Point-of-Care Ultrasound in the Evaluation of the Acutely Painful Red Eye.

BACKGROUND: Visual loss, ocular pain, and red eye are common presentations to front-line physicians in the emergency department, urgent care centers, or the primary care office. In recent decades, point-of-care ultrasound (POCUS) has been used by clinicians at the bedside in the evaluation and management of a vast array of patients, including those with ocular complaints. CASE REPORT: A 33-year-old man presented to the emergency department with left eye pain for 4 weeks' duration. The physical examination revealed visual acuity of 20/400 in the affected eye and diffuse conjunctival injection with perilimbal sparing and scleral edema. Using POCUS, he was noted to have diffuse thickening of the globe wall in the symptomatic eye with a thin layer of fluid posterior to the globe in Tenon's space and mild enlargement of the optic nerve sheath diameter. He was ultimately diagnosed with posterior scleritis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Posterior scleritis carries the potential for significant visual impairment when the diagnosis is missed or delayed. POCUS findings can aid the front-line physician in making the diagnosis of posterior scleritis allowing earlier initiation of appropriate therapy and follow-up.

High-frequency linear transducer improves detection of an intrauterine pregnancy in first-trimester ultrasonography.

OBJECTIVE: The objective was to determine if the need for transvaginal ultrasonographic examination can be decreased by the addition of the transabdominal high-frequency, 12-4-MHz linear transducer after a failed examination with the 6-2-mHz curvilinear transducer when evaluating for an intrauterine pregnancy (IUP). METHODS: This is a prospective pilot study of women in their first trimester of pregnancy presenting to the emergency department with abdominal pain and/or vaginal bleeding. If no IUP was identified using the curvilinear transducer via the transabdominal approach, they were subsequently scanned using the linear transducer. Patients without evidence of an IUP transabdominally were scanned via the transvaginal approach. RESULTS: Eighty-one patients were evaluated; no IUP was visualized in 27 using the standard curvilinear transducer approach, and these then had an ultrasonography performed with the linear transducer. Of these, 9 patients (33.3%; 0.95 confidence interval [CO], 15.5%-51.1%) were found to have an IUP with the linear transducer. For the 18 patients who received a transvaginal scan, 15 patients (83.3%; 0.95 CI, 66.1%-100%) had no IUP identified with the transvaginal transducer, and 3 (16.7%; 0.95 CI, 0%-33.9%) had an IUP identified. CONCLUSIONS: The transabdominal use of a high-frequency linear transducer in the evaluation of patients in the first trimester after failed curvilinear transducer results in a clinically significant reduction in the need for transvaginal ultrasonography to confirm the presence of an IUP.

Lung Ultrasound Utility in the Management of the Neurologically Deceased Organ Donor.

CONTEXT: Lung transplantation is limited by donor lung availability with ∼20% of deceased donor lungs transplanted. Diagnostic testing identifying pulmonary derangements guide donor management strategies to maximize lung transplantation. Lung ultrasound (LUS) identifies pathology in critically ill patients equivalent or superior to chest radiograph (CXR) or computed tomography (CT) scans. No published studies have reported on LUS in neurologically deceased donors (DNDDs). OBJECTIVE: We evaluated LUS in identifying abnormal lung pathology in DNDDs and related these findings to the standard approach. DESIGN: Prospective pilot study. SETTING: Intensive care units, university-associated teaching hospital. PARTICIPANTS: Six DNDDs evaluated during donor management. INTERVENTIONS: Deceased donors were enrolled based on the availability of ultrasound operators (USOs). Bedside LUS was performed using Lichtenstein 3- or Volpicelli 4-zone method based on the operator preference. Lungs were evaluated for sliding, A/B profile, consolidation, or pleural fluid. Ultrasound operators were blinded to donor management data. Lung ultrasound interpretations were compared for interindividual variability. Ultrasound and anteroposterior portable CXR (AP-CXR) results were compared by Organ Procurement Organization medical directors. MEASUREMENTS AND MAIN RESULTS: Bedside LUS compared well to AP-CXRs during donor management. There was no interindividual variability noted among USOs. Lung ultrasound identified all findings on AP-CXR and additional clinical pathology not reported on AP-CXR. Reports on AP-CXRs took a median 202 (13-696) minutes to occur, with LUS results available immediately. CONCLUSIONS: Lung ultrasound may play a significant role in donor management providing real-time clinical data, allowing for rapid identification of abnormalities, and leading to management interventions that may increase the number of transplanted lungs.

Elongated left lobe of the liver mimicking a subcapsular hematoma of the spleen on the focused assessment with sonography for trauma exam.

The focused assessment with sonography for trauma examination has assumed the role of initial screening examination for the presence or absence of hemoperitoneum in the patient with blunt abdominal trauma. Sonographic pitfalls associated with the examination have primarily been related to mistaking contained fluid collections with hemoperitoneum. We present a case in which an elongated left lobe of the liver was misdiagnosed as a splenic subcapsular hematoma. It is imperative that emergency physicians and trauma surgeons be familiar with this normal variant of the liver and its associated sonographic appearance on the perisplenic window in order to prevent nontherapeutic laparotomies or embolizations.

Two-point Compression Ultrasound Technique Risks Missing Isolated Femoral Vein DVTs.

BACKGROUND: Deep vein thrombosis (DVT) is a common vascular problem seen in the emergency department (ED) and is commonly identified using ultrasound performed by a vascular lab, the radiology department, or at the point of care. Previous studies have assessed the utility of a two-point vs sequential technique to identify the presence of a thrombus. One particular study reported a concerning rate of isolated femoral vein thrombi that would be missed by a two-point technique. OBJECTIVES: In this study we sought to determine whether the two-point technique misses isolated femoral vein thrombi. METHODS: We conducted a retrospective review of patients who had a new diagnosis of DVT in the ED diagnosed with vascular lab, radiology, or point-of-care ultrasound to assess for the presence and rate of thrombi that would be missed using a two-point scanning technique. RESULTS: We included in our study 356 patients with a diagnosis of new DVT. In our population, 21 (5.9%; 0.95 confidence interval: 3.7%, 8.9%) patients were identified with thrombi isolated to the femoral vein. CONCLUSION: The two-point technique for lower extremity vascular ultrasound is insufficient for ruling out proximal DVTs in ED patients.

Ultrasound-guided peripheral intravenous access in chronic kidney disease patients.

OBJECTIVE: Ultrasound-guided peripheral intravenous (USPIV) catheters are being placed in emergency department (ED) patients with increasing frequency. USPIV catheters have been shown to improve the success rates of cannulation. It is unknown what the long-term effect of USPIV placement will be on fistula creation in chronic kidney disease (CKD) patients considering these ultrasound-guided peripheral lines often target the same deeper vessels used for fistulas. This study aimed to survey whether emergency medicine programs place restrictions on USPIV placement in patients with CKD stages 3-5. METHODS: This was a survey study encompassing all 110 emergency ultrasound fellowship directors in the United States at the time the survey was conducted. Data was collected on an anonymous and voluntary basis. The primary outcome was the number of programs with restrictions on USPIV placement in patients with CKD stage 3 or greater. RESULTS: Of the 56 programs that responded, 21% reported having policies limiting which patients were appropriate for USPIV. Despite this, only one program reported placing restrictions on USPIV in CKD stage 3 or greater (p < 0.0001). CONCLUSIONS: Emergency departments do not have or follow restrictions placed on USPIV placement in patients with CKD stage 3 or greater. The use of these veins in the ED may result in thrombosis as well as inflammation and permanent scarring which could negatively impact the ability to utilize those vessels for fistula creation. Future studies are needed to further characterize the impact of USPIV on fistula creation.