The Case

Hi everyone! 
 
This is a 39 yo F post cardiac arrest NYD. She was in the weaning stages of her care and close to extubation, but she became newly febrile with increasing oxygen requirements.  Her sputum culture was positive for E. coli.  A portable CXR was done which did not show any obvious large consolidations.  A POCUS thoracic study was performed. An unusual finding was seen on the left side (shown in the clips below). Also, to orient those who aren’t familiar with the WesternSono shorthand here is a legend for the labels: L1 = Left anterior chest wall, L2 = Left anterior axillary line, L3 = Left costophrenic view, and L4 = Left PLAPS (PosteroLateral Alveolar and/or Pleural Syndrome)
 
What do you think is going on? Should we be concerned? 
 

I’m sure you all saw the strange anechoic structure above the diaphragm on the L3 and L4 views. Given the clinical history you might be tempted to think there might be something strange going on (e.g. could it be a lung abscess?).  However, when you see things like this, that look a bit strange, you should try to focus your ultrasound field on it and capture it as best you can. We did this as shown below. 

When you focus on it this way you can clearly see the distinct rugae of the stomach! You can even potentially see the NG tube in the center. Thus, this patient just had a hiatal hernia. We saw she had a CT Chest a week earlier (on admission, to ensure that the etiology of her arrest wasn’t a PE), so we quickly looked at that to confirm (image below).  If you were still uncertain you could even try flushing the NG tube while looking with US.  Moral of the story is sometimes with POCUS we will see things that look unusual, and it’s important that we try to figure out what’s going on, and avoid overcalling or labelling things when we’re not sure. Thanks for reading and stay tuned for next week!