Acute Aortic Regurgitation with Myocardial Infarction: An Important Clue for Aortic Dissection

Background

Aortic dissection is an important cause of acute chest pain that should be rapidly diagnosed, as mortality increases with each hour this condition is left untreated. The diagnosis can be challenging, especially if concomitant myocardial infarction is present. Echocardiography is an important tool for the differential diagnosis.

Objectives

To stress the importance of recognizing aortic regurgitation for the differentiation of myocardial infarction and aortic dissection.

Case Report

An 80-year-old woman was admitted to our hospital with chest pain that was diagnosed as inferior and lateral wall myocardial infarction based on electrocardiographic findings. The diagnosis was reevaluated when aortic regurgitation was detected on echocardiography. Closer inspection of the ascending aorta revealed a dissection flap as the cause of aortic regurgitation.

Conclusion

Detection of aortic regurgitation in a patient with myocardial infarction and normal valves should prompt the search for a possible aortic dissection, whether or not the dissection flap can be visualized.     

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.     

A Case of Spontaneous Coronary Artery Dissection: It is Not Always Plaque Rupture

Background

Spontaneous coronary artery dissection (SCAD) is an extremely rare cause of acute coronary syndrome (ACS). Patients may present with a broad spectrum of clinical scenarios, ranging from angina pectoris to myocardial infarction, cardiogenic shock, and sudden death. Standard therapy has not been established; current treatments range from conservative management to percutaneous revascularization or coronary artery bypass surgery.

Objective

SCAD greatly mimics ACS, and this diagnosis should be considered when evaluating young patients who present with ACS with or without classical risk factors for coronary artery disease.

Case Report

We report a case of a 45-year old man who presented with chest pain typical of ACS. He had no risk factors except for a smoking history of 2.5 pack-years. Once the clinical findings suggested acute inferolateral myocardial infarction, the patient underwent emergent cardiac catheterization, which revealed left anterior descending coronary artery dissection. This in itself is not a common cause of inferolateral ST elevation changes on electrocardiogram.

Conclusion

This case highlights the fact that although SCAD is a rare entity, it is increasingly being recognized as a significant cause of ACS. Urgent angiography should be considered if SCAD is suspected, because early diagnosis and appropriate management significantly improve the outcome in these patients.     

Bedside Ultrasound for Hip Dislocations

Background

Bedside ultrasound in the emergency department is being used with increasing frequency and for an increasing scope of conditions.

Objectives

Demonstrate the use of bedside ultrasound as an adjunct for diagnosis of hip dislocation.

Case Report

A traumatic anterior hip dislocation was diagnosed with bedside ultrasound after an initial normal plain radiograph.

Conclusion

Although the current standard of care for diagnosis of hip dislocation is plain radiographs, this case demonstrates that bedside ultrasound may be used as a diagnostic adjunct in this time-sensitive and potentially catastrophic diagnosis.     

Common Iliac Artery Tortuosity Simulating Aortic Dissection on Focused Abdominal Ultrasound in the Emergency Department

Background

Bedside ultrasonography performed by the Emergency Physician is a safe procedure for evaluating patients with trauma, hypotension, chest or abdominal pain, and dyspnea of unknown origin.

Objectives

To present a case with apparent concordance between the patient's history, symptoms, signs, and ultrasound imaging, that lead to diagnostic error.

Case Report

A 74-year-old man was admitted to the hospital due to epigastric pain, radiating to the back. He reported previous detection of a small dilatation in the ascending aorta. On physical examination, the heart rate was 120 beats/min and the blood pressure was 90/60 mm Hg. These facts suggested the possibility of an aortic dissection; therefore, a bedside emergency ultrasound examination was performed. The first part of the examination focused on the ascending aorta, but the results were not significant. Then, an abdominal evaluation was performed that revealed an ovular and pulsatile anechoic mass in the infrarenal tract, with an echoic wall and an endoluminal flap. A computed tomography scan of the aorta was ordered, and it showed a regular aorta in the entire tract, with an abnormal tortuosity of iliac arteries as the basis of the false-positive ultrasound.

Conclusions

The use of ultrasound in emergency settings has improved the clinical evaluation of critical patients by Emergency Physicians, but the possibility of a false-positive diagnostic error always should be considered.     

Ultrasound diagnosis of acute thrombosis of an abdominal aortic aneurysm: a case report

Background

Point-of-care ultrasound is an effective and reliable method to diagnosis the presence of an abdominal aortic aneurysm. However, there has been limited literature regarding ultrasound diagnosis of acute aortic thrombosis.

Objective

Discuss a patient case with acute aortic thrombosis diagnosed by point-of-care emergency ultrasound. Review common etiologies and treatment options in this rare diagnosis.

Case Report

A patient with a known abdominal aortic aneurysm presented with mottled lower extremities. Point-of-care ultrasound was utilized by her physicians to diagnose acute thrombosis of her abdominal aorta. With conservative treatment the patient survived to hospital discharge.

Conclusion

Aortic thrombosis is a rare and devastating problem that can be diagnosed with point-of-care ultrasound.     

Emergency Cesarean Section Due to Acute Aortic Dissection Type A (Debakey I) without Marfan Syndrome: A Case Report and Review of the Literature

Background

Acute aortic dissection during pregnancy is an uncommon but important emergency due to its lethal risk to both mother and child. The dissection usually involves the ascending aorta or the aortic arch. Although additional affection of the descending aorta up to bifurcation is possible, further increasing the risk of organ malperfusion, full-length aortic dissection (DeBakey I) is known to be very rare. Dissection during pregnancy has been reported predominantly in combination with Marfan syndrome. Acute aortic dissection Stanford type A (AADA) DeBakey I during pregnancy without signs of Marfan syndrome as a warning signal is very uncommon in the current literature.

Objectives

The etiology, diagnosis, differential diagnosis, and management of this rare disease are discussed in relation to the current literature.

Case Report

We report the case of an athletic 34-year-old woman in the third trimester of pregnancy, without history of previous diseases, who presented to our Emergency Department after collapsing. In the resuscitation department, an emergency cesarean section was performed due to the start of circulation failure in the mother. Computed tomography scan revealed a severe aortic dissection starting from 1 cm distal the aortic valve over the full length up to the iliac arteries, involving the brachiocephalic and carotid arteries up to the level of the larynx. Emergency replacement of the ascending aorta and the aortic arch was performed. Both the mother and baby survived and were doing well 1 year postoperatively.

Conclusion

This alarming result of AADA (DeBakey I) in late pregnancy without obvious warnings such as Marfan syndrome illustrates the importance of performing early imaging in similar cases.     

Spontaneous Coronary Artery Dissection in a Young Woman without Risk Factors

Background

Spontaneous coronary artery dissection is a very rare event and is more common in women than in men. Pregnancy and the early puerperium stage have been recognized as predisposing factors for this condition.

Case Report

A 33-year-old woman presented to the Emergency Department (ED) with chest pain; the patient's electrocardiogram (ECG) showed an ST-segment elevation similar to that observed in ST-segment elevation myocardial infarction (STEMI). She experienced a ventricular fibrillation cardiac arrest when she was in the hospital and received resuscitation, after which she regained consciousness and showed spontaneous circulation. She underwent cardiac catheterization under the impression of spontaneous coronary artery dissection, and conservative therapy was chosen.

Conclusion

In this report, we have underlined the importance of considering coronary artery dissection in the differential diagnosis of young women who present to the ED with chest pain, an ECG with ST-segment elevation, and very few cardiac risk factors.     

Septic hip arthritis: diagnosis and arthrocentesis using bedside ultrasound

Background

Septic arthritis of the hip is an infrequent disorder that is difficult to diagnose. Traditional methods of obtaining synovial fluid from the hip are not always available in most emergency departments.

Objective

To report a case of atypical septic arthritis with the diagnosis and management significantly aided by the use of bedside ultrasound.

Case Report

An 18-year-old pregnant woman presented with right hip pain, a normal temperature, and elevated inflammatory markers. She had no risk factors for septic arthritis. The differential diagnosis was broad, but the use of bedside ultrasound assisted in rapidly narrowing the differential, as well as guiding the diagnostic procedure.

Conclusions

Bedside ultrasound is a useful tool to evaluate inflammatory disorders of the hip and assists in hip arthrocentesis, a procedure that has not been traditionally performed by most emergency physicians.     

Spontaneous Coronary Artery Dissection in a 27-Year-Old Woman

Background

Spontaneous coronary artery dissection (SCAD) causes acute coronary syndromes or sudden death in young patients who are often lacking classic coronary disease risk factors. Systemic inflammatory and connective tissue diseases have been suggested as risk factors for SCAD.

Objective

To review the risk factors, diagnosis, and management of this uncommon but life-threatening disease.

Case Report

We report a case of a 27-year-old woman with a history of an ill-defined inflammatory arthropathy who presented with an acute ST-elevation myocardial infarction. SCAD was diagnosed by coronary angiography. Percutaneous coronary intervention was attempted but was unsuccessful. The patient recovered uneventfully with medical management and was ultimately diagnosed with systemic lupus erythematosus.

Conclusions

SCAD is a rare but important cause of acute coronary syndromes and sudden death. It commonly occurs in young women. Although pregnancy is the most well-established risk factor, systemic inflammatory and connective tissue diseases have also been suggested as risk factors.     

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.     

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.     

Performance comparison of lung ultrasound and chest x-ray for the diagnosis of pneumonia in the ED

Objective

The aim of our study was to assess the potential of bedside lung ultrasound examination by the attending emergency physician in the diagnosis of acute pneumonia.

Material and Methods

This observational single-center study was conducted between January 2010 and June 2012 in the emergency unit of a general hospital, and analyzed 144 adult patients. The ultrasound examination was performed by one of five trained emergency physicians, and a chest radiograph interpreted by a radiologist. The primary end point was the diagnosis of hospital discharge.

Results

We found a sensitivity of 0.95 for the ultrasound examination against 0.6 for radiography (P < .05). The negative predictive value was 0.67 against 0.25 for radiography (P < .05).

Conclusion

These results exhort to promote the use of thoracic ultrasound in the first-line diagnosis of pneumonia.     

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.     

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.     

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.     

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.     

Acute Type A Aortic Dissection in a 37-Week Pregnant Patient: An Unusual Clinical Presentation

Background

Aortic dissection in pregnancy is relatively rare, but it is often fatal. The estimated incidence of aortic dissection in the general population is 2.9 per 100,000 person-years. Early recognition and treatment of aortic dissections are crucial for survival. Whereas the majority of patients who present with aortic dissection are older than 50 years of age and have a history of hypertension, younger patients with connective tissue disease, bicuspid aortic valves, or a family history of aortic dissection are also at increased risk for developing this condition.

Small Bowel Obstruction from Potato and Broccoli Phytobezoar Mimicking Mesenteric Ischemia

Background

Bezoars are concretions of undigested foreign material that form in the gastrointestinal tract. Rare in humans, they are nonetheless a well-documented cause of intraluminal bowel obstruction.

Objectives

The objectives of this case report include describing an unusual presentation of small bowel obstruction due to phytobezoar, which mimicked mesenteric ischemia, and highlighting the risk factors, presentation, and management of bezoars, in addition to covering historical beliefs regarding bezoars.

Case Report

Here we report a 64-year-old man who presented to the Emergency Department with chest pain, vomiting, and hypotension. Initial work-up was directed at ruling out cardiac causes and aortic catastrophe such as aortic dissection or ruptured abdominal aortic aneurysm. Computed tomography angiography of the chest and abdomen showed findings suggestive of mesenteric ischemia and small bowel obstruction. However, exploratory laparotomy revealed intraluminal small bowel obstruction from a phytobezoar consisting of undigested chunks of potato, brussels sprouts, and broccoli.

Conclusions

Although rare in humans, bezoars are a documented cause of small bowel obstruction, and should be considered when intraluminal bowel obstruction occurs. Bezoars causing small bowel obstruction require surgical treatment.     

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.