Point-of-care ultrasound diagnosis of small bowel-small bowel vs ileocolic intussusception

BackgroundIdentification of intussusception is feasible with emergency department (ED) point-of-care ultrasound (PoCUS) due to its ease-of-use and high accuracy. Little is known about the clinical characteristics and outcomes of small bowel-small bowel intussusception (SB-SBI) relative to ileocolic intussusception (ICI) identified by PoCUS.MethodsWe conducted a retrospective cohort study at a single, tertiary care, urban pediatric ED of intussusception identified by PoCUS. Demographic information, clinical data, and outcomes, including clinical course, intussusception characteristics, recurrence rates, and interobserver agreement (Cohen's kappa), were evaluated.ResultsED PoCUS identified thirty-seven patients with intussusception over a 4-year period. Twenty-one patients (57%) identified were SB-SBI. The median age was 54 months (IQR 35–76 months) for SB-SBI and 8 months (IQR 5.8–13.5 months) for ICI. The mean diameter was 1.68 cm (SD 0.52 cm) for SB-SBI and 2.74 cm (SD 0.43 cm) for ICI (p < 0.05). Two of 21 (9.5%) SB-SBI subjects required surgical intervention, while the rest spontaneously reduced. Fourteen of 16 (88%) ICI subjects required intervention. There were two (9.5%) recurrences of SB-SBI and 1 (6.3%) recurrence of ICI confirmed on PoCUS. Cohen's kappa was 0.85 (95% CI 0.68–1.0).ConclusionsSB-SBI may be identified more frequently than previously thought when screened with ED PoCUS. Older children with SB-SBI may have underlying lead-points and may require surgical intervention. PoCUS can help differentiate between variants of intussusception that range from a surgical emergency to a transient source of abdominal pain that may be recurrent and otherwise unexplained, allowing clinicians to better manage these patients accordingly.     

Accelerated Idioventricular Rhythm: A Rare Case of Wide-Complex Dysrhythmia in a Teenager

BackgroundAccelerated idioventricular rhythm (AIVR) is an uncommon and typically benign dysrhythmia with similarities to more malignant forms of ventricular tachycardia (VT). It is often seen in adults after myocardial infarctions, although it also arises in the newborn period, as well as in children with and without congenital heart disease.Case ReportWe describe a presentation of AIVR in an otherwise healthy 13-year-old girl, discovered on arrival to the pediatric emergency department in the setting of post-tonsillectomy bleeding. The case reviews the diagnostic criteria of AIVR, associated symptoms, the pathophysiologic origin of AIVR, and potential treatment strategies.Why Should an Emergency Physician Be Aware of This?Given its morphologic similarities to life-threatening forms of VT, AIVR can be misdiagnosed in the emergency department or primary care settings. With an understanding of the dysrhythmia's unique features, emergency physicians can avoid unnecessary interventions and provide the correct diagnosis, workup, and management of AIVR for pediatric patients.     

儿童与成人肠套叠的比较

目的 分析儿童和成人肠套叠在临床表现、诊断和治疗上的不同之处.方法 对10年内收治的45例肠套叠的症状、诊断、套叠部位、病理和治疗方法进行回顾性分析.结果 儿童组35例,成人组10例.儿童组以血便、呕吐为主要症状,而成人组腹痛最常见.相当多儿童肠套叠通过病史和体检得以诊断,而成人肠套叠诊断多依赖影像学技术.儿童组术前确诊率高.成人肠套叠常与基础病理因素有关,均手术治疗,而儿童组可经气钡灌肠复位治疗或手术.结论 肠套叠在所有年龄段均可发生,但儿童与成人肠套叠在临床表现、诊断方法和治疗上有很多不同.这两个年龄组的肠套叠本质上有显著性差异,临床上必须区别处理.     

儿童与成人肠套叠的比较

目的 分析儿童和成人肠套叠在临床表现、诊断和治疗上的不同之处.方法 对10年内收治的45例肠套叠的症状、诊断、套叠部位、病理和治疗方法进行回顾性分析.结果 儿童组35例,成人组10例.儿童组以血便、呕吐为主要症状,而成人组腹痛最常见.相当多儿童肠套叠通过病史和体检得以诊断,而成人肠套叠诊断多依赖影像学技术.儿童组术前确诊率高.成人肠套叠常与基础病理因素有关,均手术治疗,而儿童组可经气钡灌肠复位治疗或手术.结论 肠套叠在所有年龄段均可发生,但儿童与成人肠套叠在临床表现、诊断方法和治疗上有很多不同.这两个年龄组的肠套叠本质上有显著性差异,临床上必须区别处理.     

二维超声在小儿急腹症中的应用

目的探讨二维超声显像在小儿急腹症中的诊断价值。方法回顾性分析414例经临床及手术证实的小儿急腹症病人超声资料。结果414例病例中,肠套叠200例,急性阑尾炎59例,肠梗阻21例,急性肠系膜淋巴结炎125例,先天性肥厚性幽门狭窄3例,腹腔脏器破裂6例,均由超声首先诊断。结论超声可作为小儿急腹症的临床诊断、鉴别诊断的首选影像诊断方法。     

Unusual cases of intussusception

Intussusception occurs most commonly in the first five years of life and is classically associated with intense intermittent abdominal pain, vomiting, bloody mucoid diarrhea, and a palpable abdominal mass. These cardinal findings are frequently not present, however, particularly outside the usual age range. The emergency physician must therefore be vigilant in considering intussusception as a potential cause for intestinal obstruction in all patients, if ischemic complications are to be avoided. We present three cases of "unusual" intussusception, and provide a review of this entity and a guide to its consideration and work-up in the emergency department.     

Meckel Diverticulum Presenting as Abdominal Pain and Subsequent Bowel Perforation

BackgroundAbdominal pain is a common presenting symptom with a broad array of potential etiologies. Meckel diverticulum (MD), the most common congenital gastrointestinal malformation, classically presents with painless gastrointestinal bleeding. However, it can also lead to diverticulitis, intussusception, or obstruction, manifesting as abdominal pain.Case ReportA 2-year-old boy presented to the emergency department with intermittent abdominal pain, vomiting, and loose stools. Abdominal ultrasound findings were consistent with ileitis and ileocolic intussusception, but no such intussusception was seen during fluoroscopic air enema. The patient was admitted for serial abdominal examinations and subsequently developed an acute abdomen. Emergent laparotomy revealed a perforated MD. Small bowel resection and primary anastomosis were performed and no complications developed.Why Should an Emergency Physician Be Aware of This?The presence of an MD can lead to diverticulitis, intussusception, or obstruction, putting the patient at risk of bowel perforation. As such, it is important to consider MD in the differential diagnosis of patients with abdominal pain. In cases in which sonographic findings are ambiguous or transient, additional observation or alternative imaging, such as computed tomography, should be strongly considered.     

My patient has got abdominal pain: identifying biliary problems

Right upper quadrant and epigastric abdominal pain are common presenting complaints in the emergency department. With increasing access to point-of-care ultrasound, emergency physicians now have an added tool to help identify biliary problems as a cause of a patient’s right upper quadrant pain. Point-of-care ultrasound has a sensitivity of 89.8% (95% CI 86.4–92.5%) and specificity of 88.0% (83.7–91.4%) for cholelithiasis, very similar to radiology-performed ultrasonography. In addition to assessment for cholelithiasis and cholecystitis, point-of-care ultrasound can help emergency physicians to determine whether the biliary system is the source of infection in patients with suspected sepsis. Use of point-of-care ultrasound for the assessment of the biliary system has resulted in more rapid diagnosis, decreasing costs, and shorter emergency department length of stay.     

A 21st Century Problem: Cannabis Toxicity in a 13-Month-Old Child

Background

Cannabis is one of the most abused drugs worldwide, with more than 20 million users in the United States (US). As access to cannabis products increases with expanding US legislation and decriminalization of marijuana, emergency physicians must be adept in recognizing unintentional cannabis toxicity in young children, which can range from altered mental status to encephalopathy and coma.

Adult intussusception: presentation, management, and outcomes of 148 patients

Background

Intussusception is a predominantly pediatric diagnosis that is not well characterized among adults. Undiagnosed cases can result in significant morbidity, making early recognition important for clinicians.

Study Objectives

We describe the presentation, clinical management, disposition, and outcome of adult patients diagnosed with intussusception during a 13-year period.

Methods

A retrospective study of consecutive adult patients diagnosed with intussusception at a tertiary academic center was carried out from 1996 to 2008. Cases were identified using International Classification of Diseases, 9^th Revision codes and a document search engine. Data were abstracted in duplicate by two independent authors.

Results

Among 148 patients included in the study, the most common symptoms at presentation were abdominal pain (72%), nausea (49%), and vomiting (36%). Twenty percent were asymptomatic. Sixty percent of cases had an identifiable lead point. Patients presenting to the emergency department (ED) (31%) had higher rates of abdominal pain (relative risk [RR] 5.7) and vomiting (RR 3.4), and were more likely to undergo surgical intervention (RR 1.8) than patients diagnosed elsewhere. There were 77 patients who underwent surgery within 1 month; patients presenting with abdominal pain (RR 2.2), nausea (RR 1.7), vomiting (RR 1.4), and bloody stool (RR 1.9) were more likely to undergo surgery.

Conclusions

Adult intussusception commonly presents with abdominal pain, nausea, and vomiting; however, approximately 20% of cases are asymptomatic and seem to be diagnosed by incidental radiologic findings. Patients presenting to an ED with intussusception due to a mass as a lead point or in an ileocolonic location are likely to undergo surgical intervention.     

Need for bedside emergency department ultrasonography: case report of a ruptured ectopic pregnancy

Ultrasonography is a useful tool for the immediate evaluation of patients with suspected ruptured ectopic pregnancy, abdominal aortic aneurysm, traumatic intra-abdominal hemorrhage or cardiac tamponade. The 1999 Canadian Association of Emergency Physicians position statement states that bedside emergency department ultrasonography should be available 24 hours per day. This case study illustrates how emergency physicians properly trained in emergency bedside ultrasonography can use this tool effectively to dramatically impact patient care.     

Painless intussusception and altered mental status.

A 7-month-old child presented to the emergency department (ED) with 2 hours of painless, nonprojectile emesis and a normal mental status. Over a 3-hour period in the ED, the child remained pain-free, but developed hematemesis, hematochezia, and lethargy, progressing to unresponsiveness. The patient was evaluated for toxic ingestion, intracranial bleed, sepsis/meningitis, and intraabdominal pathology. The diagnosis was made by an abdominal ultrasound, which demonstrated an ileal-cecal intussusception that ultimately required surgical reduction. This case illustrates an insidious and poorly understood presentation of a common childhood affliction, as well as the utility of abdominal ultrasound in evaluating a hemodynamically stable patient with intussusception.     

Bedside Emergency Ultrasound in a Case of Acute Parotid Duct Sialolithiasis

Background

Sialolithiasis with salivary gland obstruction can mimic more frequently occurring illnesses such as facial and dental infection and abscess. It is often difficult to discern the etiology of facial pain and swelling on physical examination alone, requiring advanced imaging in the emergency department.

Case Report

We describe the case of a 37-year-old man who presented with 5 days of worsening unilateral facial pain and swelling. Use of bedside emergency ultrasound by an emergency physician (EP) led to an appropriate diagnosis of parotid duct sialolithiasis. Why Should an Emergency Physician Be Aware of This? Use of bedside emergency ultrasound performed by a trained EP successfully diagnosed symptomatic sialolithiasis of the parotid duct in the emergency department without the need for computed tomography. The utility of bedside emergency ultrasound in the evaluation of sialolithiasis and the outcomes of our case are discussed here.     

Non-targeted HIV testing in the emergency department: not just how but where

ABSTRACT

Introduction: The emergency department (ED) has the potential to enhance early HIV diagnosis through HIV testing programs. How these are implemented is a subject of debate.

Areas covered: We describe the main HIV testing approaches: diagnostic testing, targeted screening, and non-targeted screening, and review ED-based non-targeted HIV screening studies conducted after 2006 among ≥5000 patients. As well as examining how testing is offered, we focus on where it is offered, through the patient’s journey from registration, via triage and the waiting room, to the bedside. Barriers to the testing offer, acceptance and performance were examined at each location.

While testing offer rates were higher at registration and triage, compared to the waiting room and bedside, this was sometimes at the expense of testing acceptance and performance. Variables affecting testing rates included type of consent, employment of external staff and type of testing: fourth generation serological testing versus rapid testing.

Expert commentary: These large studies shed light on the importance of where as well as how HIV testing is performed, and the ways in which the ‘where’ can influence non-targeted screening yields. This perspective enables testing approaches to be tailored to specific ED settings in order to maximize testing rates.     

The mental status evaluation. Application in the emergency department

The mental status evaluation is a useful test in the emergency department. The major purposes of the examination are to determine the presence of neuropsychiatric illness and to determine whether this illness is functional or organic. The most accepted evaluation of mental status is the formal mental status evaluation. This extensive test is rarely necessary in the emergency department; rather a short test of cognitive function, such as the Cognitive Capacity Screening Examination or Mini-Mental Status Examination, may be more appropriate. With frequent repetition in use and the concomitant development of clear standards for interpretation of the examination used, the emergency physician will become more comfortable with bedside mental status testing.     

Hypoglycemia in multiple trauma victims

The typical presentation of hypoglycemia involves a diaphoretic patient with a history of diabetes mellitus who is found with an altered mental status. The hypoglycemic patient's presentation may lead the physician to believe that the altered mentation may have been caused by some other condition. Hypoglycemia occurs rarely in the traumatic setting, yet is easily and rapidly diagnosed with bedside testing. A retrospective review was conducted in a university hospital emergency department (ED) (level 1 trauma center) of adult trauma patients with a Glasgow Coma Scale (GCS) score of <15 who had presented from July 1995 through August 1996. Hypoglycemia was defined as a serum glucose level of <60 mg/dL. A total of 926 patients (49% of all trauma cases encountered in the period) met entry criteria. Four (0.4%) cases of hypoglycemia were encountered in 1 nondiabetic and 3 diabetic patients; no patient had medical alert warnings. Rapid bedside screening identified 2 cases within a mean of 7 minutes after arrival; 1 patient had an improvement in mental status after dextrose therapy. Two cases were identified by formal laboratory analysis a mean of 35 minutes after ED arrival; dextrose therapy improved the mental status in 1 patient. These results show that hypoglycemia, rare in trauma patients with abnormal GCS scores, may mimic significant traumatic injury with mental status alterations. Physicians should consider such a diagnosis in patients with an abnormal GCS score and known risk situations for hypoglycemia, including diabetes mellitus and chronic alcohol use; in such cases, appropriate bedside screening should be performed after initial stabilization.     

Ventricular tachycardia after naloxone administration in an adolescent

Naloxone is a medication with a largely benign safety profile that is frequently administered in the emergency department to patients presenting with altered mental status. Ventricular tachycardia has been reported after naloxone administration in adult patients with prior use of opiate or sympathomimetic medications. However, no such reports exist in the pediatric population or in patients who have no known history of opiate or sympathomimetic medication use. We describe a case of ventricular tachycardia after naloxone administration in a 17-year-old male with no known prior use of opiate or sympathomimetic agents who presented to the emergency department with altered mental status of unknown etiology. Emergency physicians may wish to prepare for prompt treatment of ventricular arrythmias when administering naloxone to pediatric patients presenting with altered mental status.     

Pediatric Emergency Medicine Education in Emergency Medicine Training Programs

BACKGROUND: The educational goal of emergency medicine (EM) programs has been to prepare its graduates to provide care for a diverse range of patients and presentations, including pediatric patients. OBJECTIVE: To evaluate the methods used to teach pediatric emergency medicine (PEM) to EM residents. METHODS: A written questionnaire was distributed to 118 EM programs. Demographic data were requested concerning the type of residency program, number of residents, required pediatric rotations, elective pediatric rotations, type of hospital and settings in which pediatric patients are seen, and procedures performed. Information was also requested on the educational methods used, proctoring EM received, and any formal curriculum used. RESULTS: Ninety-four percent (111/118) of the programs responded, with 80% of surveys completed by the residency director. Proctoring was primarily performed by PEM attendings and general EM attendings. Formal means of PEM education most often included the EM core curriculum (94%), journal club (95%), EM grand rounds (94%), and EM morbidity and mortality (M&M) conference (91%). Rotations and electives most often included the pediatric intensive care unit (PICU) and the emergency department (ED) (general and pediatric). CONCLUSIONS: Emergency medicine residents are exposed to PEM primarily by rotating through a general ED, the PED, and the PICU, being proctored by PEM and EM attendings and attending EM lectures and EM M&M conferences. Areas that may merit further attention for pediatric emergency training include experience in areas of neonatal resuscitation, pediatric M&M, and specific pediatric electives. This survey highlights the need to describe current educational strategies as a first step to assess perceived effectiveness.     

Diagnosis and Reduction of a Hernia by Bedside Ultrasound: A Case Report

BackgroundEmergency physicians can utilize bedside ultrasound to aid in the diagnosis of abdominal wall hernias and in the reduction of incarcerated hernias.ObjectivesTo review the sonographic appearance and diagnostic criteria of abdominal wall hernias and to describe the potential use of ultrasound as an aid in hernia reduction.Case ReportAn emergency physician utilized bedside ultrasound to confirm the diagnosis of an incarcerated ventral abdominal wall hernia and to assist in its successful reduction.ConclusionsA physician trained in bedside ultrasound can diagnose an abdominal wall hernia and facilitate the appropriate treatment of an incarcerated hernia.     

Endoscopic reduction of colocolonic intussusception due to metastatic malignant melanoma: A case report

BACKGROUNDIntussusception rarely causes intestinal obstruction in adults. Metastatic malignant melanoma is the main cause of intussusception of the small intestine among adults. However, malignant melanoma rarely causes intussusception of the colorectum. Moreover, emergent surgery is usually performed for such cases. Here, we report a case of a patient with colocolonic intussusception caused by a malignant melanoma, for which endoscopic reduction and elective surgery were performed.CASE SUMMARYThe patient was a 64-year-old woman who underwent multiple surgeries and received chemotherapy and immunotherapy for a malignant melanoma. During immunotherapy, she had abdominal pain, diarrhea, and bloody stool. Physical examination and laboratory studies did not reveal any findings that warranted emergent surgery. Computed tomography revealed intussusception in the descending colon without intestinal necrosis and perforation. Intussusception was reduced endoscopically, and elective surgery was performed.CONCLUSIONThis report suggests that endoscopic reduction and elective surgery constitute a treatment option for colocolonic intussusception of metastatic malignant melanomas.