Ultrasound-diagnosed cardiac tamponade after blunt abdominal trauma-treated with emergent thoracotomy

Ultrasound imaging enhances the physician's ability to evaluate, diagnose, and treat emergency department (ED) patients. Because ultrasound imaging is often time-dependent in the acutely ill or injured patient, the emergency physician is in an ideal position to use this technology. Focused ultrasound examinations provide immediate information and can answer specific questions about the patient's physical condition. We report a case in which blunt trauma to the abdomen and pre-existing pericardial fluid, due to human immunodeficiency virus (HIV), caused pericardial tamponade, diagnosed by bedside ultrasonography, and subsequent cardiac arrest. An ED thoracotomy released this tamponade, and spontaneous cardiac activity returned. The indications for and efficacy of ED thoracotomy have been debated for many years. Multiple studies have shown that patients with isolated penetrating chest trauma have the best outcome and that patients with blunt trauma without signs of life at the scene or in the ED have the poorest. We demonstrate the importance of ultrasound use by emergency physicians to assess trauma patients with pulseless electrical activity and suggest that in specific clinical situations after blunt trauma, an ED thoracotomy can be life saving.     

急诊医生用床边B超在浅表软组织异物取出中的价值

目的:总结急诊医生主导床旁B超声技术在浅表异物取出术中的应用价值。方法:采用便携式迈瑞型彩色超声诊断仪BD177921对65例外伤后浅表软组织内异物存留患者行超声诊断定位,引导手术实施,探取异物。结果:结合患者病史,B型超声在异物存留患者的诊断定位中准确率高,能引导手术取出异物。结论:急诊医生主导床旁B超声技术方便、安全、高效,在浅表软组织内异物的诊断定位及引导手术取出异物中有重要的临床价值。     

Bedside ultrasound for difficult lumbar puncture

Lumbar puncture is a common procedure performed in the emergency department for evaluation of several life-threatening conditions, including meningitis and subarachnoid hemorrhage. We describe the use of bedside ultrasound to assist in performance of the lumbar puncture in situations where the standard "blind" technique of needle insertion using palpable spinal landmarks is likely to be difficult or to fail. Use of ultrasound to guide lumbar puncture needle placement was originally reported 30 years ago in the Russian literature. More recently, ultrasound has been used for guiding needle placement for epidural and spinal anesthesia by anesthesiologists and for diagnostic lumbar puncture on infants by radiologists.     

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.     

Pneumopericardium diagnosis by point‐of‐care ultrasonography

Focused cardiac ultrasound by the emergency physician has become a fundamental tool to expedite the diagnostic evaluation of the patient at bedside. We report the case of a patient admitted to the emergency department for respiratory distress. He was examined by an emergency physician who performed a bedside echocardiography. Bright spots were seen rapidly moving along the pericardial layer during diastole with comet‐tail artifacts extending across the whole image of the heart and disappearing during systole, suggesting pneumopericardium. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2013     

Ultrasound guided reduction of pediatric forearm fractures in the ED

Reducing badly displaced or angulated pediatric forearm fractures in the emergency department can be difficult. Multiple attempts at reduction may be required, with repeated trips to the radiology department, before an adequate reduction is achieved. We have recently found that bedside ultrasound by emergency physicians is very helpful in guiding the reduction of difficult forearm fractures, allowing the physician to assess the adequacy of the reduction at the patient's bedside. In this report, we describe the technique we have developed for ultrasound-guided fracture reduction and present three case histories showing the usefulness of this technique.     

Need for bedside emergency department ultrasonography: case report of a ruptured ectopic pregnancy

Ultrasonography is a useful tool for the immediate evaluation of patients with suspected ruptured ectopic pregnancy, abdominal aortic aneurysm, traumatic intra-abdominal hemorrhage or cardiac tamponade. The 1999 Canadian Association of Emergency Physicians position statement states that bedside emergency department ultrasonography should be available 24 hours per day. This case study illustrates how emergency physicians properly trained in emergency bedside ultrasonography can use this tool effectively to dramatically impact patient care.     

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. Accuracy of emergency department ultrasound scanning in detecting abdominal aortic aneurysm

A short-cut review was carried out to establish whether emergency department ultrasound scanning had clinical utility for the diagnosis of abdominal aortic aneurysm (AAA). A total of 73 papers were found using the reported searches, of which 4 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that in patients suspected of having AAA, emergency department bedside ultrasound scanning for AAA is sensitive and specific and may improve patient care.     

Emergency Ultrasonography in the Evaluation of the Acute Scrotum

Acute scrotal pain accounts for approximately 0.5% of total emergency department (ED) visits. Despite this relatively low percentage, these patients can present a considerable challenge to the treating emergency physician (EP) since the etiologies of acute scrotal pain range from organ-threatening disease to minor idiopathic pain. Few data exist on EP use of bedside ultrasound to evaluate scrotal pain, but there is some suggestion that this may represent a beneficial future application for emergency ultrasonographers. This paper briefly describes the technology and technique involved with the performance of testicular ultrasound examination and briefly discusses its potential application at bedside in the ED.     

Point-of-care ultrasound diagnosis and treatment of posterior shoulder dislocation

Acute traumatic posterior shoulder dislocations are rare. The diagnosis is often missed or delayed, as radiologic abnormalities can be subtle. We report a case of a 37-year-old man who presented to the emergency department with severe right shoulder pain and inability to move his arm after a motor vehicle collision. Based on examination, he was initially thought to have an anterior dislocation; however, point-of-care (POC) ultrasound clearly demonstrated a posterior shoulder dislocation. Real-time ultrasound-guided intra-articular local anesthetic injection facilitated closed reduction in the emergency department without procedural sedation, and POC ultrasound confirmed successful reduction at the bedside after the procedure. This case demonstrates that POC ultrasound can be a useful diagnostic tool in the rapid assessment and treatment for patients with suspected posterior shoulder dislocation.     

Current Issues with Emergency Cardiac Ultrasound Probe and Image Conventions

As emergency physicians (EPs) and other noncardiologists incorporate bedside ultrasound (US) and bedside echocardiography (echo) into their practice, confusion has resulted from the differing imaging conventions used by cardiac and general imaging. The author discusses the origin of these differences, current cardiac imaging conventions, and controversies in emergency medicine (EM) regarding adoption of imaging conventions. Also discussed in detail are specific echo windows and experience with different approaches. While there is no perfect solution to merging the differing conventions, it is important that those performing and teaching bedside US and echo have a thorough understanding of the issues involved, and adopt a consistent approach.     

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.     

Evaluation of extremity trauma with sonography.

OBJECTIVE: To report on the use of bedside sonography in the diagnosis and treatment of penetrating extremity trauma. METHODS: Sonography was performed in the emergency department of a level 1 trauma center with both curved and linear array transducers. RESULTS: In both cases, foreign bodies and fractures resulting from gunshot wounds to the extremities were found. In addition, intra-abdominal and thoracic injuries were evaluated for using sonography. CONCLUSIONS: The increasing mobility and portability of sonography has led to its increasing use at the patient' bedside to diagnose a variety of conditions. It provides potential immediate diagnosis and has the flexibility for evaluating a multitude of injuries normally requiring several different imaging technologies. In circumstances in which conventional radiography is unavailable, such as at trauma scenes, mass casualty situations, or at the bedside with unstable patients, sonography can provide unique and essential information about these patients.     

Life-threatening pulmonary embolism that occurred immediately after acute carbon monoxide poisoning in the emergency department

The risk of thromboembolism is higher in those with carbon monoxide (CO) poisoning than in the general population. Pulmonary embolisms (PE) usually develop during admission for acute CO poisoning. We report the first case of a life-threatening PE that occurred immediately after acute CO poisoning and was treated with a thrombolytic agent. A 38-year-old woman presented at the emergency department with a stuporous mental status immediately after acute CO poisoning. She was started on hyperbaric oxygen therapy (HBOT), which maintained her hemodynamic stability. After completing the first HBOT session, profound shock occurred. The results of focused cardiac ultrasound performed by an emergency physician were completely different from those of the ultrasound conducted before HBOT; hyperdynamic left ventricle systolic function and right ventricle enlargement with dysfunction were detected. We administered a thrombolytic agent as she was suspected with acute PE based on ultrasound findings; computed tomography could not be performed because of impending arrest. She recovered after the treatment. We should consider that PE is also an important differential cause in patients with hypotension. In these patients, bedside ultrasound performed by emergency physicians can act as the only diagnostic examination.     

Two cases where bedside ultrasound was able to distinguish pulmonary bleb from pneumothorax

Distinguishing large pulmonary bullae from an acute pneumothorax can present a diagnostic challenge in the emergency setting. Plain film radiography of the chest may be inadequate to make the diagnosis. As the management of these two entities varies significantly, a clinical adjunct to aid diagnosis would prove useful. Using emergency department bedside ultrasound, we identified the typical "comet tailing" phenomenon of the movement of the lung tissue against the pleura during respiration, present in bullous disease but absent if the lung has collapsed. We present two patients, one with bullous emphysema and another with pneumothorax, in whom bedside ultrasound aided in making the diagnosis.     

Status of emergency department ultrasound

Objective : To determine present attitudes to and usage of ultrasound in Australasian emergency medicine. Methods : A questionnaire was devised, field tested and sent, with Australasian College for Emergency Medicine permission, for anonymous completion by the director of emergency medicine training of each emergency department in Australia and New Zealand accredited for advanced training. Results : The overall response rate was 84% (66/79). The data were tabulated and cross‐tabulated comparing major trauma centres, base hospitals, urban hospitals and teaching hospitals. In hours, X‐ray department ultrasound was readily available, but bedside ultrasound was much less available both in and out of hours. There were marked variations in opinion as to whether bedside ultrasound was essential in clinical conditions such as trauma, abdominal or kidney pain. Computed tomography was always preferred to ultrasound. While there was little teaching of either the theoretical or practical aspects of ultrasound to emergency medicine trainees, 75% of respondents believed that ultrasound should not be undertaken only by full‐time ultrasonographers. Conclusions : The survey clearly demonstrated that while bedside or urgent ultrasound is not generally readily available, especially out of hours, the modality is considered to be important by the majority of respondents, and does not require full‐time radiographers. It is clear that formal teaching of ultrasound to trainees is infrequent.     

Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service.

OBJECTIVE: We sought to determine whether physicians with training in echocardiography could successfully use a small echocardiographic device to detect occult cardiovascular disease in patients admitted to a general medical service. METHODS: In all, 103 consecutive patients had a physician-performed bedside echocardiographic examination with a small portable ultrasound device. RESULTS: Of patients, 70% did not have a clinical indication for echocardiography and of these patients, 39% had an abnormal study with the portable ultrasound device. There was a high rate of false-positive examinations, but approximately 17% of patients without a clinical indication for echocardiography had an important cardiac abnormality detected, including 10% with unsuspected left ventricular systolic dysfunction. CONCLUSIONS: Many patients on a general medical hospital ward have unsuspected, clinically important cardiac findings such as left ventricular dysfunction that can be screened for by physicians with training in echocardiography using small portable ultrasound devices.     

External cardiac pacing for out-of-hospital bradyasystolic arrest

Cardiac pacing has been used successfully in patients with asystole or bradycardia compromising hemodynamics when it was applied soon after the onset of the event. An external cardiac pacemaker was used as part of initial resuscitative efforts for patients in primary, out-of-hospital, cardiac arrest who arrived in the emergency department in asystole, agonal rhythm, pulseless idioventricular rhythm, or bradycardia with hemodynamic compromise. A pulse was successfully generated in only one of twelve patients. That patient developed complete atrioventricular dissociation while in the emergency department. The nonresponding patients were in asystole or pulseless idioventricular rhythm when the pacemaker was applied. Pacing was initiated 1-13 minutes (mean 7 minutes) after arrival in the emergency department, but 27-90 minutes (mean 59 minutes) after arrest. The interval between arrest and application of the pacemaker was prolonged because of long periods for ambulance response, field resuscitation, and transport. It is concluded that the external cardiac pacemaker is a useful instrument for the treatment of bradyarrhythmias. While it may also be useful in the first few minutes after development of asystole, pulseless idioventricular rhythm, or agonal rhythm, it is of no benefit if applied long after the event.