Incidental Renal Cysts Found by Point-of-Care Ultrasound: A Retrospective Chart Review.

BACKGROUND: Incidental findings are unrelated to a patient's complaint, found on diagnostic imaging, such as point-of-care ultrasound (POCUS). Incidental findings represent potential harms to patients and may lead to increased patient anxiety and health care costs related to downstream testing and surveillance. STUDY OBJECTIVES: In this study, we aimed to calculate the rate of incidental renal cysts found by POCUS. Further, we hoped to describe how emergency physicians relay the findings to patients. Lastly, we hoped to examine if patients suffered harms in the 12 months following identification of an incidental renal cyst. METHODS: From our single-center, academic emergency department (ED), we reviewed renal POCUS images from 1000 consecutive adult ED patients to determine if there was a renal cyst. Next, we performed manual chart review to determine if patients were informed of the incidental renal cyst or suffered any patient harms. RESULTS: We found the prevalence of renal cysts to be 6.5% (95% confidence interval: 4.9%-8.4%). Those with cysts were more likely to be older compared to those without (63 ± 14 vs. 49 ± 15 years of age). Only 8% of patients had evidence that they were informed of their incidental renal cyst. No patients received a biopsy or were diagnosed with renal cell carcinoma or polycystic kidney disease. CONCLUSION: Incidental renal cysts are common and are more likely to be found in older adults. In our study, physicians infrequently informed patients of their incidental finding.

Point-of-care renal ultrasound: Are longitudinal views of the kidney alone sufficient to rule out hydronephrosis?

Objective: Point-of-care ultrasound for the detection of hydronephrosis is frequently used by emergency physicians. The aim of this study was to assess the accuracy of longitudinal views of the kidney compared with a combination of longitudinal and transverse views of the kidney on emergency physician-performed renal point-of-care ultrasound to detect hydronephrosis. Methods: This was a retrospective case-control study of patients who received a renal point-of-care ultrasound examination performed and interpreted as hydronephrosis in the emergency department (ED). These were then matched with a cohort of kidneys from different patients without hydronephrosis. Longitudinal ultrasound views and transverse ultrasound views were reviewed for the presence of hydronephrosis by ultrasound-trained emergency physicians. The gold standard of hydronephrosis was an overall interpretation based on the complete ultrasound examination consisting of both transverse and longitudinal views by ultrasound-trained emergency physicians. Results: Renal point-of-care ultrasound exams from 140 kidneys performed in the ED were enrolled in the study. The sensitivity and specificity of longitudinal ultrasound views compared with a combination of longitudinal and transverse ultrasound views of the kidney as a gold standard were 84.3% (95% confidence interval [CI], 77.2-89.9) and 92.9% (95% CI, 87.3-96.5), the positive predictive value was 92.2% (95% CI, 86.1-96.2), and the negative predictive value was 85.5% (95% CI, 78.9-90.7). The positive and negative likelihood ratios were 11.8 (95% CI, 6.5-21.5) and 0.2 (95% CI, 0.1-0.2), respectively. Conclusions: Longitudinal views of the kidney on ultrasound showed good sensitivity and specificity to detect the presence of hydronephrosis compared with a combination of longitudinal and transverse ultrasound views of the kidney. However, a combination of longitudinal and transverse ultrasound views may still be warranted in high-risk patients or in those with inadequate visualization of the upper pole of the kidney.

Lung Ultrasound Findings in COVID-19: A Descriptive Retrospective Study.

Background Point-of-care ultrasound (POCUS) is an indispensable tool in emergency medicine. With the emergence of the coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a need for improved diagnostic capabilities and prognostic indicators for patients who are symptomatic for COVID-19 has become apparent. POCUS has been demonstrated to be a useful diagnostic and prognostic tool in the emergency department (ED) in assessing other lung complications. Still, limited data regarding its utility in assessing COVID-19 are available. This study sought to evaluate whether POCUS findings in the ED were correlated with vital signs or laboratory abnormalities typically seen among patients with COVID-19. Methods A retrospective study was conducted that included 39 patients who presented with COVID-19 and systemic inflammatory response syndrome (SIRS) to a large, urban tertiary care ED. The study population was limited to adults aged 18 and above who came to the ED with the primary complaint of respiratory symptoms, met SIRS criteria on admission, and had images of at least one anterior and one posterior intercostal space per lung and a minimum of four intercostal spaces. POCUS images were obtained by trained operators in the ED using portable ultrasound machines, recorded in an image database, and reviewed by ultrasound fellowship-trained emergency physicians. Clinical data (e.g., acute phase reactants and vital signs) were obtained through a chart review of patients' electronic medical records. Results  Both the percentage of intercostal spaces with B-lines and the percentage of merging B-lines were correlated with decreased oxygen saturation on presentation. No other statistically significant correlations were observed between these sonographic findings and other vital signs or acute phase reactants, nor between these clinical data and the percentage of intercostal spaces that were positive for the shred sign. Conclusions With the emergence of the COVID-19 pandemic, emergency medicine physicians are on the frontline of identifying and caring for patients affected by the virus. This study found that sonographic findings associated with interstitial pneumonitis, notably merging B-lines, and the overall percentage of intercostal spaces with B-lines, were clearly associated with worsening oxygen saturation, now thought to be one of the driving causes of morbidity and mortality in COVID-19. As ultrasound has become a ubiquitous and indispensable tool in the ED, this study demonstrated its utility in assessing and managing patients with COVID-19. Bedside ultrasound is a cheap, fast, and non-invasive tool that healthcare providers can use as an essential adjunct in addition to laboratory markers and other imaging modalities for the diagnosis and prognosis of COVID-19.

Accuracy of Landmark-guided Glenohumeral Joint Injections as Assessed by Ultrasound in Anterior Shoulder Dislocations.

INTRODUCTION: To determine the accuracy of landmark-guided shoulder joint injections (LGI) with point-of-care ultrasound for patients with anterior shoulder dislocations. METHODS: Patients with anterior shoulder dislocations who underwent LGI were enrolled at our tertiary-care and trauma center. LGI attempts were recorded by an ultrasound fellowship-trained ED physician who determined if they were placed successfully. Pain and satisfaction scores were recorded. RESULTS: A total of 34 patients with anterior shoulder dislocation and their treating ED physicians were enrolled. 41.1% of all LGI were determined to be misplaced (n=14). Patients with successful LGI had a greater decrease in mean pain scores post-LGI. CONCLUSIONS: LGI had a substantial failure rate in our study. Using ultrasound-guidance to assist intra-articular injections may increase its accuracy and thus reduce pain and the need for subsequent procedural sedation.

Occult Pneumothorax Identification on Extended Focused Assessment with Sonography for Trauma Examination in Children.

OBJECTIVE: Occult pneumothoraces (OPTXs) are defined by air within the pleural space that is not visible on conventional chest radiographs (CXR). The aim of this study was to understand how frequently the Extended Focused Assessment with Sonography for Trauma (eFAST) examination identifies occult PTX in a pediatric blunt trauma population as compared with a criterion standard of chest computed tomography (CCT). METHODS: This study is a secondary analysis of blunt trauma patients younger than 18 years who underwent CCT at Los Angeles County +USC Medical Center Emergency Department from October 2015 to April 2017. The eFAST examination was performed and documented by an emergency medicine resident with attending oversight or by an emergency medicine attending for each trauma. The eFAST results were reviewed for patients diagnosed with small or trace pneumothoraces identified on CCT. RESULTS: Of 168 pediatric trauma patients undergoing CCT, 16 had OPTXs not seen on CXR and 4 patients had a small/trace PTX without a corresponding CXR performed. None were identified on eFAST. CONCLUSIONS: Although the sample size in this data set was small, our eFAST examinations identified none of 16 proven and 4 presumed OPTXs. The standard eFAST examination performed poorly in the detection of OPTXs in this single-center study of pediatric blunt trauma victims.

Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department.

Importance: Ocular symptoms represent approximately 2% to 3% of all emergency department (ED) visits. These disease processes may progress to permanent vision loss if not diagnosed and treated quickly. Use of ocular point-of-care ultrasonography (POCUS) may be effective for early and accurate detection of ocular disease. Objective: To perform a large-scale, multicenter study to determine the utility of POCUS for diagnosing retinal detachment, vitreous hemorrhage, and vitreous detachment in the ED. Design, Setting, and Participants: A prospective diagnostic study was conducted at 2 academic EDs and 2 county hospital EDs from February 3, 2016, to April 30, 2018. Patients who were eligible for inclusion were older than 18 years; were English- or Spanish-speaking; presented to the ED with ocular symptoms with concern for retinal detachment, vitreous hemorrhage, or vitreous detachment; and underwent an ophthalmologic consultation that included POCUS. Patients with ocular trauma or suspicion for globe rupture were excluded. The accuracy of the ultrasonographic diagnosis was compared with the criterion standard of the final diagnosis of an ophthalmologist who was masked to the POCUS findings. Seventy-five unique emergency medicine attending physicians, resident physicians, and physician assistants performed ocular ultrasonography. Exposure: Point-of-care ultrasonography performed by an emergency medicine attending physician, resident physician, or physician assistant. Main Outcomes and Measures: Sensitivity and specificity of POCUS in identifying retinal detachment, vitreous hemorrhage, and vitreous detachment in patients presenting to the ED with ocular symptoms. Results: Two hundred twenty-five patients were enrolled. Of these, the mean age was 51 years (range, 18-91 years) and 135 (60.0%) were men; ophthalmologists diagnosed 47 (20.8%) with retinal detachment, 54 (24.0%) with vitreous hemorrhage, and 34 (15.1%) with vitreous detachment. Point-of-care ultrasonography had an overall sensitivity of 96.9% (95% CI, 80.6%-99.6%) and specificity of 88.1% (95% CI, 81.8%-92.4%) for diagnosis of retinal detachment. For diagnosis of vitreous hemorrhage, the sensitivity of POCUS was 81.9% (95% CI, 63.0%-92.4%) and specificity was 82.3% (95% CI, 75.4%-87.5%). For vitreous detachment, the sensitivity was 42.5% (95% CI, 24.7%-62.4%) and specificity was 96.0% (95% CI, 91.2%-98.2%). Conclusions and Relevance: These findings suggest that emergency medicine practitioners can use POCUS to accurately identify retinal detachment, vitreous hemorrhage, and vitreous detachment. Point-of-care ultrasonography is not intended to replace the role of the ophthalmologist for definitive diagnosis of these conditions, but it may serve as an adjunct to help emergency medicine practitioners improve care for patients with ocular symptoms.

More than meets the eye: Point-of-care ultrasound diagnosis of acute optic neuritis in the emergency department.

Optic neuritis (ON) is an inflammatory condition that causes demyelination and thickening of the optic nerve leading to acute/subacute vision loss. It is frequently associated with other conditions like multiple sclerosis, but is often misdiagnosed, which can lead to a suboptimal prognosis. Ultrasound is rarely utilized to help make this diagnosis, even though it can easily detect a thickened retrobulbar optic nerve sheath diameter. We describe four cases in which ultrasonographic measurement of the optic nerve sheath diameter aided in the diagnosis of ON.

FascIOtomy: Ultrasound Evaluation of an Intraosseous Needle Causing Compartment Syndrome.

Intraosseous (IO) needles are used in critically ill patients when it is not possible to quickly obtain venous access. While they allow for immediate access, IO infusions are associated with complications including fractures, infections, and compartment syndrome. We present a case where point-of-care ultrasound was used to quickly identify a malfunctioning IO needle that resulted in compartment syndrome of the lower extremity.

Point-of-Care Ultrasound for the Detection of Traumatic Intracranial Hemorrhage in Infants: A Pilot Study.

OBJECTIVES: Computed tomography is the criterion standard imaging modality to detect intracranial hemorrhage (ICH) in children and infants after closed head injury, but its use can be limited by patient instability, need for sedation, and risk of ionizing radiation exposure. Cranial ultrasound is used routinely to detect intraventricular hemorrhage in neonates. We sought to determine if point-of-care (POC) cranial ultrasound performed by emergency physicians can detect traumatic ICH in infants. METHODS: Infants with ICH diagnosed by computed tomography were identified. For every infant with an ICH, 2 controls with symptoms and diagnoses unrelated to head trauma were identified. Point-of-care cranial ultrasound was performed by an emergency physician on all patients, and video clips were recorded. Two ultrasound fellowship-trained emergency physicians, blinded to the patients' diagnosis and clinical status, independently reviewed the ultrasound clips and determined the presence or absence of ICH. RESULTS: Twelve patients were included in the study, 4 with ICH and 8 controls. Observer 1 identified ICH with 100% sensitivity (95% confidence interval [CI], 40%-100%) and 100% specificity (95% CI, 60%-100%). Observer 2 identified ICH with 50% sensitivity (95% CI, 9%-98%) and 87.5% specificity (95% CI, 47%-99%). Agreement between observers was 75%, κ = 0.4 (P = 0.079; 95% CI, 0-0.95). CONCLUSIONS: Traumatic ICH can be identified with POC cranial ultrasound by ultrasound fellowship-trained emergency physicians. Although variations between observers and wide confidence intervals preclude drawing meaningful conclusions about sensitivity and specificity from this sample, these results support the need for further investigation into the role of POC cranial ultrasound.

The use of ultrasound for peripheral IV placement by vascular access team nurses at a tertiary children's hospital.

PURPOSE: Children receiving treatment in the hospital frequently require intravenous (IV) access. Placement of short peripheral catheters can be painful and challenging especially in those children who have difficult access. Many children's hospitals have teams of specialized vascular access nurses experienced in peripheral catheter insertion, and at times use vein visualization devices, including ultrasound (US), to assist in peripheral IV placement. Our objectives were to describe the prevalence and success rate of US-guided peripheral IV placement by vascular access team nurses at a single tertiary children's hospital. METHODS: We retrospectively reviewed quality assurance data kept by our institution's vascular access team between February, 2014 and March, 2014. Data extracted included: age, gender, number of attempts, if difficult, if ultimately successful and modality used to aid IV placement. Descriptive statistics and chi-square tests were used to analyze and report data. RESULTS: There were 1111 patient-nurse encounters reported for peripheral IV placement over a six-week period, and a total of 1579 attempts. Ultimately 84% of the patients had successful IV placement. Overall, visualization and palpation was the most frequently used technique (50.1%), followed by near-infrared light (40.6%), US (8.0%), and transillumination (1.3%). The success rate of US (60% overall and 59.2% difficult) was not significantly different from other advanced visualization techniques. CONCLUSIONS: Vascular access team nurses use US infrequently for peripheral IV placement, including in children with difficult access. Methods to increase its skillful use in difficult access patients and improve successful IV placements should be explored.

Point-of-Care Ultrasound Diagnosis of Deep Space Hand Infection.

BACKGROUND: Point-of-care ultrasound is emerging as an important imaging modality for characterizing soft-tissue infections and provides advantages over physical examination and magnetic resonance imaging (MRI). CASE REPORT: A 30-year-old man presented to the emergency department with extensive left upper extremity cellulitis. Magnetic resonance imaging of the left arm was preliminarily interpreted as soft-tissue swelling without evidence of deep-space infection. Point-of-care ultrasound revealed pockets of fluid with sonographic fluctuance tracking along the tendon sheath that were concerning for deep abscesses. Based on the ultrasound findings, the patient was taken emergently to the operating room, where multiple left hand and wrist loculated deep-space abscesses were decompressed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report highlights the significant advantages and easy-to-learn findings present in point-of-care ultrasound of musculoskeletal infections.

FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation.

OBJECTIVE: The objective of this study was to examine the ability of Focused Assessment Using Sonography for Trauma (FAST) to discriminate between survivors and nonsurvivors undergoing resuscitative thoracotomy (RT). BACKGROUND: RT is a high-risk, low-salvage procedure performed in arresting trauma patients with poorly defined indications. METHODS: Patients undergoing RT from 10/2010 to 05/2014 were prospectively enrolled. A FAST examination including parasternal/subxiphoid cardiac views was performed before or concurrent with RT. The result was captured as adequate or inadequate with presence or absence of pericardial fluid and/or cardiac motion. A sensitivity analysis utilizing the primary outcome measure of survival to discharge or organ donation was performed. RESULTS: Overall, 187 patients arrived in traumatic arrest and underwent FAST. Median age 31 (1-84), 84.5% male, 51.3% penetrating. Loss of vital signs occurred at the scene in 48.1%, en-route in 23.5%, and in the ED in 28.3%. Emergent left thoracotomy was performed in 77.5% and clamshell thoracotomy in 22.5%. Sustained cardiac activity was regained in 48.1%. However, overall survival was only 3.2%. An additional 1.6% progressed to organ donation. FAST was inadequate in 3.7%, 28.9% demonstrated cardiac motion and 8.6% pericardial fluid. Cardiac motion on FAST was 100% sensitive and 73.7% specific for the identification of survivors and organ donors. CONCLUSIONS: With a high degree of sensitivity for the detection of potential survivors after traumatic arrest, FAST represents an effective method of separating those that do not warrant the risk and resource burden of RT from those who may survive. The likelihood of survival if pericardial fluid and cardiac motion were both absent was zero.

The diagnosis of right heart thrombus by focused cardiac ultrasound in a critically ill patient in compensated shock.

Right heart thrombus (RHT) is a life-threatening diagnosis that is rarely made in the emergency department (ED), but with the increasing use of focused cardiac ultrasound (FocUS), more of these cases may be identified in a timely fashion. We present a case of an ill-appearing patient who had an immediate change in management due to the visualization of RHT soon after arrival to the ED. The diagnosis was confirmed after a cardiology-performed ultrasound (US). This case illustrates the value of the recognition of RHT on FocUS and how US protocols designed for the evaluation of shock and shortness of breath may potentially be expanded to patients in a 'compensated' or 'pre-shock' state to expedite the correct diagnosis and to facilitate more timely management.

Point-of-care ultrasound in diagnosing pyomyositis: a report of three cases.

BACKGROUND: Pyomyositis is a bacterial infection of skeletal muscle that often results in deep intramuscular abscesses. The absence of external dermatologic manifestations in the early stages of pyomyositis makes this a challenging diagnosis. In addition, physical examination findings can be difficult to distinguish from more common processes, such as soft-tissue cellulitis. Clinicians can fail to diagnose this serious disease in a timely manner, resulting in delayed treatment and potential clinical deterioration from sepsis. Although advanced imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI) provide excellent detail, ultrasound (US) can also be used to detect this disease. US can be performed expeditiously at the bedside and is less expensive than CT or MRI. It allows the clinician to examine the deeper tissue planes of muscle, in which purulent fluid collections will develop as pyomyositis advances. CASE REPORT: Three patients presenting with leg pain were evaluated with point-of-care (POC) US and diagnosed with pyomyositis. The early diagnosis of this condition prompted rapid treatment with administration of appropriate antibiotics and involvement of orthopedic surgery. Aspiration of fluid allowed for detailed fluid analysis and bacterial cultures. Additional diagnostic imaging was performed, confirming the initial US diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POC US can be helpful in identifying and further delineating intramuscular abscesses and can subsequently lead to expedited and appropriate care in patients who present with extremity pain, but lack significant dermatologic changes.

Ultrasound detection of a renal mass in a patient with flank pain and hematuria.

Flank pain with hematuria is a common chief complaint in the emergency department (ED). Patients are often diagnosed with renal calculi or pyelonephritis and discharged with analgesics or antibiotics and follow-up. This case study describes a patient who presented to the ED with a 1 week history of flank pain and hematuria and was subsequently found to have a large renal mass on bedside ultrasound.

Bedside ultrasound in a case of blunt scrotal trauma.

This case study describes a patient who suffered blunt force trauma to the scrotum. Use of bedside emergency ultrasound facilitated early diagnosis of a ruptured testicle and allowed for prompt urological consultation and timely surgical repair. The utility of bedside emergency ultrasound in the evaluation of testicular trauma, as well as the outcome of our case, is discussed here.