Bedside Ultrasound Diagnosis of Acute Embolic Femoral Artery Occlusion

Background

Acute limb ischemia is both a limb-threatening and life-threatening disease process. Nontraumatic acute peripheral arterial occlusion is most commonly caused by a thrombosis or an embolism.

Objectives

There is limited evidence on the use of bedside ultrasound for the detection of acute limb ischemia, but duplex ultrasonography is standard in the diagnosis and operative planning in chronic limb ischemia. Emergency physicians may use bedside ultrasound in the evaluation of patients with symptoms and signs suggestive of this disease entity.

Case Report

A 64-year-old man with a past medical history of hypertension and an ischemic stroke presented to the Emergency Department with <2 h of severe upper left leg pain that radiated down to his foot. A bedside ultrasound of the left lower extremity was emergently performed. On B-mode ultrasound evaluation, echogenic material was visualized in the left common femoral artery, the artery was noncompressible, and there was an absence of Doppler flow signal. He was then directly taken to the operating room for an emergent limb-saving procedure.

Conclusion

A focused examination of the aorta, iliac vessels, and femoral artery bifurcation with bedside ultrasonography may help to localize peripheral arterial occlusions and can assist the emergency physician in seeking timely surgical consultation and management.     

Subcapsular Liver Hematoma after Colonoscopy Diagnosed by Emergency Department Bedside Ultrasonography

Background

Hepatic subcapsular hematoma is an uncommon cause of right upper quadrant pain in the Emergency Department. It must be recognized early, as large volumes of acute blood loss and rupture into the peritoneum carry significant morbidity and mortality. In the absence of gallbladder disease, the differential diagnosis should include liver pathology. Bedside ultrasonography can be used to identify such lesions.

Objectives

To discuss the presentation, evaluation, and management options of hepatic subcapsular hematoma.

Case Report

We report a case of a 30-year-old woman who presented with the chief complaint of right upper quadrant pain radiating to the right scapula 6 h after a screening colonoscopy for intestinal polyps. Emergency physician-performed bedside ultrasound revealed a large hyperechoic mass in the right lobe of the liver. Radiology-performed comprehensive ultrasound and subsequent computed tomography scan of her abdomen and pelvis revealed a subcapsular hematoma without intestinal perforation.

Conclusion

In a patient with undifferentiated right upper quadrant abdominal pain, bedside ultrasonography is a rapid and effective modality in the diagnosis of liver masses, including subcapsular hematoma.     

Focused Cardiac Ultrasound Diagnosis of Thoracic Aortic Aneurysm: Two Cases

Background

Thoracic aortic aneurysms (TAAs) are less prevalent than abdominal aortic aneurysms. Symptomatic TAAs need to be identified quickly by the emergency physician (EP) since mortality rates increase dramatically once complications such as rupture or dissection occur. Compared with validated EP-performed ultrasound of the abdominal aorta, EP-performed focused cardiac ultrasound that includes evaluation of the thoracic aorta is relatively unreported.

Objective

Two cases illustrate EP-performed focused cardiac ultrasound and evaluation of the thoracic aorta for aneurysmal dilation.

Case Reports

(1) A 60-year-old man presented to the emergency department (ED) after a blunt traumatic injury to his back while at work. During the focused cardiac ultrasound examination, the aortic outflow tract distal to the aortic valve appeared enlarged and the aortic root measured 5.49 cm. (2) An 82-year-old man with hypertension presented to the ED with 1 month of chest pain radiating to the back. The focused cardiac ultrasound examination demonstrated enlargement of the descending thoracic aorta at 4.82 cm.

Conclusion

EPs performing focused cardiac ultrasound can visualize regions of the thoracic aorta that may reveal an aneurysm, particularly in the parasternal long axis view.     

Case Report: Ovarian Torsion in Pregnancy – Diagnosis and Management

Background

Ovarian torsion (OT) is one of the most common gynecologic surgical emergencies. All age groups can be affected, but ovarian stimulation, as found during early pregnancy or infertility treatment, is a major risk factor.

Objective

Diagnosing OT in early pregnancy can be challenging. Patients frequently present with abdominal pain and non-specific symptoms. Missed diagnosis of OT could lead not only to ovarian necrosis and sepsis, but also threaten the pregnancy. The objective of this article is to present a case of OT in early pregnancy and to review its epidemiology, diagnosis, and treatment.

Case Report

A 30-year-old woman at 10 weeks gestational age presented to the Emergency Department (ED) with 2 h duration of abdominal pain, nausea, and vomiting. The patient was not on ovarian stimulation treatments. A bedside ED ultrasound showed an enlarged edematous right ovary with a large cyst, but without flow on color Doppler. Immediate obstetric consultation was initiated. Eventual radiology ultrasound showed decreased but present flow in the right ovary. The patient underwent emergent laparoscopic surgery, during which the necrotic right ovary was removed. She was placed on progesterone therapy upon hospital discharge and eventually delivered a healthy term infant.

Conclusions

Ovarian torsion in pregnancy is increasing in frequency due to the growing prevalence of ovarian stimulation treatment. Although diagnostic ultrasound is a frequently used imaging tool in patients with suspected OT, the mere presence of blood flow on Doppler ultrasonography of the adnexa has a poor negative predictive value. A high clinical suspicion and early laparoscopic management correlate with favorable maternal and fetal outcomes.     

Ability of Emergency Ultrasonography to Detect Pediatric Skull Fractures: A Prospective,Observational Study

Background

Blunt head trauma is a common reason for medical evaluation in the pediatric Emergency Department (ED). The diagnostic work-up for skull fracture, as well as for traumatic brain injury, often involves computed tomography (CT) scanning, which may require sedation and exposes children to often-unnecessary ionizing radiation.

Objectives

Our objective was to determine if bedside ED ultrasound is an accurate diagnostic tool for identifying skull fractures when compared to head CT.

Methods

We present a prospective study of bedside ultrasound for diagnosing skull fractures in head-injured pediatric patients. A consecutive series of children presenting with head trauma requiring CT scan was enrolled. Cranial bedside ultrasound imaging was performed by an emergency physician and compared to the results of the CT scan. The primary outcome was to identify the sensitivity, specificity, and predictive values of ultrasound for skull fractures when compared to head CT.

Results

Bedside emergency ultrasound performs with 100% sensitivity (95% confidence interval [CI] 88.2–100%) and 95% specificity (95% CI 75.0–99.9%) when compared to CT scan for the diagnosis of skull fractures. Positive and negative predictive values were 97.2% (95% CI 84.6–99.9%) and 100% (95% CI 80.2–100%), respectively.

Conclusions

Compared to CT scan, bedside ultrasound may accurately diagnose pediatric skull fractures. Considering the simplicity of this examination, the minimal experience needed for an Emergency Physician to provide an accurate diagnosis and the lack of ionizing radiation, Emergency Physicians should consider this modality in the evaluation of pediatric head trauma. We believe this may be a useful tool to incorporate in minor head injury prediction rules, and warrants further investigation.     

Evaluation of Left Ventricular Function by Bedside Ultrasound in Acute Toxic Myocarditis

Background

Myocarditis can be difficult to diagnose in the Emergency Department (ED) due to the lack of classic symptoms and the wide variation in presentations. Poor cardiac contractility is a common finding in myocarditis and can be evaluated by bedside ultrasound.

Objective

To demonstrate the utility of fractional shortening measurements as an estimation of left ventricular function during bedside cardiac ultrasound evaluation in the ED.

Case Report

A 54-year-old man presented to the ED complaining of 3 days of chest tightness, palpitations, and dyspnea, as well as persistent abdominal pain and vomiting. An electrocardiogram (ECG) showed sinus tachycardia with presumably new ST-segment elevation and signs of an incomplete right bundle branch block. A bedside echocardiogram was performed by the emergency physician that showed poor left ventricular function by endocardial fractional shortening measurements. On further questioning, the patient revealed that for the past 2 weeks he had been regularly huffing a commercially available compressed air duster. Based on these history and examination findings, the patient was given a presumptive diagnosis of toxic myocarditis. A follow-up echocardiogram approximately 7 weeks later demonstrated resolution of the left ventricular systolic dysfunction and his ECG findings normalized.

Conclusion

Cardiac ultrasound findings of severely reduced global function measured by endocardial fractional shortening were seen in this patient and supported the diagnosis of myocarditis. Endocardial fractional shortening is a useful means of easily evaluating and documenting left ventricular function and can be performed at the bedside in the ED.     

Paget-Schroetter Syndrome Diagnosed by Bedside Emergency Physician performed Ultrasound: A Case Report

Background

Paget-Schroetter syndrome, or an upper-extremity deep venous thrombosis (UEDVT), occurs in young people after strenuous repetitive activity involving the upper extremity. The long-term morbidity and mortality of this condition is similar to the effects of lower-extremity DVT and therefore, its early diagnosis and treatment are essential.

Objectives

This case report describes Paget-Schroetter syndrome (effort thrombosis) diagnosed at the bedside by Emergency Physician performed ultrasound.

Case Report

This is a case report of an uncommon but potentially dangerous disease that carries high morbidity if not diagnosed and treated early. Emergency Physicians should be aware of this condition in any young patient who presents with upper-extremity complaints with a history of repetitive use. Although the role of ultrasound in the diagnosis of lower-extremity DVT is well described, this case report is unique because it illustrates the diagnosis of Paget-Schroetter syndrome completed at the bedside.

Conclusion

This article presents the case and discusses the incidence, potential causes, predisposing factors, diagnostic modalities, and the course of treatment for this particular diagnosis.     

Pitfalls in the Use of Ocular Ultrasound for Evaluation of Acute Vision Loss

Background

Retinal detachment is a true medical emergency. It is a time-critical, vision-threatening disease often first evaluated in the Emergency Department (ED). Diagnosis can be extremely challenging and confused with other ocular pathology. Several entities can mimic retinal detachment, including posterior vitreous detachment and vitreous hemorrhage. Ocular ultrasound can assist the emergency physician in evaluating intraocular pathology, and it is especially useful in situations where fundoscopic examination is technically difficult or impossible. Accurate and rapid diagnosis of retinal detachment can lead to urgent consultation and increase the likelihood of timely vision-sparing treatment.

Objectives

This case demonstrates both the utility of ocular ultrasound in the accurate and timely diagnosis of retinal detachment and potential pitfalls in the evaluation of intraocular pathology in the ED.

Case Report

A 38-year-old woman presented with acute onset of bilateral visual loss that was concerning for retinal detachment. Rapid evaluation of the intraocular space was performed using bedside ocular ultrasound. Bedside ocular ultrasound correctly diagnosed retinal detachment in the right eye. Posterior vitreous detachment in the left eye was incorrectly diagnosed as retinal detachment.

Conclusion

This case illustrates the importance of bedside ocular ultrasound and highlights some of the pitfalls that can occur when evaluating for retinal detachment. Following is a discussion regarding methods to distinguish retinal detachment from vitreous hemorrhage and posterior vitreous detachment.     

Middle-Aged Man with Left Neck Pain and Swelling

Background

Disorders of the salivary glands can be evaluated by bedside ultrasonography and should be considered in patients presenting with undifferentiated neck swelling.

Objective

Our aim was to describe the sonographic findings present in sialolithiasis and sialadenitis.

Case Report

A 61-year-old man presented to the emergency department with 2 days of neck swelling. Initial evaluation included a bedside ultrasound that demonstrated sialolithiasis, which was later confirmed by computed tomography.

Conclusions

Bedside ultrasound can be a useful imaging modality in the evaluation of the patient with neck swelling.     

Near-Miss in Focused Lower-Extremity Ultrasound for Deep Venous Thrombosis

Background

Focused, proximal compression ultrasound (FPCUS) is a commonly used point-of-care study in the Emergency Department (ED). Pelvic vein deep venous thrombosis (DVT) is a rare presentation, and Emergency Physicians need to be aware of the limitations and pitfalls of FPCUS.

Objective

A case of external iliac vein DVT diagnosed in the ED is presented, with a focus on subtle signs seen during FPCUS that led to the diagnosis and additional ultrasound techniques to aid in appropriate point-of-care diagnosis.

Case Report

We describe a patient who presented with lower-extremity pain and was subsequently diagnosed with external iliac DVT. A FPCUS study by Emergency Physicians was performed and demonstrated subtle findings that led to further investigation and appropriate diagnosis.

Conclusion

Emergency physicians using FPCUS in the evaluation of lower-extremity pain or swelling need to be aware of the pitfalls, limitations, and advanced techniques to avoid misdiagnosis while evaluating for DVT.     

Bedside Ultrasound Aids Identification and Removal of Cutaneous Foreign Bodies: A Case Series

Background

Soft tissue injury with a retained foreign body (FB) is a common emergency department (ED) complaint. Detection and precise localization of these foreign bodies is often difficult with traditional plain radiographic imaging or computed tomography (CT).

Case Report

We present three cases in which bedside ultrasound was used to identify and guide management of retained soft tissue foreign bodies. Comparison of ultrasound vs. plain radiography and CT, as well as techniques for FB identification and removal, are discussed.

Why should an emergency physician be aware of this?

Bedside ultrasound is an invaluable tool in the localization of foreign bodies in relation to other anatomic structures, and aids in the decision to remove them in the ED.     

The Ultrasound-guided “Peripheral IJ”: Internal Jugular Vein Catheterization using a Standard Intravenous Catheter

Background

Obtaining vascular access is difficult in certain patients. When routine peripheral venous catheterization is not possible, several alternatives may be considered, each with its own strengths and limitations.

Discussion

We describe a novel technique for establishing vascular access in Emergency Department (ED) patients: the placement of a standard catheter-over-needle device into the internal jugular vein using real-time ultrasound guidance. We present a series of patients for whom this procedure was performed after other attempts at vascular access were unsuccessful. In all cases, the procedure was performed quickly and without complications.

Conclusion

Although further study of this technique is required, we believe this procedure may be a valuable option for ED patients requiring rapid vascular access.     

Dedicated emergency department ultrasound rotation improves residents' ultrasound knowledge and interpretation skills

Background

Graduates of Emergency Medicine (EM) residency training programs are expected to be proficient in ultrasound. However, best practices for teaching residents ultrasonography has yet to be determined.

Study Objectives

To determine if a dedicated Emergency Department (ED) ultrasound rotation objectively improves residents’ EM ultrasound knowledge, interpretation accuracy, and clinical decision-making based on ultrasound findings.

Methods

EM residents completing a required ED-based ultrasound rotation were prospectively studied. Before the start of the rotation, each resident completed a 20-question pre-test. At the end of the rotation, residents completed a 20-question post-test. Both tests covered physics, trauma (focused assessment with sonography for trauma), first-trimester pregnancy, aorta, biliary, echocardiography, and vascular sonography, using a multiple-choice format. In both tests, ultrasound images were included in 11 of the 20 questions. The questions were divided into three categories: knowledge-based (8 questions), interpretation (9 questions), and clinical decision-making (3 questions), for both tests. Scores on pre-tests and post-tests were compared using a Wilcoxon signed-rank test.

Results

During the 2-year study period, 21 residents completed the rotation. The median pre-test score was 16 (interquartile range [IQR] 14.5–17), compared to a median post-test score of 19 (IQR 18–20), p < 0.001.

Conclusions

A dedicated ED ultrasound rotation improves residents’ EM ultrasound knowledge and interpretation accuracy based on ultrasound findings, as measured by improvement on ultrasound test scores.     

An Unusual Cause of Dysphagia: Pericardial Effusion after Implantable Cardioverter-Defibrillator Placement

Background

Dysphagia is a known complication of pericardial effusions. Most cases of pericardial effusions are idiopathic, infectious, and neoplastic, but can also occur after cardiac procedures.

Objective

To report the case of a patient who developed dysphagia from a sub-acute pericardial effusion caused by the placement of an implantable cardioverter-defibrillator (ICD).

Case Report

A 62-year-old woman presented to the Emergency Department (ED) with a 2-day history of dysphagia. Imaging revealed a large pericardial effusion compressing the esophagus from the mid-thoracic level to the gastroesophageal junction. Ten days prior, a dual-chamber ICD with small-diameter active fixation leads was placed in the patient. There had been no apparent complications from the procedure, however, over this 10-day period she developed a sub-acute pericardial effusion from an incidental perforation during ICD lead placement that led to the extrinsic compression of the esophagus and her presenting symptom of dysphagia. The patient underwent pericardiocentesis for the pericardial effusion and she was discharged in stable condition.

Conclusion

This case report highlights the importance of recognizing a non-cardiac complaint such as dysphagia as the primary symptom of a critical cardiac condition. With an increase in cardiac procedures anticipated, clinicians should consider the possibility of a pericardial effusion as a cause of dysphagia, especially for those patients with recent cardiac procedures.     

Bedside Ultrasound Maximizes Patient Satisfaction

Background

Bedside ultrasound (US) is associated with improved patient satisfaction, perhaps as a consequence of improved time to diagnosis and decreased length of stay (LOS).

Objectives

Our study aimed to quantify the association between beside US and patient satisfaction and to assess patient attitudes toward US and perception of their interaction with the clinician performing the examination.

Methods

We enrolled a convenience sample of adult patients who received a bedside US. The control group had similar LOS and presenting complaints but did not have a bedside US. Both groups answered survey questions during their emergency department (ED) visit and again by telephone 1 week later. The questionnaire assessed patient perceptions and satisfaction on a 5-point Likert scale.

Results

Seventy patients were enrolled over 10 months. The intervention group had significantly higher scores on overall ED satisfaction (4.69 vs. 4.23; mean difference 0.46; 95% confidence interval [CI] 0.17–0.75), diagnostic testing (4.54 vs. 4.09; mean difference 0.46; 95% CI 0.16–0.76), and skills/abilities of the emergency physician (4.77 vs. 4.14; mean difference 0.63; 95% CI 0.29–0.96). A trend to higher scores for the intervention group persisted on follow-up survey.

Conclusions

Patients who had a bedside US had statistically significant higher satisfaction scores with overall ED care, diagnostic testing, and with their perception of the emergency physician. Bedside US has the potential not only to expedite care and diagnosis, but also to maximize satisfaction scores and improve the patient–physician relationship, which has increasing relevance to health care organizations and hospitals that rely on satisfaction surveys.     

Identification of intraluminal thrombus by ultrasonography in emergency department patients with acute deep venous thrombosis

Background

Traditionally, the diagnosis of deep venous thrombosis (DVT) using duplex ultrasonography (DU) has relied on the absence of venous compressibility. Visualization of an intraluminal thrombus is considered an uncommon finding.

Objectives

The purpose of this study is to determine the frequency of intraluminal thrombus in emergency department (ED) patients diagnosed with acute DVT.

Methods

Retrospective chart review of adult ED patients with DU examinations demonstrating acute DVT. Patients with chronic DVT or patients in whom DU did not demonstrate DVT were excluded from data analysis. Study reports and ultrasound images were reviewed and analyzed for the presence of intraluminal thrombus.

Results

There were 189 patients who met inclusion criteria, of which 160 (85%) were found to have intraluminal thrombus.

Conclusion

Intraluminal thrombi are present in the majority of patients in our ED in whom acute DVT is identified by DU.     

An Unusual Case of an Icteric Infant with Abdominal Distention

Background

Jaundiced infants are uncommon in most emergency departments (EDs). Biliary rupture remains one of the more rare and less described causes of this condition.

Case Report

A 5-month-old male presented to our ED with scleral icterus, increasing abdominal distention, and increased irritability. A bedside ultrasound revealed a moderate amount of ascites and further imaging suggested he had a rupture of his common bile duct. Surgical exploration confirmed this and revealed the presence of choledocholithiasis, which was the likely cause of the rupture.

Why Should an Emergency Physician Be Aware of This?

Biliary rupture remains a rare but serious condition in very young patients. Emergency physicians should consider bedside ultrasound as an adjunct in undifferentiated abdominal distention or jaundice in this patient population.     

Right Flank Pain: A Case Report of an Interesting Sonographic Finding

Background

Focused bedside ultrasound is a screening tool frequently used by emergency physicians to evaluate hepatobiliary and renal pathology in patients presenting with abdominal complaints in the emergency department (ED).

Objective

This case report describes a sonographic finding that was interpreted as free fluid in the right upper quadrant. Computed tomography (CT) was used to confirm the diagnosis.

Case Report

A 44-year-old man presented to the ED with the sudden onset of right-sided abdominal pain and exhibited right costovertebral angle tenderness on physical examination. Focused bedside ultrasound of the right upper quadrant revealed severe hydronephrosis of the right kidney and free fluid of either subcapsular, perinephric, or peritoneal location represented by an anechoic stripe in Morison’s pouch. On CT evaluation, this patient was found to have perinephric fluid accumulation from a presumed ruptured renal calyx in the setting of chronic ureteropelvic junction obstruction with severe hydronephrosis.

Conclusion

The exact location of anechoic fluid in the abdomen is not always apparent on bedside ultrasound. To minimize misinterpreting focused bedside ultrasound examination findings, we recommend a number of sonographic techniques to identify possible mimics of free fluid. Suspected free fluid findings on bedside ultrasound should always be evaluated within the clinical context of the patient’s presentation.     

Implementation of transvaginal ultrasound in an emergency department residency program: an analysis of resident interpretation

Background

Emergency physicians are increasingly performing transvaginal ultrasound (TVUS) to rule out ectopic pregnancy. However, little is known about appropriate educational pathways to train emergency medicine residents in TVUS.

Study Objectives

To evaluate the ability of Emergency Medicine (EM) residents who underwent a training program in TVUS to detect the presence or absence of an intrauterine pregnancy (IUP) in patients of < 13 weeks gestation with vaginal bleeding or abdominal pain, as compared to the final interpretation of each study as determined by the Emergency Department (ED) Director of Ultrasound.

Methods

This was a prospective, observational study in a single residency program. Training included a lecture, competency examination, and 10 supervised TVUSs. The EM residents then performed TVUSs with the goal of determining the presence or absence of an IUP without input from an attending physician. Correlation with the ED Director of Ultrasound was assessed for the cohort, and stratified by year of training. Results: There were 22 residents who performed 75 TVUSs over 17 months. Correlation with the ED Director of Ultrasound was 93.3%. Differences in correlation with the ED Director of Ultrasound were noted when compared by year of training: post-graduate year (PGY)-3 (93.3%), PGY-2 (92.1%), and PGY-1 (100%); p < 0.001.

Conclusion

Residents were able to perform TVUSs to determine the presence or absence of an IUP in patients in whom the diagnosis of ectopic pregnancy was being considered with a high degree of correlation with the ED Director of Ultrasound after a brief training program. Correlation with the ED director of ultrasound was influenced by year of training.     

Optic Neuritis Diagnosed by Bedside Emergency Physician−Performed Ultrasound: A Case Report

Background

Optic neuritis is an inflammatory demyelinating condition of the optic nerve that causes subacute visual loss. It is often the result of an underlying systemic condition, such as multiple sclerosis. Due to the possible long-term morbidity associated with this condition, it is essential that the emergency physician recognizes the diagnosis and expedites treatment.

Objective

This case report describes optic neuritis diagnosed at the bedside by emergency physician−performed ultrasound.

Case Report

This is a case report of a young man presenting with unilateral painful vision loss. Optic neuritis must be considered in the differential diagnosis of any young patient who presents with visual complaints without any other neurologic findings. This report is unique because there are very few cases describing the findings of optic neuritis on emergency physician−performed bedside ultrasound in the literature.

Conclusions

This article presents the case, describes diagnostic modalities, especially the use of ultrasound in its diagnosis, and the course of treatment for this particular condition.