Bedside Transorbital Ultrasound in the Clinical Evaluation of Pediatric Optic Neuritis in the Emergency Department

Background

Headache and monocular visual disturbance are worrisome pediatric presenting complaints in the emergency department. Appropriate and timely initial evaluation is critical. Most would opt for urgent computer tomography in such cases. Pediatric optic neuritis is a rare condition and is better evaluated by magnetic resonance imaging. With the increase in the use and scope of bedside ultrasound, there might be a potential role for transorbital ultrasound to be part of the emergency department evaluation of pediatric optic neuritis.

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.     

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.     

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.     

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.     

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.     

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.     

Bedside Emergency Ultrasound in a Case of Acute Parotid Duct Sialolithiasis

Background

Sialolithiasis with salivary gland obstruction can mimic more frequently occurring illnesses such as facial and dental infection and abscess. It is often difficult to discern the etiology of facial pain and swelling on physical examination alone, requiring advanced imaging in the emergency department.

Case Report

We describe the case of a 37-year-old man who presented with 5 days of worsening unilateral facial pain and swelling. Use of bedside emergency ultrasound by an emergency physician (EP) led to an appropriate diagnosis of parotid duct sialolithiasis. Why Should an Emergency Physician Be Aware of This? Use of bedside emergency ultrasound performed by a trained EP successfully diagnosed symptomatic sialolithiasis of the parotid duct in the emergency department without the need for computed tomography. The utility of bedside emergency ultrasound in the evaluation of sialolithiasis and the outcomes of our case are discussed here.     

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.     

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.     

Right Atrial Thrombus Secondary to Pacemaker Wires

Background

Pacemaker-induced right atrial thrombus is a rare condition that has not been described in the Emergency Medicine literature. This is a potentially fatal condition that is diagnosed with an echocardiogram and treated with surgical removal, thrombolytics, or long-term anticoagulation.

Objectives

This case report is designed to increase awareness among emergency physicians of this potentially fatal condition.

Case Report

We describe the case of a patient with a massive right atrial thrombus secondary to pacemaker wire who presented to the Emergency Department with syncope, bradycardia, and rapid hemodynamic deterioration.

Conclusion

Emergency physicians should be aware of this life-threatening entity. Emergency bedside cardiac ultrasound or echocardiogram may be of value in its early identification.     

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.     

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.     

Bedside Ultrasound Maximizes Patient Satisfaction

Background

Bedside ultrasound (US) is associated with improved patient satisfaction, perhaps as a consequence of improved time to diagnosis and decreased length of stay (LOS).

Objectives

Our study aimed to quantify the association between beside US and patient satisfaction and to assess patient attitudes toward US and perception of their interaction with the clinician performing the examination.

Methods

We enrolled a convenience sample of adult patients who received a bedside US. The control group had similar LOS and presenting complaints but did not have a bedside US. Both groups answered survey questions during their emergency department (ED) visit and again by telephone 1 week later. The questionnaire assessed patient perceptions and satisfaction on a 5-point Likert scale.

Results

Seventy patients were enrolled over 10 months. The intervention group had significantly higher scores on overall ED satisfaction (4.69 vs. 4.23; mean difference 0.46; 95% confidence interval [CI] 0.17–0.75), diagnostic testing (4.54 vs. 4.09; mean difference 0.46; 95% CI 0.16–0.76), and skills/abilities of the emergency physician (4.77 vs. 4.14; mean difference 0.63; 95% CI 0.29–0.96). A trend to higher scores for the intervention group persisted on follow-up survey.

Conclusions

Patients who had a bedside US had statistically significant higher satisfaction scores with overall ED care, diagnostic testing, and with their perception of the emergency physician. Bedside US has the potential not only to expedite care and diagnosis, but also to maximize satisfaction scores and improve the patient–physician relationship, which has increasing relevance to health care organizations and hospitals that rely on satisfaction surveys.     

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.     

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.     

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.     

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.     

Bedside ultrasound diagnosis of a traumatic bladder rupture

Background

Urinary bladder rupture is a complication of both blunt and penetrating trauma. Significant morbidity and mortality can result from a missed rupture and its ensuing complications. Patients who are at risk for traumatic bladder rupture should undergo appropriate testing to expedite the diagnosis. Current diagnostic modalities include computed tomography (CT) cystography, and retrograde cystography. Although these modalities carry a sensitivity and specificity of 95-99% and 95-100%, their utility is limited by the resources and staff available. Furthermore, both techniques require that a potentially hemodynamically unstable trauma patient be transported out of the Emergency Department for the entire duration of the procedure.

Objective

The following case report reviews the incidence and management of traumatic bladder rupture and describes how emergency physicians (EP) can use ultrasound to make this diagnosis quickly and safely at the bedside.

Case Report

The case report describes a patient involved in a motor vehicle collision with a history concerning for urinary bladder injury. A bedside ultrasound study performed by the EP was used to establish the diagnosis of urinary bladder rupture. The ultrasound demonstrated a small contracted urinary bladder with copious free fluid anterior to the bladder wall. The diagnosis was confirmed by CT and the patient was taken expeditiously to the operating room.

Conclusion

This case provides an example of how bedside ultrasound can be used to make an accurate and timely diagnosis of urinary bladder rupture and help expedite patient care.     

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.