Pelvic POCUS

September 09, 2021

Pelvic POCUS

ID6893

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00:00Hi, my name is Julie Leviter.
00:03I'm going to talk to you today
00:06about Pocus for the pelvis.
00:08Let's start with the case.
00:10An 18 year old girl with a positive
00:12pregnancy test presents with
00:13right lower quadrant pain and
00:15vaginal bleeding for three days.
00:17So what are we going
00:18to do? Let's use our ultrasound machine,
00:22so I want you to take a look at
00:24this clip for a moment and think to
00:26yourself is this normal or abnormal
00:28and what are the anatomical landmarks?
00:30And what concerning features strike you here.
00:34So this turned out to be a ruptured
00:37ectopic pregnancy which went to.
00:39Where 500CC's of Hemoperitoneum were drained.
00:44So in this case, Pocus expedited care.
00:47So in this lecture we'll talk
00:49through the anatomy in the pelvis.
00:51Come back to this clip and
00:52dissect what makes it concerning.
00:54Includes you into the diagnosis.
00:57So what are we going to talk
00:59about in this lecture?
01:00Well, we've already seen a case where free
01:03fluid can clue you in to an abnormality
01:06that can also be helpful in trauma.
01:08We'll talk about early pregnancy and how to
01:12confirm an intrauterine pregnancy or IUP.
01:16We'll see some cases of
01:18ovarian torsion of infection,
01:20like appendicitis or tubo ovarian Abscess,
01:23and we'll talk briefly about bladder
01:25volume and how that can be helpful.
01:29Let's first talk about our
01:32approach to pelvic ultrasound.
01:34We're going to use a curvilinear low
01:36frequency probe because this will give
01:38us the deep penetration that we need
01:41to see the structures in the pelvis.
01:43We're going to fan through
01:45in two orthogonal planes,
01:46transverse and sagittal.
01:47And we're going to aim the probe
01:50inferiorly to see under the pubic bone.
01:53The biggest mistake
01:55that I see folks make is
01:56that they place the probe.
01:58Two superiorly too high on
01:59the abdomen and can't see the
02:01bladder or they place the probe
02:03right where they need to be
02:05right above the pubic synthesis,
02:07and they don't sweep inferiorly
02:09to get under the pubic synthesis
02:12to see the bladder, and they may mistake
02:15something in the pelvis for the bladder,
02:18which would lead to a false negative
02:20interpretation. So for example,
02:22they might see free fluid and not
02:25see the bladder and thus think.
02:28That it is the bladder,
02:30and then interpret the scan as negative.
02:34So let's talk about these transverse and
02:37sagittal views that you're looking for.
02:41So first, the transversal probe
02:43we're going to have the probe marker
02:45towards the patients for eight,
02:47and we're going to be right above
02:49the pubic synthesis and tilt
02:51inferior Lee under the pubic bone.
02:55Notice the shape of the bladder. In this
02:57view, it's a little bit rectangular.
03:00Look for this if you're not
03:01seeing this shape as expected,
03:04consider the possibility that
03:05you're purely looking at free fluid
03:07or an Abscess or something else.
03:11In fan through the area more fully,
03:14make sure to really interrogate
03:17inferiorly under that pubic synthesis.
03:24So take a look at this view and
03:27think to yourself what landmarks
03:29you see here in the female pelvis.
03:32The uterus and uterine stripe
03:34will be just posterior to the
03:36bladder or lower on the screen.
03:41Let's take a look at the sagittal view.
03:43We have the probe marker
03:45towards the patients head,
03:46and you're sweeping right to left.
03:51In sagittal orientation,
03:52the bladder is more triangular
03:55in shape. Again, look for this when you're
03:58viewing the bladder in the pelvic skin.
04:06What landmarks do you see here?
04:09So we have the bladder.
04:10We have the uterus, the uterine stripe,
04:13and the vaginal strength.
04:15So look for these landmarks when
04:17you're looking at the female pelvis.
04:18Make sure that you can identify all
04:21the structure that that you see.
04:22If you see something that you
04:24can't really identify, it might
04:26be something I'm normal.
04:31Think to yourself where
04:33free fluid will collect first in the pelvis.
04:37So free fluid is
04:38going to first accumulate posterior
04:40to the bladder, so in a female this
04:43will be in the pouch of Douglas.
04:47Here's an example of a 15 year
04:49old girl status post MVC.
04:52So what orientation are we in?
04:56Well, you can tell based on
04:58the slightly more rectangular
04:59as opposed to triangular shape of the
05:03bladder. This is the transverse orientation.
05:05Now, does this look normal or abnormal? So
05:10I'll give you a hint, this
05:11is abnormal. We see some free
05:14fluid here posterior to the bladder
05:17and more anteriorly on the left
05:19of the screen in the later views.
05:22So actually in children
05:24and menstruating woman,
05:25a trace amount of free fluid just
05:27closer to the bladder is normal.
05:29But here it comes up all the
05:31way around the bladder.
05:32So this is a very concerning.
05:35Fast in this trauma,
05:37patient and highly concerning.
05:38For intra abdominal injury.
05:43Let's talk next about Pocus for pregnancy, so
05:46this can be used for a pregnant
05:48female with pelvic or abdominal pain,
05:50vaginal cleaning, or syncope. You're
05:54going to look for the following.
05:57When you're doing emergency department point
06:01of care ultrasound for pregnancy, your
06:03goal is to distinguish between
06:06intrauterine pregnancy, IUP,
06:08or no definitive inuki ndep.
06:12Those are your goals
06:14within intrauterine pregnancy.
06:16You can identify
06:18yolk SAC and or fetal pole, and
06:20then you want to distinguish is it alive IEP.
06:23So is there fetal motion and feel healthy. No
06:27definitive value paid. This can
06:29happen being early pregnancy
06:31in ectopic pregnancy,
06:33particularly if you see free fluid.
06:35It can happen in a miscarriage.
06:37It can happen in molar pregnancy.
06:42If you have determined that this is no
06:47definitive intrauterine pregnancy or ND IUP,
06:50then you need to obtain a beta HCG.
06:55The number to know is the discrimina
06:57Tori zone, so this is the level
07:00at which you should see in IUP.
07:02So if you're doing a transabdominal
07:06ultrasound and the. Beta HCG is 800.
07:13Then this is probably early pregnancy,
07:16and it's probably too early to
07:20see the intrauterine pregnancy.
07:22This patient should receive
07:25another beta HCG in two days.
07:28However, if you're doing a transabdominal
07:32ultrasound and the beta HCG is 10,000.
07:36This is highly concerning.
07:39This could be an ectopic and
07:42you need to call OB right away.
07:49Let's talk a little bit more
07:51about what defines an IEP.
07:53First, we have the gestation ilsac this
07:56fluid collection embedded within the uterus.
07:58This has two layers and it's the
08:01first sign of pregnancy on ultrasound.
08:04It can be seen at five weeks on
08:07trans vaginal ultrasound and
08:09six weeks on transabdominal.
08:11Here's the yolk SAC.
08:12It looks like a cheerio or a lifesaver,
08:15and it can be seen at five to six
08:18weeks on trans vaginal and usually a
08:20little bit later on transabdominal.
08:25Here's the fetal pole.
08:26It looks like a thickening on
08:29the margin of the yolk SAC,
08:30and it can be seen at five
08:32and a half to six weeks
08:33on trans. Vaginal ultrasound
08:35and seven weeks on transabdominal ultrasound.
08:40What parts of an IEP can
08:42you make out in this clip?
08:44You can see the gestational SAC as
08:46the hyperechoic circles surrounding
08:49the anechoic fluid collection.
08:51In this uterus you can see the
08:53yolk SAC at about the seven o'clock
08:55position in there and the fetal pole
08:58just to the left of the yolk SAC
09:01and then. You can make out
09:03the fetal heart rate.
09:06So this fetal heart rate looks
09:08like a flickering in the fetal
09:09pole and is usually seen at six
09:13weeks on trans vaginal ultrasound
09:15and about seven weeks on
09:17transabdominal ultrasound.
09:22Now the last part to this entire
09:25definition of an intrauterine
09:27pregnancy is that all of these different
09:30items need to be within the uterus.
09:38For example, do you remember
09:40this example from the beginning?
09:43This is the pregnant patient who
09:45came in with abdominal pain.
09:47We're seeing all of those features
09:49that define in early pregnancy.
09:52We see the gestational
09:53SAC, the yolk SAC, the fetal pole,
09:57and we even see the flickering
09:58of the fetal heart rate. But we don't
10:01see the uterine stripe or the adjacent
10:04bladder. To confirm to us
10:06that this is in the uterus,
10:08we also see a lot of free fluid here,
10:11which is an ominous finding and
10:13should prompt stat OB konsult. So
10:17this patient went to the OR and
10:19was found to have a ruptured
10:21ectopic in the fallopian tube.
10:23They drained 500CC's of Hemoperitoneum
10:27and underwent to self inject.
10:29With this case in mind,
10:31what are some potential
10:33pitfalls in defining an IEP?
10:38Do you see a gestational SAC here?
10:42Does the scan seem normal or abnormal?
10:47So. Maybe the free fluid tipped
10:51you off to the fact that something
10:53isn't right here, but this is a
10:55potential pitfall when you're
10:57looking for a gestational SAC.
11:00What we're seeing here is
11:01a pseudo gestational SAC or
11:04a pseudo SAC. Basically it's a fluid
11:07collection within the uterus in the
11:09setting of a positive pregnancy test,
11:12but it does not actually contain
11:14the yolk SAC or the fetal pole. It's
11:16generally irregularly shaped,
11:18has pointed edges,
11:19and may be filled with debris,
11:21but I would say that if you're not
11:23at least seeing the yolk SAC within
11:26the gestational SAC, then I would
11:28not be totally reassured of an IEP.
11:31This clip was from a
11:34ruptured ectopic pregnancy.
11:36Here's a 30 year old woman
11:38with a positive pregnancy test.
11:39Six weeks by last menstrual period
11:42presenting with acute onset,
11:44lower abdominal pain.
11:45What do you think of this uterus?
11:49Again, our pseudo sack.
11:52Also the free fluid posterior
11:53to the uterus is another tip
11:55off that something isn't right.
11:56This was another ruptured
11:58ectopic and went to the OR.
12:02So let's move on to another type of pitfall.
12:05Do you see a just stational sack with
12:07a fetal pole within this uterus?
12:12So here's something that
12:14could be a gestational SAC,
12:16and if you decided that that's a
12:19gestational SAC, you would be correct,
12:22but there's a problem.
12:24The distance from the gestational
12:26SAC to the edge of the uterus or
12:29the myometrial mantle is too small
12:31for gestational SAC should be at
12:33least one centimeter from the edge
12:35of the uterus and below this the
12:37myometrial mantle is too small.
12:39This tells us that it's actually
12:42in the wrong place.
12:43This too is an ectopic pregnancy.
12:46It's what's called an interstitial pregnancy.
12:49These are very vascular.
12:51They can bleed a lot, and they have.
12:54Seven times the morbidity and
12:56mortality than tubal ectopics.
12:58It occurs in about 2 to 4% Divock topics.
13:02So it's rare, but it's deadly.
13:05Be suspicious if the distance from
13:06the Miami trim to the edge of the
13:09uterus is less than 1 centimeter.
13:13Let's practice does this
13:15myometrial mantle size look OK?
13:17Yeah, it's 1.48 centimeters,
13:20so it's over 1 centimeter so it looks great.
13:24This is an intrauterine pregnancy.
13:27Does this myometrial mantle size look OK?
13:30No, it's .6 centimeters,
13:32so less than one centimeter.
13:35This one concerns me.
13:37I'm concerned for an interstitial pregnancy.
13:39Let's call OB gyne Let's talk
13:43about another potential pitfall.
13:45Do you see an IEP here?
13:47Do you see something else?
13:50Do you see anything that concerns you?
13:53Are you confused?
13:55I guarantee that whatever you said
13:58you are correct.
14:01Here's your IUP. It has all the
14:05fetal components and with and
14:07is within the uterus. Here's
14:10another image from the same clip.
14:13And here we see and ectopic pregnancy.
14:17So this is an example of
14:19a heterotopic pregnancy.
14:20There are both intrauterine and extrauterine
14:25pregnancies occurring simultaneously.
14:27This is extremely rare in general,
14:30but there's increased risk in those
14:33receiving assistive reproductive techniques,
14:35so about one to one in 100
14:38to one in 500 patients.
14:41Experience this.
14:42Be suspicious for it,
14:45particularly in the right clinical
14:46setting and in a patient
14:49with fertility treatments.
14:50And don't be reassured by the
14:53presence of an IUP until you have
14:56fanned fully through the pelvis
14:59and interrogated to determine
15:02that there is only one
15:04IUP and nothing else that's concerning.
15:10Let's talk next about fetal
15:12dating and department.
15:16Let's talk briefly about fetal
15:17dating first. Four
15:19of fetus of less than 13 weeks
15:22will use crown rump length or CRL.
15:25We'll use the OB setting
15:28on our machine.
15:29Use the calculation package
15:32to click on curl and
15:35will measure the baby in the plane
15:37in which it looks the longest.
15:39And remember, don't include
15:40the arms or legs.
15:44For a fetus that's greater
15:46than 13 weeks and age, we're going
15:48to use the biparietal diameter orbed.
15:52What we're going to do is fan
15:54until we find the septum pellucida.
15:56It's this line here, running anterior
15:58to post area across the cranium.
16:01The hemisphere should appear symmetric
16:03on either side of this line,
16:04and we're going to measure in axial plane
16:07across the septum pellucida perpendicular
16:09to the central axis of the head.
16:12We're going to place the calibres outer
16:14edge of the interior
16:15wall to the inner edge of the
16:17posterior wall, so outer to inner
16:20or leading edge to leading edge.
16:23In order to maintain the
16:25standard of management.
16:29Let's talk now about calculating
16:31the fetal heart rate.
16:32So first we're going to find a plane
16:35that slices through the heart such
16:37that you can see it flickering.
16:39Now let's talk about calculating
16:41the fetal heart rate. So first
16:44find a plane that slices through
16:46the heart such that you can
16:48see it flickering like this.
16:54Here's another example.
16:56See how you can really clearly
16:58see that flickering heart.
17:01So once we find that plane will
17:04click on end mode and put that
17:06icepick right through the heart where
17:08you're seeing cardiac activity.
17:11This will allow us to capture the
17:13movement of the heart with time and
17:15then could freeze. When we click measure,
17:19we'll get those calibers and will
17:22choose two beats peak to peak.
17:28I don't know if you can tell
17:29that they've done that here,
17:30so I've highlighted their calibers
17:32and then the machine will calculate
17:34for you the fetal heart rate.
17:36A normal heart rate is 120 to 160
17:40beats per minute, so this fake fetal
17:43heart rate is 143, so that's normal.
17:50Now one thing I want to talk about is
17:52the concept of using Doppler for fetal
17:55heart rate in the emergency department.
17:58In the Ed, we're abiding
18:00by the principle of ALARA,
18:02meaning we're using the amount of
18:04energy from the machine that's as low
18:07as reasonably achievable for what
18:09we're trying to do when we use Doppler,
18:12we're sending more intense
18:14energy to the heart itself,
18:16which could hypothetically
18:18result in fetal heart defects.
18:21The OBSE use this for
18:24their purposes sometimes,
18:25but any emergency department all we're doing.
18:28Is measuring fetal heart rate,
18:30which could just be done with M mode
18:33using a lot lower amount of energy.
18:35So when it comes to Doppler I say no.
18:42Let's talk through some cases.
18:44We have a 25 year old woman
18:46with a beta HCG presenting with
18:48severe lower abdominal pain.
18:54Where is this clip being recorded?
18:56This is in Morrison's pouch
18:57in the right upper quadrant.
19:00We're seeing a little bit of free fluid here.
19:03Now, free fluid in Morrison's
19:05pouch is always an ominous sign.
19:11So now we move down to the pelvis in
19:14our sagittal plane. And what do you see?
19:21So here are landmarks,
19:22the bladder and the uterus there
19:25with the uterine stripe telling
19:27you where we are. This is clott.
19:31This is a ruptured ectopic pregnancy
19:33and this patient went to the ER.
19:39Our next patient is a 20 year old
19:41girl who is 10 weeks pregnant,
19:43presenting with lower abdominal
19:45pain starting this morning.
19:51What do you see in this clip?
19:55We see the fetus within the gestational SAC,
19:58which is within the uterus.
20:00But we also see an anechoic stripe
20:03below the gestational SAC and
20:07with it still within the uterus.
20:11This is a subchorionic hemorrhage.
20:13It's an accumulation of broad blood
20:15between the uterine lining and the Korean.
20:18Subchorionic hemorrhage
20:19and subchorionic matoma are the
20:21most common cause of vaginal
20:23bleeding in patients or 10 to
20:2520 weeks of gestational age. It
20:27can increase the risk
20:28of an array of pregnancy complications and
20:30should be referred to OB.
20:37What do you see here?
20:40It's twins. All right, let's move on. Now
20:46we're going to talk about some non
20:48pregnant patients. Will talk about
20:50some kids with abdominal pain.
20:54Spoiler Alert you'll soon
20:56notice a pattern connecting
20:57the following slew of cases,
20:59but I won't regulate yet.
21:03So we have some young women with pelvic pain.
21:07Our first case is a 9 year old girl with
21:10vomiting and right lower quadrant pain
21:12referred to the emergency department by her
21:14pediatrician to rule out appendicitis. She
21:17had an acute
21:18onset of her symptoms about 12 hours ago.
21:21On exam she has rebound tenderness.
21:24Localising to the right lower quadrant,
21:26her labs demonstrate a white count
21:30of 12.983% neutrophils so ever
21:32in search of an inflamed. Appendix
21:34captured on purpose.
21:35We pulled out the machine into the
21:38room and went right for the right lower
21:40quadrant to get that appendix right.
21:43So we actually started
21:44with some pelvic views.
21:46Take a look at this sagittal
21:48and transverse view.
21:50See if you could pick out the bladder
21:52in each view.
21:55And you'll notice on the left that there
21:58are two anechoic cystic looking structures.
22:05So here they are labeled.
22:07The bladder is the triangular
22:10structure to the right to the
22:12left of the platter or superior
22:14to it is a large cystic lesion.
22:18On the bottom of the screen
22:19you'll see the ovary marked,
22:22so this pocus expedited this patients
22:26radiology performed ultrasound.
22:29Let's take a look at the results of
22:31the radiology performed ultrasound.
22:33They read the peripheral right,
22:35ovary is of normal appearance with
22:38normal follicles demonstrated.
22:39They mentioned that the resistive index,
22:41or RI is .68 and then they measure
22:44the dimensions which appear normal.
22:47The impression is a large right sided
22:49simple cyst arising from the right ovary
22:52with no associated evidence for torsion.
22:54Now you may be looking at this resistive
22:57index and wondering what the heck this is,
22:59so I just want to take a tangent
23:02to discuss the resistive index.
23:04This is really important to
23:06understand when we're evaluating
23:07flow in an ovary or testicle.
23:09It's a measure of flow in the
23:11organ through the cardiac cycle,
23:13calculated as the peak systolic
23:15velocity minus the end diastolic
23:17velocity over the peak,
23:18systolic velocity.
23:19Arterial waveforms are pulsatile and
23:21have a high flow pattern while the bean
23:24is typically continuous with minimal.
23:26Changes in the velocity of flow and any
23:28kind of outflow obstruction is going to
23:31cause resistance to arterial blood flow,
23:33so it increases the resistive index.
23:38A value of greater than Queen
23:40Devon indicates high resistance,
23:42which is concerning for torsion.
23:44Here you can see that the
23:46resistive index was .68,
23:47so it's just at the upper limit of normal.
23:51Well,
23:52this patient based on her
23:54clinical presentation
23:56and this large simple cyst was taken to
24:00the operating room.
24:02There on laparoscopy they
24:05found that the fallopian tube and
24:07ovary had a 180 degree of torsion
24:10and was dusky in appearance.
24:13So unfortunately, the operating
24:15room findings did not correlate with
24:18the reassuring radiology
24:20performed ultrasound findings. What
24:24is the evidence show for ovarian torsion?
24:27This is a retrospective review of
24:29SONOGRAPHIC reports compared to 41
24:31cases of surgically or pathology.
24:32Proven ovarian torsion
24:34all had abnormal adnexa,
24:37so that's important to note the
24:40most common finding was in a large,
24:43heterogeneous appearing ovary.
24:46All of these other aspects of ultrasound,
24:48though may not be present.
24:50Particularly important is the fact
24:52that Colorflow was present in
24:5662% of cases. We see this over and over
25:00again and it's because of the dual blood
25:02supply to the ovaries. I'd love to
25:05show a couple of other examples.
25:08So this is a 16 year old girl
25:10presenting with worsening right
25:12lower quadrant pain for two days.
25:14She was diagnosed with
25:15ovarian cyst the day before.
25:20Here's her sagittal view.
25:24And here's her transverse view.
25:29What do you see here?
25:32This large cystic structure was
25:34interpreted by a well meaning team
25:36member as the bladder and it was
25:38measured as such to determine if
25:40this patient had a full enough
25:43bladder to undergo transabdominal
25:45ultrasound to evaluate the ovary.
25:48Unfortunately, as you might have predicted,
25:50this is not the bladder.
25:52This is an ovarian cyst.
25:56In this sagittal view,
25:57you can get a sense of where the
25:59bladder actually lies by where
26:01I've traced it out in red. This
26:04is the pitfall that I mentioned before
26:07where a ovarian cystic structure or another
26:12abnormal finding in the pelvis
26:14is mistaken for the bladder.
26:19The other clue to what's going on
26:21here is that you're noticing the
26:24uterus just posterior to the bladder.
26:26As we know the structure.
26:28That course is just posterior
26:29to the bladder should be the vagina, and
26:31the uterus should lie just
26:34superior to the bladder.
26:35The relationship between these
26:38structures clues you in to
26:40what's normal and abnormal. This
26:42next case is a 16 year old
26:44woman with lower abdominal pain,
26:45nausea and vomiting.
26:47She has a history of an
26:48ovarian cyst three years ago.
26:50Here on the left in the sagittal pelvis
26:52view you see the bladder
26:54as this large cystic
26:55structure in the center of the
26:56screen, with the vagina coursing
26:59below it posterior to the bladder
27:02and the uterus just comes into view.
27:05But we also see this heterogeneous
27:09looking structure just
27:11superior to the bladder
27:12and sort of pressing on it.
27:16Here in the transverse pelvic
27:17view we see it again a little
27:20bit to the right of midline.
27:21This heterogeneous looking structure
27:24just superior to the bladder.
27:27Now, what is this structure?
27:31This is a tourist over.
27:34It is enlarged.
27:35It is medialize,
27:37meaning that it has shifted
27:39medially and it has no.
27:41This is Victor Stover.
27:51Here's another young woman with
27:54acute onset of right lower quadrant
27:55pain and emesis for one day
27:58and take a look at the anatomy
27:59that you see in this transverse pelvis view.
28:05And think to yourself,
28:07are you seeing the correct anatomy
28:10or is there anything abnormal?
28:12He said that this does not appear to be the
28:16bladder. You are correct.
28:19It has some heterogeneous
28:21structures around the periphery.
28:22This is an ovarian teratoma with torsion.
28:32Just to pause the image and
28:36take a look at the structures that
28:38we're actually seeing anatomically,
28:39we're seeing again the uterus
28:42here, below, or posterior
28:45to the cystic structure.
28:48So if you were looking at this at bedside,
28:51you could be clued in to the
28:53fact that this this cystic
28:55structure is not the bladder,
28:57but actually an adnexal.
28:59Structure based on the fact
29:01that the uterus is coursing
29:03posteriores to it as opposed to
29:06more a little more superior to it.
29:12Let's take a look at this 17
29:14year old woman presenting with
29:15stabbing right lower quadrant pain.
29:17This patient is takach Arctic to 120.
29:20She's tender in the right lower
29:22quadrant and left lower quadrant.
29:23She is a positive Rob Zing.
29:26If you were preparing this patient
29:28for transabdominal ultrasound,
29:29you might ask her if she feels
29:31like she has to avoid and based
29:33on the size of this tiny little
29:36bladder that you see on the upper
29:38right hand portion of this screen,
29:40she might just tell you that
29:42she does not have to pee,
29:43and then you might fill her with more
29:45fluids to prepare her for transabdominal
29:48ultrasound performed by radiology,
29:50however.
29:52Take a look at the pelvis.
29:54There is a heterogeneous structure
29:56in here in the middle of the screen
29:59that's pushing the uterus anteriorly
30:01and the uterus itself is acting as
30:04an acoustic window to see the pelvis.
30:06So while you're taking a look with
30:08your ultrasound with your bedside
30:11ultrasound to check for bladder volume
30:13to see if this patient is ready
30:16for a transabdominal ultrasound,
30:17you're also looking in the pelvis to
30:20see if there's anything abnormal large.
30:23Heterogeneous and abnormal anatomic.
30:28Arrangement of these structures
30:30because this will expedite your
30:34care and and this patient can go
30:37to the OR as soon as possible.
30:40This is a tourist ovary.
30:42It is enlarged,
30:44heterogeneous and it needs to
30:46go to the OR stat.
30:49So there is actually this interesting
30:51article that's worth a look by
30:54letter and Constantine was published
30:56in 2020 and it gives an algorithmic
31:00approach for undifferentiated
31:02abdominal pain in a pediatric patient.
31:05So this left side of the algorithm gives
31:08an approach to lower abdominal pain,
31:10and as we all know,
31:13rule any rule out appendicitis is
31:15also a rule out gonadal torsion, so.
31:18This algorithm does advocate for
31:21starting in the right lower quadrant,
31:22and if you don't see
31:23a positive appendix to continue
31:25on to the pelvis. But I've
31:27actually since changed
31:28my thinking and I've started to
31:30go right for that pelvic view,
31:32and this serves several purposes.
31:34First of all, it prioritizes looking
31:37for free fluid in the most sensitive
31:39place of the pediatric pelvis.
31:42It also allows you to check the
31:44bladder volume to see if it's
31:45full in preparation for going
31:47over to radiology performed.
31:50Ultrasound transabdominal, pelvic view, and
31:54it also gives you an
31:55opportunity to note any time
31:57sensitive abnormalities of the pelvis.
32:02Now I also
32:02want to talk about this concept
32:04of performing point of care ultrasound
32:07for assessing bladder fullness in female
32:11patients awaiting radiology performed
32:13transabdominal pelvic ultrasound
32:15in pediatric emergency department.
32:18This randomized control trial
32:21looked at 120 patients age 8 to
32:2318 to report subjective bladder
32:25fullness or receive pocus to
32:28assess their bladder fullness.
32:31Sonographically the median time to
32:34pelvic ultrasound completion was
32:37139 minutes and usual care group
32:39and 87 minutes in the focus group.
32:42All patients in the focus group
32:44had a successful pelvic ultrasound
32:46on first attempt compared with
32:4885% in the usual care group,
32:51so they found that
32:52pokas assessment of bladder fullness
32:55decreases the time to pelvic ultrasound
32:57and improves first attempt success
33:00rate for female patients. In the PVD.
33:05So this is what I want you
33:06to go. Do I want you to focus
33:08the pelvis. Find the bladder,
33:11make sure it's really the bladder,
33:13and then assess for abnormalities.
33:15I want you to really identify those
33:17anatomic structures that you're seeing
33:19and make sure you're seeing what
33:21you're supposed to be seeing and
33:23interpreting everything correctly.
33:25The other thing that you can do
33:27is assess the bladder size for
33:29readiness for transabdominal
33:31radiology performance ultrasound in
33:33the pediatric emergency department.
33:37Will end with this 11 year old boy
33:39with vomiting, diarrhea and
33:40abdominal pain for five days.
33:43This kid had been diagnosed
33:45with gastroenteritis.
33:47Was pain free at this point and was just
33:49waiting to be admitted upstairs for
33:50some Ivy hydration. He was scanned
33:53really more for educational purposes.
33:55What do you see in the pelvis?
33:58You look posterior
33:59to the bladder. You'll see some echogenic
34:02folk, I some shadow
34:06the in a fluid collection. This is a
34:10perforated appendicitis with Abscess.
34:12So once again Pokus gave clues that were
34:15not appreciated clinically and this
34:17patient's diagnosis was made in
34:19a timely fashion thanks to focus.
34:24Thank you so much for watching this video.
34:27I would love to hear your questions,
34:29comments and stories. You can email me at
34:33julie.leviter@yale.edu. Thank you again.