Aortic dissection: How to identify it during an abdominal ultrasound examination and achieve a potentially lifesaving diagnosis.

Aortic dissection (AD) is a rare and potentially fatal condition that may be diagnosed late. During an emergency or elective abdominal ultrasound (US) examination, when going to evaluate the abdominal aorta for other reasons, it may happen that we find ourselves suspecting an AD. It is therefore important to know the US characteristics of this pathology to avoid wrong or missed diagnoses. Here, we present our practical experience regarding the application of US in the study of the abdominal aorta, which allowed us on several occasions to find an unexpected dissection in patients brought to our attention for other reasons.

Point-of-Care Ultrasound Diagnosis of Cesarean Scar Ectopic Pregnancy: A Case Series.

BACKGROUND: A cesarean scar pregnancy (CSP) is a clinically important form of ectopic pregnancy that carries a high risk of maternal morbidity and mortality. As the rate of cesarean sections has risen, this diagnosis is becoming an increasingly important consideration for providers caring for patients in early pregnancy. CASE REPORT: We present three cases of CSPs in which point-of-care ultrasound expedited the diagnosis and treatment in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the risks of an undiagnosed CSP, the increasing incidence of CSP, and the number of effective treatment options available in early gestation, the prompt and accurate diagnosis of CSP remains crucial to its successful management. As such, it is an important diagnosis for the emergency physician to consider when evaluating a patient in early pregnancy.

Utility of Point-of-Care Ultrasound in the Diagnosis of Idiopathic Intracranial Hypertension in the Emergency Department.

BACKGROUND: Emergency physicians are frequently required to identify and triage patients with increased intracranial pressure (ICP). Idiopathic intracranial hypertension (IIH) is a possible cause that must be considered. Its prognosis depends on prompt recognition and treatment, and progression of the disease can lead to permanent vision loss and considerable morbidity. Point-of-care ultrasound can rapidly identify elevated ICP. Measurements of the optic nerve sheath diameter (ONSD) and optic disc elevation (ODE) can act as surrogates for ICP. CASE SERIES: We describe five cases in which ultrasound was used to identify increased ICP and aid clinical decision-making. In several of the cases, ultrasound was used to confirm a suspicion for IIH and initiate therapy while awaiting the results of a more time-consuming and technically challenging test, such as lumbar puncture or optical coherence tomography. One of the patients was pregnant, and sonographic evidence of elevated ICP helped avoid exposing the patient to unnecessary radiation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound is a quick and versatile tool for screening patients with neurologic symptoms, and when integrated into the proper clinical context, can reduce the use of more invasive tests. It can be particularly useful in patients with pathology that may not show abnormalities on computed tomography scan or in whom lumbar puncture is technically difficult, making patients at risk for IIH well-suited to examination by ultrasound. We use a cutoff of 5 mm for ONSD and 0.6 mm for ODE, though there are no universally agreed on cutoff values.

Lung Ultrasound vs. Chest X-Ray Study for the Radiographic Diagnosis of COVID-19 Pneumonia in a High-Prevalence Population.

BACKGROUND: The viral illness severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), more commonly known as Coronavirus 2019 (COVID-19), has become a global pandemic, infecting over 100 million individuals worldwide. OBJECTIVES: The objective of this study was to compare the test characteristics of point-of-care lung ultrasound (LUS) with chest x-ray study (CXR) at radiographically detecting COVID-19 pneumonia. METHODS: This was a single-center, prospective, observational study at an urban university hospital with > 105,000 patient visits annually. Patients ≥ 18 years old, who presented to the Emergency Department with predefined signs and symptoms of COVID-19, were eligible for enrollment. Each patient received an LUS using a portable, handheld ultrasound followed by a single-view, portable anteroposterior CXR. Patients with an abnormal LUS or CXR underwent a non-contrast-enhanced computed tomography scan (NCCT). The primary outcome was the radiographic diagnosis of COVID-19 pneumonia on NCCT. RESULTS: One hundred ten patients underwent LUS, CXR, and NCCT; 99 LUS and 73 CXRs were interpreted as positive; 81 NCCTs were interpreted as positive, providing a prevalence of COVID-19 pneumonia of 75% (95% confidence interval [CI] 66-83.2) in our study population. LUS sensitivity was 97.6% (95% CI 91.6-99.7) vs. 69.9% (95% CI 58.8-79.5) for CXR. LUS specificity was 33.3% (95% CI 16.5-54) vs. 44.4% (95% CI 25.5-64.7) for CXR. LUS positive predictive value and negative predictive value were 81.8% (95% CI 72.8-88.9) and 81.8% (95% CI 48.2-97.7), respectively, vs. 79.5% (95% CI 68.4-88), and 32.4% (95% CI 18-49.8), respectively, for CXR. CONCLUSION: LUS was more sensitive than CXR at radiographically identifying COVID-19 pneumonia.

Point-of-care ultrasound diagnosis of pediatric intussusception: a case series.

Intussusception is an intestinal emergency caused by the telescoping of proximal bowel into an adjacent distal bowel segment. Nearly 50% of cases are missed on initial presentation leading to an increased risk of intestinal obstruction, ischemia, and perforation. The authors present two cases of pediatric intussusception whereby point-of-care ultrasound expedited the diagnosis and treatment in a non-pediatric dedicated emergency department. Given the risks of an undiagnosed intussusception and its nonspecific presentations, a prompt and precise diagnosis remains crucial to its successful management. The ubiquity and accuracy of point-of-care ultrasound make it an ideal adjunct for the diagnosis of intussusception.

Evidence-Based Medicine Improves the Emergent Management of Peritonsillar Abscesses Using Point-of-Care Ultrasound.

BACKGROUND: Physical examination for peritonsillar abscess (PTA) has limited sensitivity. Traditional management involves blind needle aspiration, which has a false negative rate of 10-24%. A randomized controlled trial by Costantino et al. demonstrated that point-of-care ultrasound (POCUS) improves PTA management. OBJECTIVES: Compare the use and impact of POCUS between patient cohorts prior to and after the trial by Costantino et al. METHODS: Retrospective cohort study of adult patients diagnosed with PTA. Cohort 1 presented to the emergency department (ED) January 2007-December 2008. Cohort 2 presented between January 2013 and December 2014. Data were separated into those with POCUS vs. without ultrasound (NUS). Primary endpoint was POCUS utilization. Secondary endpoints were successful aspiration, otolaryngology (ear, nose, and throat [ENT]) consultation, computed tomography (CT) imaging, unscheduled return visits, and length of stay (LOS). The Fisher's exact and t-tests analyzed data. RESULTS: Cohort 1 enrolled 48 patients, vs. 114 patients for cohort 2. Twelve patients in cohort 1 had a POCUS (25%) vs 89 in cohort 2 (78%) (p < 0.0001; odds ratio [OR] 0.09 (95% confidence interval [CI] 0.04-0.20). Emergency physician (EP) successful aspiration: 89.1% POCUS vs. 24.5% NUS (p < 0.0001; OR 25 [95% CI 10-59]). Combined EP/ENT successful aspiration: 99.0% POCUS vs. 80.3% NUS (p < 0.0001; OR 24 [95% CI 3-193]). ENT consultation:12.9% POCUS vs. 65.6% NUS (p < 0.0001; OR 0.07 [95% CI 0.03-0.17]). CT usage: 23.8% POCUS vs. 37.7% NUS (p = 0.07; OR 0.51 [95% CI 0.25-1.02]). Return visits: 3.96% POCUS vs. 18.0% NUS (p = 0.004; OR 0.18 [95% CI 0.05-0.61]). CONCLUSION: POCUS use has increased for PTA treatment, improves aspiration, and decreases consultations, CTs, return visits, and LOS.

Ultrasound Guidance Versus Landmark-Guided Palpation for Radial Arterial Line Placement by Novice Emergency Medicine Interns: A Randomized Controlled Trial.

BACKGROUND: More than 10 million arterial lines are placed annually worldwide, many of which happen in the emergency department. Before the introduction of point-of-care ultrasound, landmark-guided palpation (LMGP) was considered standard of care. OBJECTIVE: The objective of this study is to compare ultrasound-guided (USG) and LMGP of radial arterial line cannulation by novice emergency medicine interns. METHODS: This was a single-center, prospective, randomized controlled trial (NCT03326739) of a convenience sample of adult patients who presented to an urban, university hospital with 100,000 visits annually. There was no funding for this study. Patients who required an arterial line were blindly randomized into LMGP or USG groups. Only novice emergency medicine interns, defined as interns with <15 previous placements, who were not blinded, performed the cannulation. Statistical analyses included t and Fisher exact tests. RESULTS: Forty patients were enrolled with 20 patients randomized to each group. USG had a first-pass success of 75% vs. 0% for LMGP (p < 0.00001) and an overall success of 100% vs. 15% for LMGP (p < 0.00001), a mean of 1.30 attempts vs. 2.95 attempts for LMGP (a difference of 1.65; p < 0.0001), and a mean time for placement of 264 s vs. 524 s for LMGP (a difference of 260; p = 0.0025). Of the failed LMGP, USG crossover was 100% successful with a mean of 1.37 attempts (95% confidence interval 0.58-2.16) and 180 s for placement (95% confidence interval 97.92-262.08). Five percent of LMGP had a complication vs. 0% for USG (p = 1.0). CONCLUSIONS: USG improved first-pass and overall success of radial arterial line cannulation while reducing time to access and attempts when used by novice emergency medicine interns.

Effort Thrombosis Provoked by Saxophone Performance.

BACKGROUND: Internal jugular venous thrombosis (IJVT) is an uncommon condition rarely diagnosed in the outpatient setting. IJVT carries significant morbidity and mortality and must be considered in the differential diagnosis for new-onset neck pain and swelling, especially in the emergency setting. Paget-Schroetter syndrome (PSS), or primary thrombosis secondary to effort, is an uncommon, likely under-recognized etiology of thrombosis. We report a case of PSS extending from the right subclavian vein into the right internal jugular vein, suspected based upon patient history and physical examination and confirmed by point-of-care ultrasound (POCUS). We then review the presentation, causes, and diagnostic standards for PSS. CASE REPORT: We present a case of a 79-year-old man who presented to the Emergency Department with acute right-sided neck pain 1 day after playing the saxophone for 4 h the prior evening. POCUS confirmed Paget-Schroetter syndrome, or primary effort thrombosis of the internal jugular vein. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first documented case of PSS resulting from venous stasis with prolonged Valsalva maneuver and vascular trauma with activity of playing the saxophone. The significance of this case is the unusual etiology of a rare presentation and the ability to diagnose this condition quickly and accurately with POCUS.

Xanthogranulomatous Pyelonephritis: A Complicated Febrile Urinary Tract Infection Detected by Point-of-Care Ultrasound in the Emergency Department.

BACKGROUND: Febrile urinary tract infections (UTIs) include a spectrum of pathologies from uncomplicated pyelonephritis to urosepsis, including xanthogranulomatous pyelonephritis (XGP). Most febrile UTIs are treated with antibiotics alone, but studies indicate nearly 12% of cases of presumed simple pyelonephritis require emergent urologic intervention. How to identify these individuals, while limiting unnecessary advanced imaging and delays in diagnosis, challenges all emergency providers. We review the diagnosis and management of XGP, as well as the evidence regarding the role of renal ultrasound in the identification of complicated presentations of febrile UTIs. CASE REPORT: We present a case of XGP, a complicated febrile UTI requiring immediate urologic intervention, diagnosed by point-of-care ultrasound. A 40-year-old female presented in severe sepsis and complaining of flank pain. Prompt bedside ultrasound demonstrated hydronephrosis, expediting definitive urologic treatment via percutaneous nephrostomy tube placement. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With a mortality rate exceeding 40%, obstructed pyonephrosis requires prompt decompression. Given its exceptional sensitivity for identifying hydronephrosis and ability to detect abscesses and emphysematous changes, we advocate a point-of-care ultrasound-first approach to screen for cases of complicated febrile UTIs in order to expedite treatment and limit radiation in uncomplicated presentations.

The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study.

OBJECTIVES: An aortic dissection (AoD) is a potentially life-threatening emergency with mortality rates exceeding 50%. While computed tomography angiography remains the diagnostic standard, patients may be too unstable to leave the emergency department. Investigators developed a point-of-care ultrasound (POCUS) protocol combining transthoracic echocardiography (TTE) and the abdominal aorta. The study objective was to determine the test characteristics of this protocol. METHODS: This was an institutional review board-approved, multicenter, prospective, observational, cohort study of a convenience sample of adult patients. Patients suspected of having an AoD received a TTE and abdominal aorta POCUS. Three sonographic signs suggested AoD: a pericardial effusion, an intimal flap, or an aortic outflow track diameter measuring more than 35 mm. Investigators present continuous and categorical data as medians with interquartile ranges or proportions with 95% confidence intervals (CIs) and utilized standard 2 × 2 tables on MedCalc (Version 19.1.6) to calculate test characteristics with 95% CI. RESULTS: Investigators performed 1314 POCUS examinations, diagnosing 21 Stanford type A and 23 Stanford type B AoD. Forty-one of the 44 cases had at least one of the aforementioned sonographic findings. The protocol has a sensitivity of 93.2% (95% CI 81.3-98.6), specificity of 90.9 (95% CI 89.2-92.5), positive and negative predictive values of 26.3% (95% CI 19.6-33.9) and 99.7% (95% CI 99.2-100), respectively, and an accuracy of 91% (95% CI 89.3-92.5). CONCLUSIONS: The SPEED protocol has an overall sensitivity of 93.2% for AoD.

Diagnostic Accuracy of a Handheld Ultrasound vs a Cart-based Model: A Randomized Clinical Trial.

Introduction: Numerous studies have demonstrated the accuracy of point-of-care ultrasound (POCUS). Portable, handheld devices have expanded the clinical scope of POCUS at a fraction of the cost of traditional, cart-based models. There is a paucity of data assessing the diagnostic accuracy of portable devices. Our objective in this study was to compare the diagnostic accuracy of a portable device with a cart-based model. Methods: This was an institutional review board-approved, observational, prospective, randomized clinical trial (NCT05196776) of a convenience sample of adult patients who presented to a university-based health system. Patients who required a cardiac, lung, renal, aorta, or biliary POCUS were randomized to a portable device or to a cart-based model. We hypothesized that the cart-based model would have a 90% diagnostic accuracy vs 70% for the handheld device. To detect a 20% difference, the sample size was calculated to be 98, with 49 patients randomized to each arm. We used standard 2x2 tables to calculate test characteristics with 95% confidence intervals (CI). Results: A total of 110 patients were enrolled, with 56 patients randomized to the cart-based model and 54 to the handheld device. The sensitivity, specificity, and diagnostic accuracy of the cart-based vs handheld were 77.8% (40-97.2) vs 92.9% (66.1-99.8), 91.5% (79.6-97.6) vs 92.3% (79.1-98.4%), and 89.3% (78.1-96) vs 92.5% (81.8-97.9), respectively. Conclusion: The diagnostic accuracy of a portable, handheld device is similar to that of a cart-based model.

Reverse Takotsubo cardiomyopathy in the setting of anaphylaxis treated with high-dose intravenous epinephrine.

BACKGROUND: Takotsubo cardiomyopathy is seen, though rarely, in anaphylaxis treated with epinephrine. Stress cardiomyopathy is most likely to occur in middle-aged women. The underlying etiology is believed to be related to catecholamine release in periods of intense stress. Catecholamines administered exogenously, and those secreted by neuroendocrine tumors (e.g., pheochromocytoma) or during anaphylaxis have been reported to cause apical ballooning syndrome, or takotsubo syndrome. However, reverse takotsubo stress cardiomyopathy is rarely seen or reported in anaphylaxis treated with epinephrine. OBJECTIVES: To report a case illustrating that high-dose intravenous epinephrine can trigger stress cardiomyopathy, and that the risk is heightened with inappropriate dosing in the treatment of anaphylaxis. CASE REPORT: We report a rare case of iatrogenic reverse takotsubo syndrome in a young woman who was inappropriately treated with high-dose intravenous epinephrine for mild anaphylaxis. CONCLUSION: Inappropriately high doses of intravenous epinephrine can trigger stress cardiomyopathy. Emergency physicians should be familiar with the diagnosis, grading, and appropriate treatments of anaphylaxis to avoid this unnecessary complication.

Hemolytic anemia following mitral valve repair: A case presentation and literature review.

Hemolytic anemia is a known complication after valve replacement, but the incidence of hemolysis following valve repair is unknown. A case involving mitral annuloplasty complicated by hemolytic anemia, which resolved after replacement of the valve, is presented. Only 70 cases of hemolysis after mitral valve repair have been reported in the literature. In nearly all of these cases, replacement or rerepair of the valve was the definitive treatment for hemolysis.

Ultrasound-versus landmark-guided medium-sized joint arthrocentesis: A randomized clinical trial.

OBJECTIVES: Arthrocentesis is commonly performed in the emergency department, but success rates vary based on location. Presently, there is a paucity of data assessing the utility of ultrasound-guided (USG) medium-sized joint arthrocentesis. The objective of this study was to compare the success of USG and landmark-guided (LMG) medium-sized joint arthrocentesis. METHODS: This was a single-center, prospective, randomized clinical trial (NCT03327584) of a convenience sample of adult patients who presented to an urban, university hospital with > 105,000 visits annually. Patients with a suspected medium-sized joint effusion (defined as elbow, wrist, or ankle) undergoing arthrocentesis were randomized into LMG or USG using the GE Logiq e linear transducer (4-10 MHz). The following patients were excluded: on anticoagulation, with soft tissue infection overlying the joint, or involving an artificial joint. Statistical analysis included the Fisher exact, Mann-Whitney U-test, and t-test. RESULTS: Overall, 44 patients were enrolled with 23 patients randomized into the LMG group and 21 patients into the USG arm. USG was significantly better than LMG with an overall success of 94.1% versus 60% for LMG (difference = 34.1%, 95% confidence interval [CI] = 4.90 to 58.83). USG first-pass success was 82.4% versus 46.7% for LMG (difference = 35.7%, 95% CI = 2.76 to 60.37) and a mean of 1.35 attempts versus 2.00 for LMG (difference = 0.65, 95% CI = 0.005 to 1.296). Of the 14 LMG failures, eight had no effusion present on USG crossover. Four patients in the USG group had no effusion present. CONCLUSIONS: Ultrasound guidance improved first-pass and overall successful arthrocentesis of medium-sized joint effusions.

Breast arterial calcifications on mammograms do not predict coronary heart disease at coronary angiography.

PURPOSE: To examine, in women who underwent cardiac catheterization, whether breast arterial calcifications (BACs) seen at screening mammography correlate with coronary heart disease (CHD) seen at coronary angiography. MATERIALS AND METHODS: In an institutional review board-approved, HIPAA-compliant study, 172 women (mean age, 64.29 years +/- 11.97 [standard deviation]) who underwent coronary angiography were recruited, interviewed, and assigned to two groups: those with (CHD+) and those without (CHD-) CHD. The severity and location of the CHD were considered. Their mammograms were reviewed by a breast imaging specialist who was blinded to the CHD status. Student t test, chi(2), and multiple logistic regression tests were performed as appropriate. Presence of BAC was noted and correlated with presence of CHD and presence of cardiac risk factors. RESULTS: There were 104 women with and 68 women without CHD. Thirty-seven (36%) women in the CHD+ group versus 20 (29%) in the CHD-group (P = .40) had BAC. The mean age of the patients with BAC, 72 years +/- 9.8, was significantly older than the mean age of the patients without BAC, 60.4 years +/- 11.1 (P < .001). Therefore, subjects were divided into those younger than 65 years and those 65 years and older. No correlation existed, despite the fact that BAC was associated with some cardiac risk factors. CONCLUSION: The authors did not observe a correlation between BAC and coronary angiography-detected CHD, even when CHD severity was considered. On the basis of these results, caution should be exercised when using screening mammography-detected BAC to identify patients with CHD.

Ultrasound-guided peripheral venous access vs. the external jugular vein as the initial approach to the patient with difficult vascular access.

BACKGROUND: Traditionally, Emergency Physicians (EPs) have used the external jugular (EJ) vein to gain vascular access in patients who have failed nursing attempts at peripheral access. Recently, some EPs have used ultrasound (USIV) to gain peripheral access. STUDY OBJECTIVE: This study seeks to determine which initial approach by EPs would lead to greater success. METHODS: This was a prospective, randomized study of all adult patients who presented to the Emergency Department (ED) between June and December 2007. Inclusion criteria were failed nursing attempts at peripheral access (at least three). EPs were 2(nd)- or 3(rd)-year residents who had previously performed more than five each of EJs and USIVs. Patients were randomized into either an initial EJ or USIV approach. RESULTS: Sixty patients were enrolled, 32 in the ultrasound group, 28 in the EJ group. Fifteen different EPs performed access. Initial Success: USIV 84% (95% confidence interval [CI] 68-93%) vs. EJ 50% (95% CI 33-67%), p = 0.006. Success if EJ visible: USIV 84% vs. EJ 66% (p = 0.18). Overall success, including data from the crossover pathway: a total of 41 lines were successfully placed by ultrasound out of 46 attempts (89%) vs. 18 out of 33 for EJ (55%), p = 0.001. In total, 59/60 patients (98%) had a peripheral i.v. successfully placed. The percentage of functioning lines when the patient left the ED was: USIV 89% (95% CI 72-96%) vs. EJ 93% (95% CI 68-98%), p = 0.88. CONCLUSION: As an initial approach to all patients with difficult venous access, ultrasound-guided peripheral lines are superior to the EJ approach. However if the EJ was visible, there was no difference in success among the initial approaches. Both techniques, when used together, could achieve peripheral vascular access in 98% of difficult access patients.

Comparison of ultrasound-guided and standard landmark techniques for knee arthrocentesis.

BACKGROUND: Ultrasound is a useful adjunct to many Emergency Department (ED) procedures. Arthrocentesis is typically performed using a landmark technique but ultrasound may provide an opportunity to improve arthrocentesis performance. OBJECTIVE: To assess the success of emergency physicians performing landmark (LM) vs. ultrasound (US)-guided knee arthrocentesis techniques. METHODS: This was a prospective, randomized, controlled study of patients requiring knee arthrocentesis who presented to one urban university ED and two community EDs between June 2005 and February 2007. RESULTS: There were 66 patients enrolled (39 US-guided, 27 LM). Among all users, there was no difference in arthrocentesis success (US 37/39 vs. LM 25/27); p = 1.0. SECONDARY ENDPOINTS: 1) Patients reported less pain with ultrasound; US-guided 3.71 (95% confidence interval [CI] 2.61-4.80) cm vs. LM 5.19 (95% CI 3.94-6.45) cm; p = 0.02. 2) Providers felt the US-guided technique was easier to perform than LM; 1.67 units on 5-point scale (95% CI 1.37-1.97) vs. 2.11 (95% CI 1.79-2.42) units; p = 0.02. 3) The total procedure time was shorter with the US-guided technique; 10.58 (95% CI 7.36-13.80) min vs. LM 13.37 (95% CI 9.83-16.92) min; p = 0.05. 4) There was no difference in the amount of fluid obtained between techniques; US-guided 45.33 (95% CI 35.45-55.21) mL vs. LM 34.7 (95% CI 26.09-43.32) mL; p = 0.17. CONCLUSION: US-guided knee arthrocentesis technique does not improve overall success of obtaining joint fluid aspirate vs. the standard LM and palpation technique. An US-guided approach does not result in more pain for the patient, takes no additional time to perform and, at least for novice physicians, leads to more fluid aspiration and greater novice provider confidence with the procedure. Further studies with more participants and standardization of anesthetic quantity are required to validate these findings.

Point-of-care Ultrasound Diagnosis of Acute Abdominal Aortic Occlusion.

Acute aortic occlusion is an emergent vascular condition not encountered routinely. Given its varied presentations, including neurovascular deficits and mimicking an acute abdomen, the diagnosis is often delayed causing increased morbidity and mortality. We present a case of acute abdominal aortic occlusion masquerading as sudden onset lower extremity pain and weakness in an 86-year-old female requiring emergent thrombectomy. This is only the second case report to discuss the use of point-of-care ultrasound to expedite diagnosis and management.1.