Ultrasound
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“Seeing is believing” you mutter as you shake your head in amazement. You can’t believe your good luck tonight. You ordered a CT scan on a patient with pleuritic right-sided chest pain looking for a pulmonary embolism, and instead you found her leaking thoracic aortic aneurysm. And then, your senior resident performed a bedside abdominal ultrasound on a 40-year-old male with chronic back pain and discovered a 5 cm abdominal aortic aneurysm.

“I can’t believe the pathology we see here!” your spunky new intern exclaims. “Lucky for him, but too bad for us, this new guy in the trauma bay isn’t going to have anything cool.” In the midst of all of the “cool cases” you’ve seen tonight, you are inclined to agree with your intern that the next one in the queue might just be a run-of-the-mill Friday night bar brawl gone bad. He’s a 40 year old who looks like he could probably use a self-defense class and a week or so in rehab. In between mumbling about his wallet and his iPhone, the guy doesn’t seem to be complaining about much. Your intern has completed a pretty comprehensive primary and secondary survey, and the only thing she’s found is extensive, bilateral periorbital edema and some suspected facial fractures by exam.

You ask her what the patient’s ocular exam showed, and she says she was just about to go back and take a better look with the senior resident. With all of the edema and ecchymosis, she couldn’t get a good look at the patient’s eyes without assistance. You walk her through some tips and tricks on how to pry open the swollen lids, and give her a list of things she needs to rule-out on exam.

After you help the rest of your team discharge a few more patients, you walk up to the trauma bay and beam with pride as your new intern and one of your senior residents is performing a bedside ocular ultrasound on Mr. Bar Brawl. With all of the edema on exam, they have decided it would be prudent to do a screening B-mode scan before they put the patient at risk for any more orbital or ocular trauma.

To avoid worsening any pre-existing injury, they float the linear array transducer lightly over his left eye and obtain the image above (right).
Satisfied with their view of the left eye, they slide the transducer over the right eye and do the same, obtaining this image (left).

click on image to enlarge

alt

What abnormalities do you note on ocular ultrasound?
Conclusion on next page

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