Xanthogranulomatous Pyelonephritis: Case Report.

BACKGROUND: In the emergency department (ED), pyelonephritis is a fairly common diagnosis, especially in patients with unilateral flank pain. Xanthogranulomatous pyelonephritis (XGP) is a rare type of pyelonephritis that is associated with unique features, which may lead to its diagnosis. CASE REPORT: A 30-year-old male patient presented to the ED for evaluation of right-sided abdominal pain that has been ongoing for the past 24 hours. He noted the pain was located predominantly in the right flank and described it as sharp in nature. The pain was nonradiating and was associated with scant hematuria. He stated that he had similar pains approximately 1 month earlier that resolved after a few days. The patient underwent a bedside ultrasound and a subsequent computed tomography (CT) scan of the abdomen and pelvis, which showed an enlarged, multiloculated right kidney with dilated calyces and a large staghorn calculus, findings that represent XGP. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report highlights an unusual variant of pyelonephritis, a relatively common ED diagnosis. XGP should be considered in patients with recurrent pyelonephritis, as treatment for XGP may require surgical intervention in addition to traditional antibiotic management.

Aortic Dissection Case Report.

Although uncommon, acute aortic dissections are a life-threatening, cannot miss diagnosis for the emergency medicine clinician. Point of care ultrasound can play an integral role in the initial work up of the undifferentiated patient. While not initially utilized to make the diagnosis of aortic dissection, the ultrasound images obtained in this case describe key findings on ultrasound vital for an emergency clinician to recognize. It is essential for emergency medicine clinicians to differentiate an aortic dissection from other causes of chest pain and abdominal pain because the quick mobilization of resources plays a key role in the management and outcome of such patients. Topics: Aortic dissection, vascular, dissection flap, back pain, point of care ultrasound, POCUS.

Agreement on Interpretation of Point-of-Care Ultrasonography for Cardiac Tamponade Among Emergency Physicians.

STUDY OBJECTIVE: Cardiac tamponade is an impending calamitous disorder that emergency physicians need to consider and diagnose rapidly. A pericardial effusion with right atrial systolic collapse (earliest sign) or right ventricular diastolic collapse (most specific sign) and a plethoric inferior vena cava are indicators of cardiac tamponade physiology and may be identified with point-of-care ultrasonography (POCUS). The goal of this study is to assess the agreement among emergency physicians with varying levels of sonographic training and expertise in interpreting echocardiographic signs of cardiac tamponade in adult patients.  Methods: Emergency physicians at different levels of training as sonographers were surveyed at didactic conferences at three major academic medical centers in northern New Jersey. Two cardiologists were also included in the study for comparison. Survey respondents were shown 15, 20-second video clips of patients who had presented to the emergency department (ED) with or without significant pericardial effusions and were asked to rate whether tamponade physiology was present or not. Data were collected anonymously on Google Forms (Google LLC, Mountain View, CA) and included self-reported levels of POCUS expertise and level of training. Data were analyzed using Fleiss' kappa (k). All patients had an echocardiogram performed by the department of cardiology within 24 hours of the POCUS, and the results are presented in the paper.  Results: There were 97 participant raters, including attendings, fellows, and resident physicians specializing in adult emergency medicine and two cardiologists. There was a fair degree of inter-rater agreement among all participants in interpreting whether tamponade physiology was present or not. This low level of agreement persisted across self-reported training levels and self-reported POCUS expertise, even at the expert level in both emergency medicine and cardiology specialties. CONCLUSION: According to the results of our study, there appears to be a low level of agreement in the interpretation of cardiac tamponade in adult patients. The lack of agreement persisted across specialties, self-reported training levels, and self-reported ultrasonographic expertise. This low level of agreement seen among both specialists indicates that emergency physicians are not limited in their ability to determine cardiac tamponade on POCUS. This highlights the technical nature of POCUS clips and strengthens the importance of physical exam findings when diagnosing cardiac tamponade in emergency department patients. Further research utilizing POCUS for the diagnosis of tamponade is warranted.

Does Patient Weight, Age, or Gender Correlate With the Ability to Visualize the Distal Aorta on Bedside Aortic Ultrasounds in the Emergency Department?

INTRODUCTION: Abdominal aortic aneurysms (AAA) have a varied presentation, which often makes the diagnosis difficult. The most common location for an AAA is in the infra-renal or distal aorta, which can be difficult to visualize using bedside ultrasound.  Objective: This study was designed to identify if a patient's weight, gender, or age influenced our ability to visualize the distal aorta on bedside abdominal aortic ultrasound scans.  Methods: All aortic scans completed in the Emergency Department (ED) from September 2010 to September 2013 were retrospectively evaluated. Patients 21 years and older were included. Scans missing age, gender, or self-reported weight were excluded.  Results: 500 aortic scans were included. The distal aorta was visualized in 393 scans (78.6%). The mid aorta was visualized in 417 scans (83.4%). The proximal aorta was visualized in 454 scans (90.8%). For the distal aorta, the average weight for visualized versus not visualized was 75.7 kg versus 79.7 kg. For the proximal aorta, the average weight for visualized versus not visualized was 75.8 kg versus 84.0 kg. Weight significantly predicted the ability to visualize the proximal aorta (unadjusted p=0.0098, adjusted p=0.0095) and marginally predicted the ability to visualize the distal aorta (unadjusted p=0.071, adjusted p=0.019). Neither age (unadjusted p=0.13, adjusted p=0.052) nor gender (unadjusted p=0.74, adjusted p=0.40) was significantly associated with visualization. CONCLUSION: There is no clinically significant difference in the ability to visualize a patient's distal aorta with bedside ultrasound based on a patient's body weight, gender, or age.

Thigh Mass Case Report.

Patients commonly present to the Emergency Department for the evaluation of soft tissues masses of various etiology. Point-of-care ultrasound (POCUS) can aid in the initial evaluation of these masses to begin narrowing a given differential. Soft tissue sarcomas are a malignant neoplasm that frequently present in an extremity, and require close follow-up for the evaluation of metastasis and possible resection, among other treatment options. Being able to effectively differentiate between infectious, inflammatory, benign, or potentially malignant pathology for undifferentiated soft tissue masses is critical for Emergency Medicine clinicians to ensure patients receive appropriate treatment and referrals for definitive care. Topics: Thigh mass, soft tissue mass, sarcoma, point-of-care ultrasound.

Vitreous Hemorrhage Case Report.

Ocular issues are a common reason to present to the emergency department (ED). This case discusses a patient who presented to the ED with unilateral atraumatic partial vision loss. The patient underwent a point of care ultrasound that was concerning for a vitreous hemorrhage. Although vitreous hemorrhages require urgent, rather than emergent evaluation, it is important to differentiate this diagnosis from vitreous and retinal detachment. Topics: Vitreous hemorrhage, eye complaint, point of care ultrasound, POCUS.

Impact of Bedside Ultrasound on Emergency Department Length of Stay and Admission in Patients With a Suspected Peritonsillar Abscess.

Introduction Patients presenting to the Emergency Department (ED) with a suspected peritonsillar abscess (PTA) often pose a diagnostic dilemma, as clinical impression is often unreliable and traditional diagnostic methods have multiple downsides. Bedside ultrasonography has been cited as a modality to improve the diagnosis and management of PTA. We aimed to determine the impact bedside ultrasound (US) could have in suspected PTA on ED length of stay (LOS) and hospital admission rates. Methods We performed a retrospective chart review on patients who presented to the ED with suspected ''peritonsillar abscess''. Results From a sample of 58 charts, seven had documented bedside US performed. The average ED length of stay for these seven cases was 160 minutes (range: 52 to 270 minutes). The ED length of stay for all other cases utilizing other diagnostic methods during the same time period was 293 minutes (range: 34 to 780 minutes). None of the patients who were diagnosed with US were admitted to the hospital, whereas 36.4% of patients where US was not used were admitted. Conclusion The use of bedside US in seven cases of suspected PTA had reduced LOS in the ED and none required hospital admission.

Hemorrhagic Renal Cyst, a Case Report.

History of present illness: A 73-year-old male presented with one day of hematuria associated with urinary frequency and acute on chronic abdominal cramping. On exam, he had diffuse abdominal tenderness, which he stated was normal for him. He was afebrile with no costovertebral angle tenderness or any other pertinent findings on physical exam. The urinalysis showed large red blood cells and small leukocyte esterase and nitrites. Labs were significant for white blood cell count (WBC) 24.6/mm3, hemoglobin 11.6 g/dL, blood urea nitrogen (BUN) 56 mg/dL, creatinine 3.8 mg/dL (baseline 2.8 six months ago), glomerular filtration rate (GFR) 16 mL/min. These findings were consistent with acute on chronic kidney injury with concomitant urinary tract infection - specifically concerning for pyelonephritis or an infected renal stone. Significant findings: Bedside renal ultrasound demonstrated a right renal cyst with echogenic debris consistent with a hemorrhagic cyst (red arrow). In addition, a computed tomography (CT) scan of the abdomen and pelvis revealed a 4mm non-obstructing right renal stone and bilateral renal cysts. The CT also confirmed the ultrasound finding of a right renal cyst with mild perinephric stranding possibly consistent with a hemorrhagic cyst. Discussion: Simple renal cysts are typically single, unilateral, and usually possess four distinct characteristics: lack internal echoes, have increased posterior acoustic enhancement, have a uniform round/oval shape, and have thin posterior walls/demarcated borders.1 If all of these ultrasound features are met, additional imaging does not always have to be obtained.1,2 Simple renal cysts are usually benign, asymptomatic, and often appear as incidental findings on imaging.2,3 Generally, the number of renal cysts increase as a person ages.3A renal cyst may be classified as a complex cyst when it fails to be defined as a simple cyst.1 Characteristics of complex renal cysts may include septations, calcifications, internal echoes, or other irregularities.1 Cysts can also become more complex by hemorrhage or infection, which is usually evident on ultrasound by internal echoes.1 Calcifications can also form within the cyst, which can make it challenging to discriminate a simple cyst from cystic renal tumors.2 Both malignant and hemorrhagic cysts often have irregular boarders and echogenic material within their walls and within the cyst.4 On ultrasound, infected renal cysts are characterized by thickened walls sometimes with debris or gas.1,3 Calcifications may be present with increased attenuation.3 Infected cysts are diagnosed by a combination of imaging findings and clinical characteristics.3,5 While simple cysts are usually asymptomatic, malignant or more complex cysts are more likely to be symptomatic.3To further distinguish hemorrhagic cysts from malignant tumors, a CT or magnetic resistance imaging (MRI) should be performed.2 Computed tomography is more sensitive than ultrasound for identifying a renal mass, but ultrasound is effective for further characterizing a simple cyst from a complex cyst.3,6 One study reported that CT, MRI, and MRI with diffusion-weighted imaging (DWI) had 100% sensitivity at identifying the presence of possible malignant renal lesions, but CT and MRI had lower specificity (66.9% and 68.8%) than MRI with DWI (93.8%).7Further classifying the type of renal cyst - simple vs complex or hemorrhagic vs infected vs malignant - aids in guiding management. While simple cysts usually do not need additional imaging, complex cysts may need to be further characterized.2 If malignancy is unlikely, hemorrhagic cysts are typically followed with serial ultrasounds.1 If there is concern for infection, antibiotics should be started.5 Further evaluation may include aspiration and drainage.1. Patient Course: This patient was started on antibiotics and admitted to the hospital. Urology, nephrology, and infectious disease were consulted. He was continued on antibiotics for 3 weeks due to concern for possible infected renal cyst. The patient was discharged and recommended to follow-up with urology for an outpatient cystoscopy and repeat renal ultrasound in 3 months to evaluate for a possible neoplasm. Topics: Renal cyst, hemorrhagic cyst, hematuria, bedside ultrasound, POCUS.

Procedure rates performed by emergency medicine residents: a retrospective review.

BACKGROUND: The purpose of our study is to investigate rates of individual procedures performed by residents in our emergency medicine (EM) residency program. Different programs expose residents to different training environments. Our hypothesis is that ultrasound examinations are the most commonly performed procedure in our residency. METHODS: The study took place in an academic level I trauma center with multiple residency and fellowship programs including surgery, surgical critical care, trauma, medicine, pulmonary/critical care, anesthesiology and others. Also, the hospital provides a large emergency medical services program providing basic and advanced life support and critical care transport, which is capable of performing rapid sequence intubation. Each EM residency class, except for the first 2 months of the inaugural class, used New Innovations to log procedures. New Innovations is an online database for tracking residency requirements, such as procedures and hours. For the first 3 months, procedures were logged by hand on a log sheet. In addition, our department has a wireless electronic system (Qpath) for recording and logging ultrasound images. These logs were reviewed retrospectively without any patient identifiers. Actual procedures and simulation procedures were combined for analysis as they were only logged separately halfway through the study period. Procedures were summed and the average procedure rate per resident per year was calculated. RESULTS: In total, 66 full resident years were analyzed. Overall, ultrasound was the most commonly performed procedure, with each resident performing 125 ultrasounds per year. Removing "resuscitations," the second most common was endotracheal intubation, performed 28.91 times per year, and third most was laceration repair, which was performed 17.39 times per year. Our lowest performed procedure was thoracentesis, which was performed on average 0.11 times per resident per year. CONCLUSIONS: Residents performed a variety of procedures each year. Ultrasound examinations were the most frequent procedure performed. The number of ultrasound procedures performed may reflect the changing training landscape and influence future Accreditation Council of Graduate Medical Education requirements.