Applications of Transcranial Color‐Coded Sonography in the Emergency Department

Transcranial color‐coded Doppler sonography is a noninvasive bedside ultrasound application that combines both imaging of parenchymal structures and Doppler assessment of intracranial vessels. It may aid in rapid diagnoses and treatment decision making of patients with intracranial emergencies in point‐of‐care settings. This pictorial essay illustrates the technical aspects and emergency department applications of transcranial color‐coded Doppler sonography, and provides some rationale for implementation of this technique into the emergency department practice.     

A Study of Bedside Ocular Ultrasonography in the Emergency Department

The use of ocular ultrasonography for the evaluation of emergency patients has recently been described in the emergency medicine (EM) literature. There are a number of potential uses that may greatly aid the emergency physician (EP) and avoid lengthy consultation or other diagnostic tests. OBJECTIVE: To examine the accuracy of bedside ultrasonography as performed by EPs for the evaluation of ocular pathology. METHODS: This prospective, observational study took place in a high-volume, suburban community hospital with an EM residency program. All patients arriving with a history of eye trauma or acute change in vision were eligible to participate in the study. A 10-MHz linear-array transducer was used for imaging. All imaging was performed through a closed eyelid, using water-soluble ultrasound gel. Investigators filled out standardized data sheets and all examinations were taped for review. All ultrasound examinations were followed by orbital computed tomography or complete ophthalmologic evaluation from the ophthalmology service. Statistical analysis included sensitivity, specificity, and positive and negative predictive values. RESULTS: Sixty-one patients were enrolled in the study; 26 were found to have intraocular pathology on ultrasound. Of these, three had penetrating globe injuries, nine had retinal detachments, one had central retinal artery occlusion, and two had lens dislocations. The remaining pathology included vitreous hemorrhage and vitreous detachment. Emergency sonologists were in agreement with the criterion standard examination in 60 out of 61 cases. CONCLUSIONS: Emergency bedside ultrasound is highly accurate for ruling out and diagnosing ocular pathology in patients presenting to the emergency department. Further, it accurately differentiates between pathology that needs immediate ophthalmologic consultation and that which can be followed up on an outpatient basis.     

A Narrative Review of Common Uses of Ophthalmic Ultrasound in Emergency Medicine

BackgroundThe timely evaluation of ocular conditions in the emergency department (ED) can be difficult due to a general lack of specialized equipment, trained personnel, and the time-sensitive nature of emergent ocular conditions. Recently, the use of ocular point-of-care ultrasound (POCUS) has been shown to be particularly useful in the ED. POCUS can be used to promptly diagnose various ocular pathologies, which include ocular trauma, vitreous hemorrhage, central retinal artery occlusion, and retinal detachment.ObjectivesThis narrative review seeks to inform the reader of current literature regarding the use of POCUS for the assessment of various ocular emergencies in the ED. The goal of this review is to provide the emergency physician with succinct and up-to-date information and instruction regarding the current uses of POCUS for patients presenting with particular ocular emergencies. Ocular pathologies that are common (ocular trauma) or for which ultrasound is particularly useful (such as retinal detachment) are discussed. Other ocular pathologies are also briefly discussed, such as central retinal artery occlusion, which is a promising new application for ultrasound evaluation.DiscussionThere have been many studies that provide evidence for the utility of POCUS in the evaluation of trauma and other ocular pathologies, including vitreous hemorrhage, retinal detachment, and central retinal artery occlusion.ConclusionsOcular POCUS is a useful modality in the evaluation of acute ocular complaints in the ED. Emergency physicians should be aware of these findings and feel confident in the utility of ocular POCUS in the ED.     

Clinician‐led design for optimising flow: Seizing the opportunity for a new‐build Australian Emergency Department

A new ED build creates a unique opportunity to improve the way we provide clinical care. Often, the focus is primarily on increasing clinical cubicle numbers but this may have a negligible, or even negative impact on care delivery. Instead, Australian EDs should examine the entire patient journey to inform design, reviewing outdated triage and registration models and maximising physical capacity by introducing advanced split‐flow models that optimise clinical space and provide high‐risk patients faster access to clinical care. Efficient ED patient flow is critical for success and is closely linked with departmental design, but too often this design process is delegated to architects with limited knowledge of ED function and with limited input from emergency clinicians. This relationship between clinicians and architects should remain collaborative but requires re‐alignment. Independent, expert ED‐specific designers can empower and provide valuable support for clinician‐led design teams in their interactions with architects.     

A critical appraisal of point‐of‐care coagulation testing in critically ill patients

Derangement of the coagulation system is a common phenomenon in critically ill patients, who may present with severe bleeding and/or conditions associated with a prothrombotic state. Monitoring of this coagulopathy can be performed with conventional coagulation assays; however, point‐of‐care tests have become increasingly attractive, because not only do they yield a more rapid result than clinical laboratory testing, but they may also provide a more complete picture of the condition of the hemostatic system. There are many potential areas of study and applications of point‐of‐care hemostatic testing in critical care, including patients who present with massive blood loss, patients with a hypercoagulable state (such as in disseminated intravascular coagulation), and monitoring of antiplatelet treatment for acute arterial thrombosis, mostly acute coronary syndromes. However, the limitations of near‐patient hemostatic testing has not been fully appreciated, and are discussed here. The currently available evidence indicates that point‐of‐care tests may be applied to guide appropriate blood product transfusion and the use of hemostatic agents to correct the hemostatic defect or to ameliorate antithrombotic treatment. Disappointingly, however, only in cardiac surgery is there adequate evidence to show that application of near‐patient thromboelastography leads to an improvement in clinically relevant outcomes, such as reductions in bleeding‐related morbidity and mortality, and cost‐effectiveness. More research is required to validate the utility and cost‐effectiveness of near‐patient hemostatic testing in other areas, especially in traumatic bleeding and postpartum hemorrhage.     

Bedside Contrast‐Enhanced Sonography of Critically Ill Patients

The transfer of critically ill patients to the radiology department is, in itself, potentially dangerous, so radiologists are frequently asked to perform bedside sonographic studies in the intensive care unit, surgical or medical department, sterile area, and operating room. In these circumstances, injection of a contrast agent may give the radiologist relevant additional information, which is useful for diagnosis and for better therapeutic management of these critically ill patients. Contrast‐enhanced sonography may allow detection of findings not recognizable on baseline sonography or even color Doppler imaging. In this pictorial essay, we highlight the value of real‐time contrast‐enhanced sonography when performed at the bedside in critically ill patients.     

Review article: Paediatric status epilepticus in the pre‐hospital setting: An update

Paediatric status epilepticus (SE) is a medical emergency and a common critical condition confronting pre‐hospital providers. Management in the pre‐hospital environment is challenging but considered extremely important as a potentially modifiable factor on outcome. Recent data from multicentre clinical trials, quality observational studies and consensus documents have influenced management in this area, and is important to both pre‐hospital providers and emergency physicians. The objective of this review was to: (i) present an overview of the available evidence relevant to pre‐hospital care of paediatric SE; and (ii) assess the current pre‐hospital practice guidelines in Australia and New Zealand. The review outlines current definitions and guidelines of SE management, regional variability in pre‐hospital protocols within Australasia and aspects of pre‐hospital care that could potentially be improved. Contemporary data is required to determine current practice in our setting. It is important that paediatric neurologists, emergency physicians and pre‐hospital care providers are all engaged in future endeavours to improve clinical care and knowledge translation efforts for this patient group.     

High‐Resolution Sonography Is Effective in Detection of Soft Tissue Foreign Bodies

Objective. Patients with penetrating trauma or field injuries are commonly encountered by emergency physicians. Clinical examination by inspection or palpation can detect superficial foreign bodies (FBs), and radiographs can detect radiopaque FBs. However, soft tissue FBs can be easily missed. The aim of our series was to evaluate the role of high‐resolution sonography in detection of soft tissue FBs. Methods. All patients referred to our center for sonographic evaluation of suspected soft tissue FBs from 1999 to 2008 were included in this analysis. Patients were scanned with an ultrasound machine using a 7.5‐MHz transducer. The suspected area was scanned in both axial and sagittal planes. The nature of the FB, length, and depth from the surface were recorded and reported. The presence of an FB was confirmed by surgical excision. Results. During the study period, 123 patients underwent sonography for a suspected FB, of which 12 were lost to follow‐up and excluded from the analysis. The study group included 73.8% male patients; the mean age was 36.2 years. Wood fragments and wooden thorns were the most frequently observed FBs, at 46.2% and 36.2%, respectively. The surgeon was satisfied with the reported depth of the FB from the surface in most cases (89%). The overall sensitivity and specificity of sonography were 94.5% and 53.8%. Conclusions. High‐resolution sonography is a very sensitive tool in diagnosis of soft tissue FBs. It also helps the surgeon with accurate localization, permitting easy removal.     

Mid‐level providers and emergency care: Let's not lose the force

The progressive rise of ED visits globally, and insufficient numbers of emergency physicians, has resulted in the use of mid‐level providers as adjuncts for the provision of emergency care, especially in the US and Canada. Military medics, midwives, aeromedical paramedics, EMT‐Ps, flight nurses, forensic nurses, sexual assault nurse examiner nurses ‐ are some examples of well‐established mid‐level provider professionals who achieve their clinical credentials through accredited training programmes and formal certification. In emergency medicine, however, mid‐level providers are trained for general care, and typically acquire emergency medicine skills through on‐the‐job experience. There are very few training programmes for NPs and PAs in emergency care. The manpower gap for physicians in general, and emergency physicians specifically, will not be eliminated in the reasonable future. Mid‐level providers – ENTs, paramedics, NPs, PAs – are an excellent addition to the emergency medicine workforce. However, the specialty of emergency medicine developed because specific and focused training was needed for physicians to practice safe and qualify emergency care. This same principle applies to mid‐level providers. Emergency Medicine needs to develop a vision and a plan to train emergency medicine specialist NPs and PAs, and explore other innovations to expand our emergency care workforce.     

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.     

Point-of-care ultrasound for the evaluation of non-traumatic visual disturbances in the emergency department: The VIGMO protocol

ObjectivesTo establish a standardized approach for the rapid and accurate identification of non-traumatic, ophthalmologic pathology in patients with eye complaints in the emergency department.MethodsIn this detailed protocol we offer an easy, reproducible method for the use of ocular point-of-care ultrasound (POCUS) in helping practitioners identify and distinguish between common eye pathology encountered in the emergency setting: retinal detachment, vitreous detachment, vitreous hemorrhage, optic nerve pathology, and syneresis.ConclusionsThis protocol can help identify patients that may need urgent ophthalmology consultation those that can follow-up on an outpatient, and those that may need additional emergent testing.     

Review article: Clinical impact of non‐cardiologist‐performed transthoracic echocardiography in emergency medicine,intensive care medicine and anaesthesia

There is increased realisation of the emerging role of point‐of‐care transthoracic echocardiography (TTE) as ‘ultrasound‐assisted examination’, given the low sensitivity of clinical examination for cardiovascular pathologies and the time‐critical nature of these pathologies. There is evidence that point‐of‐care TTE provides higher accuracy in patient assessment and management, with potential prognostic impact by assessing the severity of cardiac dysfunction and response to treatment. Point‐of‐care TTE is increasingly used by non‐cardiologists, as a diagnostic, screening or monitoring tool. The literature shows that TTE identifies new clinical findings, and conversely can accurately rule out clinically important pathologies. Recent reports have examined more advanced ultrasound devices and patients in the critical care settings of emergency medicine, intensive care and anaesthesia. The diagnostic capability of new portable devices is improving rapidly and outdating its predecessors, thereby improving confidence in echocardiography findings.     

Prenatal Diagnosis of Persistent Hyperplastic Primary Vitreous

Persistent hyperplastic primary vitreous is a spectrum of congenital ocular abnormalities characterized by leukocoria, microphthalmia, cataracts, extensive intravitreal hemorrhage, persistence of the hyaloid artery, glaucoma, and retinal detachment. It might be isolated or associated with congenital syndromes such as trisomy 13, Walker‐Warburg syndrome, and Norrie disease. We present 2 cases of persistent hyperplastic primary vitreous diagnosed by prenatal sonography in the early third trimester. Bilateral hyperechoic lenses and retinal nonattachment were detected in the sonographic examination of the first case, whereas irregular echogenic bands between the lenses and posterior walls of the eyes were prominent in the second case. In both of the cases, ocular findings were accompanied by intracranial findings, including severe hydrocephalus, an abnormal gyral pattern, and cerebellar hypoplasia, suggesting the diagnosis of Walker‐Warburg syndrome. We also present a review of the literature regarding the prenatal diagnosis of this malformation.     

Emergency clinician‐delivered screening and intervention for high‐risk alcohol use: A qualitative analysis

Objectives: To evaluate qualitative feedback from patients who received opportunistic screening and brief intervention for harmful alcohol use during an ED attendance; to evaluate emergency staff attitudes to performing alcohol screening and delivering opportunistic brief intervention; and to document process issues associated with the introduction of routine clinician‐initiated opportunistic screening and training and administration of brief intervention. Methods: Structured and semi‐structured interviews with emergency staff and recipients of brief intervention. Results: Sixty‐nine patients were interviewed 3 months after an ED attendance where they received emergency clinician‐delivered brief intervention for high‐risk alcohol use. Twenty‐two (32%; 95% CI 21–43%) reported a positive effect of brief intervention on thoughts or behaviour, but 29% (95% CI 18–40%) felt the intervention was not relevant for them or could not recall it. Four people (6%; 95% CI 1–12%) felt confronted or embarrassed, and 17 (25%; 95% CI 15–36%) felt timing or delivery could be improved. Staff had a positive attitude to delivering brief intervention, but nominated lack of time as the main barrier. Fourteen of 15 staff felt brief intervention should become routine in emergency care. Conclusion: Emergency clinicians can be trained to provide brief intervention for high‐risk alcohol in an ED. The use of emergency clinician brief intervention is acceptable to most staff and patients.     

Out‐of‐hospital emergency care providers' work and challenges in a changing care environment

Acutely ill patients are often treated on site instead of being transported to hospital, so wide‐ranging professional competence is required from staff. The aim of this study was to describe and produce new information about out‐of‐hospital emergency care providers' competence, skills and willingness to engage in self‐development activities, and to uncover challenges experienced by care providers in the midst of changing work practices. A quantitative questionnaire was sent to out‐of‐hospital emergency care providers (N = 142, response rate 53%) of one Finnish hospital district. Data were analysed using spss for Windows 22 software. Almost all respondents found their work interesting and their ability to work independently sufficient. The majority found the work meaningful. Almost 20% felt that work was dominated by constant rush, and 40%, more than half of 25‐year‐olds but <10% of over 45‐years‐olds, found the work physically straining. The majority indicated that they had a sufficient theoretical–practical basis to perform their regular duties, and more than one‐third felt that they had sufficient skills to deal with multiple patient or disaster situations. Over 20% stated that they were unsure about performing new or infrequent procedures. A number of factors experienced as challenging were revealed. The results provide a basis for improving care providers' initial and further training.     

Color and Power Doppler Sonography for Pneumothorax Detection

The use of B‐ and M‐mode sonography for detection of pneumothorax has been well described and studied. It is now widely incorporated by sonographers, emergency physicians, trauma surgeons, radiologists, and critical care specialists worldwide. Lung sonography can be performed rapidly at the bedside or in the prehospital setting. It is more sensitive, specific, and accurate than plain chest radiography. The use of color and power Doppler sonography as an adjunct to B‐ and M‐mode imaging for detection of pneumothorax has been described in a small number of studies and case reports but is much less widely known or used. Color and power Doppler imaging may be used for confirmation of the presence or absence of lung sliding detected with B‐mode sonography. In this article, we examine the physics behind Doppler sonography as it applies to the lung, technique, an actual case, and the past literature describing the use of color and power Doppler sonography for the detection of pneumothorax.     

A review of the role of emergency nurses in management of chemotherapy‐related complications

Aims and objectives. To examine the role of emergency nurses in caring for patients who receive chemotherapy in ambulatory oncology settings. Reasons for emergency department presentations are examined, specific sources of clinical risk for patients receiving chemotherapy who require emergency care are discussed and cost implications of emergency department presentations related to chemotherapy are analysed. Background. Given the increased administration of chemotherapy in ambulatory settings, emergency nurses play an important role in the management of patients undergoing adjuvant chemotherapy. Emergency departments are the major entry point for acute inpatient hospital care of complications arising from chemotherapy. Design. Systematic review. Results. Chemotherapy‐related emergency department presentations have considerable clinical and cost implications for patients and the healthcare system. Strategies to improve emergency department management of chemotherapy complications and reduction in preventable emergency department presentations has significant implications for improving cancer patients’ quality of life and reducing the cost of cancer care. Conclusions. Nurses are well placed to play a pivotal role in chemotherapy management and lead interventions such as a specialist oncology nursing roles that provide information and support to guide patients through their chemotherapy cycles. These interventions may prevent emergency department presentations for patients receiving chemotherapy in ambulatory settings. Relevance to clinical practice. Patients receiving chemotherapy require access to specialised care to manage distressing symptoms, as they are at significant clinical risk because of immunosuppression and may not exhibit the usual signs of critical illness. A team approach both within and across nursing specialities may improve care for patients receiving chemotherapy and increase effective use of healthcare resources.     

Point‐of‐Care Ultrasound Findings Associated With Langerhans Cell Histiocytosis in the Pediatric Emergency Department

Langerhans cell histiocytosis is a rare disease characterized by clonal proliferation of Langerhans‐type cells, causing local or systemic effects. One of the most affected sites in children is the skull. We describe 2 cases of children presenting to the pediatric emergency department with symptoms isolated to the scalp and the point‐of‐care focused skull ultrasound findings, which assisted in the diagnosis of Langerhans cell histiocytosis in both cases.     

Use of Ocular Ultrasound for the Evaluation of Retinal Detachment

Background: Retinal detachment is an ocular emergency posing diagnostic difficulty for the emergency practitioner. Direct fundoscopy and visual field testing are difficult to perform and do not completely rule out retinal detachment. Ophthalmologists use ocular ultrasound to enhance their clinical acumen in detecting retinal detachments (RD), and bedside ultrasound capability is readily available to many emergency practitioners (EP). Study Objective: Our study sought to assess whether ocular ultrasound would be a helpful adjunct for the diagnosis of RD for the practicing EP. Methods: This was a prospective observational study with a convenience sample of patients. As part of a general course on emergency ultrasonography, practitioners received a 30-min training session on ocular ultrasound before beginning the study. Trained practitioners submitted ultrasound scans with interpretation on patients with signs and symptoms consistent with retinal detachment. Results: Thirty-one of the 72 practitioners trained submitted ocular ultrasound reports on patients presenting to the Emergency Department with concerns for retinal detachments. EPs achieved a 97% sensitivity (95% confidence interval [CI] 82–100%) and 92% specificity (95% CI 82–97%) on 92 examinations (29 retinal detachments). Disc edema and vitreous hemorrhage accounted for false positives, and a subacute retinal detachment accounted for the only false negative. Conclusion: These data show that trained emergency practitioners can use ocular ultrasound as an adjunct to their clinical assessment for retinal detachment.