Ultrasonography versus computed tomography for suspected nephrolithiasis.

BACKGROUND: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography. METHODS: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analogue scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy. RESULTS: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to CT. The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (P<0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (P=0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (P=0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups. CONCLUSIONS: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations. (Funded by the Agency for Healthcare Research and Quality.).

Success of ultrasound-guided versus landmark-guided arthrocentesis of hip, ankle, and wrist in a cadaver model.

PURPOSE: The objectives of this study were to evaluate emergency medicine resident-performed ultrasound for diagnosis of effusions, compare the success of a landmark-guided (LM) approach with an ultrasound-guided (US) technique for hip, ankle and wrist arthrocentesis, and compare change in provider confidence with LM and US arthrocentesis. METHODS: After a brief video on LM and US arthrocentesis, residents were asked to identify artificially created effusions in the hip, ankle and wrist in a cadaver model and to perform US and LM arthrocentesis of the effusions. Outcomes included success of joint aspiration, time to aspiration, and number of attempts. Residents were surveyed regarding their confidence in identifying effusions with ultrasound and performing LM and US arthrocentesis. RESULTS: Eighteen residents completed the study. Sensitivity of ultrasound for detecting joint effusion was 86% and specificity was 90%. Residents were successful with ultrasound in 96% of attempts and with landmark 89% of attempts (p=0.257). Median number of attempts was 1 with ultrasound and 2 with landmarks (p=0.12). Median time to success with ultrasound was 38s and 51s with landmarks (p=0.23). After the session, confidence in both US and LM arthrocentesis improved significantly, however the post intervention confidence in US arthrocentesis was higher than LM (4.3 vs. 3.8, p<0.001). CONCLUSIONS: EM residents were able to successfully identify joint effusions with ultrasound, however we were unable to detect significant differences in actual procedural success between the two modalities. Further studies are needed to define the role of ultrasound for arthrocentesis in the emergency department.

Point-of-Care Ultrasound for the Detection of Traumatic Intracranial Hemorrhage in Infants: A Pilot Study.

OBJECTIVES: Computed tomography is the criterion standard imaging modality to detect intracranial hemorrhage (ICH) in children and infants after closed head injury, but its use can be limited by patient instability, need for sedation, and risk of ionizing radiation exposure. Cranial ultrasound is used routinely to detect intraventricular hemorrhage in neonates. We sought to determine if point-of-care (POC) cranial ultrasound performed by emergency physicians can detect traumatic ICH in infants. METHODS: Infants with ICH diagnosed by computed tomography were identified. For every infant with an ICH, 2 controls with symptoms and diagnoses unrelated to head trauma were identified. Point-of-care cranial ultrasound was performed by an emergency physician on all patients, and video clips were recorded. Two ultrasound fellowship-trained emergency physicians, blinded to the patients' diagnosis and clinical status, independently reviewed the ultrasound clips and determined the presence or absence of ICH. RESULTS: Twelve patients were included in the study, 4 with ICH and 8 controls. Observer 1 identified ICH with 100% sensitivity (95% confidence interval [CI], 40%-100%) and 100% specificity (95% CI, 60%-100%). Observer 2 identified ICH with 50% sensitivity (95% CI, 9%-98%) and 87.5% specificity (95% CI, 47%-99%). Agreement between observers was 75%, κ = 0.4 (P = 0.079; 95% CI, 0-0.95). CONCLUSIONS: Traumatic ICH can be identified with POC cranial ultrasound by ultrasound fellowship-trained emergency physicians. Although variations between observers and wide confidence intervals preclude drawing meaningful conclusions about sensitivity and specificity from this sample, these results support the need for further investigation into the role of POC cranial ultrasound.

External Validation of the STONE Score, a Clinical Prediction Rule for Ureteral Stone: An Observational Multi-institutional Study.

STUDY OBJECTIVE: The STONE score is a clinical decision rule that classifies patients with suspected nephrolithiasis into low-, moderate-, and high-score groups, with corresponding probabilities of ureteral stone. We evaluate the STONE score in a multi-institutional cohort compared with physician gestalt and hypothesize that it has a sufficiently high specificity to allow clinicians to defer computed tomography (CT) scan in patients with suspected nephrolithiasis. METHODS: We assessed the STONE score with data from a randomized trial for participants with suspected nephrolithiasis who enrolled at 9 emergency departments between October 2011 and February 2013. In accordance with STONE predictors, we categorized participants into low-, moderate-, or high-score groups. We determined the performance of the STONE score and physician gestalt for ureteral stone. RESULTS: Eight hundred forty-five participants were included for analysis; 331 (39%) had a ureteral stone. The global performance of the STONE score was superior to physician gestalt (area under the receiver operating characteristic curve=0.78 [95% confidence interval {CI} 0.74 to 0.81] versus 0.68 [95% CI 0.64 to 0.71]). The prevalence of ureteral stone on CT scan ranged from 14% (95% CI 9% to 19%) to 73% (95% CI 67% to 78%) in the low-, moderate-, and high-score groups. The sensitivity and specificity of a high score were 53% (95% CI 48% to 59%) and 87% (95% CI 84% to 90%), respectively. CONCLUSION: The STONE score can successfully aggregate patients into low-, medium-, and high-risk groups and predicts ureteral stone with a higher specificity than physician gestalt. However, in its present form, the STONE score lacks sufficient accuracy to allow clinicians to defer CT scan for suspected ureteral stone.

Pelvic Free Fluid in Asymptomatic Pediatric Blunt Abdominal Trauma Patients: A Case Series and Review of the Literature.

BACKGROUND: With focused assessment with sonography in trauma (FAST) examinations being performed more commonly on pediatric trauma patients, emergency providers will encounter a positive FAST examination in patients with benign abdominal examinations. This poses a diagnostic dilemma for the provider when deciding whether to obtain a computed tomography (CT) scan of the abdomen/pelvis, observe the patient, or admit the patient. CASE REPORT: We report a series of pediatric patients involved in blunt abdominal trauma who had small pelvic free fluid on FAST but a benign abdominal examination. Three patients were managed without CT scan and 2 with CT scan. All patients did well and were discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Free intra-abdominal fluid may be physiologic in both male and female pediatric patients. Clinical examination and hemodynamic stability should be taken into account when deciding to order a CT scan. We review the literature and highlight new protocols that may decrease CT utilization and ionizing radiation exposure, though further studies in this specific population are needed.

Point-of-Care Ultrasound to Diagnose Infantile Parotid Hemangioma.

Soft tissue masses are common in the pediatric population and may represent a broad range of conditions. Point-of-care ultrasound can be used for rapid visualization and assessment of soft tissue masses in the emergency setting. We report a case of a pediatric head and neck mass in which point-of-care ultrasound was used to identify an infantile parotid hemangioma.

Use of pelvic computed tomography and sonography in women of reproductive age in the emergency department.

OBJECTIVES: The purpose of this study was to review use of pelvic computed tomography (CT) and sonography in the emergency department for women of reproductive age and to identify cases in which sonography might have been adequate. METHODS: Computed tomographic and sonographic examinations of the pelvis performed on women up to 55 years of age in our emergency department during a 6-month period were reviewed. Repeated CT and CT with indications for which sonography would not be the first-line imaging modality (eg, diverticulitis and trauma) were excluded. For the sonographic-only assessment, repeated sonography and sonography with indications for which CT would not be the first-line imaging modality (eg, vaginal bleeding) were excluded. Patient referral indications, imaging diagnoses, and discharge diagnoses were compared for the groups with CT only, CT first, sonography first, and sonography only. RESULTS: Of 509 women who underwent CT, 407 (80%) underwent CT only; 54 (11%) underwent CT first; and 48 (9%) underwent pelvic sonography first. The percentages with negative CT findings were 42%,17%, and 50%, respectively. Overall, 63 (CT only), 38 (CT first), and 12 (sonography first) patients had CT diagnoses of pelvic conditions only (113 of 509 women [22%]). Of the patients with CT and discharge diagnoses of pelvic conditions, 36 of 44 (82%) had CT only or CT first; 58 of 110 (53%) of cases with sonography only showed acute pelvic conditions. CONCLUSIONS: Twenty-two percent of pelvic CT examinations performed in women of reproductive age in our emergency department showed only pelvic conditions, suggesting that sonography would have been a reasonable primary imaging test for these patients.

A randomized controlled trial of incision and drainage versus ultrasonographically guided needle aspiration for skin abscesses and the effect of methicillin-resistant Staphylococcus aureus.

STUDY OBJECTIVE: The incidence of skin and soft tissue infections has increased dramatically during the last decade, in part because of increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Incision and drainage is considered the primary intervention; however, some clinicians prefer ultrasonographically guided needle aspiration because it represents a less invasive alternative. Our hypothesis is that ultrasonographically guided needle aspiration is equivalent to incision and drainage in treating simple skin and soft tissue abscesses. METHODS: This study was a nonblinded randomized controlled trial. Patients with uncomplicated superficial abscesses were randomized to incision and drainage with packing or ultrasonographically guided needle aspiration. Purulence obtained from the abscess was cultured to identify the causative organism. Bedside ultrasonography was performed pre- and postintervention to confirm the presence or absence of an abscess cavity. Patients were followed up at 48 hours (in person by a clinician) and on day 7 (telephone follow-up by research staff). The primary outcome was a combination of sonographic resolution and clinical resolution of the signs and symptoms of ongoing infection at day 7. The signs and symptoms of ongoing infection include increasing pain, erythema, and the presence of pus. Resolution was assessed with both sonographic resolution (day 0 and day 2) and improvement of clinical symptoms (day 2) and resolution of clinical symptoms (day 7) without further intervention. RESULTS: A total of 101 patients were enrolled, 54 incision and drainage and 47 ultrasonographically guided needle aspiration patients. At initial presentation, 60% (95% confidence interval [CI] 45% to 70%) of needle aspirations yielded little or no purulence, despite sonographic visualization of an abscess cavity and sonographic guidance during the procedure. The overall success of ultrasonographically guided needle aspiration was 26% (95% CI 18% to 44%) compared with 80% (95% CI 66% to 89%) success in patients randomized to incision and drainage. The difference between groups was 54% (95% CI 35% to 69%). Overall success of both incision and drainage and ultrasonographically guided needle aspiration was lower in patients with CA-MRSA. Patients with CA-MRSA (n=33) were less likely to receive successful drainage with needle aspiration (8% versus 55%) or incision and drainage (61% versus 89%). The difference for needle aspiration and incision and drainage was 47% (95% CI 15% to 57%) and 28% (95% CI 4% to 45%), respectively. CONCLUSION: Ultrasonographically guided needle aspiration is insufficient therapy for skin abscesses. The presence of CA-MRSA decreases the success of both incision and drainage and ultrasonographically guided needle aspiration.

Isolated, spontaneous superior mesenteric and celiac artery dissection: case report and review of literature.

Spontaneous, isolated dissection of the superior mesenteric artery (SMA) and celiac artery (CA) is rare. Although there are known risk factors, there is no particular mechanism that is common to vascular dissections. The objectives of this study were to review the current literature on diagnosis and treatment of isolated SMA and CA dissection, and to review aortic complications in giant cell arteritis, Takayasu arteritis, and polyarteritis nodosa. Giant cell arteritis, Takayasu arteritis, and polyarterteritis nodosa are vasculitides that are associated with SMA and CA dissection. An interesting aspect of this case is that the patient was a healthy person before presentation, and ultimately, did not have an underlying etiology to explain the dissection. In addition, the patient was successfully managed without operative intervention. Although there are known risk factors in patients who present with isolated, spontaneous SMA and CA dissection, the pathogenesis is still unclear. The prognosis has improved significantly with the early use of computed tomography angiography to diagnosis this entity. Although most cases require surgical intervention, there are some, as in this case, that are managed non-operatively.

Accuracy of Landmark-guided Glenohumeral Joint Injections as Assessed by Ultrasound in Anterior Shoulder Dislocations.

INTRODUCTION: To determine the accuracy of landmark-guided shoulder joint injections (LGI) with point-of-care ultrasound for patients with anterior shoulder dislocations. METHODS: Patients with anterior shoulder dislocations who underwent LGI were enrolled at our tertiary-care and trauma center. LGI attempts were recorded by an ultrasound fellowship-trained ED physician who determined if they were placed successfully. Pain and satisfaction scores were recorded. RESULTS: A total of 34 patients with anterior shoulder dislocation and their treating ED physicians were enrolled. 41.1% of all LGI were determined to be misplaced (n=14). Patients with successful LGI had a greater decrease in mean pain scores post-LGI. CONCLUSIONS: LGI had a substantial failure rate in our study. Using ultrasound-guidance to assist intra-articular injections may increase its accuracy and thus reduce pain and the need for subsequent procedural sedation.

Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department.

Importance: Ocular symptoms represent approximately 2% to 3% of all emergency department (ED) visits. These disease processes may progress to permanent vision loss if not diagnosed and treated quickly. Use of ocular point-of-care ultrasonography (POCUS) may be effective for early and accurate detection of ocular disease. Objective: To perform a large-scale, multicenter study to determine the utility of POCUS for diagnosing retinal detachment, vitreous hemorrhage, and vitreous detachment in the ED. Design, Setting, and Participants: A prospective diagnostic study was conducted at 2 academic EDs and 2 county hospital EDs from February 3, 2016, to April 30, 2018. Patients who were eligible for inclusion were older than 18 years; were English- or Spanish-speaking; presented to the ED with ocular symptoms with concern for retinal detachment, vitreous hemorrhage, or vitreous detachment; and underwent an ophthalmologic consultation that included POCUS. Patients with ocular trauma or suspicion for globe rupture were excluded. The accuracy of the ultrasonographic diagnosis was compared with the criterion standard of the final diagnosis of an ophthalmologist who was masked to the POCUS findings. Seventy-five unique emergency medicine attending physicians, resident physicians, and physician assistants performed ocular ultrasonography. Exposure: Point-of-care ultrasonography performed by an emergency medicine attending physician, resident physician, or physician assistant. Main Outcomes and Measures: Sensitivity and specificity of POCUS in identifying retinal detachment, vitreous hemorrhage, and vitreous detachment in patients presenting to the ED with ocular symptoms. Results: Two hundred twenty-five patients were enrolled. Of these, the mean age was 51 years (range, 18-91 years) and 135 (60.0%) were men; ophthalmologists diagnosed 47 (20.8%) with retinal detachment, 54 (24.0%) with vitreous hemorrhage, and 34 (15.1%) with vitreous detachment. Point-of-care ultrasonography had an overall sensitivity of 96.9% (95% CI, 80.6%-99.6%) and specificity of 88.1% (95% CI, 81.8%-92.4%) for diagnosis of retinal detachment. For diagnosis of vitreous hemorrhage, the sensitivity of POCUS was 81.9% (95% CI, 63.0%-92.4%) and specificity was 82.3% (95% CI, 75.4%-87.5%). For vitreous detachment, the sensitivity was 42.5% (95% CI, 24.7%-62.4%) and specificity was 96.0% (95% CI, 91.2%-98.2%). Conclusions and Relevance: These findings suggest that emergency medicine practitioners can use POCUS to accurately identify retinal detachment, vitreous hemorrhage, and vitreous detachment. Point-of-care ultrasonography is not intended to replace the role of the ophthalmologist for definitive diagnosis of these conditions, but it may serve as an adjunct to help emergency medicine practitioners improve care for patients with ocular symptoms.

FascIOtomy: Ultrasound Evaluation of an Intraosseous Needle Causing Compartment Syndrome.

Intraosseous (IO) needles are used in critically ill patients when it is not possible to quickly obtain venous access. While they allow for immediate access, IO infusions are associated with complications including fractures, infections, and compartment syndrome. We present a case where point-of-care ultrasound was used to quickly identify a malfunctioning IO needle that resulted in compartment syndrome of the lower extremity.

The combined utility of extended focused assessment with sonography for trauma and chest x-ray in blunt thoracic trauma.

BACKGROUND: Portable chest x-ray (CXR) and extended focused assessment with sonography for trauma (EFAST) screen patients for thoracic injury in the trauma bay. It is unclear if one test alone is sufficient, if both are required, or if the two investigations are complementary. Study objectives were to define the combined diagnostic yield of EFAST and CXR among stable blunt thoracic trauma patients and to determine if a normal EFAST and CXR might obviate the need for computed tomography (CT) scan of the chest. METHODS: All blunt trauma patients 15 years or older presenting to LAC+USC Medical Center in 2016 were screened. Only patients who underwent CT thorax were included. Patients were excluded if they presented more than 24 hours after injury, were transferred, or if they did not undergo EFAST and CXR. Demographics, physical examination (PEx) of the thorax, injury data, investigations, procedures, and outcomes were collected. The EFAST, CXR, and PEx findings were compared to the gold standard CT thorax to calculate the diagnostic yield of each investigation and combinations thereof in the assessment for clinically significant thoracic injury. RESULTS: One thousand three hundred eleven patients met inclusion/exclusion criteria. Most common mechanisms of injury were motor vehicle collision (n = 385, 29%) and auto versus pedestrian trauma (n = 379, 29%). Mean Injury Severity Score was 11 (1-75), with mean Abbreviated Injury Scale chest score of 1.6 (1-6). The sensitivities of EFAST, CXR, and PEx, either individually or in combination, were less than 0.73 in the detection of clinically significant thoracic injury. The most common missed clinically significant injuries were sternal fractures, scapular fractures, clavicular fractures, and pneumothoraces. Motorcycle collisions and auto versus pedestrian traumas resulted in the highest rates of missed injury. CONCLUSION: Even in conjunction with the physical examination, the sensitivity of EFAST+CXR in the detection of clinically significant thoracic injury is low. Therefore, if clinical suspicion for injury exists after blunt thoracic trauma, a normal EFAST+CXR is insufficient to exclude injury and CT scan of the chest should be performed. LEVEL OF EVIDENCE: Diagnostic tests/criteria, level III.

Systemwide Clinical Ultrasound Program Development: An Expert Consensus Model.

Clinical ultrasound (CUS) is integral to the practice of an increasing number of medical specialties. Guidelines are needed to ensure effective CUS utilization across health systems. Such guidelines should address all aspects of CUS within a hospital or health system. These include leadership, training, competency, credentialing, quality assurance and improvement, documentation, archiving, workflow, equipment, and infrastructure issues relating to communication and information technology. To meet this need, a group of CUS subject matter experts, who have been involved in institution- and/or systemwide clinical ultrasound (SWCUS) program development convened. The purpose of this paper was to create a model for SWCUS development and implementation.

Erratum: This Article Corrects: "Systemwide Clinical Ultrasound Program Development: An Expert Consensus Model".

[This corrects the article on p. 649 in vol. 19, PMID: 30013699.].

A Woman with Unilateral Rash and Fever: Cellulitis in the Setting of Lymphedema.

Cellulitis in the setting of lymphedema is an uncommon but clinically important presentation to the emergency department. Stagnant lymph is an ideal medium for bacterial growth and progression can be rapid due to decreased ability to fight infection in the affected area. Infections are commonly caused by gram-positive cocci, though blood cultures are often negative. Treatment should be aimed at rapid initiation of antibiotics targeting these species. There may be a role for antibiotic prophylaxis in recurrent cases.

Web-based teaching in point-of-care ultrasound: an alternative to the classroom?

OBJECTIVES: To evaluate two educational methods for point-of-care ultrasound (POC US) in order to: 1) determine participant test performance and attitudes in using POC US and 2) compare cost and preparation time to run the courses. METHODS: This was a pilot study conducted at a county teaching hospital. Subjects were assigned to participate in either a large group course with live classroom lectures (Group A) or a group asked to watch 4.5 hours of online prerecorded lectures (Group B). Both groups participated in small-group hands-on training after watching the lectures. Both groups took a pre- and post-course exam, and completed course surveys. Cost and time spent running the courses were also compared. RESULTS: Forty-seven physicians participated in the study. The pre-test and post-test scores between the two groups did not differ significantly. Of those with prior ultrasound experience, the majority of both groups preferred to continue classroom-based teaching for future courses. Interestingly, in the groups who had no ultrasound experience prior to their course participation, there was a higher percentage who preferred web-based teaching. Lastly, Group B was shown to have the potential to take less preparatory time when compared to Group A. CONCLUSION: A web-based curriculum in POC US appears to be a promising and potentially time saving alternative to live classroom lectures and seems to offer similar educational benefits for the postgraduate learner.