Chapter 31: Critical Care Ultrasound

Chapter 31: Critical Care Ultrasound

A 23-year-old woman presents with worsening of right-sided pleuritic chest pain, intermittent episodes of nighttime chills, and a cough productive of yellow sputum. She received a 5-day oral course of azithromycin without relief. Her initial vital signs are temperature of 97.8°F, heart rate of 141 beats/min, respiratory rate of 34 breaths/min, and oxygen saturation of 86% on room air. A chest radiograph is performed and is pictured in Figure 31-10.

Figure 31-10. Portable chest radiograph.

A medical intensive care unit (ICU) consultation is called for evaluation of multilobar and impending respiratory failure. A lung ultrasound of the right lung base is performed and is pictured in Figure 31-11.

Figure 31-11. Thoracic ultrasound obtained in the midaxillary scan line.

This image is highly suggestive of what process?

A. Ascites

B. Complex pleural effusion

C. Pleural mass

D. Atelectasis

B. Complex pleural effusion

The image shown was acquired on the lateral thorax in the midaxillary line using a low-frequency convex probe with the indicator pointed cephalad. The key anatomic boundaries for defining a pleural effusion are shown: the chest wall (anterior), diaphragm (caudad), liver (caudad) pleural surface, and lung (cephalad). Identification of the diaphragm is imperative to avoid an intra-abdominal tap. Choice A is incorrect because there is no fluid seen below the diaphragm in this image. Choice C is incorrect because there is no pleural mass noted. Choice D is incorrect because atelectasis would appear simple without septations or loculations often with a small tail at the lung edge, known as the plankton sign. The prevalence of pleural effusions in IUCs can range as high as 60% to 90%. Pleural ultrasound can detect as little as 3 to 5 mL of fluid and has been shown to have a higher sensitivity for detecting and characterizing pleural effusions than chest radiographs. Compared with chest computed tomography, pleural ultrasound had a sensitivity and specificity of 93%. The presence of septations seen in part B on pleural ultrasound is highly suggestive of empyema (Fig. 31-22).

Figure 31-22. Complex pleural effusion with appropriate landmarks. Septations of a complex pleural effusion.

A 23-year-old woman presents with worsening of right-sided pleuritic chest pain, intermittent episodes of nighttime chills, and a cough productive of yellow sputum. She received a 5-day oral course of azithromycin without relief. Her initial vital signs are temperature of 97.8°F, heart rate of 141 beats/min, respiratory rate of 34 breaths/min, and oxygen ...