Critical Care: Fellow Case Report Poster - Critical Care I |

Point of Care Ultrasound: A Tool for Rapid Diagnosis of a Life-Threatening Hematoma FREE TO VIEW

Mohsin Ijaz, MD; Ariel Shiloh, MD; Lewis Eisen, MD
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Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):239A. doi:10.1016/j.chest.2016.08.252
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SESSION TITLE: Fellow Case Report Poster - Critical Care I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Ultrasound is useful in the diagnosis and management of superficial soft tissue pathologies. There is a growing interest in the use of ultrasound for rapid evaluation of critically ill patients.

CASE PRESENTATION: A 61-year-old woman presented to the Emergency Department with sudden onset neck swelling. She underwent total thyroidectomy 10 days prior. Her vital signs were stable and physical examination was notable for swelling at the surgical site and a hoarse voice. There was no stridor heard. Her routine labs were within normal limits. A critical care consult was called for a threatened airway. Neck ultrasonography was performed with a high frequency linear transducer (5-10 MHz) suitable for imaging superficial structures (Figure). A large hematoma was revealed, prompting immediate bedside drainage by the otorhinolaryngology team. The patient’s symptoms resolved shortly after and she was discharged home.

DISCUSSION: Postoperative and post-procedural hematomas occur frequently. The ultrasonographic appearance of hematomas differs depending on the amount of time elapsed since the bleeding occurred. In the acute stage, a hematoma appears heterogeneously hypoechoic; representing uncoagulated (liquid) blood and the beginning interface between clots and fibrin strands. As the clotting process progresses, the hematoma becomes progressively hyperechoic; appearing as an irregularly marginated, complex, cystic mass with thickened hyperechoic walls or irregular internal septations. A chronic hematoma may be anechoic or isoechoic, hypoechoic or mildly echoic with a subtle fluid/debris level. Additional sonographic signs associated with hematomas are the “plankton sign” and the “hematocrit sign”. The “plankton sign” is a dynamic movement of protein or cellular debris within the hematoma due to respiratory or cardiac movements. The “hematocrit sign” is the layering deposition of cellular debris and is visualized as a gradient of echogenicity.

CONCLUSIONS: This case demonstrates point of care ultrasound as an excellent imaging modality for visualizing superficial hematomas in a potential airway emergency. An expediting diagnosis and management was delivered while avoiding transport to other imaging modalities. Ultrasound training of intensivists allows prompt identification of superficial hematomas and potential evacuation at the bedside.

Reference #1: Ryu JK et al Sonographic appearances of small organizing hematomas and thrombi mimicking superficial soft tissue tumors. J Ultrasound Med. 2011Oct;30(10):1431-6.PMID 21968496

DISCLOSURE: The following authors have nothing to disclose: Mohsin Ijaz, Ariel Shiloh, Lewis Eisen

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