Foreign Body Localization

Great case illustrative of the value of point of care ultrasound for suspected foreign body. 11 year old boy who yesterday caught his pant leg in a tree branch while running around the woods in his back yard. Today complains of leg pain and mother notes a small puncture wound to the leg. Brought to the ER "to get some antibiotics". Films did not demonstrate a foreign body (as you would expect given suspicion of wooden foreign body). Video demonstrates wound appearance, radiographs, ultrasound images, and use of ultrasound to localize foreign body with needle, cut down onto foreign body and extract. All that said, check out the size of that thing!!!

Ultrasound Guided Internal Jugular Catheterization, courtesy of Arun Nagdev, MD

Arun says you should use ultrasound to place IJ CVC's. Let him convince you...

Ultrasound to Assess for Pericardial Effusion, courtesy of Arun Nagdev, MD

You think you know everything about pericardial effusions on ultrasound? Arun doesn't think you do...

Ultrasound and Pneumothorax, courtesy of Arun Nagdev, MD

An introduction to the use of ultrasound for the identification of pneumothorax.

Intro to FAST exam, courtesy of Arun Nagdev, MD

A 15 minute or so lecture on the Focused Assessment with Sonography in Trauma.

Abdominal Aortic Aneurysm, courtesy of Arun Nagdev, MD

A 12 minute lecture on the use of bedside point-of-care ultrasound for the detection of AAA.

Valvular Pathology : Mitral Stenosis

Was talking to a bunch of residents who were skeptical that they'd be able to pick up on valvular pathology doing a bedside echo. So here's the first of what will be a few posts on valvular heart disease for the EM and Critical Care physician.

Mitral stenosis usually results from rheumatic carditis (though there are, of course, a number of other causes) and most commonly presents decades later with atrial fibrillation (due to LAE), embolic events (due to afib), hoarseness (compression of recurrent laryngeal due to LAE), or hemoptysis (secondary to pulmonary HTN). TEE is more accurate for estimating gradients and judging severity of disease, but TTE is just fine for making the diagnosis at the point of care.

Hallmarks are left atrial enlargement, thickening and restrictive motion of the mitral valve, and atrial thrombus. On a parasternal long or apical 4 chamber view, a characteristic "elbowing" of the anterior mitral valve leaflet (AMVL) is seen as the valve apparatus opens during diastole but the leaflet's tip is tethered at the valve orifice. Clip below is apical oblique with left side of heart on right side of screen (note the elbowing of the AMVL and the biatrial enlargement in this patient with longstanding mitral stenosis):



A parasternal or subcostal short axis view will demonstrate thickening of both anterior and posterior mitral valve leaflets as seen here:



Also M-mode can demonstrate anterior motion of the posterior mitral valve leaflet during diastole as it is tethered to the AMVL.

Grading severity and estimating mitral valve area is best done using Doppler estimation of the pressure gradient between LV and LA, and while not extremely complicated is beyond the focus of this blog and will not be covered here.