Differential Diagnosis of Acute Dyspnea: The Usefulness of Tissue Doppler Echocardiography in Emergency Department by Emergnecy Physician

PURPOSE: In managing acutely dyspneic patients, differentiating the underlying disease rapidly is important but not easy. Although B-type natriuretic peptide (BNP) is generally accepted as a useful marker, inconclusive results require an emergency physician (EP) to have something more confirmative. We evaluate whether Tissue Doppler Echocardiography (TDE) performed by an EP can better discriminate between heart disease and lung disease than can BNP in the emergency department (ED). METHODS: For enrolled ED patients with acute dyspnea and unclear pathology, initial BNP level and TDE performed by EP were checked prospectively. The ratios of peak early diastolic transmitral blood flow velocity (E) versus the peak early diastolic tissue velocity over mitral annulus (Ea) on TDE were recorded. The sensitivity and specificity of tissue Doppler parameters and BNP levels for diagnosing acute heart failure were calculated and we compared the discriminatory ability of the two tools. RESULTS:49 patients (39 heart failure, 10 respiratory disease) were enrolled. The area under the ROC curves for BNP and E/Ea were 0.946 and 0.888 (p<0.001) respectively. Cutoff values were 350 pg/ml for BNP (sensitivity and specificity of 82.1% and 100%) and 9.0 for E/Ea (89.2% and 100%). Especially in the group with low BNP (<350), BNP was a poor discriminator of the underlying disease, whereas E/Ea was still effective (AUC: 0.943, p=0.021). CONCLUSION: TDE by EP is a useful tool for diagnosing acute heart failure in ED and could easily and rapidly discriminate the underlying disease of acutely dyspneic patients, especially in patients with inconclusive BNP levels.

Emergency Abdominal Ultrasonography for Differential Diagnosis of Acute Abdominal Pain : COUCH (Complaint-oriented Ultrasonography with CHecklist) approach

PURPOSE: The purpose of this study was to verify objectively whether abdominal ultrasonography performed by emergency physicians (EP) in emergency departments (ED) immediately after history taking and physical examination could give effective diagnostic information and to check the feasibility and usefulness of the COUCH method. METHODS: From May 1, 2005 to September 30, 2005 we recruited 368 patients who complained of abdominal pain in the ED. Senior level emergency physicians (EP) conducted history taking and physical examinations, following which they were asked for their suspected diagnosis and their level of confidence (from maximum 5 to minimum 1) regarding each diagnosis. The same EP then performed abdominal ultrasonography (US), using the COUCH method and were again asked for their suspected diagnosis and level of confidence. We compared the suspected diagnoses and levels of confidence before and after abdominal US by using the t-test. RESULTS: A total of 106 patients (55 male, 51 female, average age 35.46+/-18.11 years) were enrolled. The number of patients with a suspected diagnosis of after history taking and physical examination only (2.43+/-0.5) was significantly greater than after abdominal US (1.34+/-0.5) (p<0.01). The level of confidences of suspected diagnosis of after history taking and physical examination only (3.43+/-1.14), by contrast, was less than after abdominal US (4.40+/-1.22) (p<0.01). Each year of postgraduate residents could have the same results after US. CONCLUSION: We found that abdominal ultrasonography could give EP more informations for pronouncing a correct diagnosis for patients with abdominal pain in the ED, and the COUCH method could lead the EP to get better training for ultrasonography and to diagnose more rapidly and accurately.

The Utility of Emergency Ultrasound for Diagnosing Wrist and Ankle Injuries

PURPOSE: Ultrasound is of proven accuracy in abdominal and thoracic trauma and may be useful for diagnosing extremity injury in situations where radiography is not available, such as disasters and military and space applications. However, the diagnosis of fractures is suggested by history and physical examination and is typically confirmed with radiography. As a alternative to radiography, we prospectively evaluated the utility of extremity ultrasound performed by trained residents of emergency medicine (EM) one patient with wrist and ankle extremity injuries. METHODS: Initially, residents of EM performed physical examinations for fractures. The emergency ultrasound (EM US) was performed by trained residents, who used a portable ultrasound device with a 10- to 5-MHz linear transducer, on suspected patients before radiography examination. The results of emergency ultrasound and radiography and the final diagnosis were recorded, and correlations among them were determined by using Kappa`s test. RESULTS: Thirty-nine patients were enrolled in our study. The average age was 36.6+/-19.3 years. There were radius Fx. (n=21), radius-ulna Fx. (n=1), ulna Fx. (n=1), and contusion (n=2) injuries among the wrist injury and lat.-med. malleolar Fx. (n=13), lat. malleolar Fx. (n=6), and med. malleolar Fx. (n=3) injuries among the ankle injury. Comparing EM US with radiography, we found the sensitivity, specificity, positive predictive value, and negative predictive value of EM US for Fx. diagnosis to be 100%, 66.7%, 97.3%, 100% and those of radiography to be 97.2%, 100%, 100%, and 75%, respectively. Kappa`s test for a correlation between the Fx. diagnosis of EM US and the final diagnosis of Fx was performed, and Kappa`s value was 0.787 (P = 0.004). CONCLUSION: EM US for Fx. can be performed quickly and accurately by EM residents with excellent accuracy in remote locations such as disaster areas and in military and aerospace applications. EM US was as useful as radiography in our study and had a high correlation to the final diagnosis of Fx. Therefore, ultrasound should performed on patients with extremity injury to determine whether extremity evaluation should be added to the FAST (focused abdominal sonography trauma) examination.

The Change of the Optic Nerve Sheath Diameter (ONSD) Following Treatment in Patients with Increased ICP

PURPOSE: Many reports have shown that the optic nerve sheath diameter (ONSD) can be measured easily by ultrasonography, and that it becomes wider when the intra-cranial pressure (ICP) is increased. However, there have been no reports comparing the two ONSDs following proper treatment. We measured the 2nd ONSDs of patients who were diagnosed with intra-cranial hemorrhage and increased ICP and who were admitted to an intensive care unit following management of their conditions, and analyzed the changes of the ONSDs and their relationship to the outcomes. METHODS: During the 10 months beginning December 1, 2004, we recruited 29 patients who were suspected to have increased ICP as indicated by computed tomography at the emergency center. Meeting any one of the following criteria was defined as elevated ICP: mid-line shifting of 3 mm or greater due to mass effect; a collapsed 3rd ventricle; hydrocephalus; effacement of sulci with significant edema; abnormal mesencephalic cisterns. We determined initial ONSDs by ultraonography and the Glasgow Coma Scale (GCS). At the 7th hospital day, GCS and ONSDs were re-evaluated and compared against the previous data. RESULTS: 29 patients (21 male, 8 female, average age 55.55 years) were enrolled. Mean GCS at the admission was 7.86+/-3.60. 18 patients had spontaneous hemorrhage (62%) and 11 patients had traumatic hemorrhage (38%). 22 patients received emergency surgery, 18 patients (62%) showed improved neurological outcomes and 11 (38%) failed to achieve any good outcomes. The initial mean ONSD was 5.41+/-0.70 mm. The average ONSD for traumatic hemorrhage (5.51+/-0.45 mm) was not statistically different from the ONSD for non-traumatic hemorrhage (5.35+/-0.84 mm) (p=0.55). The mean ONSD after 7 days of admission was 4.41+/-0.53 mm, which represented a significant decrease compared with the initial measurements (p<0.05). The mean GCS and ONSD showed significant differences between the improved group and the nonimproved group (GCS: 13.44+/-2.15, 3.82+/-3.82 respectively; and ONSD: 4.13+/-0.40 mm, 4.86+/-0.37 mm respectively; p<0.05). CONCLUSION : Among the patients with increased ICP, the ONSDs who progressed to good neurological outcomes after treatment had a significantly smaller diameter than those of the others. Through measurement of the ONSDs using ultrasonography, we could not only predict increased ICP but also determine the correlation between a patient's ICP and clinical course.

The Change of the Optic Nerve Sheath Diameter (ONSD) Following Treatment in Patients with Increased ICP

PURPOSE: Many reports have shown that the optic nerve sheath diameter (ONSD) can be measured easily by ultrasonography, and that it becomes wider when the intra-cranial pressure (ICP) is increased. However, there have been no reports comparing the two ONSDs following proper treatment. We measured the 2nd ONSDs of patients who were diagnosed with intra-cranial hemorrhage and increased ICP and who were admitted to an intensive care unit following management of their conditions, and analyzed the changes of the ONSDs and their relationship to the outcomes. METHODS: During the 10 months beginning December 1, 2004, we recruited 29 patients who were suspected to have increased ICP as indicated by computed tomography at the emergency center. Meeting any one of the following criteria was defined as elevated ICP: mid-line shifting of 3 mm or greater due to mass effect; a collapsed 3rd ventricle; hydrocephalus; effacement of sulci with significant edema; abnormal mesencephalic cisterns. We determined initial ONSDs by ultraonography and the Glasgow Coma Scale (GCS). At the 7th hospital day, GCS and ONSDs were re-evaluated and compared against the previous data. RESULTS: 29 patients (21 male, 8 female, average age 55.55 years) were enrolled. Mean GCS at the admission was 7.86+/-3.60. 18 patients had spontaneous hemorrhage (62%) and 11 patients had traumatic hemorrhage (38%). 22 patients received emergency surgery, 18 patients (62%) showed improved neurological outcomes and 11 (38%) failed to achieve any good outcomes. The initial mean ONSD was 5.41+/-0.70 mm. The average ONSD for traumatic hemorrhage (5.51+/-0.45 mm) was not statistically different from the ONSD for non-traumatic hemorrhage (5.35+/-0.84 mm) (p=0.55). The mean ONSD after 7 days of admission was 4.41+/-0.53 mm, which represented a significant decrease compared with the initial measurements (p<0.05). The mean GCS and ONSD showed significant differences between the improved group and the nonimproved group (GCS: 13.44+/-2.15, 3.82+/-3.82 respectively; and ONSD: 4.13+/-0.40 mm, 4.86+/-0.37 mm respectively; p<0.05). CONCLUSION : Among the patients with increased ICP, the ONSDs who progressed to good neurological outcomes after treatment had a significantly smaller diameter than those of the others. Through measurement of the ONSDs using ultrasonography, we could not only predict increased ICP but also determine the correlation between a patient's ICP and clinical course.