Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension.

BACKGROUND: Non-traumatic undifferentiated hypotension is a common critical presentation in the emergency department. In this group of patients, early diagnosis and goal-directed therapy is essential for an optimal outcome. The usefulness of focused bedside ultrasound is reviewed and a protocol for Abdominal and Cardiac Evaluation with Sonography in Shock (ACES) is proposed. METHODS: The protocol consists of six windows including cardiac, peritoneal, pleural, inferior vena cava and aortic views, and aims to shorten the time period taken to establish a diagnosis and hence to deliver the most appropriate goal-directed therapy. Its use in seven case examples is described. RESULTS: In all cases the ACES protocol helped in guiding the initial management while further information was obtained. CONCLUSION: The six-view ACES protocol is a useful adjunct to clinical examination in patients with undifferentiated hypotension in the emergency department. A prospective randomised trial or multicentre database/registry is needed to investigate the validity and impact of this protocol on the early diagnosis and management of hypotensive patients.

Emergency ultrasound of the abdominal aorta by UK emergency physicians: a prospective cohort study.

OBJECTIVE: To establish whether UK emergency physicians could reliably perform focused ultrasound of the abdominal aorta in patients with suspected abdominal aortic aneurysm (AAA). METHODS: A prospective cohort study was conducted in the emergency department of a tertiary level UK teaching hospital. All patients who underwent an abdominal aortic ultrasound by an emergency physician during a 12 month period from January to December 2005 were included. The principle outcomes were presence of an AAA (external wall diameter >3 cm) or death from ruptured AAA. Outcome data were obtained from paper and electronic patient records and primary care telephone follow up. RESULTS: 120 focused ultrasound scans looking for AAA were performed by 19 different UK emergency physicians of various grades. Of the 120 scans, 26 (22%) were positive for an AAA, of which 17 cases represented a new diagnosis. Ruptured aneurysms represented 46% (12/26) of all positive scans, of which four patients underwent emergency repair. In the remaining 14 patients the AAA was an incidental finding that was not the reason for their presentation to the emergency department. Emergency ultrasound had a sensitivity of 96.3% (95% confidence interval (CI) 81.0% to 99.9%); a specificity of 100% (95% CI 91.8% to 100%); a negative predictive value of 98.6% (95% CI 88.0% to 99.9%); and positive predictive value of 100% (95% CI 86.8% to 100%) for the detection of AAA. CONCLUSION: Emergency ultrasound scanning by UK emergency physicians has high sensitivity and specificity for identifying AAA, consistent with international experience.

Is hot water immersion an effective treatment for marine envenomation?

Envenomation by marine creatures is common. As more people dive and snorkel for leisure, the incidence of envenomation injuries presenting to emergency departments has increased. Although most serious envenomations occur in the temperate or tropical waters of the Indo-Pacific region, North American and European waters also provide a habitat for many stinging creatures. Marine envenomations can be classified as either surface stings or puncture wounds. Antivenom is available for a limited number of specific marine creatures. Various other treatments such as vinegar, fig juice, boiled cactus, heated stones, hot urine, hot water, and ice have been proposed, although many have little scientific basis. The use of heat therapies, previously reserved for penetrating fish spine injuries, has been suggested as treatment for an increasing variety of marine envenomation. This paper reviews the evidence for the effectiveness of hot water immersion (HWI) and other heat therapies in the management of patients presenting with pain due to marine envenomation.

Case of the month: Buffalo chest: a case of bilateral pneumothoraces due to pleuropleural communication.

Simultaneous spontaneous bilateral pneumothoraces, the presentation of separate right and left pneumothoraces together, is a rare event. The pleural cavities in humans are separated completely and the only previous reports of pleuropleural communication have been associated with major invasive thoracic procedures, specifically mediastinal surgery. The term "buffalo chest" has been coined for the condition on the basis that the buffalo or bison has a single pleural cavity, one of the few mammals to do so. We present the case of a woman with a past history of a single right sided spontaneous pneumothorax but no major thoracic surgery, who presented to the emergency department with a second spontaneous right pneumothorax that was under tension. After thoracostomy, she was found to have bilateral pneumothoraces which resolved with a unilateral chest drain demonstrating pleuropleural communication. We believe this to be the first reported case of such a presentation in the literature. The case demonstrates an unusual emergency presentation of a rare anatomical anomaly.