An Approach to Point-Of-Care Ultrasound Evaluation of the Abdominal Aorta.

Disorders of the abdominal aorta, including aneurysms and dissection, have potentially high rates of morbidity and mortality. While computed tomography (CT) is the current gold standard to image the abdominal aorta, the process of obtaining a CT may be time-consuming, requires the use of intravenous contrast dye, and involves exposure to ionizing radiation. Point-of-care Ultrasound (POCUS) can be performed at the bedside and has excellent sensitivity and specificity for the diagnosis of abdominal aortic aneurysm and excellent specificity for the diagnosis of abdominal aortic dissection. Additionally, POCUS is non-invasive, cost-effective, lacks ionizing radiation, requires no intravenous contrast dye, and can be performed without taking the patient from a critical care area. Screening for abdominal aortic aneurysm (AAA) can be done in primary care settings as well. This article will review the approach to POCUS of the abdominal aorta to evaluate such critical pathology. In this paper, we will review the sonographic anatomy of the abdominal aorta as well as the choice of the ultrasound probe, description of POCUS image acquisition, and some pearls and pitfalls of using POCUS to aid in the diagnosis of potentially life-threatening abdominal aortic pathology.

Comparison of dynamic versus static ultrasound to confirm endotracheal tube depth.

INTRODUCTION: After endotracheal intubation is performed, the location of the endotracheal tube (ETT) is confirmed followed by assessment of ETT depth. Physical examination can be unreliable and chest radiographs can lead to delayed recognition. Ultrasound may facilitate rapid determination of ETT depth at the bedside; however, the ideal technique is unknown. METHODS: This was a randomized trial comparing the static versus dynamic technique for ETT depth assessment using a cadaver model. The ETT was randomized to correct versus deep placement. Seven physicians blinded to ETT location assessed the location using static (direct visualization of an inflated cuff) versus dynamic (active inflation of the ETT cuff) visualization. Outcomes included diagnostic accuracy, time to identification, and operator confidence with subgroup analyses by physician ultrasound experience. RESULTS: 420 total assessments were performed. The static technique was 99.1% (95% CI 94.8%-100%) sensitive and 97.1% (95% CI 91.9%-99.4%) specific. The dynamic technique was 100% (95% CI 96.7%-100%) sensitive and 100% (95% CI 96.7%-100%) specific. Time to identification was faster for the static technique (6.6 s; 95% CI 5.9-7.4 s) versus the dynamic technique (8.7 s; 95% CI 8.0-9.5 s). Operator confidence was lower for the static technique (4.4/5.0; 95% CI 4.3-4.5) versus the dynamic technique (4.7/5.0; 95% CI 4.6-4.8). There were no differences in the findings when assessed among expert or non-expert sonographers. CONCLUSION: There was no statistically significant difference in the accuracy of ETT depth identification between the static or dynamic technique. However, utilizing the dynamic technique showed a statistically significant improvement in sonographer confidence and a concomitant increase in time to identification.

Diagnostic accuracy of ultrasound to confirm endotracheal tube depth.

INTRODUCTION: Endotracheal intubation is commonly performed in the Emergency Department. Traditional measures for estimating and confirming the endotracheal tube (ETT) depth may be inaccurate or lead to delayed recognition. Ultrasound may offer a rapid tool to confirm ETT depth at the bedside. METHODS: This was a randomized trial assessing the diagnostic accuracy of ultrasound to confirm ETT depth. Three cadavers were intubated in a random sequence with the ETT placed high (directly below the vocal cords), middle (2 cm above the carina), or deep (ETT at the carina). Seven blinded sonographers assessed the depth of the ETT using ultrasound. Outcomes included diagnostic accuracy of sonographer identification, time to identification, and operator confidence based upon ETT location. A subgroup analysis was performed to assess diagnostic accuracy by operator confidence. RESULTS: 441 total assessments were performed (154 high, 154 middle, and 133 deep ETT placements). Overall accuracy was 84.8% (95% CI 81.1% to 88.0%). When placed high, ultrasound was 82.5% sensitive (95% CI 75.5% to 88.1%) and 92.3% specific (95% CI 88.6% to 95.1%) with a mean time to identification of 15.3 s (95% CI 13.6-17.0) and a mean operator confidence of 3.9/5.0 (95% CI 3.7-4.1). When the ETT was placed in the middle, ultrasound was 83.8% sensitive (95% CI 77.0% to 89.2%) and 92.3% specific (95% CI 88.6% to 95.1%) with a mean time to identification of 16.7 s (95% CI 14.6-18.8) and a mean operator confidence of 3.7/5.0 (95% CI 3.5-3.9). When the ETT was placed deep, ultrasound was 88.0% sensitive (95% CI 81.2% to 93.0%) and 92.2% specific (95% CI 88.6% to 94.6%) with a mean time to identification of 19.0 s (95% CI 17.3-20.7) and a mean operator confidence of 3.4/5.0 (95% CI 3.2-3.6). Sonographers were significantly more accurate when they reported a higher confidence score. CONCLUSION: Ultrasound was moderately accurate for identifying the ETT location in a cadaveric model and was more accurate when sonographers felt confident with their visualization. Future research should determine the accuracy of combining transtracheal ultrasound with lung sliding and other modifications to improve the accuracy.

Hypotension Unresponsive to Fluid Resuscitation: A Case Report.

INTRODUCTION: Iron deficiency anemia is commonly seen in the emergency department (ED), and the cause can be complex and variable. CASE REPORT: We present a case of a female without known medical history who presented to the ED for generalized weakness and was found to have severe anemia in the setting of chronic lice infestation. CONCLUSION: Severe and chronic pediculosis can cause chronic blood loss and be an unusual and rare cause of iron deficiency anemia. In the setting of anemia and hypotension unresponsive to fluid resuscitation, consideration should be given to early packed red blood cell transfusion and subsequent investigation of causes of severe anemia.

Comparison of saline versus air for identifying endotracheal intubation with ultrasound.

INTRODUCTION: After intubation has been performed, it is important to rapidly confirm the correct location of the endotracheal tube (ETT). Multiple techniques have been described, each with different limitations. Ultrasound has been increasingly recognized as an alternate modality for identifying the ETT location. However, it can be challenging to visualize the air-filled ETT cuff. Saline insufflation of the ETT cuff has been suggested to improve visualization of the ETT but data are limited. Our study sought to compare the diagnostic accuracy of air versus saline ETT cuff inflation on the diagnostic accuracy of intubation. METHODS: This was a randomized trial comparing air versus saline cuff inflation using a cadaver model. Adult cadavers were intubated in a random sequence with respect to both the location of intubation (i.e., tracheal vs esophageal) and air versus saline. Blinded sonographers assessed the location of the ETT using the static technique. Outcomes included accuracy of sonographer identification, time to identification, and operator confidence. RESULTS: 480 total assessments were performed. When using air, ultrasound was 95.8% sensitive (95% CI 90.5% to 98.6%) and 100% specific (95% CI 97.0% to 100%) with a mean time to confirmation of 8.5 s (95% CI 7.6 s to 9.4 s) and a mean operator confidence of 4.32/5.0 (95% CI 4.21 to 4.42). When using saline, ultrasound was 100% sensitive (95% CI 97.0% to 100%) and 100% specific (95% CI 97.0% to 100%) with a mean time to confirmation of 6.3 s (95% CI 5.9 s to 6.8 s) and a mean operator confidence of 4.52/5.0 (95% CI 4.44 to 4.60). CONCLUSION: There was no statistically significant difference between air versus saline for intubation confirmation. However, saline was associated with fewer false negatives. Additionally, time to confirmation was faster and operator confidence was higher with the saline group. Further studies should determine if the outcomes would change with more novice sonographers or in specific patient populations.

Current Applications of Pediatric Abdominal Point-of-Care Ultrasound.

Point-of-care ultrasound (POCUS) for pediatric abdominal symptoms has expanded in both the inpatient and outpatient settings. POCUS may be used to aid in the diagnosis of appendicitis, hypertrophic pyloric stenosis, and intussusception in the pediatric population. This article reviews the benefits of POCUS for the diagnosis of these pediatric pathologies. This article also provides instruction on how to perform these important examinations. [Pediatr Ann. 2021;50(10):e419-e423.].

Erectile dysfunction and viagra use: what's up with college-age males?

We surveyed 234 sexually active males aged 18-25 years about erectile dysfunction (ED). Thirteen percent reported ED, but rarely discussed this with medical providers; 25% reported ED occurring with condom use, which was associated with risky sex. Six percent used ED medications, rarely under medical supervision, and often mixed with recreational drugs.