Emergency Physician-Performed Bedside Ultrasound in the Evaluation of Acute Appendicitis in a Pediatric Population.

Background/Objective Many pediatric emergency departments in the United States have adopted a staged ultrasound and CT pathway for the diagnosis of acute appendicitis. However, most algorithms only include radiology-performed ultrasound (RUS) and not emergency physician- performed bedside ultrasound (BUS). Our objective was to determine if emergency physician-performed BUS provides sufficient diagnostic accuracy for acute appendicitis in a pediatric population, thereby limiting additional cost and/or delays in disposition. Methods This is a single-center prospective study of pediatric patients with concern for and requiring further work-up for acute appendicitis. Each patient had a focused bedside ultrasound (BUS) performed by an emergency physician with training in BUS. Diagnostic accuracy was compared with surgical pathology standard, as well as radiology- performed ultrasound (RUS), computed tomography (CT), and clinical follow-up. Results Among46 enrolledpatients, 12were diagnosed with acute appendicitis (26%). There were no negative laparotomies in those who had surgery. There was one case of missed appendicitis at 4-week follow-up. BUS had a sensitivity of 100% (95% Cl: 72% to 100%) and. a specificity of 81% (61% to 93%) when the app6ndix'was visualized (37). This resulted in positive likelihood ratio of5.2 and a negative likelihood ratio ofo. In the cases where the appendix was not visualized on BUS (9), 1 patient was diagnosed with appendicitis, and the other 8 patients were negative for appendicitis. In RUS both the sensitivity and specificity was 100% when the appendix was visualized. The sensitivity and specificity of CT in our studywas 90% and 100% respectively. Conclusions Emergency physicians can perform bedside ultrasound with high accuracy for acute appendicitis in a pediatric population. When the appendix is not visualized by ultrasound, a staged ultrasound and CT pathway should be considered.

Validation of the Sonographic Ottawa Foot and Ankle Rules (SOFAR) Study in a Large Urban Trauma Center.

INTRODUCTION: Differentiating the severity of acute ankle injuries is a common problem in the emergency department (ED). The Ottawa Foot and Ankle Rules (OFAR) were designed to obviate the need for unnecessary x-rays. Although these rules have been determined to be very sensitive, they lack the specificity necessary to make them practically useful for a condition in which a misdiagnosis could result in a significant disability. Our study objective was to determine if the addition of a bedside ultrasound (US) to the evaluation process could be used to significantly reduce the number of negative x-rays in OFAR positive patients. METHODS: A prospective observational studywas conducted in a Level I urban trauma center over a 12 month period in which bedside US was utilized to detect foot and/or ankle fractures in OFAR positive patients of age 18 years and older. All patients in the study received foot and/or ankle x-rays based on OFAR exam. Prior to viewing the x-rays, trained clinicians performed bedside US targeting the medial and lateral malleoli, navicular, and base of the 5th metatarsal and provided a diagnostic impression based on their US findings. The US findings were then compared to the formal x-ray interpretation. RESULTS: A total of fifty patients was enrolled into the study of which twenty-one patients were discovered to have a fracture by US. The sensitivity ofUS in detecting foot and/or ankle fractures was 100% (95% Confidence Interval [CI] 78%-100%) and the specificity of OFAR increased from 50% (95% CI 37%-63%) to 100% (95% CI 87%-100%) with the addition of US. The negative predictive value was 100% (95% CI 89%-100%), and the positive predictive value was 100% (95% CI 81%-100%). CONCLUSIONS: Among OFAR positive patients, bedside US has high sensitivity and specificity for detecting foot and/or ankle fractures. Further studies should be conducted to determine if utilizing bedside US in addition to OFAR could significantly reduce the number of x-rays and improve the efficiency and costs associated with evaluating these injuries in the ED. Implication for health policy/medical education/research/ practice. Utilizing bedside ultrasonography in addition to Ottawa Foot and Ankle Rules in acutely injured patients could significantly reduce the number of ordered x-rays and length of stay in the emergency department.

Bedside Renal Ultrasound for the primary care physician.

Basic concepts of bedside ultrasound have been discussed in two previous articles. The focus of this article is the evaluation of the renal system with bedside ultrasound.

Bedside gallbladder ultrasound for the primary care physician.

Modern ultrasound machines are relatively inexpensive to own and simple to operate. Basic ultrasound exams can be easily learned and mastered. As with any clinical exam skill, practice makes perfect. Providers interested in learning ultrasound should seek hands-on guidance from an expert in the field. There are several quality hands-on ultrasound courses (http:// emergencyultrasound.com/) as well as free online videos (http:// emergency ultrasound teaching.com/index.html). The emergency ultrasound team at UMMC will be offering a hands-on ultrasound training course in the spring of 2015. Please contact Dr Brian Tollefson for specific dates and times of the course (btollefson@umc.edu).

Bedside ultrasound detection of long bone fractures.

INTRODUCTION: Rapid identification of fractures of long bones is prudent, since associated bleeding and neurovascular compromise can cause significant morbidity and mortality. We describe two patients who presented to the Emergency Department with orthopedic trauma and underwent bedside ultrasound of the affected extremity. Ultrasound rapidly revealed fractures in both patients, and led to early treatment and disposition. MATERIALS AND METHODS: Rapid bedside ultrasound of long bones was performed on affected extremities and compared to X-rays. CONCLUSION: Bedside ultrasonography of long bones is a rapid, reliable, and non-invasive method of evaluating patients with suspected orthopedic trauma.

Testicle ischemia resulting from an inguinal hernia.

BACKGROUND: Scrotal pain in the emergency department (ED) should be evaluated rapidly for sources that may cause irreversible testicular ischemia. OBJECTIVES: This case report discusses a patient presenting with a large inguinal hernia causing testicle ischemia. CASE REPORT: A 48-year-old man with a 1-year history of a large right-sided indirect inguinal hernia was transferred to the ED from the ultrasound laboratory after the patient experienced acute onset of severe right-sided testicular pain. The radiologist urgently called the attending emergency physician to notify him of ultrasound findings that showed compromised vascular flow to the right testicle. Urology and General Surgery were consulted immediately. The patient was placed in a supine position and reduction of the large hernia was attempted. After approximately 15 min of manual pressure, the herniated bowel was reduced back into the abdominal cavity and the patient experienced immediate relief of his symptoms. CONCLUSIONS: Scrotal ultrasound was repeated, and vascular flow to his right testicle was found to be re-established. This case highlights a rare presentation of acute onset of testicular ischemia caused by vascular compression from a large indirect inguinal hernia in an adult male.

A comparative study of American football helmet removal techniques using a cadaveric model of cervical spine injury.

BACKGROUND: American football is the source of a significant number of cervical spine injuries. Removal of the helmets from these individuals is often problematic and presents a potential for exacerbation of the injury. There are two widely recognized helmet removal techniques that are currently in practice. In this study, the two methods are compared for cervical movement and potential for cord injury to determine their relative efficiency and clinical utility. METHODS: A single cadaver with a simulated cervical injury was used to compare the National Athletic Trainers' Association (NATA) and cast saw techniques of helmet removal. Directed lateral fluoroscopy was used to measure the relative changes in angulation, translation, distraction, and space available to the spinal cord during helmet removal using the two techniques as performed by medical personnel with limited training in the methods. RESULTS: By radiologists' reports, there were no detectable changes in disc height, translation or space available for the spinal cord during helmet removal with either of the studied techniques. Operators noted that the noise of the cast saw would probably be significantly uncomfortable for any live subject inside of a helmet. CONCLUSION: Both the NATA and cast saw methods appear effective for the safe removal of a football helmet and with little risk of further injury to the cervical spine. Considering the simplicity and efficiency of the NATA helmet removal technique, the authors conclude that the NATA technique should be the preferred helmet removal method.

Relief of acute pain in chronic idiopathic gastroparesis with intravenous phentolamine.

OBJECTIVE: To report a case in which complete relief of pain associated with gastroparesis, with promotion of gastric emptying, was achieved with administration of phentolamine. CASE SUMMARY: A 37-year-old opiate-tolerant female with a history of recurrent abdominal pain, gastroparesis, cyclic vomiting syndrome, and migraine headaches was admitted to the emergency department (ED) with severe acute abdominal pain, nausea, and vomiting. The patient had been previously implanted with a permanent gastric electrical stimulator and she was adherent to her prokinetic, antiemetic, analgesic, and migraine prophylactic medications. Pain relief was achieved rapidly and completely in the ED with sympatholysis by administration of intravenous phentolamine 0.5 mg/kg over 60 minutes, with continuous cardiac monitoring. At a 2 month follow-up visit, the patient reported chronic pain relief, and a decrease in opiate doses was maintained by oral administration of clonidine 0.1 mg twice daily. DISCUSSION: Gastroparesis represents a difficult treatment challenge because management of gastric dysmotility and the accompanying severe abdominal pain is often mutually exacerbating and ineffective. Sympatholysis by intravenous phentolamine provided profound and immediate relief of acute gastroparesis-related abdominal pain in our patient. The mechanism of phentolamine is believed to be receptor blockade at alpha-adrenergic receptors and, therefore, inhibition of the peripheral sensitizing effects of circulating norepinephrine. Although action at a peripheral nerve level is presumed, modulation of alpha-adrenoreceptors receptors is also possible at the dorsal root ganglion or at other central nervous system sites. CONCLUSIONS: The dramatic relief of acute pain in gastroparesis by phentolamine observed in this case would warrant investigation of a larger, controlled case series. Patients who respond to intravenous sympatholysis may likewise be candidates for longer term sympathetic modulation with oral sympatholytics.