Right Ventricular "Bubble Time" to Identify Patients With Right Ventricular Dysfunction.

STUDY OBJECTIVE: We propose a novel method of evaluating right ventricular (RV) dysfunction in the emergency department (ED) using RV "bubble time"-the duration of time bubbles from a saline solution flush are visualized in the RV on echocardiography. The objective was to identify the optimal cutoff value for RV bubble time that differentiates patients with RV dysfunction and report on its diagnostic test characteristics. METHODS: This prospective diagnostic accuracy study enrolled a convenience sample of hemodynamically stable patients in the ED. A sonographer administered a 10-mL saline solution flush into the patient's intravenous catheter, performed a bedside echocardiogram, and measured RV bubble time. Subsequently, the patient underwent a comprehensive cardiologist-interpreted echocardiogram within 36 hours, which served as the gold standard. Patients with RV strain or enlargement of the latter found on an echocardiogram were considered to have RV dysfunction. Bubble time was evaluated by a second provider, blinded to the initial results, who reviewed the ultrasound clips. The primary outcome measure was the optimal cutoff value of RV bubble time that identifies patients with and without RV dysfunction. RESULTS: Of 196 patients, median age was 67 year, and half were women, with 69 (35.2%) having RV dysfunction. Median RV bubble time among patients with RV dysfunction was 62 seconds (interquartile range [IQR]: 52, 93) compared with 21 seconds (IQR: 12, 32) among patients without (P<.0001). The optimal cutoff value of RV bubble time for identifying patients with RV dysfunction was 40 or more seconds, with a sensitivity of 0.97 (95% CI 0.93 to 1.00) and specificity of 0.87 (95% CI 0.82 to 0.93). CONCLUSION: In patients in the ED, an RV bubble time of 40 or more seconds had high sensitivity in identifying patients with RV dysfunction, whereas an RV bubble time of less than 40 seconds had good specificity in identifying patients without RV dysfunction. These findings warrant further investigation in undifferentiated patient populations and by emergency physicians without advanced ultrasound training.

Hip effusions or iliopsoas hematomas on ultrasound in identifying hip fractures in the emergency department.

OBJECTIVE: We evaluated the sensitivity, specificity, predictive values, and likelihood ratios of hip effusion and/or iliopsoas hematoma on point-of-care ultrasound (POCUS) performed by ultrasound fellows and fellowship trained emergency providers to identify hip fractures in emergency department (ED) patients with a high suspicion of hip fracture. METHODS: This was a prospective observational study of a convenience sample of patients with high suspicion of hip fracture at two academic EDs between 2018 and 2021. Patients with negative x-rays who did not receive further imaging with magnetic resonance imaging (MRI) or computed tomography (CT) were excluded. Sonographers were blinded to clinical data and ED imaging results. At the primary site, 8 ultrasound fellows and 4 emergency ultrasound fellowship-trained emergency providers performed the ultrasonographic examinations. At the secondary site, 2 ultrasound fellows, 4 emergency ultrasound-fellowship trained physicians, and 1 sports medicine fellowship-trained emergency provider performed the ultrasonographic examinations. A positive ultrasound was defined as either the presence of a hip effusion or iliopsoas hematoma on the affected extremity. The primary outcome measures were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) of POCUS findings for identification of a hip fracture compared with a ranked composite reference standard consisting of x-ray, CT, or magnetic resonance imaging (MRI); the highest-level test performed for each patient was used for comparison. RESULTS: Among 213 patients analyzed, all 213 received an x-ray, 116 received a CT scan, and 14 received an MRI; 113/213 x-rays (53.1%), 35/116 CT scans (30.2%), and 7/14 MRIs (50.0%) were positive for a hip fracture. A total of 123 patients were diagnosed with a hip fracture (57.7%). There were 13 false negative x-ray results. Overall, compared with the reference standard of x-ray, CT, or MRI, POCUS had a sensitivity of 97% (95% CI: 94%, 100%), specificity of 70% (95% CI: 61%, 79%), PPV of 82% (95% CI: 75%, 88%), and NPV of 94% (95% CI: 88%, 100%) in the identification of hip fractures; with a positive likelihood ratio of 3.22 (95% CI: 2.35, 4.43) and negative likelihood ratio of 0.05 (95% CI: 0.02, 0.12). CONCLUSION: In a convenience sample of ED patients with high clinical suspicion for hip fracture, the presence of a hip effusion and/or iliopsoas hematoma on POCUS performed by expert emergency ultrasonographers showed high sensitivity in diagnosing patients with a hip fracture.

Pulmonary Congestion on Lung Ultrasound Predicts Increased Risk of 30-Day Readmission in Heart Failure Patients.

OBJECTIVES: Heart failure exacerbations are a common cause of hospitalizations with a high readmission rate. There are few validated predictors of readmission after treatment for acute decompensated heart failure (ADHF). Lung ultrasound (LUS) is sensitive and specific in the assessment of pulmonary congestion; however, it is not frequently utilized to assess for congestion before discharge. This study assessed the association between number of B-lines, on LUS, at patient discharge and risk of 30-day readmission in patients hospitalized for acute decompensated heart failure (ADHF). METHODS: This was a single-center prospective study of adults admitted to a quaternary care center with a diagnosis of ADHF. At the time of discharge, the patient received an 8-zone LUS exam to evaluate for the presence of B-lines. A zone was considered positive if ≥3 B-lines was present. We assessed the risk of 30-day readmission associated with the number of lung zones positive for B-lines using a log-binomial regression model. RESULTS: Based on data from 200 patients, the risk of 30-day readmission in patients with 2-3 positive lung zones was 1.25 times higher (95% CI: 1.08-1.45), and in patients with 4-8 positive lung zones was 1.50 times higher (95% CI: 1.23-1.82, compared with patients with 0-1 positive zones, after adjusting for discharge blood urea nitrogen, creatinine, and hemoglobin. CONCLUSION: Among patients admitted with ADHF, the presence of B-lines at discharge was associated with a significantly increased risk of 30-day readmission, with greater number of lung zones positive for B-lines corresponding to higher risk.

Using Ultrasound to Determine Optimal Location for Needle Decompression of Tension Pneumothorax: A Pilot Study.

BACKGROUND: Chest injury can result in life-threatening complications like tension pneumothorax, in which rapid deterioration can occur without decompression. Traditionally, the second intercostal space (ICS) along the mid-clavicular line is taught as the site for decompression. However, this has been questioned due to high rates of treatment failure. The fifth ICS on the mid-axillary line (MAL) is hypothesized to have a shorter distance from skin to pleura based on recent studies. OBJECTIVE: The purpose of this study was to use point-of-care ultrasound (POCUS) to compare chest wall thickness at these two locations. The primary objective was to evaluate the distance from skin to pleura line at the second ICS along the mid-clavicular line and the fifth ICS along the MAL. Secondarily, we aimed to evaluate inter-rater reliability of the two assessments. METHODS: This was a single-center, observational, pilot study. POCUS was performed using a linear transducer. Measurements of skin to pleura line were obtained at the right second ICS and fifth ICS. These measurements were then repeated by a blinded second ultrasonographer. Intraclass correlations (ICCs) for each measurement site were calculated to determine the inter-rater reliability. RESULTS: Ninety-three percent of volunteers had a smaller chest wall distance at the fifth ICS-MAL. The median distance at the second and fifth ICS was 2.28 cm and 1.80 cm. The ICC for second ICS was 0.75 (95% CI 0.54-0.87), and 0.90 for the fifth ICS (95% CI 0.81-0.95), both indicating good reliability. CONCLUSIONS: The data support that patients have a smaller chest wall distance at the fifth ICS vs. the second ICS. We support performing needle decompression at the fifth ICS and believe POCUS can be used to determine the optimal location for decompression.

Ultrasound Measurement of the Intervertebral Space in the Lateral Recumbent Versus Sitting Positions.

BACKGROUND: Diagnostic lumbar puncture (LP) is an invasive procedure routinely performed within the emergency department (ED). LP is traditionally performed with the patient in either the lateral recumbent or sitting position. We investigated if the intervertebral space is larger in one of these positions. If one position is larger than the other, this would imply that one position offers a higher chance of a successful lumbar puncture than the other position. OBJECTIVE: We sought to determine if there is a significant size difference of the L4/L5 intervertebral space in the lateral recumbent compared with the sitting position. METHODS: Point-of-care ultrasound (POCUS) was performed to measure the size of each volunteer's L4/L5 intervertebral space in both the seated and lateral recumbent positions. All volunteers >18 years of age were eligible for the study. Thirty volunteers had measurements taken. Three measurements were taken by each investigator in both positions for each volunteer. RESULTS: The median L4/L5 intervertebral space distance was 1.7511 cm in the lateral recumbent position and 1.9511 cm in the seated position with a Wilcoxon signed rank p value <.0001. The interspinous space in the seated position was found to be significantly larger than in the lateral recumbent position. CONCLUSION: The size of the interspinous space in the seated position on ultrasound was found to be larger than the lateral recumbent position, suggesting that LP may be more successful in the seated position.

A Prospective Evaluation of Point-of-Care Ultrasonographic Diagnosis of Diverticulitis in the Emergency Department.

STUDY OBJECTIVE: We evaluate the sensitivity and specificity of point-of-care ultrasonography, performed by ultrasonographic fellowship-trained emergency physicians and physician assistants, compared with computed tomography (CT) scan in diagnosing acute diverticulitis in the emergency department (ED). METHODS: This was a prospective observational study of a convenience sample of patients with suspected diverticulitis who were treated at an academic ED between 2017 and 2020. Sonographers were blinded to clinical data, laboratory results, and CT scan findings. A total of 19 ultrasonographic fellowship-trained emergency physicians and physician assistants performed the ultrasonographic examinations. Point-of-care ultrasonographic diagnosis of acute diverticulitis was defined as the presence of bowel wall thickening, greater than 5 mm, surrounding a diverticulum, enhancement of the surrounding pericolonic fat, and sonographic tenderness to palpation. The primary outcome measures were sensitivity, specificity, positive predictive value, and negative predictive value of point-of-care ultrasonography in the diagnosis of diverticulitis compared with CT, which was considered the criterion standard. RESULTS: Data from 452 patients were analyzed. Median age was 60 years, 54% were women, and 36% had a diagnosis of diverticulitis based on CT scan. Of the 452 patients, there were 13 false-positive (3%) and 10 false-negative (2%) point-of-care ultrasonographic examinations. Overall, compared with CT, point-of-care ultrasonography had a sensitivity of 92% (95% confidence interval 88% to 96%), specificity of 97% (95% confidence interval 94% to 99%), positive predictive value of 94% (95% confidence interval 90% to 97%), and negative predictive value of 96% (93% to 98%) in the diagnosis of diverticulitis. CONCLUSION: In a convenience sample of ED patients with suspected diverticulitis, point-of-care ultrasonography performed by ultrasonographic fellowship-trained emergency physicians and physician assistants could be used as an imaging modality for diagnosing acute diverticulitis, with high sensitivity and specificity compared with CT scan.

Use of Point-of-Care Ultrasound to Facilitate Guidance and Intrauterine Placement of a Foley Urinary Catheter to Tamponade Life-Threatening Postprocedure Hemorrhage Caused by Disseminated Intravascular Coagulation.

BACKGROUND: Severe vaginal hemorrhage caused by disseminated intravascular coagulation (DIC) after dilation and evacuation is a rare but life-threatening situation that can be difficult to manage. Obtaining hemostasis in such a patient with heavy vaginal bleeding secondary to DIC can be difficult. One technique involves the use of a urinary bladder catheter inserted into the uterus that is inflated to apply pressure on the endometrium, allowing for tamponade of the bleeding. CASE REPORT: A 36-year-old female gravida 2 para 0 at 21 weeks' gestation presented to the emergency department after being transferred from another facility for a higher level of care available at our facility, after a dilation and evacuation procedure that was indicated because of intrauterine fetal demise. The physical examination was significant for an ill-appearing female with active heavy vaginal bleeding. Resuscitation was initiated with packed red blood cells, cryoprecipitate, and platelets. Because of her thrombocytopenia, the development of DIC was suspected. Point-of-care ultrasound (POCUS) was performed and showed a thickened endometrial stripe with evidence of multiple anechoic foci, which were thought to represent intrauterine clots. To tamponade the bleeding, a 30-cc standard Foley urinary bladder catheter was placed into the uterus, using POCUS for guidance, to attempt to induce hemostasis via tamponade of the bleeding after inflation of the catheter balloon. Placement of an intrauterine urinary catheter to enable tamponade can be useful for the management of uncontrolled hemorrhage, but can be difficult to accomplish without use of POCUS for guidance. POCUS enabled us to accomplish accurate intrauterine placement of the urinary catheter and confirmation of a properly placed catheter balloon within the uterus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Menorrhagia in the emergency department can be difficult to manage, especially in the setting of DIC. Placement of an intrauterine urinary catheter can be useful in management but may be difficult for the inexperienced provider. POCUS can be used to guide the catheter into place and confirm the location once the balloon is inflated.

Pyomyositis Diagnosed by Point-of-Care Ultrasound in the Emergency Department.

BACKGROUND: Currently, the role of ultrasound in diagnosing superficial abscesses is well validated, however, its role for deep space infections and intramuscular pathology is limited. Distinguishing between simple cellulitis and abscess is critical for emergency physicians (EP), as the treatment is very different. Management of cellulitis relies on antibiotic therapy, whereas abscess treatment requires incision and drainage. It is important that EPs can accurately distinguish between the two entities. CASE REPORT: We report a case of a 41-year-old man with a history of high blood pressure and poorly controlled diabetes who presented with right lateral thigh redness, warmth, and tenderness. A point-of-care ultrasound (POCUS) of the patient's right lateral thigh with a high-frequency linear (8 MHz) ultrasound probe showed a 2.93 × 3.38 × 6.0-cm complex fluid collection deep to the fascial plane, approximately 3.0 cm from the skin surface, that contained mixed echogenicities with posterior acoustic enhancement consistent with an intramuscular abscess of the vastus lateralis. The patient was diagnosed with pyomyositis of his vastus lateralis. He was started on vancomycin and admitted to the surgical service for antibiotic treatment and surgical drainage. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: This case demonstrates that the use of POCUS by EPs can facilitate the rapid recognition and treatment of a disease that is challenging to diagnose on physical examination and can be potentially life-threatening if missed. EPs can consider performing a POCUS when evaluating skin infections to ensure rapid diagnosis and appropriate medical care for a potentially severe condition.

Profound Prolonged Bradycardia and Hypotension after Interscalene Brachial Plexus Block with Bupivacaine.

BACKGROUND: Interscalene brachial plexus blocks have been a routinely performed method of anesthesia for shoulder surgery that decreases the need for general anesthesia, length of stay, and recovery time. We describe a case of bupivacaine toxicity after an interscalene block. CASE REPORT: The patient was a 66-year-old man who presented to our Emergency Department by emergency medical services from an ambulatory surgery center where he had undergone rotator cuff surgery, with bradycardia and hypotension. His symptoms began upon completion of the surgery in which he received interscalene nerve block with bupivacaine and lidocaine. He was given three doses of 0.5 mg atropine and one dose of 1 mg epinephrine for a heart rate of 40 beats/min without any improvement prior to arrival. His bradycardia was refractory to atropine. He was started on a dopamine drip and transferred to the coronary care unit. The timing of his symptoms, minutes after his regional nerve block, and his complete recovery with only supportive care, make the diagnosis of bupivacaine toxicity likely. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite the safety profile of local anesthetics, we must be aware of their potential side affects. Whereas most adverse reactions are secondary to misdirection of anesthetic or accidental vascular puncture, local anesthetic systemic toxicity (LAST) is the major cause of significant adverse events with regional anesthesia. As regional anesthesia becomes more common, emergency physicians must be more aware of the potential complications and be able to both diagnose and treat.

Engineering adenylate cyclases regulated by near-infrared window light.

Bacteriophytochromes sense light in the near-infrared window, the spectral region where absorption by mammalian tissues is minimal, and their chromophore, biliverdin IXα, is naturally present in animal cells. These properties make bacteriophytochromes particularly attractive for optogenetic applications. However, the lack of understanding of how light-induced conformational changes control output activities has hindered engineering of bacteriophytochrome-based optogenetic tools. Many bacteriophytochromes function as homodimeric enzymes, in which light-induced conformational changes are transferred via α-helical linkers to the rigid output domains. We hypothesized that heterologous output domains requiring homodimerization can be fused to the photosensory modules of bacteriophytochromes to generate light-activated fusions. Here, we tested this hypothesis by engineering adenylate cyclases regulated by light in the near-infrared spectral window using the photosensory module of the Rhodobacter sphaeroides bacteriophytochrome BphG1 and the adenylate cyclase domain from Nostoc sp. CyaB1. We engineered several light-activated fusion proteins that differed from each other by approximately one or two α-helical turns, suggesting that positioning of the output domains in the same phase of the helix is important for light-dependent activity. Extensive mutagenesis of one of these fusions resulted in an adenylate cyclase with a sixfold photodynamic range. Additional mutagenesis produced an enzyme with a more stable photoactivated state. When expressed in cholinergic neurons in Caenorhabditis elegans, the engineered adenylate cyclase affected worm behavior in a light-dependent manner. The insights derived from this study can be applied to the engineering of other homodimeric bacteriophytochromes, which will further expand the optogenetic toolset.

Point-of-Care Ultrasound: Sonographic Posterior Fat Pad Sign: A Case Report and Brief Literature Review.

BACKGROUND: Diagnosis of elbow fracture can sometimes be difficult with plain radiography due to overlapping bones, growth plates, and maturing bones in the pediatric population. The radiographic posterior fat pad (PFP) sign is one of the frequently referenced indirect signs of an occult elbow fracture. This sign can be falsely negative if the sign is subtle, and can be falsely positive when the position of the elbow is not flexed at 90 degrees. CASE REPORT: We discuss a case in which sonographic PFP sign helped to diagnose an elbow fracture. A 57-year-old female presented to the emergency department (ED) after a fall on an outstretched hand. The point-of-care ultrasound (POCUS) was completed identifying an elevated PFP and an anechoic joint fluid collection with innumerous floating hyperechogenic spicules visualized in the olecranon fossa. Diagnosis of a radial head fracture was later confirmed by plain radiograph. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The increase in use and availability of POCUS in the ED makes this a very practical application. Our ability to rapidly perform the ultrasound of the elbow may allow us a more rapid diagnosis of pathology, as well as provide a way to further triage our patients. With time, it may even allow us to avoid routine use of plain radiography.

An unusual case of right upper quadrant pain in a pregnant woman.

Uterine fibroids occur in up to 30% of women of reproductive age and can cause complications during pregnancy that can harm mother and fetus, such as prematurity and increased risk of miscarriage. This article describes a pregnant woman whose abdominal pain was diagnosed as degenerating uterine fibroids.

Diagnosis of Traumatic Temporal Artery Pseudoaneurysm by Ultrasound in the Emergency Department.

BACKGROUND: Emergency bedside point-of-care ultrasound provides an extremely fast and cost-effective diagnostic modality for the diagnosis of vascular abnormalities, such as pseudoaneurysms. The cost-benefit and timing advantages of ultrasound are increasingly apparent when compared to more conventional diagnostic tests, such as computed tomography angiography and magnetic resonance angiography scans. CASE REPORT: A 33-year-old man with no medical history presented to our emergency department complaining of a constant, throbbing, left-sided headache over his temple with an associated mass. The physical examination revealed a 0.5-cm, tender, flesh-colored, pulsatile mass over his left temple. The tender mass was evaluated at the bedside by an emergency physician with a linear array L-14 probe on the ZONARE ultrasound system (ZONARE Medical Systems, Inc., Mountain View, CA). A small anechoic collection adjacent to the superficial temporal artery was identified with a sac containing flow in a prototypical "yin and yang" pattern. These findings were consistent with a superficial temporal artery pseudoaneurysm. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case report because of the implications of missing the diagnosis. Emergency physicians should be aware of the possible diagnosis of pseudoaneurysm of the temporal artery because of the plethora of head injuries that we evaluate on a regular basis. Missing the diagnosis can lead to delayed neurologic sequela and potential life-threatening bleeding in patients presenting with what appears to be a minor complaint.

Point of Care Ultrasound Diagnosis of Empyema.

BACKGROUND: Emergency ultrasonography is an efficient and cost effective tool for patients who are in respiratory distress. Chest radiographs can yield limited information for these patients. Computed tomography scans have long been the criterion standard for advanced imaging in patients with respiratory complaints, but point of care ultrasound (POCUS) can be performed at bedside, does not expose the patient to radiation, and at times may provide more information than a computed tomography scan. CASE REPORT: A 60-year-old man with a medical history of hypertension presented to the emergency department complaining of a productive cough associated with fever, weakness, and progressively worsening dyspnea on exertion over the previous 1 to 2 weeks. The physical examination was remarkable for rhonchi in the right upper lobe and diminished breath sounds throughout the right lung. POCUS was performed, and the results revealed severe atelectasis and hepatization of the right lung parenchyma with visualized air bronchograms. Complex hypoechoic material with a posterior spine sign was noted, which increased concern for complex consolidation and effusion. The diagnosis of pneumonia with empyema was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS has become a much more commonly used imaging modality within many emergency departments. Ultrasound is more sensitive than chest radiographs for identifying pathologies such as pneumothorax and simple effusions. This case shows how well POCUS can diagnose empyema even in the setting of diagnostic uncertainty of computed tomographic imaging.

Central Venous Catheterization: Are We Using Ultrasound Guidance?

OBJECTIVES: To assess the self-reported frequency of use of ultrasound guidance for central venous catheterization by emergency medicine (EM) residents, describe residents' perceptions regarding the use of ultrasound guidance, and identify barriers to the use of ultrasound guidance. METHODS: A longitudinal cross-sectional study was conducted at 5 academic institutions. A questionnaire on the use of ultrasound guidance for central venous catheterization was initially administered to EM residents in 2007. The same questionnaire was distributed again in the 5 EM residency programs in 2013. RESULTS: In 2007 and 2013, 147 and 131 residents completed questionnaires, respectively. A significant increase in the use of ultrasound guidance for central venous catheterization was reported in 2013 compared to 2007 (P< .001). In 2007, 53% (95% confidence interval, 44%-61%) of residents reported that they were initially trained in central venous catheterization using ultrasound guidance compared to 96% (95% confidence interval, 92%-99%) in 2013 (P < .0001). In 2007, more residents thought that faculty were insufficiently adopting ultrasound (42% versus 9%), and there was a lack of ultrasound teaching during residency training (14% versus 5%) compared to 2013. CONCLUSIONS: The use of self-reported ultrasound guidance for central venous catheterization significantly increased from 2007 to 2013 at academic institutions. Most residents were aware of the benefits of using ultrasound guidance. Although faculty adoption of ultrasound for central venous catheterization remains a barrier, it has decreased.

Saline Flush Test: Can Bedside Sonography Replace Conventional Radiography for Confirmation of Above-the-Diaphragm Central Venous Catheter Placement?

OBJECTIVES: Resuscitation often requires rapid vascular access via central venous catheters. Chest radiography is the reference standard to confirm central venous catheter placement and exclude complications. However, radiographs are often untimely. The purpose of this study was to determine whether dynamic sonographic visualization of a saline flush in the right side of the heart after central venous catheter placement could serve as a more rapid confirmatory study for above-the-diaphragm catheter placement. METHODS: A consecutive prospective enrollment study was conducted in the emergency departments of 2 major tertiary care centers. Adult patients of the study investigators who required an above-the-diaphragm central venous catheter were enrolled during the study period. Patients had a catheter placed with sonographic guidance. After placement of the catheter, thoracic sonography was performed. The times for visualization of the saline flush in the right ventricle and sonographic exclusion of ipsilateral pneumothorax were recorded. Chest radiography was performed per standard practice. RESULTS: Eighty-one patients were enrolled; 13 were excluded. The mean catheter confirmation time by sonography was 8.80 minutes (95% confidence interval, 7.46-10.14 minutes). The mean catheter confirmation time by chest radiograph availability for viewing was 45.78 minutes (95% confidence interval, 37.03-54.54 minutes). Mean sonographic confirmation occurred 36.98 minutes sooner than radiography (P< .001). No discrepancy existed between sonographic and radiographic confirmation. CONCLUSIONS: Confirmation of central venous catheter placement by dynamic sonographic visualization of a saline flush with exclusion of pneumothorax is an accurate, safe, and more efficient method than confirmation by chest radiography. It allows the central line to be used immediately, expediting patient care.

Ileocolic intussusception secondary to gastrointestinal stromal tumor in a 61-year-old.

Intussusception is a common emergency in patients age of 3 months to 5 years. In adults, the diagnosis is infrequent but must be considered in the clinical setting of abdominal pain and vomiting. We present a case of a 61-year-old woman presenting with epigastric abdominal pain and vomiting, diagnosed with intussusception secondary to gastrointestinal stromal tumor. Serial bedside ultrasound examinations uncovered the diagnosis of intussusception, confirmed by computed tomographic scan during a paroxysm of pain. Intussusception has a much higher predilection for neoplasms in adults, with a high morbidity and mortality, so early recognition is critical in improving patient outcomes.

Point-of-Care Ultrasound Findings in Occlusive Iliac Vein Thrombus During Pregnancy: A Case Report.

Introduction: Diagnosing deep venous thromboses and venous thromboemboli (DVT/VTE) in pregnant patients presents a unique challenge for emergency physicians. The risk of DVT/VTE increases during pregnancy, and the potential consequences of misdiagnoses are severe. Point-of-care ultrasonography (POCUS) is frequently a first-line diagnostic imaging modality. However, recent studies have shown a high incidence of thromboses proximal to the common femoral vein during pregnancy, and these would not be visualized using compressive ultrasonography, which traditionally can only visualize thromboses distal to the femoral vein. Case Report: A 38-year-old female, 25-weeks primiparous, presented to the emergency department with a three-day history of left lower extremity swelling. Point-of-care three-point compression testing was used to evaluate for a DVT; however, no thrombus was visualized. Given high clinical suspicion, color and spectral Doppler testing were performed and demonstrated turbulent flow and reduced respiratory variation in the common femoral vein. This prompted further additional testing for a proximal DVT using magnetic resonance venography, which revealed an occlusive left external iliac thrombus. The patient was subsequently started on daily subcutaneous enoxaparin and discharged home with close follow-up. Conclusion: Emergency physicians play a critical role in evaluations for the presence of DVT/VTE, particularly in pregnant patients. We endorse the use of POCUS with three-point compression testing, as well as color and spectral Doppler imaging, to help identify proximal DVTs in this patient population. This case report can aid physicians in the diagnosis of this pathological condition that if left untreated can have severe consequences.

Return of the Living Dead Gut - A Case Report of Ischemic Colitis Identified on Point of Care Ultrasound.

Ischemic colitis is the most common form of gastrointestinal ischemia 1. The diagnosis of ischemic colitis is made by clinical data and computed tomography (CT) imaging of the abdomen and pelvis 1. While colonoscopy is considered the gold standard for diagnosis, this is not performed in the emergency department (ED) 2. Few studies have been performed to describe the sonographic findings of ischemic colitis using point of care ultrasound (POCUS). We report a case that highlights the sonographic findings of ischemic colitis in a patient who had two separate visits to the ED, showcasing the utility of POCUS in making this diagnosis. POCUS can be used as a diagnostic tool for early detection of ischemic colitis leading to prompt treatment with antibiotics, CT imaging, and surgical consultation.

A Case Report of a LVAD Driveline Infection Diagnosed by Point-of-care Ultrasound.

INTRODUCTION: As the prevalence of patients with left ventricular assist devices (LVAD) presenting to the emergency department (ED) increases, clinicians must be aware of LVAD-associated infections. CASE REPORT: A well-appearing, 41-year-old male with history of heart failure status post prior-LVAD placement presented to the ED for swelling of his chest. What appeared initially as a superficial infection was further assessed with point-of-care ultrasound and found to represent a chest wall abscess involving the driveline, ultimately resulting in sternal osteomyelitis and bacteremia. CONCLUSION: Point-of-care ultrasound should be considered an important tool in the initial assessment of potential LVAD-associated infection.