A prospective, multicenter evaluation of point-of-care ultrasound for appendicitis in the emergency department.

OBJECTIVE: The main objective of this study was to evaluate the accuracy of point-of-care ultrasound (POCUS) for the diagnosis of appendicitis in a general emergency department (ED) population as performed by emergency physicians with variable ultrasound experience. METHODS: We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential appendicitis presenting to the ED between July 2014 and February 2020. Each emergency physician-performed POCUS was interpreted at the bedside and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS and blinded expert interpretation compared to surgical pathology in patients undergoing appendectomy and advanced imaging in patients managed nonoperatively. RESULTS: A total of 256 subjects were included in the primary analysis with an overall appendicitis prevalence of 28.1%. For the diagnosis of appendicitis, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.85 (95% confidence interval [CI] = 0.74 to 0.92), 0.63 (95% CI = 0.56 to 0.70), 2.29 (95% CI = 1.85 to 2.84), and 0.24 (95% CI = 0.14 to 0.42), respectively. Expert review yielded a lower sensitivity (0.74 [95% CI = 0.62 to 0.83]) with a similar specificity (0.63 [95% CI = 0.56 to 0.70]). CONCLUSION: POCUS is moderately accurate for acute appendicitis as performed by emergency physicians with a wide range of ultrasound expertise, but lacks adequate sensitivity and specificity to function as a definitive test in an undifferentiated ED population. Further study is warranted to elucidate the optimal role of integrated POCUS in the general approach to suspected appendicitis.

Case Report: Diagnosis of Late Spontaneous Intraocular Lens Dislocation on Point-of-care Ultrasound.

INTRODUCTION: Spontaneous intraocular lens (IOL) dislocation is a rare, but serious, complication following cataract surgery. CASE REPORT: We report a case of patient with a remote history of cataract surgery presenting to the emergency department with monocular blurred vision. Ocular point-of-care ultrasound (POCUS) facilitated diagnosis of a late spontaneous IOL dislocation. DISCUSSION: Prosthetic IOL dislocations are being reported with increasing frequency. Prompt recognition of IOL dislocation is essential to prevent secondary complications, including acute angle-closure glaucoma and retinal detachment, which can result in permanent vision loss. CONCLUSION: Point-of-care ultrasound is a rapid, noninvasive imaging modality for early detection of IOL dislocation to help guide management, improve patient outcomes, and mitigate long-term sequelae.

Sonographic exploration for fascial exploration (SEFE) in necrotizing fasciitis: a case report.

BACKGROUND: Necrotizing skin and soft tissue infections are life-threatening conditions. Reliance on gas in tissue planes leads to worsened outcomes in patients with non-gas forming types of necrotizing fasciitis (NF). CASE PRESENTATION: We present a case of Group A Strep (GAS) necrotizing fasciitis, which was identified at bedside with point-of-care ultrasound (US) including an area of subfascial fluid. Computerized tomography only revealed diffuse cellulitic changes. Patient was taken to the operating room where fascial exploration was not performed at the concerning area seen on ultrasound and thus falsely negative. The patient subsequently developed multi-system organ failure and required amputation of the limb due to rapid spread of GAS NF. CONCLUSION: We suggest an US protocol to help identify optimal areas for fascial exploration-sonographic exploration for fascial exploration (SEFE).

A Prospective, Multicenter Evaluation of Point-of-care Ultrasound for Small-bowel Obstruction in the Emergency Department.

OBJECTIVE: The main objective of this study was to evaluate the accuracy of emergency physician-performed point-of-care ultrasound (POCUS) for the diagnosis of small-bowel obstruction (SBO) compared to computed tomography (CT). METHODS: We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential SBO presenting to the emergency department (ED) between July 2014 and May 2017. Each POCUS was interpreted at the bedside by the performing emergency physician and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS, blinded expert interpretation, and specific POCUS parameters. RESULTS: A total of 217 subjects were included in the primary analysis with an overall SBO prevalence of 42.9%. For the diagnosis of SBO, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.88 (95% confidence interval [CI] = 0.80 to 0.94), 0.54 (95% CI = 0.45 to 0.63), 1.92 (95% CI = 1.56 to 2.35), and 0.22 (95% CI = 0.12 to 0.39), respectively. Expert review yielded a similar sensitivity (0.89 [95% CI = 0.81 to 0.95]) with a significantly higher specificity (0.82 [95% CI = 0.74 to 0.88]). The more sensitive sonographic parameters for both POC sonographers and expert reviewers were small-bowel dilation ≥ 25 mm (0.87 [95% CI = 0.79 to 0.93], 0.87 [95% CI = 0.79 to 0.93]) and abnormal peristalsis (0.82 [95% CI = 0.72 to 0.89], 0.85 [95% CI = 0.76 to 0.87]). The more specific parameters for both groups were transition point (0.82 [95% CI = 0.74 to 0.89], 0.98 [95% CI = 0.94 to 1.00]), intraperitoneal free fluid (0.82 [95% CI = 0.74 to 0.89], 0.93 [95% CI = 0.87 to 0.97]), and bowel wall edema (0.76 [95% CI = 0.67 to 0.83], 0.93 [95% CI = 0.87 to 0.97]). CONCLUSION: POCUS is moderately sensitive for SBO, although less specific, when performed by a diverse group of emergency physicians across multiple EDs. Interpretation of acquired POCUS images is significantly more accurate when performed by physicians with prior emergency ultrasound fellowship training and familiarity with the sonographic appearance of SBO.

Spontaneous Bilateral Internal Carotid Artery Dissections in a Young Female with Headache.

Spontaneous cervical artery dissection (sCAD) occurs when the intimal lining separates from the outer wall of the artery. Although rare, it is a common cause of stroke in young people. Presentations range from isolated headache to severe stroke symptoms. A 41-year-old woman with minimal past medical history presented with left-sided headache and transient right leg weakness and numbness. The patient underwent computed tomography (CT) angiography of the neck that showed bilateral internal carotid artery dissections with a relative stenosis from pseudoaneurysm formation on the left. She was placed on a heparin drip and transitioned to warfarin but subsequently required stent placement 10 days later. If this patient had not undergone CT angiography at the time of presentation, she might have suffered significant morbidity and possible mortality.

Intraosseous access in the obese patient: assessing the need for extended needle length.

BACKGROUND: Intraosseous (IO) access can be complicated by obesity. Successful placement of a 25 mm IO needle is unlikely when soft tissue depth exceeds 20 mm. OBJECTIVES: The authors examined the relationship between body mass index (BMI), the ability to palpate the tibial tuberosity (TT), and soft tissue depth at recommended IO insertion sites. METHODS: Obese emergency department patients were assessed for a palpable TT and received ultrasound measurement of the soft tissue depth at recommended IO insertion sites. Linear and logistic regression were used to determine cut-off BMI values predicting soft tissue depth >20 mm. RESULTS: Seventy-five patients were enrolled with a mean BMI of 47.2. The mean soft tissue depth at the proximal humerus, proximal tibial, and distal tibial were 29.6 [95% CI 27.5-31.7] mm, 11.0 [8.9-13.0] mm, and 10.7 [9.4-12.1] mm, respectively. In 5 patients without a palpable TT the soft tissue depth exceeded 20 mm at all three anatomic sites. A BMI ≥43 and BMI ≥60 predicted a soft tissue depth >20 mm at the proximal tibia and distal tibia, respectively, while no reliable BMI cut-off was identified at the proximal humerus. CONCLUSIONS: In obese adults with a palpable TT or BMI ≤43 a 25 mm IO needle is likely adequate at the proximal and distal tibial insertion sites. Empiric use of an extended 45 mm IO needle is advisable at the proximal humeral insertion site in obese patients.

Extracorporeal Life Support for Cardiopulmonary Resuscitation for Adults: Evolving Evidence.

For years, conventional cardiopulmonary resuscitation (CPR) has been the cornerstone of treatment for cardiac arrest. However, the survival of patients that suffer a cardiac arrest is unsatisfactory despite the use of CPR. The use of extracorporeal life support (ECLS) to aid in the resuscitation of patients in cardiac arrest has the potential benefit of immediate restoration of circulation. Previously, several case reports and small series have suggested that ECLS might provide benefit for patients with refractory cardiac arrest. Several recent larger series, including a number of prospective studies, have emerged that provide further evidence for the utility of emergent institution of ECLS as an adjunct to conventional CPR in the management of cardiac arrest. These studies, which are reviewed here, have provided useful insight into the role of ECLS in cardiac arrest and have set the stage for randomized controlled trials. Ongoing ECLS trials, logistical issues, and future direction of ECLS are reviewed as well.

Focused Cardiac Ultrasound Diagnosis of Cor Triatriatum Sinistrum in Pediatric Cardiac Arrest.

Cardiac arrest in the adolescent population secondary to congenital heart disease (CHD) is rare. Focused cardiac ultrasound (FoCUS) in the emergency department (ED) can yield important clinical information, aid in resuscitative efforts during cardiac arrest and is commonly integrated into the evaluation of patients with pulseless electrical activity (PEA). We report a case of pediatric cardiac arrest in which FoCUS was used to diagnose a critical CHD known as cor triatriatum sinistrum as the likely cause for PEA cardiac arrest and help direct ED resuscitation.

Point-of-care ultrasound diagnosis of necrotizing fasciitis missed by computed tomography and magnetic resonance imaging.

BACKGROUND: Necrotizing fasciitis (NF) is a rare but deadly disease. Diagnosis of necrotizing soft tissue infections can be challenging for a variety of reasons. Point-of-care (POC) ultrasound (US) has been described as a diagnostic tool to help the acute care clinician make the early diagnosis that is imperative to optimize outcomes. OBJECTIVE: To report a case of Group A Streptococcus NF recognized with POC US, and subsequent negative findings on computed tomography (CT) and magnetic resonance imaging (MRI). CASE REPORT: A 54-year-old diabetic woman presented to the Emergency Department with atraumatic right foot and lower leg pain associated with fever. Examination was concerning for NF, and a POC US was performed, which showed thickened deep fascia and fluid tracking along the deep fascial plane, with fluid pockets measuring 6 mm in depth, consistent with NF. Surgical consultation was obtained. Per request, CT and MRI of the patient's lower extremity were performed; both were interpreted by the radiologist as showing changes consistent with cellulitis. Septic shock and multisystem organ failure ensued; the patient was eventually taken to the operating room, where operative findings were consistent with NF. Operative cultures grew Streptococcus pyogenes. CONCLUSION: NF is a surgical emergency. Early and accurate diagnosis is critical to ensure the necessary aggressive management needed to optimize outcomes. This case illustrates the utility of POC US to make the prompt diagnosis of NF, particularly in light of subsequently negative CT and MRI.

The effect of sonologist experience on the ability to determine endotracheal tube location using transtracheal ultrasound.

STUDY OBJECTIVE: Transtracheal ultrasound has been described as a method to evaluate endotracheal tube placement. Correlation between sonologist experience and the successful use of transtracheal ultrasound to identify endotracheal tube location has not been examined. Our objectives were to evaluate emergency physicians' ability to correctly identify endotracheal tube location using transtracheal ultrasound and to evaluate the role operator experience plays in successful identification of tube placement. METHODS: This was a cross-sectional, single-blinded study conducted in a cadaver laboratory. Two cadavers were used as models. One cadaver had an endotracheal tube placed in the esophagus, and the second had the tube placed in the trachea. Participants were asked to evaluate tube placement using transtracheal ultrasound and to record their interpretation. Examination clips were reviewed by the emergency ultrasound fellowship director. Descriptive statistics and χ(2) test were used for analysis. RESULTS: Twenty-nine participants were included, 8 (27.6%) of whom were considered to be "most experienced" based on previous ultrasound experience (>150 scans). Eleven of 29 correctly identified esophageal intubation and 18 of 29 correctly identified tracheal intubation, resulting in a sensitivity of 62.0% (95% confidence interval [CI], 42.3-79.3) and a specificity of 37.9% (95% CI, 20.7-57.7). Transtracheal ultrasound performed by the most experienced sonologists showed better sensitivity and specificity, 75.0% (95% CI, 34.9-96.8) and 62.5% (95% CI, 24.5-91.5), respectively. CONCLUSION: Most participants obtained adequate images, but correct interpretation of the images was poor. The most experienced sonologists correctly identified tube location more often. Additional education would be required before adopting this method.

A descriptive study of myoclonus associated with etomidate procedural sedation in the ED.

BACKGROUND: Myoclonus is a well-recognized side effect of etomidate when given in induction doses for rapid sequence intubation. Most of the data reported on myoclonus with emergency department (ED) sedation doses are reported as a secondary finding. STUDY OBJECTIVES: Our objective was to prospectively quantify the incidence and duration of myoclonus associated with the administration of etomidate in the lower doses given for procedural sedation in the ED. METHODS: This was a prospective descriptive study performed between September 2008 and September 2010 at an urban teaching hospital ED with approximately 50000 patient visits per year. Procedural sedation was performed at the discretion of the treating emergency physician, and adult patients receiving etomidate were eligible for enrollment. The occurrence and duration of myoclonus were observed and recorded. Any interference of myoclonus with the ability to complete the procedure was recorded, and adverse effects were identified. RESULTS: Thirty-four eligible subjects were enrolled, and 36 separate sedation procedures were performed. The mean initial etomidate dose was 0.13 mg/kg (range, 0.077-0.20), and the mean total etomidate dose was 0.15 mg/kg (range, 0.077-0.29). Myoclonus was noted in 26 (72%) of 36 sedations. Mean time to onset of myoclonus was 50 seconds (range, 15-146), and the mean duration was 93 seconds (range, 03-557). Myoclonus interfered with the procedure in only 1 (3%) of 36 attempted procedures, and no procedure was unsuccessful because of myoclonus. CONCLUSION: Myoclonus associated with sedation doses of etomidate was common but rarely interfered with the completion of a procedure.

Safety and effectiveness of acetadote for acetaminophen toxicity.

BACKGROUND: Acetaminophen (APAP) toxicity is commonly encountered in the Emergency Department. Until 2004, treatment consisted of either oral N-acetylcysteine (NAC) or filtered oral NAC administered intravenously (i.v.). Intravenous acetylcysteine (Acetadote) is a new Food and Drug Administration-approved i.v. formulation of acetylcysteine manufactured by Cumberland Pharmaceuticals in Nashville, Tennessee. Little post-marketing data exists on the effectiveness and safety of i.v. acetylcysteine. OBJECTIVES: We evaluated the clinical presentations and outcomes of patients treated with i.v. acetylcysteine for APAP toxicity. METHODS: We performed a retrospective chart review of patients treated with i.v. acetylcysteine for APAP ingestion. The primary outcome measures were: adverse reactions to and effectiveness of i.v. acetylcysteine, as defined by elevation of transaminases, liver failure, renal failure, death, and hospital length of stay (LOS). Data collected included: comorbidities, allergies, intentionality, timing and dosing of i.v. acetylcysteine, hospital LOS, transaminases > 1000 IU/L, development of liver failure requiring transplant, development of renal failure requiring hemodialysis, death, and anaphylactoid reactions. RESULTS: Sixty-four patients met our study criteria. Overall, 16 (25%) patients developed transaminases > 1000 IU/L, 4 (6%) of them died and 2 (3%) received liver transplants. Of the 15 patients (23%) treated within 8 h, none died or developed liver or renal failure, and only 1 developed transient transaminase elevation > 1000 IU/L. In the patients treated outside of 8 h, the median LOS was 3 days, whereas the group treated within 8 h had a median LOS of only 1 day. Six (9%) patients developed anaphylactoid reactions, 2 of whom received the i.v. acetylcysteine bolus over 15 min. Five of these patients were treated pharmacologically and completed treatment, and one had treatment discontinued for undocumented reasons. CONCLUSION: Intravenous acetylcysteine seemed to be a safe and effective formulation of N-acetylcysteine.