Utilization of point-of-care ultrasound to evaluate for enterovesical fistula.

Enterovesical fistula formation is a relatively rare disease process although a common complication for patients with inflammatory bowel disease (IBD), notably Crohn's disease. Enterovesical fistulas most commonly arise from diverticulitis (65-80%), cancer (10-20%), or Crohn's disease (5-7%). An increasing amount of evidence supports the use of ultrasonography as the primary imaging method for the monitoring of complications in individuals with a documented history of IBD. Our case report presents a 30-year-old female with a history of Crohn's disease who presented to the Emergency Department with concern for possible enterovesical fistula formation. Using bedside gray-scale ultrasonography, a fistulous tract clearly visualizing air bubbles and fecal matter actively moving from bowel to the bladder through the fistula was visualized confirming the diagnosis of an enterovesical fistula. While CT imaging is instrumental in identifying mural and extramural complications of IBD, performing ultrasonography in patients with IBD serves as an efficient, inexpensive, and noninvasive diagnostic aid for the diagnosis of enterovesical fistula.

Esophageal Stent Migration Diagnosed With Point-of-Care Ultrasound.

This unique case depicts the first published report of a physician using point-of-care ultrasound to diagnose an esophageal stent migration. Discussed in this article are the sonographic findings that clinicians should be familiar with when evaluating patients with abdominal pain or chest pain who have a history of an esophageal stent. When coupled with a high index of suspicion, ultrasound can be one of the most portable, readily available, low-cost, and minimally invasive techniques for making a rapid diagnosis of esophageal stent migration.

Determination of Endovaginal Ultrasound Proficiency and Learning Curve Among Emergency Medicine Trainees.

OBJECTIVES: Performing and interpreting endovaginal ultrasound is an important skill used during the evaluation of obstetric and gynecologic emergencies. This study aims to describe the level of proficiency and confidence achieved after performing 25 endovaginal examinations. METHODS: This is a prospective study at a single urban academic emergency department. Participants performed a minimum of 25 endovaginal ultrasounds under the supervision of a point-of-care ultrasound expert. Anatomical structures were identified by the expert under ultrasound prior to each session. Each examination was scored for agreement of findings between the participant and expert. The data were used to develop a performance curve identifying when proficiency was achieved, where experiential benefit diminished, and when participants felt confident. RESULTS: A total of 1117 endovaginal ultrasound examinations were performed by 50 participants. Agreement after 25 examinations was highest (>95%) for probe insertion and preparation, bladder and uterus identification, and directionality. Agreement was lowest for identification of the ovaries (76%). Experiential benefit plateaus occurred earliest (10 exams) for preparation and insertion followed by bladder identification and directionality. Surprisingly, ovarian experiential benefit plateaued at 16 exams. Participant confidence improved overall and was lowest for the identification of ovaries and abnormal pelvic anatomy. CONCLUSIONS: There is a significant learning curve when performing endovaginal ultrasound. Our data do not support the use of 25 examinations as a minimum standard for identification of the ovaries or abnormal ovarian pathology.

How Many Ultrasound Examinations Are Necessary to Gain Proficiency in Accurately Identifying the Nerves of the Brachial Plexus at the Level of the Interscalene Space?

INTRODUCTION: There has been a trend toward the use of alternative treatments to opioids for adequate pain management. This has paralleled a growing interest in the utilization of bedside point-of-care ultrasonography to guide placement of regional anesthesia in the emergency department. The purpose of this study was to establish the number of supervised examinations required for an emergency medicine resident to gain proficiency in accurately locating and identifying the nerves of the brachial plexus at the level of the interscalene space. METHODS: Proficiency was defined as the number of attempts a resident required to accurately locate and identify the nerves of the brachial plexus on 10 separate, consecutive examinations. Didactic education was provided prior to the study and residents also participated in two instructional hands-on ultrasound examinations prior to the commencement of initial data collection. Count data are summarized using medians, means, and ranges. Random effects negative binomial regression was used for modeling panel count data where negative coefficients indicate increase in proficiency. RESULTS: A total of 24 emergency medicine residents were enrolled in the study. Fourteen males and ten females participated. There were nine PGY-1 residents (37.5%), nine PGY-2 residents (37.5%), and six PGY-3 residents (25%). The median number of required supervised attempts and range for correctly performing both steps in the identification of the nerves of the brachial plexus was 2 (range 2-12). The median starting confidence level was 2 (range 1-4), and the median ending confidence level was 4 (range 1-5). Increases in confidence from start to finish were found to be statistically significant (P < 0.001). CONCLUSION: Emergency medicine residents are easily adept in the identification of the nerves of the brachial plexus at the level of the interscalene space following two supervised examinations. Residents made steady gains in confidence and proficiency throughout the study; statistical analysis found a significant association between the two.

The Effect of Head Rotation on the Relative Vascular Anatomy of the Neck: Implications for Central Venous Access.

CONTEXT: Previous studies have shown that safe venous cannulation is difficult when the internal jugular vein (IJV) overlies the carotid artery (CA) as the probability of inadvertent arterial penetration is greatly increased. AIMS: The goal of this study was to examine the anatomical relationships of the IJV and CA as a function of the degree of head rotation in order to minimize the risk for CA puncture. SETTINGS AND DESIGN: Our study was a prospective study using a sample of 496 Emergency Department patients. METHODS AND MATERIAL: The anatomic relationships of the right and left IJVs and CAs were recorded with head rotation at three different positions. Patients who had the IJV in a 45 to 135 degree relationship to the CA were deemed to be in the high-risk zone for arterial puncture. STATISTICAL ANALYSIS: Chi square, ANOVA. RESULTS: Right IJVs were in the high risk zone for 39.5%, 47.8% and 60.9% of cases at 0, 45 and 80 degrees of head rotation, respectively (P < 0.001). Left IJVs were in the high risk zone for 59.1%, 69.2% and 80.0% at 0, 45 and 80 degrees of head rotation, respectively. (P < 0.001). CONCLUSIONS: Head rotation should be minimized during IJV cannulation to decrease the overlap of CA by IJV. Cannulation of the left IJV appears to carry a higher degree of risk as compared to the right IJV. Placing the head in neutral position, avoiding rotation, and using ultrasound guidance are recommended to minimize complications during central venous access.

Emergency Medicine Resident Assessment of the Emergency Ultrasound Milestones and Current Training Recommendations.

OBJECTIVES: Emergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment. METHODS: This study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents. RESULTS: There were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM. CONCLUSIONS: EM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.

Sonographic identification of peripheral nerves in the forearm.

BACKGROUND: With the growing utilization of ultrasonography in emergency medicine combined with the concern over adequate pain management in the emergency department (ED), ultrasound guidance for peripheral nerve blockade in ED is an area of increasing interest. The medical literature has multiple reports supporting the use of ultrasound guidance in peripheral nerve blocks. However, to perform a peripheral nerve block, one must first be able to reliably identify the specific nerve before the procedure. OBJECTIVE: The primary purpose of this study is to describe the number of supervised peripheral nerve examinations that are necessary for an emergency medicine physician to gain proficiency in accurately locating and identifying the median, radial, and ulnar nerves of the forearm via ultrasound. METHODS: The proficiency outcome was defined as the number of attempts before a resident is able to correctly locate and identify the nerves on ten consecutive examinations. Didactic education was provided via a 1 h lecture on forearm anatomy, sonographic technique, and identification of the nerves. Participants also received two supervised hands-on examinations for each nerve. Count data are summarized using percentages or medians and range. Random effects negative binomial regression was used for modeling panel count data. RESULTS: Complete data for the number of attempts, gender, and postgraduate year (PGY) training year were available for 38 residents. Nineteen males and 19 females performed examinations. The median PGY year in practice was 3 (range 1-3), with 10 (27%) in year 1, 8 (22%) in year 2, and 19 (51%) in year 3 or beyond. The median number (range) of required supervised attempts for radial, median, and ulnar nerves was 1 (0-12), 0 (0-10), and 0 (0-17), respectively. CONCLUSION: We can conclude that the maximum number of supervised attempts to achieve accurate nerve identification was 17 (ulnar), 12 (radial), and 10 (median) in our study. The only significant association was found between years in practice and proficiency (P = 0.025). We plan to expound upon this research with an additional future study that aims to assess the physician's ability to adequately perform peripheral nerve blocks in efforts to decrease the need for more generalized procedural sedation.

Rapid Diagnosis of Rhabdomyolysis with Point-of-Care Ultrasound.

It is important to rapidly diagnosis and treat rhabdomyolysis in order to decrease morbidity and mortality. To date there are no reports in the emergency medicine literature on the use of point-of-care ultrasound in the diagnosis of rhabdomyolysis. This unique case describes how ultrasound was used in the emergency department (ED) to quickly diagnose and treat rhabdomyolysis prior to confirmation with an elevated serum creatine kinase. When coupled with a high index of suspicion, ultrasound can be one of the most portable, readily available, low cost, and minimally invasive techniques for making a rapid diagnosis of rhabdomyolysis in the ED.

Unusual ectopic pregnancies: sonographic findings and implications for management.

Ectopic pregnancy is a considerable source of morbidity and mortality for women of childbearing age. Improved detection and increased risk factors have led to a dramatic rise in the incidence of ectopic pregnancy in recent years. Early diagnosis is critical for the health of the patient as well as the success rate of future pregnancies. Besides laparoscopy, sonography is the mainstay for evaluating ectopic pregnancy. It is important to understand the sonographic features of ectopic pregnancies, including unusual cases that occur outside the fallopian tube.

Pulmonary embolism: An abdominal pain masquerader.

Abdominal pain is an uncommon presenting symptom for pulmonary embolism (PE). A delay in the diagnosis when a patient presents with atypical symptoms can postpone proper treatment and can be catastrophic. We report the case of a 48-year-old male who presented to the emergency department with worsening right upper quadrant abdominal pain. Abnormal findings on biliary ultrasound and chest radiograph could have resulted in misdiagnosis. Instead, the physician maintained a high index of suspicion, and further diagnostic testing revealed a large central PE in the right main pulmonary artery. The present article discusses the dangers of using a pattern recognition approach to medical decision making in patients with abdominal pain. Included are the various pathophysiologic mechanisms that may contribute to the development of abdominal pain in patients with PE. Additionally, we review the role of chest radiography in the setting of PE and present the findings that ultimately lead to the diagnosis.

Bedside ultrasound in the diagnosis of uterine rupture following surgical abortion.

Reports of uterine rupture following surgical abortion are rare but may result in hemorrhage, sepsis, and even death. In this unique case, we describe how a transabdominal pelvic ultrasound performed at the bedside by an emergency department physician identified uterine rupture with retained products of conception and led to an emergent laparotomy and hysterectomy. This case illustrates how bedside ultrasound may be used in patients presenting with abdominopelvic pain following surgical abortion to shorten the time to definitive treatment and ultimately lower the morbidity and mortality associated with a diagnosis of life-threatening uterine rupture.

Bilateral dacryoadenitis.

Acute dacryoadenitis is an uncommon condition that involves inflammation of the lacrimal gland. In rare instances, dacryoadenitis may be bilateral. A delay in proper treatment of an otherwise simple case of dacryoadenitis may lead to significant soft tissue morbidity such as cellulitis, lacrimal gland abscess, or orbital abscess. We report the case of a 24-year-old male who presented to the emergency department with acute bilateral dacryoadenitis. The patient's symptoms did not respond to oral antibiotics and he subsequently required admission for intravenous antibiotics. During his hospitalization the patient had diagnostic testing to try to determine the etiology for his symptoms. The unique aspects of managing a case of bilateral dacryoadenitis as well as treatment recommendations are discussed in this case report.

Esophageal rupture diagnosed with bedside ultrasound.

A 69-year-old man presented to the emergency department with hematemesis, hypotension, tachycardia, and hypothermia. The emergency physician performed a bedside ultrasound of the chest, heart, and abdomen. The heart was unable to be visualized in the parasternal, apical, or subxiphoid windows, and free fluid and particulate matter were visualized in the chest and abdomen. The inability to visualize the heart in the normal cardiac windows suggested a diagnosis of pneumopericardium. Based upon the patient's presenting symptoms and ultrasound findings, an esophageal perforation was suspected. Esophageal perforation is a medical emergency. Deterioration and death due to sepsis can occur within hours of presentation [6]. Although there is a great deal of literature discussing the diagnosis of esophageal perforation by chest radiograph, computed tomography (CT), and esophagography, there are no articles on the role of ultrasound. Esophageal perforation may result in the communication of air between the esophagus and pericardium and the leakage of gastric contents into the chest and peritoneal cavity. The presence of air in the pericardial sac results in nonvisualization of the heart on ultrasound. Fluid in the chest and abdomen may be visualized in the posterior upper abdominal windows. Although these ultrasound findings alone are not entirely specific for esophageal perforation, when coupled with a high index of suspicion due to the patient presentation, ultrasound can be one of the most portable, readily available, low-cost, and minimally invasive techniques to make the diagnosis of esophageal perforation.

Posttraumatic appendicitis: further extending the extended Focused Assessment with Sonography in Trauma examination.

Several cases of appendicitis after blunt abdominal trauma have been reported in the literature. A 41-year-old man on a cruise ship began to experience acute abdominal pain several hours after cliff diving from a 20-ft height and landing hard against the water on his right side. The patient's symptoms were treated and he remained on the ship until its scheduled arrival in port 2 days later. In the emergency department, a bedside extended Focused Assessment with Sonography in Trauma (eFAST) examination showed no evidence of free fluid in the abdominal cavity, pericardial effusion, or pneumothorax. Next, an ultrasound of the right lower quadrant was performed, which revealed a 1.06 cm, noncompressible appendix consistent with appendicitis. Although physical examination remains the gold standard for evaluation of the acute abdomen, the presentation of acute appendicitis is historically unreliable and delays in its diagnosis can result in significant increases in morbidity and mortality. Ultrasonography has been shown to have clear value in the evaluation of the acute abdomen. It is the authors' opinion that ultrasonography may have an unrealized potential as a diagnostic tool for traumatic appendicitis in the trauma bay and as a triage tool for the cruise ship physician who must evaluate a patient with traumatic abdominal pain and determine the need for medical evacuation.