Anechoic Stripe Size Influences Accuracy of FAST Examination Interpretation

Objectives: Accurate and precise interpretations of Focused Assessment with Sonography for Trauma (FAST) findings are important factors in managing trauma patients. The objectives were to analyze the influence of anechoic stripe (AS) size on interpretation accuracy by emergency physicians (EPs) and to assess the precision of FAST examination interpretation as a function of EP FAST experience.
Methods: A prospective comparison study of FAST examination interpretation by 11 emergency medicine faculty (FAC), nine community attending EPs (ATT), and nine senior emergency medicine residents (RES) was conducted; these physicians were then divided into more experienced and less experienced cohorts to assess precision. Participants interpreted video recordings of the four standard views from five FAST examinations (20 total video clips); each examination contained views with various AS sizes. Accuracy of FAST examination interpretation was calculated for each group stratified by size of AS. Precision (reproducibility) of FAST examination interpretation was assessed by calculating κ values.
Results: With large, moderate, or no AS, no significant differences in accuracy were found between groups. For small AS, significant differences in accuracy were found between the ATT and RES groups and between the combined FAC + ATT group and the RES group. κ was good to excellent when the nth and the (n + 1)th experienced physicians in the more experienced cohort were compared. κ values reflected that the more experienced cohort was more precise than the less experienced cohort.
Conclusions: AS size visible on FAST examinations and EP experience level with FAST examination interpretation exerted a significant influence on the interpretation accuracy of videotaped FAST examinations. In addition, precision was enhanced by increased EP experience with FAST.     

实时超声显像对先天性输尿管狭窄的诊断评价

本文报告２８例先天性输尿管狭窄的超声诊断结果，经与手术和病理诊断结果对比，超声诊断符合率为８５．７（２４／２８）。结果表明，实时超声显像能为临床诊断与治疗本病提供较为可靠的依据，尤其对碘过敏或行静脉上尿路造影显影不佳而又难以接受逆行上尿路造影的患者，超声显像具有独特的优点。本文就输尿管狭窄的超声扫查方法、输尿管各段狭窄病变的声像图表现及超声诊断存在的不足与对策等问题，进行了详细的讨论。     

Hemoperitoneum from ruptured cyst in a hyperstimulated ovary: a sonographic mimic of ovarian hyperstimulation syndrome

We report a case of a ruptured cyst in a hyperstimulated ovary that was initially misinterpreted as ovarian hyperstimulation syndrome (OHSS). A 22-year-old woman who was on oral clomiphene citrate for primary infertility presented with pain in the lower abdomen, hypotension, and tachycardia. Sonographic examination revealed multiple cysts in both ovaries and free fluid in the abdomen, and the initial diagnosis was OHSS. However, sonographically guided aspiration of free fluid revealed a hemoperitoneum, and the patient underwent emergent surgery. At laparotomy, an actively bleeding ruptured cyst in a hyperstimulated ovary was found to be the cause of the hemoperitoneum. Radiologists must be familiar with the imaging features of this condition to avoid misdiagnosing it as OHSS, because this could potentially delay urgently required surgery.     

Ultrasonographic Examination by Emergency Physicians of Patients at Risk for Ectopic Pregnancy

Objective: To evaluate a diagnostic protocol that includes the early use of endovaginal sonography (EVS) by emergency physicians of patients at risk for ectopic pregnancy.
Methods: During this prospective study. pregnant patients ≥ 18 years old and at risk for ectopic pregnancy were assessed. Emergency physicians who had completed a training program performed EVS on a convenience sample of eligible women. Clinical disposition was based on predetermined clinical, laboratory, and ultrasonographic criteria. The EVS examinations were reviewed on video by a gynecologist whose interpretation was correlated with the emergency physician EVS readings and with the final clinical diagnoses. Quantitative serum P-human chorionic gonadotropin (βhCG) levels were determined for patients who had no definite intrauterine pregnancy (IUP) on EVS.
Results: Of 157 patients studied during a 12-month period. four were lost to follow-up. Emergency physician ultrasonographic diagnoses included: definite IUP, 87/146 (59%): probable abnormal IUP. 17/148 (11%); definite ectopic pregnancy. 31148 (2%); and no definite IUP. 41/148 (28%). The gynecologist agreed with 93% of the initial interpretations. Twelve of 16 patients who had the final diagnosis of ectopic pregnancy were admitted from the ED with this diagnosis. The ultrasonographic diagnosis of the other four was no definite IUP. and no mass or free fluid. For the latter four patients, the presenting serum βhCG level was < 2,000 mlU/mL (First International Reference Preparation). They were diagnosed as having ectopic pregnancy after serial outpatient EVS and βhCG measurements.
Conclusions: The application of EVS to emergency practice appears promising. Emergency physicians trained in its use and who apply this diagnostic tool in conjunction with a defined protocol can stratify the risk of patients who have the potential for ectopic pregnancy.     

Contrast-Enhanced Ultrasound (CEUS) in the Evaluation of Hemoperitoneum in Patients With Cirrhosis

Hemoperitoneum in cirrhosis is a life-threatening condition that requires emergent evaluation. Contrast-enhanced ultrasound (CEUS) permits multiple dynamic characterizations of abdominal structures through all vascular phases, and contrast extravasation or the presence of microbubbles in the ascites could be a sensitive tool. We reviewed 13 patients with cirrhosis that underwent CEUS due to high suspicion for intra-abdominal bleeding. In 10 cases, CEUS demonstrated extravasation of contrast, including 2 instances where CEUS detected active bleeding despite negative computed tomography. These data support further study of CEUS in direct comparison to other imaging modalities in this clinical context.     

Emergency Evaluation of Patients Presenting with Acute Scrotum Using Bedside Ultrasonography

Acute scrotal pain is not a rare emergency department (ED) complaint. Traditional reliance on medical history and physical examination can be precarious as signs and symptoms can overlap in various etiologies of acute scrotal pain. OBJECTIVE: To determine the accuracy with which emergency physicians (EPs) using bedside ultrasonography are able to evaluate patients presenting to the ED with acute scrotal pain. METHODS: The study was performed at an urban community hospital ED with a residency program and an annual census of 70,000. A retrospective chart review identified 36 patients who presented with complaints of acute scrotal pain and were evaluated by EPs using bedside ultrasound. A 5.0- or 7.5-MHz linear-array transducer with color and power Doppler capability was used to scan the scrotum. Patients were seen between July 1998 and September 1999. Diagnoses were verified by radiology or surgery. Sensitivity and specificity with 95% confidence intervals were calculated. RESULTS: The EP ultrasound examinations agreed with confirmatory studies for 35 of 36 patients, resulting in a sensitivity of 95% (95% CI = 0.78 to 0.99) and a specificity of 94% (95% CI = 0.72 to 0.99). Diagnoses included three testicular torsions, six cases of epididymitis, four cases of orchitis, one testicular fracture, three hernias, three hydroceles, and 15 normal examinations. One case of epididymitis was misdiagnosed as an epididymal mass. CONCLUSIONS: This study suggests that EPs using bedside ultrasonography are able to accurately diagnose patients presenting with acute scrotal pain. In addition, they appear able to differentiate between surgical emergencies, such as testicular torsion, and other etiologies.     

超声内镜诊断上消化道间质瘤的评价

目的评价超声内镜(endoscopicultrasonography,EUS)诊断胃肠道间质瘤(gastrointestinalstro-maltumors,GIST)的临床价值。方法回顾分析25例GIST的临床表现和EUS特征。结果25例患者中,18例直径小于3cm的GIST边缘规整,呈低回声匀质肿块,符合良性肿瘤特征,另外7例直径大于3cm的GIST中,5例患者的EUS图像呈不均匀声像伴无回声区,其中3例患者出现上消化道出血,另外2例直径为9cm和12cm者边缘不规整,4例内镜下黏膜表面呈溃疡样病变,所有7例患者术后病理和免疫组化均证实为GIST,2例为恶性肿瘤。结论EUS对GIST的诊断很有帮助,并提供临床医师确定下一步处理。     

超声造影在腹部外伤急诊诊断中的应用

目的:探讨超声造影技术在腹部急诊外伤超声诊断中的应用价值。方法:对61例腹部急诊外伤患者进行二维超声及超声造影检查,对损伤程度进行分级。检查结果与手术、血管造影等对照,分析不同超声技术在腹部闭合性损伤中的诊断价值。结果:超声造影能安全的用于闭合性腹部损伤患者损伤的诊断,对于判断腹部实质性脏器,如肝、脾、肾等损伤较常规超声技术有较高的灵敏度,并进行损伤程度分级,结果得到血管造影及手术证实。结论:超声造影技术在腹部外伤急诊诊断中有很高的应用价值,值得临床推广。     

Splenic Artery Aneurysm: An Important Cause of Hemoperitoneum and Shock

Background

Splenic artery aneurysm ruptures are rare and highly morbid events that are frequently associated with pregnancy. However, approximately 15% may occur in men, and it is important to have this possibility in the differential diagnosis in cases of hemoperitoneum and hemorrhagic shock. Rapid diagnosis and treatment is essential to survival.

Objectives

The aim of this report is to educate emergency physicians on the early recognition and treatment of this life-threatening event and to increase the awareness of this condition in male patients.

Case Report

We describe the evaluation and management of two cases of splenic artery rupture in male patients with unique presentations.

Conclusion

Splenic artery aneurysm ruptures should be considered in the differential diagnosis in any patient with undifferentiated shock. Early diagnosis and treatment can save lives.     

Tissue Harmonic Imaging Improves Organ Visualization in Trauma Ultrasound When Compared with Standard Ultrasound Mode

The focused abdominal sonography for trauma (FAST) examination is complicated by brightly lit trauma bays, limited time, and body habitus. Recently, new ultrasound (US) technology has become available that improves organ visualization in abdominal scans. OBJECTIVE: The hypothesis was that a new US mode, tissue harmonic (TH) imaging, improves visualization of critical organ relationships in the FAST examination by making use of previously unused frequencies. The authors performed a blind, prospective observational study to compare the images obtained in typical FAST views with those obtained in standard US and TH modes. METHODS: Blunt trauma patients presenting to a level I trauma center between April and September 2000 were enrolled on a convenience basis. Typical FAST views were obtained in standard and TH modes. The emergency ultrasonographer (EU) switched between modes for each view, optimizing the gain each time. Multiple digital still images were made with all indications of the mode used disguised. For each view on a patient, the best image in each mode was selected in a blinded fashion. Three experienced EUs, blinded to the mode used, rated each image pair for resolution, detail, and total image quality as previously defined on a ten-point Likert scale, 10 being the best for each category. Wilcoxon signed-ranks test, 95% confidence intervals (95% CIs), and interobserver correlation were calculated. RESULTS: A total of 76 image groups (39 of Morison's pouch, 20 splenorenal, and 17 bladder) from 52 patients were rated. Tissue harmonics produced improved resolution, detail, and quality when compared with the standard US mode, with median scores of 6.7 vs. 6.0, 6.7 vs. 6.0, and 6.3 vs. 6.0, respectively. The differences of 0.7 (95% CI = 0.4 to 0.93), 0.7 (95% CI = 0.4 to 0.93), and 0.33 (95% CI = 0.17 to 0.67) were statistically significant, with p = 0.0001, 0.0001, and 0.0003, respectively. There was good interobserver agreement (kappa = 0.74; 95% CI = 0.68 to 0.79). CONCLUSIONS: Tissue harmonics produced FAST images higher in detail, resolution, and total image quality than standard-mode US images.     

Delayed Diagnosis of Injury in Pediatric Trauma Patients at a Level I Trauma Center

BackgroundTrauma care per Advanced Trauma Life Support addresses immediate threats to life. Occasionally, delays in injury diagnosis occur. Delayed diagnosis of injury (DDI) is a common quality indicator in trauma care, and pediatric DDI data are sparse.ObjectiveOur aim was to describe the DDI rate in a severely injured pediatric trauma population and identify any factors associated with DDI in the pediatric population.MethodsA prospective cohort of trauma activations in 0- to 16-year-old patients admitted to a pediatric level I trauma center over 12 months with injuries prospectively recorded were followed during admission to identify DDI.ResultsA total of 170 trauma activations were enrolled. Twelve patients had type I DDI (7.1%), 15 patients had type II DDI (8.8%), and 5 patients had both type I and type II DDI (2.9%). DDI patients had twice as many injuries and higher Injury Severity Scores (ISS) as non-DDI patients. DDI patients were more likely to require intensive care unit (ICU) admission, longer hospital stay, and ventilator support. Controlling for age and ISS in multivariate analysis, the number of injuries found and requiring a ventilator were significantly associated with DDI.ConclusionsThis prospective study found a type I DDI rate of 7.1% and a type II DDI rate of 8.8% in the pediatric population. DDI patients had a greater number of injuries, higher ISS, higher rate of ICU admission, and were more likely to require mechanical ventilation. This study adds prospective data to the pediatric DDI literature, increases provider awareness of pediatric DDI, and lays the foundation for future study and quality improvement.     

Ultrasonographic Screening of Clinically-suspected Necrotizing Fasciitis

OBJECTIVE: To determine the accuracy of ultrasonography for the diagnosis of necrotizing fasciitis. METHODS: This study was a prospective observational review of patients with clinically-suspected necrotizing fasciitis presenting to the emergency department of an urban (Taipei) medical center between October 1996 and May 1998. All patients underwent ultrasonographic examination, with the ultrasonographic diagnosis of necrotizing fasciitis based on the criterion of a diffuse thickening of the subcutaneous tissue accompanied by a layer of fluid accumulation more than 4 millimeters in depth along the deep fascial layer, when compared with the contralateral position on the corresponding normal limb. The final diagnosis of necrotizing fasciitis was determined by pathological findings for patients who underwent fasciotomy or biopsy results for patients managed nonoperatively. RESULTS: Data were collected for 62 patients, of whom 17 (27.4%) were considered to suffer from necrotizing fasciitis. Ultrasonography revealed a sensitivity of 88.2%, a specificity of 93.3%, a positive predictive value of 83.3%, a negative predictive value of 95.4%, and an accuracy of 91.9% as regards the diagnosis of necrotizing fasciitis. CONCLUSIONS: Ultrasonography can provide accurate information for emergency physicians for the diagnosis of necrotizing fasciitis.     

Sonographic assessment of blunt abdominal trauma: a 4-year prospective study

PURPOSE: Emergency abdominal sonography has become a common modality worldwide in the evaluation of injuries caused by blunt trauma. The sensitivity of sonography in the detection of hemoperitoneum varies, and little is known about the accuracy of sonography in the detection of injuries to specific organs. The purpose of this study was to determine the overall accuracy of sonography in the detection of hemoperitoneum and solid-organ injury caused by blunt trauma. METHODS: From January 1995 to October 1998, 3,264 patients underwent emergency sonography at our institution to evaluate for free fluid and parenchymal abnormalities of specific organs caused by blunt trauma. All patients with intra-abdominal injuries (IAIs) were identified, and their sonographic findings were compared with their CT and operative findings, as well as their clinical outcomes. RESULTS: Three hundred ninety-six (12%) of the 3,264 patients had IAIs. Sonography detected free fluid presumed to represent hemoperitoneum in 288 patients (9%). The sonographic detection of free fluid alone had a 60% sensitivity, 98% specificity, 82% positive predictive value, and 95% negative predictive value for diagnosing IAI. The accuracy was 94%. Seventy patients (2%) had parenchymal abnormalities identified with sonography that corresponded to actual organ injuries. The sensitivity of the sonographic detection of free fluid and/or parenchymal abnormalities in diagnosing IAI was 67%. CONCLUSIONS: Emergency sonography to evaluate patients for injury caused by blunt trauma is highly accurate and specific. The sonographic detection of free fluid is only moderately sensitive for diagnosing IAI, but the combination of free fluid and/or a parenchymal abnormality is more sensitive.     

Evaluation of an Instructional Model for Emergency Ultrasonography

Objective: To evaluate a 4-hour ultrasonography course in the setting of an emergency medicine (EM) training program. Methods: EM residents and faculty at a large urban center were provided a 4-hour emergency ultrasonography course. Then, during an 18-month period, a nonconsecutive sample of ultrasonographic examinations were videotaped and later reviewed. The interpretations of the emergency physician examinations were compared with the following reference standards: 1) an official ultrasound performed and interpreted by the departments of radiology or cardiology; 2) an operative report; 3) A CT scan or IV pyelogram (IVP); or 4) a cardiologist's or a radiologist's interpretation of the videotaped examinations. Results: Of 258 examinations reviewed, 28 (11%) of these were excluded because the cardiologist or radiologist reviewing the videotape determined them to be “technically limited” studies. Of the remaining 230 examinations, there were: 127 gallbladder studies [disease prevalence = 0.58; sensitivity = 0.89; specificity = 0.80; kappa (κ) = 0.69; 95% CI: 56–82%]; 39 echocardiograms to rule out pericardial effusions [disease prevalence = 0.15; sensitivity = 0.83; specificity = 0.97; κ= 0.80; 95% CI: 54–100%]; 25 abdominal ultrasounds to rule out free peritoneal fluid [disease prevalence = 0.32; sensitivity = 0.88; specificity = 0.94; κ= 0.81; 95% CI: 26–95%]; 16 renal ultrasounds to rule out hydronephrosis [disease prevalence = 0.25; sensitivity = 1.0; specificity = 0.92; κ= 0.84; 95% CI: 56–100%]; 12 pelvic ultrasounds to rule in an intrauterine pregnancy [disease prevalence = 0.67; sensitivity = 1.0; specificity = 0.75; κ= 0.80; 95% CI: 43–100%]; and 11 abdominal ultrasounds to rule out abdominal aortic aneurysms [disease prevalence = 0.09; sensitivity = 1.0; 95% CI: 2.5–91%; specificity = 1.0; 95% CI: 68–100%]. Conclusion: This 4-hour ultrasonography course has potential to serve as a foundation for an instructional model for ultrasonography training in the setting of an EM residency program.     

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.     

Emergency Department Right Upper Quadrant Ultrasound Is Associated with a Reduced Time to Diagnosis and Treatment of Ruptured Ectopic Pregnancies

OBJECTIVE: To determine whether the time to diagnosis and treatment of patients with ruptured ectopic pregnancy is significantly less for patients who had emergency department (ED) right upper quadrant (RUQ) ultrasound (US) compared with those who had US in the radiology department. METHODS: The authors conducted a retrospective review of eligible patients presenting to an urban ED between January 1990 and December 1998. Patients were included in the study if they were seen in the ED, had a discharge diagnosis of ruptured ectopic pregnancy, were brought immediately to the operating room after a definitive diagnosis of ectopic pregnancy rupture was made, and had more than 400 mL of intraperitoneal blood found at the time of surgery. The ED, hospital, radiology, and operative records were reviewed to determine presenting vital signs, intraperitoneal blood loss, time to diagnosis, time to treatment, and type of US performed. RESULTS: There were 37 patients enrolled; 16 received ED RUQ US (group I) and 21 had a formal US in radiology (group II). The ages, pulses, systolic blood pressures, and volumes of hemoperitoneum were similar between the two groups. The average time to diagnosis from ED arrival was 58 minutes for group I (SD = 57; 95% CI = 28 to 87) and 197 minutes for group II (SD = 82; 95% CI = 162 to 232) (p < or = 0.0001). The average time to operative treatment was 111 minutes (group I) (SD = 86; 95% CI = 69 to 153) and 322 minutes (group II) (SD = 107; 95% CI = 270 to 364) (p < or = 0.0001), respectively. CONCLUSIONS: Patients with ruptured ectopic pregnancy, who were selected to have RUQ US performed in the ED by emergency physicians, had an average decrease in time to diagnosis of two and a quarter hours, and an average decrease in time to treatment of three and a half hours, compared with those having a formal pelvic US in the radiology department. Further prospective investigation is needed to determine whether ED RUQ US can safely expedite care of patients with suspected ectopic pregnancy.     

The CRASH trial: the first large-scale, randomised, controlled trial in head injury

The global epidemic of head injuries is just beginning. Many are caused by road traffic crashes. It is estimated that, by 2020, road traffic crashes will have moved from its present position of ninth to third in the world disease burden ranking, as measured in disability adjusted life years. In developing countries, it will have moved to second. The Corticosteroid Randomisation After Significant Head Injury (CRASH) trial is a large-scale, randomised, controlled trial, among adults with head injury and impaired consciousness, of the effects of a short-term infusion of corticosteroids on death and on neurological disability. Following a successful pilot phase, which included over 1000 randomised participants, the main phase of the trial is now underway. Over the next 5 years, the trial aims to recruit a total of 20,000 patients. Such large numbers will only be possible if hundreds of doctors and nurses can collaborate in emergency departments all over the world. The trial is currently recruiting, and new collaborators are welcome to join the trial (see ).