ED endovaginal pelvic ultrasound in nonpregnant women with right lower quadrant pain

Introduction

We hypothesized that emergency physician–performed endovaginal ultrasound (EVUS) would change diagnostic decision making in nonpregnant women with right lower quadrant (RLQ) pain.

Methods

A prospective cohort of female patients was enrolled at an urban emergency department (ED). Inclusion criteria were RLQ pain, hemodynamic stability, and a strong suspicion for appendicitis or right adnexal pathology. Treating physicians were queried regarding pre– and post–ED EVUS probability of disease, differential diagnoses, consultation, and management. Positive findings included large cysts or multitissue densities, tubal dilation, uterine enlargement/mass, and extensive peritoneal fluid.

Results

With a positive ED EVUS, mean physician probability increased for gynecologic (24%) and decreased for both surgical (14%) and medical (20%) disease. With a negative ED EVUS, mean physician probability increased for surgical disease (5.3%) and decreased for gynecologic disease (18.6%).

Conclusion

Emergency department EVUS changes physician diagnostic decision making in nonpregnant women with undifferentiated RLQ pain.     

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.     

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.     

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.     

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.     

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.     

Emergency ultrasound diagnosis of ovarian hyperstimulation syndrome: case report

Background

Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy. It is a known complication of ovarian stimulation in patients undergoing treatment for infertility. As assisted reproductive technology and the use of ovulation induction agents expands, it is likely that there will be more cases of OHSS presenting to the Emergency Department (ED).

Objectives

OHSS has a broad spectrum of clinical manifestations, from mild abdominal pain to severe cases where there is increased vascular permeability leading to significant fluid accumulation in body cavities and interstitial space. Severe cases may present to the ED with ascites, pericardial effusions, pleural effusions, and lower extremity edema. Through a case report, we review OHSS with an emphasis on early diagnosis by Emergency Physician (EP)-performed bedside ultrasonography.

Case Report

We present a case of a patient undergoing treatment for infertility who presented to the ED with shortness of breath and abdominal pain. The diagnosis of severe OHSS was made, largely based on EP-performed bedside ultrasonography showing peritoneal free fluid and bilateral pleural effusions, as well as multiple ovarian follicles.

Conclusions

This report reviews the pathophysiology of OHSS, its clinical features, and pertinent diagnostic and management issues. This report emphasizes the importance of early EP-performed bedside ultrasonography.     

Emergency Biliary Sonography: Utility of Common Bile Duct Measurement in the Diagnosis of Cholecystitis and Choledocholithiasis

Background

Measurement of the common bile duct (CBD) has traditionally been considered an integral part of gallbladder sonography, but accurate identification of the CBD can be difficult for novice sonographers.

Objective

To determine the prevalence of isolated sonographic CBD dilation in emergency department (ED) patients with cholecystitis or choledocholithiasis without laboratory abnormalities or other pathologic findings on biliary ultrasound.

Methods

We conducted a retrospective chart review on two separate ED patient cohorts between June 2000 and June 2010. The first cohort comprised all ED patients undergoing a biliary ultrasound and subsequent cholecystectomy for presumed cholecystitis. The second cohort consisted of all ED patients receiving a biliary ultrasound who were ultimately diagnosed with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. Postoperative gallbladder pathology reports and endoscopic retrograde cholangiopancreatography (ERCP) reports were used as the criterion standard for final diagnosis.

Results

Of 666 cases of cholecystitis, there were 251 (37.7%) with a dilated CBD > 6 mm and only 2 cases (0.3%; 95% confidence interval [CI] 0.0–0.7%) of isolated CBD dilation with an otherwise negative ultrasound and normal laboratory values. Of 111 cases of choledocholithiasis, there were 80 (72.0%) with a dilated CBD and only 1 case (0.9%; 95% CI 0.0–2.7%) with an otherwise negative ultrasound and normal laboratory values.

Conclusion

The prevalence of isolated sonographic CBD dilation in cholecystitis and choledocholithiasis is <1%. Omission of CBD measurement is unlikely to result in missed cholecystitis or choledocholithiasis in the setting of a routine ED evaluation with an otherwise normal ultrasound and normal laboratory values.     

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.     

Torsion of an undescended testis located in the inguinal canal

Background

Torsion of undescended testis located within the inguinal canal is a rare finding in the emergency department (ED). This diagnosis can present as undifferentiated abdominal or groin pain, and a full genitourinary examination is essential to making this diagnosis.

Objectives

We present this case to increase awareness among emergency physicians regarding torsion of undescended testis.

Case Report

A 5-year-old boy presented to the ED with abdominal pain and a mass in his right groin. Physical examination and Doppler ultrasound were used to diagnose torsion of undescended testis.

Conclusions

In a patient with undescended testis, torsion must be considered as a cause of abdominal or groin pain. Full genitourinary examination is essential to making this 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.     

Migrating Sternal Rod: Ultrasound Identification of an Unusual Soft Tissue Foreign Body

Background

Sternal hardware migration from its original site of implantation is a rare entity. Bedside ultrasound may identify migrated hardware if the site of migration is the subcutaneous tissue.

Objectives

This case report will discuss the unusual phenomenon of migrating sternal hardware, as well as the ultrasonographic characteristics of soft tissue foreign bodies.

Case Report

A 51-year-old man presented to the Emergency Department with a 2-month history of intermittent lower abdominal pain, 11 months status post bilateral lung transplant surgery. His examination was remarkable for a palpable mass over the left lower quadrant of the abdomen. Initial bedside ultrasound identified a soft tissue foreign body in the subcutaneous tissue overlying the left lower quadrant of the abdomen. Further evaluation using plain radiography and computed tomography ultimately diagnosed the foreign body as a metal rod, which had migrated from his sternum. The sternal rod was removed at the bedside, and he was discharged the next day without any complications.

Conclusion

Sternal hardware migration is uncommon, but in patients who have undergone surgery involving sternal fixation, this diagnosis should be considered as a cause for unusual symptoms.     

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.     

E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction

Objectives

Rapid assessment of left ventricular ejection fraction (LVEF) may be critical among emergency department (ED) patients. This study examined the predictive relationship between ED physician performed bedside mitral-valve E-point septal separation (EPSS) measurements to the quantitative, calculated LVEF. We further evaluated the relationship between ED physician visual estimates of global cardiac function (GCF) and calculated LVEF values.

Methods

A prospective observational study was conducted on a sequential convenience sample of patients receiving comprehensive transthoracic echocardiography (TTE). Three ED ultrasound fellows performed bedside ultrasound examinations to obtain both EPSS measurements and subjective visual GCF estimates. A linear regression analysis was conducted to examine the relation of EPSS to the calculated LVEF from the comprehensive TTE. Agreement (modified Cohen κ) between ED ultrasound fellow GCF estimates and the calculated LVEF was also assessed.

Results

Linear regression analyses revealed a significant correlation (r = 0.73, P < .001) between bedside EPSS and the calculated LVEF. The sensitivity and specificity of an EPSS measurement of greater than 7 mm for severe systolic dysfunction (LVEF ≤ 30%) were 100.0% (95% confidence interval, 62.9-100.0) and 51.6% (95% confidence interval, 38.6-64.5), respectively. Subjective estimates of GCF were moderately correlated with calculated LVEF (Cohen κ = 0.58).

Conclusions

Measurements of EPSS by ED physicians were significantly associated with the calculated measurements of LVEF from comprehensive TTE. Subjective visual estimates of GCF, however, demonstrated only moderate agreement with the calculated LVEF. An EPSS measurement greater than 7 mm was uniformly sensitive at identifying patients with severely reduced LVEF.     

Identification of Splenic Infarction by Emergency Department Ultrasound

Background

Splenic rupture or infarction can occur secondary to acute infectious mononucleosis. Patients with abdominal pain and known or suspected infectious mononucleosis mandate evaluation for these complications, which can have significant morbidity or mortality.

Case Report

An 18-year old man presented to the emergency department (ED) with a 2-day history of left upper quadrant abdominal pain. He had been diagnosed with mononucleosis 4 days before his ED presentation. Physical examination was notable for focal left upper quadrant tenderness. The treating physician's principal diagnostic considerations were splenic rupture or infarction secondary to mononucleosis. Point-of-care ultrasound was performed by the emergency physician, demonstrating multiple hypoechoic areas in the splenic parenchyma with absent Doppler flow, consistent with multiple splenic infarcts. The patient was admitted for observation, managed conservatively, and had an uneventful course.

Conclusion

Emergency ultrasound of the spleen can allow rapid diagnosis of splenic infarction and exclusion of splenic rupture in a patient at risk for splenic pathology.     

Introduction of Ultrasound into Gross Anatomy Curriculum: Perceptions of Medical Students

Background

The exposure to ultrasound technology during medical school education is highly variable across institutions.

Objectives

The objectives of this study were to assess medical students’ perceptions of ultrasound use to teach Gross Anatomy along with traditional teaching methods, and determine their ability to identify sonographic anatomy after focused didactic sessions.

Methods

Prospective observational study. Phase I of the study included three focused ultrasound didactic sessions integrated into Gross Anatomy curriculum. During Phase II, first-year medical students completed a questionnaire.

Results

One hundred nine subjects participated in this study; 96% (95% confidence interval [CI] 92–99%) agreed that ultrasound-based teaching increased students’ knowledge of anatomy acquired through traditional teaching methods. Ninety-two percent (95% CI 87–97%) indicated that ultrasound-based teaching increases confidence to perform invasive procedures in the future. Ninety-one percent (95% CI 85–96%) believed that it is feasible to integrate ultrasound into the current Anatomy curriculum. Ninety-eight percent (95% CI 95–100%) of medical students accurately identified vascular structures on ultrasound images of normal anatomy of the neck. On a scale of 1 to 10, the average confidence level reported in interpreting the images was 7.4 (95% CI 7.1–7.7). Overall, 94% (95% CI 91–99%) accurately answered questions about ultrasound fundamentals and sonographic anatomy.

Conclusions

The majority of medical students believed that it is feasible and beneficial to use ultrasound in conjunction with traditional teaching methods to teach Gross Anatomy. Medical students were very accurate in identifying sonographic vascular anatomy of the neck after brief didactic sessions.     

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.     

Emergency Bedside Ultrasound Diagnosis of Superior Mesenteric Artery Dissection Complicating Acute Aortic Dissection

Background

A timely diagnosis of aortic dissection is associated with lower mortality. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, there is limited literature regarding the use of bedside ultrasound to identify superior mesenteric artery dissection, a known high-risk feature of aortic dissection.

Objective

Our aim was to present a case of superior mesenteric artery dissection identified by bedside ultrasound and review the utility of bedside ultrasound in the diagnosis of aortic emergencies.

Case Report

We report a case of superior mesenteric artery dissection found on emergent bedside ultrasound in a 46-year-old male complaining of abdominal pain with a history of cocaine abuse and prior aortic dissection. Bedside ultrasound in the emergency department revealed an intimal flap in the descending aorta with extension into the superior mesenteric artery prompting early surgical consultation before computed tomography because of concern for acute mesenteric ischemia.

Conclusion

Superior mesenteric artery dissection is a high-risk feature of aortic dissection and can be identified with emergent bedside ultrasound.     

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.     

Right-sided Diverticulitis Mimics Appendicitis

Background

Right-sided diverticulitis is a rare source of right lower quadrant pain in Western society; however, it is quite common in Asian societies. Right-sided diverticulitis presents very similarly to appendicitis, with right lower quadrant pain, fever, nausea, and laboratory abnormalities, and is often seen in young patients.

Objectives

In this report, we present a case of right-sided diverticulitis. We review right-sided diverticulitis’ diagnosis and management. It is important to diagnose right-sided diverticulitis because it is a good mimic of appendicitis and ideally should be diagnosed before a patient has unnecessary surgery.

Case Report

A 26-year-old Asian woman presented for evaluation of right lower quadrant pain and fever. She was initially thought to have appendicitis clinically, but had right-sided diverticulitis diagnosed by computed tomography (CT) scan. She was admitted and received intravenous antibiotics and bowel rest. Her right-sided diverticulitis resolved in 3 days.

Conclusions

Severe right lower quadrant pain in young patients of Asian descent can be right-sided diverticulitis. Right-sided diverticulitis is a benign condition managed medically that mimics appendicitis. CT imaging seems to be the best way to avoid unnecessary surgery.