Integration of Point-of-Care Ultrasound Education Into the Internal Medicine Core Clerkship Experience

Point-of-care ultrasound (POCUS) is becoming an essential skill for internists. To date, there are no professional guidelines for how POCUS skills should be taught to medical students. A panel of POCUS experts from seven academic medical centers in the United States was convened to describe the components of independently developed IM clerkship POCUS training programs, identify areas of similarity and difference, and propose recommendations for alignment.     

Choroid Detachment,a Rare Cause of Vision Loss Diagnosed by Point-of-Care Ultrasound

Background

Choroid detachment is a rare disease process that has a multitude of etiologies; usually related to recent ophthalmological surgery, eye trauma, corneal ulcers, or intraocular pressure-lowering agents. Point-of-care ocular ultrasound has high utility and accuracy in diagnosing pathology of the eye.

Use of Ocular Point-of-Care Ultrasound in a Difficult Pediatric Examination: A Case Report of an Emergency Department Diagnosis of Retinoblastoma

BackgroundEye examination in distressed young children can be challenging in a busy emergency department. A full, detailed evaluation is, however, often needed in ocular emergencies.Case ReportA 2-year-old boy presented to our pediatric emergency department with refusal to open his left eye for 1 day. Eye examination was difficult and yielded limited findings, despite analgesia and parental facilitation. Under such circumstances, this might require sedation or forcibly everting the child's eyelids for the eye evaluation. A rapid ocular point-of-care ultrasound was performed, which revealed sonographic findings suggestive of a retinoblastoma in the left eye.Why Should an Emergency Physician Be Aware of This?The use of ocular point-of-care ultrasound facilitated the diagnosis of retinoblastoma in a child who was highly distressed and difficult to examine. Its use under such circumstances facilitated the patient's prompt evaluation and subsequent management.     

Point-of-Care Ultrasound in Diagnosing Pyomyositis: A Report of Three Cases

Background

Pyomyositis is a bacterial infection of skeletal muscle that often results in deep intramuscular abscesses. The absence of external dermatologic manifestations in the early stages of pyomyositis makes this a challenging diagnosis. In addition, physical examination findings can be difficult to distinguish from more common processes, such as soft-tissue cellulitis. Clinicians can fail to diagnose this serious disease in a timely manner, resulting in delayed treatment and potential clinical deterioration from sepsis. Although advanced imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI) provide excellent detail, ultrasound (US) can also be used to detect this disease. US can be performed expeditiously at the bedside and is less expensive than CT or MRI. It allows the clinician to examine the deeper tissue planes of muscle, in which purulent fluid collections will develop as pyomyositis advances.

Case Report

Three patients presenting with leg pain were evaluated with point-of-care (POC) US and diagnosed with pyomyositis. The early diagnosis of this condition prompted rapid treatment with administration of appropriate antibiotics and involvement of orthopedic surgery. Aspiration of fluid allowed for detailed fluid analysis and bacterial cultures. Additional diagnostic imaging was performed, confirming the initial US diagnosis.

Why Should an Emergency Physician Be Aware of This?

POC US can be helpful in identifying and further delineating intramuscular abscesses and can subsequently lead to expedited and appropriate care in patients who present with extremity pain, but lack significant dermatologic changes.     

Point-of-Care Ultrasound Diagnosis of Cesarean Scar Ectopic Pregnancy: A Case Series

BackgroundA cesarean scar pregnancy (CSP) is a clinically important form of ectopic pregnancy that carries a high risk of maternal morbidity and mortality. As the rate of cesarean sections has risen, this diagnosis is becoming an increasingly important consideration for providers caring for patients in early pregnancy.Case ReportWe present three cases of CSPs in which point-of-care ultrasound expedited the diagnosis and treatment in the emergency department.Why Should an Emergency Physician Be Aware of This?Given the risks of an undiagnosed CSP, the increasing incidence of CSP, and the number of effective treatment options available in early gestation, the prompt and accurate diagnosis of CSP remains crucial to its successful management. As such, it is an important diagnosis for the emergency physician to consider when evaluating a patient in early pregnancy.     

Diagnosis of Rectus Sheath Hematoma by Point-of-Care Ultrasound

BackgroundRectus sheath hematoma is a rare but dangerous cause of undifferentiated hypotension and abdominal pain in the emergency department (ED). Point-of-care ultrasound is a useful tool in its identification.Case ReportA 75-year-old woman presented to the ED with hypotension of an unclear etiology. She was found, via point-of-care ultrasound, to have a large and expanding rectus sheath hematoma. She ultimately had embolization of a lacerated epigastric artery, likely caused by enoxaparin injection.Why Should an Emergency Physician Be Aware of This?Rectus sheath hematomas are a dangerous and often unrecognized source of abdominal pain and shock in anticoagulated patients. Commonly applied point-of-care ultrasound algorithms to assess hypotension may miss this entity.     

Diagnosis of Megaureter by Point-of-Care Ultrasound

Background

Presentation of congenital megaureter in adult life is rare; patients usually become symptomatic in childhood.

Case Report

A 32-year-old man presented to the Emergency Department (ED) with dyspnea, tongue swelling, and a rash, which he attributed to amoxicillin he had taken shortly prior to onset of symptoms. He was hypotensive on arrival to the ED. To further evaluate the hypotension, point-of-care ultrasound of the heart, lungs, and abdomen were performed while treatment for anaphylaxis was initiated. Ultrasound examination did not identify a cause for hypotension, but the treating physician noted an anechoic structural abnormality posterior to the bladder, suggestive of megaureter. The patient responded well to treatment of anaphylaxis; further history and diagnostic imaging subsequently confirmed a diagnosis of congenital megaureter.

Conclusion

We report an unusual case of congenital megaureter, identified by point-of-care ultrasound performed to evaluate hypotension. Clinicians performing limited ultrasound examinations must be attentive to incidental findings that will require follow-up.     

Emergency Point-of-Care Ultrasound Diagnosis of a Femoral Artery Pseudoaneurysm

BackgroundIatrogenic femoral artery pseudoaneurysm formation after intervention of the femoral artery may present weeks after intervention. We report a case of a patient with delayed pseudoaneurysm diagnosis that was ultimately diagnosed with bedside ultrasound. Importantly, our case demonstrates a patient who had a left-sided atherectomy and angioplasty with microcatheter access of the right femoral artery.Case ReportA 68-year-old man with multiple comorbidities presented to the Emergency Department (ED) with right inguinal pain, swelling, and overlying skin changes 17 days after an interventional radiology-guided left-sided femoral artery atherectomy and angioplasty. His first postoperative ED visit at an outside hospital led to the diagnosis of a hematoma vs. abscess, with attempted bedside drainage. On presentation to our ED, a bedside ultrasound confirmed arterial pseudoaneurysm formation of the right femoral artery.Why Should an Emergency Physician Be Aware of This?In patients presenting with the constellation of symptoms after arterial site intervention of either side, iatrogenic pseudoaneurysm should be in the differential. Although the patient had atherectomy and angioplasty of the left femoral artery, it is important to highlight that both femoral arteries were accessed during intervention, and thus, both sites are at risk for pseudoaneurysm formation. Emergency sonography can be a useful tool to diagnose, expedite treatment, and avoid potentially harmful invasive procedures in patients presenting with pain and swelling after arterial site intervention.     

Point-of-Care Ultrasound to Diagnose Colitis in the Emergency Department: A Case Series and Review of the Literature

BackgroundColitis refers to an inflammatory process of the colon, composed of a variety of different etiologies including inflammatory bowel disease, infectious colitis, ischemic colitis, and allergic colitis. Usually, abdominal computed tomography (CT) is the gold standard in diagnosing the various forms of colitis. However, by the use of point-of-care ultrasound (POCUS), one may occasionally be able to discern wall thickening, pericolic fluid, and adjacent hyperechoic mesenteric fat. One may also see abscesses, fistulae, or ascites.Case SeriesThis is a series of 6 patients who had findings consistent with colitis seen on POCUS performed by an emergency physician. These were confirmed by abdominal CT with contrast. Early detection by POCUS was able to lead to a rapid diagnosis and to expedite treatment.Why Should an Emergency Physician Be Aware of This?The ability to detect findings of colitis by POCUS can be quickly learned by the emergency physician with a strong background in basic ultrasound. For many of the different subtypes of colitis, the initial treatment in the emergency department is the same: i.v. antibiotics, i.v. fluids, and “bowel rest” by maintaining the patient in nothing-by-mouth status. For the stable patient with high clinical suspicion of an infectious etiology of colitis, ultrasound can help confirm the diagnosis and rule out other etiologies. This may be especially important in certain populations such as children and young women, where one can avoid a significant amount of radiation being directed toward the pelvic area.     

The Use of Point-of-Care Ultrasound to Evaluate Pulsus Paradoxus in Children With Asthma

Pulsus paradoxus (PP) is defined as a fall of systolic blood pressure of greater than 10 mm Hg during the inspiratory phase of respiration. Measurement of PP is recommended by national and international asthma guidelines as an objective measure of asthma severity but is rarely used in clinical practice. Cardiac point-of-care ultrasound with pulsed wave Doppler imaging measuring respiratory-phasic changes of mitral valve inflow velocities is well described in cardiac tamponade as “sonographic” PP. We present 10 cases of acute asthma presenting to an emergency department showing the finding of sonographic determined PP in the apical 4-chamber view of the heart on pulsed wave Doppler imaging.     

Point-of-Care Ultrasound Diagnosis of Necrotizing Fasciitis Missed By Computed Tomography and Magnetic Resonance Imaging

Background

Necrotizing fasciitis (NF) is a rare but deadly disease. Diagnosis of necrotizing soft tissue infections can be challenging for a variety of reasons. Point-of-care (POC) ultrasound (US) has been described as a diagnostic tool to help the acute care clinician make the early diagnosis that is imperative to optimize outcomes.

Objective

To report a case of Group A Streptococcus NF recognized with POC US, and subsequent negative findings on computed tomography (CT) and magnetic resonance imaging (MRI).

Case Report

A 54-year-old diabetic woman presented to the Emergency Department with atraumatic right foot and lower leg pain associated with fever. Examination was concerning for NF, and a POC US was performed, which showed thickened deep fascia and fluid tracking along the deep fascial plane, with fluid pockets measuring 6 mm in depth, consistent with NF. Surgical consultation was obtained. Per request, CT and MRI of the patient's lower extremity were performed; both were interpreted by the radiologist as showing changes consistent with cellulitis. Septic shock and multisystem organ failure ensued; the patient was eventually taken to the operating room, where operative findings were consistent with NF. Operative cultures grew Streptococcus pyogenes.

Conclusion

NF is a surgical emergency. Early and accurate diagnosis is critical to ensure the necessary aggressive management needed to optimize outcomes. This case illustrates the utility of POC US to make the prompt diagnosis of NF, particularly in light of subsequently negative CT and MRI.     

Nurse Practitioner Use of Point-of-Care Ultrasound in Critical Care

The use of point-of-care ultrasound (POCUS) is considered the standard of care in the management of patients in the intensive care unit (ICU). No current evidence demonstrates the ability of ICU NPs to accurately utilize POCUS. The purpose of this project was to determine ICU NPs’ ability to accurately acquire and interpret POCUS images. NPs working in a surgical ICU obtained POCUS images of the inferior vena cava and documented their interpretation of the volume status of the patient based on the image. ICU NPs demonstrated 86% acquisition accuracy and 80.5% interpretation accuracy of POCUS images.     

Diagnostic Accuracy of Point-Of-Care Ultrasound for Intussusception Performed by Pediatric Emergency Medicine Physicians

BackgroundIntussusception (INT) is a common cause of bowel obstruction in young children. Delay in diagnosis can lead to significant morbidity and mortality. There have been several studies evaluating early point-of-care ultrasound (POCUS) in the diagnosis of INT by nonradiologists.ObjectiveOur objective was to determine the diagnostic accuracy of POCUS by novice sonographer pediatric emergency medicine physicians (PEM-Ps) who received focused US training for diagnosing INT.MethodsWe performed a prospective observational study including 17 PEM-Ps (14 attendings, 3 fellows) trained to perform abdominal US for INT. Children suspected of having INT received POCUS performed and interpreted by a PEM-P, followed by a US study performed by a certified ultrasonographer and interpreted by an attending pediatric radiologist. Diagnostic concordance between PEM-P–and radiology-performed US (RPUS) results was assessed.ResultsOne hundred patients were enrolled; median patient age was 24 months. There was excellent diagnostic agreement for presence or absence of INT between PEM-Ps and RPUS (97% of cases; κ = 0.826). POCUS-diagnosed INT was present in 8 of 9 patients with RPUS-diagnosed INT (sensitivity 89%; 95% confidence interval [CI] 51–99%; specificity 98%; 95% CI 92–100%; positive predictive value 80%; 95% CI 44–96%; negative predictive value 99%; 95% CI 93–100%). Likelihood ratio for INT with a positive POCUS was 40.44 (95% CI 10.07–162.36) and with a negative POCUS was 0.11 (95% CI 0.02–0.72).ConclusionsPOCUS performed by novice sonographers to diagnose INT has high diagnostic concordance with RPUS. Emergency department–performed POCUS is a rapid and accurate method for diagnosing INT.