Quality and Feasibility of Automated Digital Retinal Imaging in the Emergency Department.

BACKGROUND: Emergency physicians (EPs) frequently evaluate patients at risk for sight-threatening conditions but may have difficulty performing direct ophthalmoscopy effectively. Digital fundus photography offers a potential alternative. OBJECTIVE: We sought to assess the performance of an automated digital retinal imaging platform in a real-world emergency department. METHODS: We performed a prospective, observational study of emergency department patients who were at risk for acute, nontraumatic, posterior segment pathology. Photographs were obtained using an automated digital retinal camera and were subsequently reviewed by an ophthalmologist. We recorded the number of attempts required, total time required, patient comfort, and findings on EP-performed direct ophthalmoscopy, if performed. RESULTS: Of 123 participants completing the study, 93 (75.6%) had ≥1 eye with a diagnostically useful image, while 29 (23.6%) had no photographs of diagnostic value. The mean number of attempts required to obtain images was 1.45 (range 1-3) and the mean elapsed time required to complete photography was 109.6 s. The mean patient comfort score was 4.6 on a 5-point scale, where 5 was the most comfortable. Direct ophthalmoscopy was performed by an emergency department provider for 19 (15.4%) patients. Acute findings were noted in 14 patients during expert review of fundus photographs, though in only 2 of these cases was direct ophthalmoscopy performed by an EP with only 1 finding ultimately identified correctly. CONCLUSIONS: Automated digital imaging of the ocular fundus is rapidly performed, is well tolerated by patients, and can be used to obtain diagnostic quality images without the use of pharmacologic pupillary dilation in most emergency department patients who are at risk for acute posterior segment pathology.

Point-of-care ultrasound for the evaluation of non-traumatic visual disturbances in the emergency department: The VIGMO protocol.

OBJECTIVES: To establish a standardized approach for the rapid and accurate identification of non-traumatic, ophthalmologic pathology in patients with eye complaints in the emergency department. METHODS: In this detailed protocol we offer an easy, reproducible method for the use of ocular point-of-care ultrasound (POCUS) in helping practitioners identify and distinguish between common eye pathology encountered in the emergency setting: retinal detachment, vitreous detachment, vitreous hemorrhage, optic nerve pathology, and syneresis. CONCLUSIONS: This protocol can help identify patients that may need urgent ophthalmology consultation those that can follow-up on an outpatient, and those that may need additional emergent testing.

Right Lower Quadrant Abdominal Pain: Do Not Forget About Ovarian Torsion on the Computed Tomography Scan.

BACKGROUND: Abdominal pain is one of the most common chief complaints of patients presenting to emergency departments, and emergency physicians (EPs) often evaluate patients with right lower quadrant abdominal pain. Ovarian torsion is a rare cause of abdominal pain, but early diagnosis is essential for salvage of the affected ovary. The diagnostic study of choice for ovarian torsion is a pelvic ultrasound with color Doppler, but it is important for EPs and radiologists to be aware of findings of ovarian torsion that might appear on computed tomography (CT). CASE REPORT: We present a case of a young female with right lower quadrant abdominal pain with CT evidence of ovarian torsion that was not recognized; the patient was discharged and then called back when the study was over-read as concerning for ovarian torsion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The presence of radiographic findings associated with ovarian torsion on a CT scan should encourage an EP to order a pelvic ultrasound with color Doppler (if available) and obtain an obstetrics/gynecology consult.

Point-of-Care Diagnosis of Cardiac Tamponade Identified by the Flow Velocity Paradoxus.

The presentation of cardiac tamponade is a spectrum from occult to extreme. The clinical history, physical exam, electrocardiogram, and radiographic findings of tamponade have poor sensitivities and even worse specificities. We use a clinical scenario to demonstrate how point-of-care cardiac ultrasound can diagnose impending cardiac tamponade in a clinically stable patient. The ultrasound finding we recommend is the flow velocity paradoxus, in which respiratory variation causes significant changes in transvalvular inflow velocities, which are exaggerated when tamponade is present. The management of a pericardial effusion depends on its physiologic effect, and point-of-care ultrasound directly measures that effect and expedites patient care.

A randomised experiment comparing low-cost ultrasound gel alternative with commercial gel.

OBJECTIVE: Point-of-care ultrasound is a portable, relatively low-cost imaging modality with great potential utility in low-resource settings. However, commercially produced ultrasound gel is often cost-prohibitive and unavailable. We investigated whether images obtained using an alternative cornstarch-based gel would be of comparable quality with those using commercial gel. METHODS: This was a blinded, randomised, cross-over study comparing commercially produced ultrasound gel with home-made cornstarch-based gel. Ultrasound-trained faculty obtained three video clips with each gel type from patients at one urban ED. The clips were evaluated by a radiologist and an ultrasound-trained emergency physician. Images were assessed in terms of overall adequacy (dichotomous) and quality, resolution and detail using a rating scale (0-10). All sonographers and physicians reviewing the images were blinded to the type of gel used. RESULTS: Thirty-four patients were enrolled in the study, producing 204 separate images (102 with each gel). The cornstarch gel clips were deemed accurate in 70.6% (95% CI 63.9% to 76.5%) of the scans, as compared with 65.2% (95% CI 58.4% to 71.4%) of those using commercial gel. There was no difference between the two groups with respect to image detail, resolution or quality. CONCLUSIONS: Images produced using the cornstarch-based alternative ultrasound gel were of similar quality to those using commercial gel. The low cost and easy preparation of the cornstarch-based gel make it an attractive coupling medium for use in low-resource settings.

Sonographic Findings in Necrotizing Fasciitis: Two Ends of the Spectrum.

Necrotizing fasciitis is a rare but serious disease, and early diagnosis is essential to reducing its substantial morbidity and mortality. The 2 cases presented show that the key clinical and radiographic features of necrotizing fasciitis exist along a continuum of severity at initial presentation; thus, this diagnosis should not be prematurely ruled out in cases that do not show the dramatic features familiar to most clinicians. Although computed tomography and magnetic resonance imaging are considered the most effective imaging modalities, the cases described here illustrate how sonography should be recommended as an initial imaging test to make a rapid diagnosis and initiate therapy.

The ultrasound-guided "peripheral IJ": internal jugular vein catheterization using a standard intravenous catheter.

BACKGROUND: Obtaining vascular access is difficult in certain patients. When routine peripheral venous catheterization is not possible, several alternatives may be considered, each with its own strengths and limitations. DISCUSSION: We describe a novel technique for establishing vascular access in Emergency Department (ED) patients: the placement of a standard catheter-over-needle device into the internal jugular vein using real-time ultrasound guidance. We present a series of patients for whom this procedure was performed after other attempts at vascular access were unsuccessful. In all cases, the procedure was performed quickly and without complications. CONCLUSION: Although further study of this technique is required, we believe this procedure may be a valuable option for ED patients requiring rapid vascular access.

Ultrasound assessment of optic disc edema in patients with headache.

Point-of-care ocular ultrasonography is emerging as a powerful tool to evaluate emergency department (ED) patients at risk for ophthalmologic and intracranial pathology.We present cases of 3 patients in whom optic disc swelling was identified using ocular ultrasound. Causes for optic disc swelling in our patients included idiopathic intracranial hypertension, secondary syphilis, and malignant hypertension with associated hypertensive retinopathy. Because direct visualization of the optic disc may be challenging in an ED setting, ultrasound examination of the optic disc may represent an important adjunct to fundoscopy when assessing patients with headache or visual complaints.

Calculated decisions: local anesthetic dosing calculator.

A review of the uses and evidence for the Local Anesthetic Dosing Calculator, which is used to help avoid toxic doses local anesthetics.

Ultrasound assessment of extraocular movements and pupillary light reflex in ocular trauma.

We present the case of a 26-year-old man with significant periorbital trauma after blunt head trauma. Ultrasound techniques for evaluation of extraocular movements and pupillary light reflex are described as a proposed adjunct to physical examination and manual retraction of the eyelids.

Accuracy of emergency physicians using ultrasound to determine gestational age in pregnant women.

INTRODUCTION: Rapid and accurate determination of gestational age may be vital to the appropriate care of the critically ill pregnant patient. Before the use of emergency ultrasound, physical examination of fundal height (FH) in the nonverbal patient was considered the quickest method to estimate gestational age. We conducted a prospective, observational study of the performance of bedside sonography to determine gestational age. METHODS: We enrolled a convenience sample of women in their second or third trimester of pregnancy. Emergency physicians (EPs) made ultrasound measurements of fetal biparietal diameter (BPD) and femur length, followed by a measurement of FH. These measurements were compared with true gestational age (TGA), sonography by an ultrasound technician, and measurement of FH performed by an obstetrician. Main outcome measures were the average time needed to complete measurements; correlation coefficients between EP measurements and those made by an ultrasound technician, an obstetrician, and TGA, and overall accuracy to determine fetal age greater than 24 weeks. RESULTS: The average time to complete ultrasound measurements was less than 1 minute. When physician-performed measurements were compared with TGA, the correlation coefficients were 0.947 (0.926-0.968) for BPD, 0.957 (0.941-0.973) for femur length, and 0.712 (0.615-0.809) for FH. When determining fetal viability, EP's overall accuracy was 96% using ultrasound and 80% using FH. CONCLUSIONS: With brief training, EPs can quickly and accurately determine gestational age using ultrasound, and these estimates may be more accurate than those obtained through physical examination. Emergency physicians should consider using ultrasound in emergent evaluation of pregnant patients who are unable to provide history.

Is the ordering of imaging for suspected venous thromboembolism consistent with D-dimer result?

STUDY OBJECTIVE: We assessed whether the ordering of imaging studies in patients with suspected venous thromboembolism was consistent with the results of D-dimer testing. METHODS: We performed a retrospective chart review of consecutive cases in which a D-dimer assay was performed at an urban academic emergency department during a 13-month period. Measurements included D-dimer result and results of imaging for venous thromboembolism. The primary outcome measure was the percentage of patients in each D-dimer category (positive or negative result with a cutoff value of 500 ng fibrinogen equivalent units/dL) who underwent subsequent imaging within 48 hours. We also report the results of the imaging studies obtained. RESULTS: A total of 553 D-dimer tests were ordered, with 266 (48.1%) negative and 287 (51.9%) positive results. Of patients with a negative D-dimer result, 37 (14%; 95% confidence interval [CI] 10% to 19%) underwent at least 1 imaging study. Of patients with a positive D-dimer result, 137 (48%; 95% CI 42% to 54%) did not undergo imaging. CONCLUSION: Evaluation for venous thromboembolism occasionally proceeded despite a negative D-dimer result, whereas frequently no further evaluation occurred despite a positive result. These findings suggest that actual clinical practice differs from what is recommended by published algorithms that guide evaluation of patients with suspected venous thromboembolism.

Ultrasonographic confirmation of intraosseous needle placement in an adult unembalmed cadaver model.

STUDY OBJECTIVE: Intraosseous access is widely used in pediatric and adult resuscitations when vascular access cannot be promptly established. Confirmation of intraosseous needle placement has traditionally relied on the ability to aspirate blood or marrow or infuse crystalloid easily. This study's aim is to determine the value of bedside ultrasonography as a means of confirming intraosseous needle placement by visualizing the flow of crystalloid within the intraosseous space. METHODS: A controlled trial was conducted in which intraosseous access was obtained in the bilateral distal tibia of 4 freshly frozen, unembalmed cadavers. In 8 legs, an intraosseous needle (15-gauge Jamshidi) was inserted 1 fingerbreadth superior to the medial malleolus and flushed with 10 mL of crystalloid. Measurements included whether crystalloid was observed to flow by gravity into the drip reservoir of the intravenous tubing and whether color flow was visualized within the intraosseous space of the tibia with a 5- to 10-MHz linear transducer in color power Doppler mode, positioned just cephalad to the intraosseous needle. Intraosseous needles were then intentionally placed into the subcutaneous space just posterior to the distal tibia, and these measurements were repeated. Two blinded observers reviewed ultrasonographic video recordings and rated the presence or absence of color flow within the intraosseous space. RESULTS: Intraosseous color flow on ultrasonography correctly identified all placements, but flow into the drip reservoir was incorrect for one of the intraosseous lines (P=1.0 versus ultrasonography) and 6 of the subcutaneous lines (P=0.31 versus ultrasonography). There was perfect interobserver agreement (kappa=1) during video review. CONCLUSION: In freshly frozen cadavers, ultrasonographic visualization of flow within the intraosseous space may be a reliable method of confirming intraosseous placement. The observation of flow into the drip reservoir appears to be an unreliable indicator of intraosseous placement in fresh frozen cadavers.

Gastrointestinal manifestations of hereditary angioedema diagnosed by ultrasound in the emergency department.

Abdominal angioedema is a less recognized type of angioedema, which can occur in patients with hereditary angioedema (HAE). The clinical signs may range from subtle, diffuse abdominal pain and nausea, to overt peritonitis. We describe two cases of abdominal angioedema in patients with known HAE that were diagnosed in the emergency department by point-of-care (POC) ultrasound. In each case, the patient presented with isolated abdominal complaints and no signs of oropharyngeal edema. Findings on POC ultrasound included intraperitoneal free fluid and bowel wall edema. Both patients recovered uneventfully after receiving treatment. Because it can be performed rapidly, requires no ionizing radiation, and can rule out alternative diagnoses, POC ultrasound holds promise as a valuable tool in the evaluation and management of patients with HAE.

Point-of-care ocular ultrasound to detect optic disc swelling.

OBJECTIVES: Emergency physicians (EPs) frequently evaluate patients at risk for diseases that cause optic disc swelling, and they may encounter conditions that make traditional fundoscopy difficult or impossible. The objective was to assess whether EP-performed point-of-care (POC) ultrasound (US) could accurately assess swelling of the optic disc. METHODS: This was a blinded, prospective study using a convenience sample of patients presenting to a neuroophthalmology clinic who were thought to be at risk for conditions associated with optic disc edema. Two EPs performed POC US examinations. Patients then underwent standard clinical assessment by a specialist. RESULTS: Fourteen patients were assessed with disc swelling noted on dilated fundoscopic exam in 11 of 28 (39%) eyes. A maximum disc height greater than 0.6 mm as measured by US predicted the presence of optic disc edema noted on fundoscopic exam, with a sensitivity of 82% (95% confidence interval [CI] = 48% to 98%) and a specificity of 76% (95% CI = 50% to 93%). A threshold value of 1.0 mm for disc height yielded a sensitivity of 73% (95% CI = 39% to 94%) and a specificity of 100% (95% CI = 81% to 100%). Measurements of disc height as determined by optical coherence tomography (OCT) exhibited good correlation when compared to US measurements (r = 0.836, p < 0.0001, 95% CI = 0.65 to 0.93). CONCLUSIONS: These data suggest that EP-performed POC US can detect clinically apparent optic disc swelling. Because sonography can be performed readily at the bedside, even in cases where fundoscopy is difficult or impossible, this technique may prove to be a valuable tool for the assessment of optic disc swelling in the emergency department (ED).