from memory. Oxygen saturation okay. We really didn't know what the history was, but she's 40 years old, she's got severe abdo pain, and and I got you in and you were standing by. Do an ultrasound for me. Um see if you can help. And I guess I wasn't really thinking what you might be able to find, but what was going through your mind is what you might find, Emma.
SPEAKER_00Yeah, well, I mean, my first thought in a young female with abdo pain was ectopic. Um, so I went for looking for free fluid, um, kept trying to ask the patient if she was pregnant, but didn't really get a response.
SPEAKER_01No, no. I think the partner eventually came in and he said he did, he's probably not pregnant.
SPEAKER_00Yeah, probably not, yeah. Yeah.
SPEAKER_01But ectopic was the number one thing to look for. Yeah.
SPEAKER_00Ectopic, um, and then I was thinking ovarian torsion because I think we also had a VBG and the lactate was a bit high.
SPEAKER_01Yeah, yeah.
SPEAKER_00Um so that's kind of where my mind went. So sort of looking for free fluid um and then looking to see if I could see a big ovarian cyst.
SPEAKER_01Yeah, which would and you'd see the cyst and you'd imply that tort that would be the right thing.
SPEAKER_00Yeah, it would increase my suspicion of of a torsion, yeah.
SPEAKER_01And uh and it wasn't trauma. We we knew it wasn't trauma. So so um the we weren't doing the fast for trauma, which is what I would normally do. So we're looking for the ectopic, we're looking for the torsion, we don't think it's trauma. Any other abdominal things you could get a clue on um in someone like this? Severe abdot pain.
SPEAKER_00Um yeah, definitely so renal colic would be the other one. Of course, yeah. Yeah, so having a look at the kidneys, see if was there any obvious hydro nephrosis, um, but her kidneys look normal.
SPEAKER_01Yeah, it was all normal. And then and then uh, you know, abdopain and gave her some allergies here, reassessed her, and about the only thing this poor lady could say was hernia. Hernia. And then we thought, hernia, okay, so whereabouts? Yeah. So then you had a great idea.
SPEAKER_00Yeah, um, so yeah, didn't really know any any um details about the hernia, um, and so I I think she might have pointed towards a um uh you know um belicus. So I was like, oh I'm just gonna have a look with the op sound.
SPEAKER_01And this is what you saw.
SPEAKER_00Yes.
SPEAKER_01So take a look at this. Um and Emma, do you want to just describe uh this image? Describe what we're seeing.
SPEAKER_00So this was just kind of just above her um umbilicus, and I could see her abdominal wall muscles, uh, and then there was just this really obvious collection outside of that, and I thought, oh, that looks like a hernia.
SPEAKER_01And even I could understand that. So abdo wall, big pouch-like structure sticking out. And could you say, and so something's herniated? Um could you say what it was containing?
SPEAKER_00Yeah, well, the first thing I I saw was that there was fluid, and then I thought, oh, that actually looks like bowel, and I could see with live scanning, you could actually see um you know that it was obvious bowel, you could see the bowel wall, um, and then this collection of fluid around it.
SPEAKER_01Um so yeah, I was like, So we had hernia, we had bow, we had strangulated, incarcerated, whatever you want to say, hernia. So we had a diagnosis. So we we had a start and we were on the way. So and then we kind of felt it. We said, yeah, actually there is a tender golf ball size nubbin there. It was a bit hard to appreciate because she was in so much pain. So we had a hernia. So uh what happens next?
SPEAKER_00Well, we thought she's already had quite a bit of sedation, so and she bit on ketamine, that's right.
SPEAKER_01So we did actually give her ketamine for pain relief.
SPEAKER_00Because morphine wasn't wasn't working.
SPEAKER_01So I think it was like, hell, let's just and and she was fasted and and I thought, well, let's just give us some more ketamine. Let's see if we can reduce it. Um so lo and behold, ketamine goes in.
SPEAKER_00She relaxed, and we could actually it was actually only really then that you could clinically really feel the hernia. Um and we could we reduced it.
SPEAKER_01And it reduced pretty easily. Yeah. Yeah. And uh and I think at that stage the surgical team came down who we called, uh, and you're able to show them this.
SPEAKER_00Yes, so we were able to show them the the picture that I had saved of of what we saw before. Um, and then we re-ultrasound. We could see this where we yeah, clearly this is where we had the lump before. A little bit of fluid left over, but all of the bowel had um had been reduced.
SPEAKER_01Yeah, so look, and I thought that was just amazing. Um because you know, it's hard to kind of prove to someone sometimes that you've done something. No, surgeons are great, but you know, was there a problem there in the first place? What were you going on? That kind of thing. No, we had photographic evidence, and we were and I was really happy to see that reduced because now I was confident that she was okay. And eventually as she came out from under the ketamine, pain's better. Yeah. Um and look, we got a CT and we confirmed things were okay, and and she did just fine. So, great case. I I I wondered, um Emma, then I got me thinking, are there other things that ultrasound could be useful for in severe abdo pain? Are there other conditions you would look at?
SPEAKER_00Um Yeah, yeah, so I think definitely.
SPEAKER_01What might your approach be?
SPEAKER_00Yeah, I think always um the first thing I'm looking for is free fluid because even in a non-trauma patient, you know, be thinking about uh particularly females, is it a hemorrhagic cyst rupture? Um, you know, if if think about ectopic, ruptured ectopic, obviously. Um so I normally look for free fluid and then I'd be looking at the pelvis.
SPEAKER_01So so when you say free fluid, you'd start up.
SPEAKER_00Yeah, yeah, usually so you write up a quadrant around your liver tip.
SPEAKER_01This is where the fluid usually accumulates first.
SPEAKER_00Yeah, it's the most sensitive spot around the liver tip. So yeah, exactly. Same so you need to see that first.
SPEAKER_01Look for the fluid, uh, and then go for where the money is. It's probably going to be a gyne pelvis thing. Yes.
SPEAKER_00So move into the pelvis and pelvis, and then um, and then I probably look at you know, depending on what history you've got, so where's the sore spot? Is it you know, is it flank pain? We can look at the kidneys, you know, is there hydro nephrosis and obvious um you know renal abscess or something?
SPEAKER_01Yes, yeah.
SPEAKER_00Um, and then you can have billary, have a look at the gallbladder, is there obvious gallstone, um, you know, pericolocytic fluid.
SPEAKER_01Um obviously in an older patient, triple A, which triple A we didn't mention, and you know, she's 40 years old, so unlikely, but I guess that's the other thing, isn't it? So um, yeah, and then appendix, what do you reckon? What's the deal with that? I know there's a lot of stuff about option with appendix. Is that useful?
SPEAKER_00Yeah, I mean it can be really useful if there's um you know if there is signs of appendicides that you can see, then obviously you know that really helps you to rule it in. Doesn't exclude it if you don't see um, you know, if you see what you think is a normal appendix. Um yeah, so it can can rule in but not so so great.
SPEAKER_01So look, I mean that was just a great case, a nice demonstration of how ultrasound really saved us. And then to and just to think a little bit further, how the other things that ultrasound could be useful for, and what I'm hearing is go for go for looking for fluid because that's going to tell you there's something serious going on, and then think irony, because that's probably where the money is, uh see this to um anectopic, and then just have a squirt around um metal colic, which obviously can give you severe pain and even billary pain. Um, so fantastic. Well, thanks for that. That was really fun, and uh let's look forward to some more ultra sound case and cut the case. See you next time. Bye.