Ultrasound-Guided Manual Testicular Detorsion in the Emergency Department

BackgroundScrotal ultrasound helps in the rapid diagnosis of complete testicular torsion and assessment of alternative causes of acute scrotal pain. Early detection of torsion of the testis and reperfusion, either manually or surgically, is paramount to preserving testicular viability. Manual detorsion also offers immediate symptom relief by alleviating ischemia. Bedside ultrasound performed by a trained emergency physician (EP) can significantly reduce the time to diagnosis and reperfusion by means of performing an ultrasound-guided manual detorsion in the emergency department (ED).Case ReportWe report two cases of ultrasound-guided manual detorsion of testis that were performed successfully by EPs in the ED. After manual detorsion, both patients underwent nonemergent orchidopexy and recovered well after surgery.Why Should an Emergency Physician Be Aware of This?Manual testicular detorsion is a simple, safe, and effective maneuver that can be performed in the ED by EPs. Bedside ultrasound is helpful in confirming the diagnosis of complete torsion of the testicle (no blood flow) and successful reperfusion after manual detorsion. We recommend EPs be trained to perform scrotal ultrasound and manual detorsion of a torted testicle. We strongly emphasize that manual detorsion of the testes is not a substitute for definitive surgical management and should only be used as a temporary measure for reperfusion to allow more time to organize the logistics of surgery, which can be critical in remote settings.     

Intramural atrial hematoma complicating transesophageal echocardiography during cardiac arrest

Background

Adequate strategies using either transthoracic (TTE) or transesophageal (TEE) echocardiography in patients receiving cardiopulmonary resuscitation (CPR) is an ongoing area of research.

Handheld transabdominal ultrasound,after limited training,may confirm first trimester viable intrauterine pregnancy: a prospective cohort study

ObjectivesHandheld point-of-care abdominal ultrasound (POCUS) may be used by primary care physicians while vaginal ultrasound is limited to use in specialist care. We aimed to compare abdominal handheld ultrasound to vaginal ultrasound in determining first trimester viable intrauterine pregnancy and estimate gestational length.DesignProspective cohort study.SettingGynaecologic outpatient clinic; women referred from GPs during early pregnancy. Handheld ultrasound using VscanExtend^® was performed by fourth-year medical students with limited training. Transvaginal ultrasound using high-end devices was performed by ordinary hospital staff.SubjectsWomen in the first trimester of pregnancy referred for termination of pregnancy or with symptoms of early pregnancy complications.Main outcome measuresRate of confirming vital intrauterine pregnancy (visualizing foetal heart beats) and measurement of crown-rump length (CRL) using handheld abdominal versus vaginal ultrasound.ResultsIn all 100 women were included; 86 confirmed as viable intrauterine pregnancies and 14 pathological pregnancies (miscarriages/extrauterine pregnancies). Handheld abdominal ultrasound detected fetal heartbeats in 63/86 (73% sensitivity) of healthy pregnancies and confirmed lack of fetal heartbeats in all pathological pregnancies, total positive predictive value (PPV) 100% and total negative predictive value (NPV) 38%. From gestational week 7, handheld abdominal ultrasound confirmed vitality in 51/54 patients: PPV 100% and NPV 79%. CRL (n = 62) was median 1 mm shorter (95% confidence interval 1–2 mm) measured by handheld abdominal versus vaginal ultrasound.ConclusionHandheld ultrasound has an excellent prediction confirming viable intrauterine pregnancy from gestational week 7. Validation studies are needed to confirm whether the method is suitable in primary care assessing early pregnancy complications.

KEY POINTS

• When early pregnancy vitality needs to be confirmed, women will traditionally be referred to secondary care for transvaginal comprehensive ultrasonography performed with high-end devices by imaging specialists.
• In this study personnel with limited former training (fourth-year medical students) performed transabdominal POCUS using a handheld device, investigating 100 first trimester pregnancies for confirmation of viability.
• Using handheld ultrasound viable pregnancy was confirmed from gestational week 7 with 79% positive and 100% negative predictive value.
• If handheld ultrasound used in primary care confirms vital intrauterine pregnancy, the need for specialist referral could be reduced.

     

Strangulated epigastric hernia in a 90-year-old man: Point-of-Care Ultrasound (POCUS) as a saving kit: Case report

IntroductionThe physiological reserve of extreme elderly patients is very limited and has major impact on clinical decisions on their management. Hereby we report a 90-year-old man who presented with a strangulated epigastric hernia and who developed postoperative intra-abdominal bleeding, and highlight the value of Point-of-Care Ultrasound (POCUS) in critical decisions made during the management of this patient.Presentation of caseA 90-year-old man presented with a tender irreducible epigastric mass. Surgeon-performed POCUS using colour Doppler showed small bowel in the hernia with no flow in the mesentery. Resection anastomosis of an ischaemic small bowel and suture repair of the hernia was performed. Twenty four hours after surgery, in a routine follow up using POCUS, significant intra-peritoneal fluid was detected although the patient was haemodynamically stable. The fluid was tapped under bedside ultrasound guidance and it was frank blood. During induction of anaesthesia for a laparotomy, the patient became hypotensive. Resuscitation under inferior vena cava sonographic measurement, followed by successful damage control surgery with packing, was performed. 36 h later, the packs were removed, no active bleeding could be seen and the abdomen was closed without tension. The patient was discharged home 50 days after surgery with good general condition.ConclusionPOCUS has a central role in the management of critically-ill elderly patients for making quick critical decisions.     

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

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

Examiner Position in Ocular Point-of-Care Ultrasound: A Proposed Technique

BackgroundOcular point-of-care ultrasound (POCUS) is a fast and safe non-invasive procedure used to evaluate the structural integrity and pathology of the eye. Ocular POCUS can be used for evaluation of posterior chamber and orbital pathology, including retinal detachment, vitreous detachment or hemorrhage, foreign body, lens dislocation, and increased intracranial pressure.DiscussionThe purpose of this brief communication is to describe a technique for conducting an ocular POCUS that may in some cases be easier and more comfortable by adjusting the position of the sonographer relative to the patient.ConclusionsTo our knowledge, this proposed technique has not been described in previous literature and may result in greater comfort for both sonographer and patient.     

Critical care chest radiology

Before requesting any test, clinicians must consider how likely it is to be able to answer the clinical question. Multiple radiological investigations are available to aid diagnosis, assist with practical procedures and direct management of critically ill patients. This article gives an overview of commonly used thoracic imaging modalities and summarizes their indications, important findings and potential pitfalls.