Alternative treatment of carpal tunnel syndrome with ultrasound-guided median nerve hydrodissection in the emergency department.

Hydrodissection is becoming increasingly recognized as a treatment for nerve entrapment syndromes in the orthopedic and rehabilitation world. Carpal Tunnel Syndrome (CTS) is the most prevalent nerve entrapment neuropathy, characterized by compression of the median nerve as it passes through the carpal tunnel. Initial management includes NSAIDs and wrist splints, but surgical intervention is often necessary when these measures fail. Ultrasound-guided hydrodissection of the median nerve is both safe and effective and presents a minimally invasive option when first-line treatments fail to provide adequate symptom relief. This case report demonstrates the potential for an alternative approach to analgesia in the Emergency Department (ED) for patients presenting with pain related to CTS. Here we discuss a case of a 26-year-old female presenting with CTS symptoms and her successful treatment with ultrasound-guided hydrodissection in the ED.

Ultrasound guided transgluteal sciatic nerve hydrodissection for the treatment of acute sciatica in the emergency department.

Radicular pain due to sciatica is a common occurrence with a lifetime incidence of up to 40%. Typical approaches to treatment vary and may include topical and oral analgesics, such as opioids, acetaminophen, and non-steroidal anti-inflammatory drugs (NSAIDs); however, these medications may be contraindicated in some or result in untoward effects in others. The use of ultrasound-guided regional anesthesia is an important component of multimodal analgesia in the emergency department. Transgluteal sciatic nerve block has been described as an effective method to treat patients with sciatica but carries risk of injury and falls due to its resultant loss of motor function and potential for systemic toxicity when higher volumes are used. Ultrasound-guided peripheral nerve hydrodissection with D5W has been shown to be an effective treatment of various compressive neuropathies in the outpatient setting. Here we present 4 cases of patients who presented to the emergency department with severe acute sciatica and were treated successfully using an ultrasound guided transgluteal sciatic nerve hydrodissection (TSNH). This technique may offer a safe and effective approach to treating patients with sciatica, but more studies are needed to assess its utility on a larger scale.

Ultrasound guided lumbar erector spinae block: A case series on a novel technique for the treatment of acute low Back pain.

Low back pain is among one of the most common presentations to the emergency department (ED). Regional anesthesia has recently gained traction as an option for analgesia in ED patients, especially in the wake of the opioid epidemic. Data on lumbar application of the ESPB in the setting of acute, refractory low back pain in the ED is scarce. We describe a series of three cases of patients who presented to the ED with severe low back pain refractory to traditional therapy, successfully treated using lumbar ESPB. Lumbar ESPB may be an effective approach to achieving rapid analgesia in patients who present with low back pain who may otherwise be poor candidates for more traditional therapy, such as with opioids or NSAIDs, or who may have refractory pain despite use of these medications.

Point-of-Care Ultrasound in the Evaluation of COVID-19.

BACKGROUND: The novel coronavirus SARS-CoV-2 has caused a pandemic, overwhelming health care systems around the world. Hospitals around the world, including the United States, have been struggling to adapt to the influx of patients with COVID-19, the illness caused by SARS-CoV2, given limited resources and high demand for medical care. OBJECTIVES: This article seeks to provide emergency physicians with a guide to sonographic findings in COVID-19 and an algorithm by which point-of-care lung ultrasound may assist emergency physicians caring for these patients during the SARS-CoV-2 pandemic. DISCUSSION: The studies currently being published have established a typical set of ultrasound findings in COVID-19. Point-of-care lung ultrasound is rapid and accessible in most emergency departments in the United States, and even in many resource-poor settings. CONCLUSION: Point-of-care ultrasound provides numerous benefits to emergency providers caring for patients with COVID-19, including decreasing resource utilization, assisting in diagnosis, guiding management of the critically ill patient, and aiding in rapid triage of patients under investigations for COVID-19.

A novel method of assessing for lung sliding using Doppler imaging.

Ultrasound is an ideal modality in the emergency department (ED) to assess for pneumothorax given its rapid availability, portability, and repeatability to assess clinical status changes. Certain patient populations and clinical circumstances may present challenges to the performance of this examination. In this article, we review patterns of the presence or absence of lung sliding in the commonly utilized sonographic modes in the ED setting. We also describe a novel technique to evaluate lung sliding using tissue Doppler.

Reliability, Laterality and the Effect of Respiration on the Measured Corrected Flow Time of the Carotid Arteries.

BACKGROUND: Corrected flow time (FTc) measured via sonography of the carotid artery is a novel method that has shown promising results for predicting fluid responsiveness in shock states. It is a rapid and noninvasive examination that can be taught to emergency physicians with ease. However, its reliability has not been assessed, and the effects of several variables, including respiration and side of evaluation, are unclear. OBJECTIVES: The objectives were to compare carotid FTc during different phases of the respiratory cycle, (at end-inspiration and end-expiration), to compare FTc reproducibility among providers, and to compare FTc on the right and left sides in a given individual. METHODS: The FTc of both the right and left carotid arteries was measured in 16 healthy volunteers during an inspiratory hold and an expiratory hold. Examinations were completed by three sonographers blinded to previous results and were analyzed for reliability and reproducibility. RESULTS: Reliability and reproducibility were poor when comparing sonographers under all circumstances. No significant differences were found when comparing left vs. right sides of measurement regardless of respiratory phase. CONCLUSION: Although this method for predicting fluid responsiveness has many promising aspects, reproducibility between sonographers was found to be poor. No significant difference was found between the two sides of the body or respiratory phase.

Air and its Sonographic Appearance: Understanding the Artifacts.

BACKGROUND: Although air has traditionally been considered a barrier to sonographic imaging, when encountered in unusual settings it can serve as an important indicator of various pathologic states as well. Clinician recognition and thorough understanding of the characteristic pattern of artifacts generated by air are critical for making a number of important diagnoses. CASE SERIES: We present five emergency department cases in which air was visualized in a pathologic location. Pneumothorax, pneumoperitoneum, necrotizing fasciitis, or Fournier's gangrene, and subcutaneous emphysema and pneumomediastinum, can be rapidly and easily identified on ultrasound by the presence of air artifacts. The relevant sonographic findings are described and discussed in this article. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to its inherent impedance mismatch with other human tissues, air has a characteristic appearance on ultrasound that includes irregular hyperechoic structures, "dirty shadowing," A-lines, and decreased visualization of deeper structures. Knowledge of the sonographic appearance of air artifacts can assist the physician in making a diagnosis, selecting appropriate additional imaging, and enlisting specialist consultation.

Ultrasound-guided dorsal penile nerve block performed in a case of zipper entrapment injury.

Injury to the penis resulting from zipper entrapment is a painful condition that presents a unique anesthetic challenge to the emergency physician and may even require procedural sedation for removal. In this case report, we describe successful removal of zipper entrapment from the penis of a 34-year-old patient after the application of an ultrasound-guided dorsal penile nerve block. We discuss the anatomy, sonographic features, and steps required for the nerve block procedure. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:589-591, 2017.

Ultrasound for the evaluation of soft tissue foreign bodies before and after the addition of fluid to the surrounding interstitial space in a cadaveric model.

BACKGROUND: Point-of-care ultrasound may be used to facilitate foreign body (FB) localization and removal. We hypothesized that injection of normal saline adjacent to an FB may make it easier to detect. METHODS: The study was performed on one embalmed human cadaver. Potential FB sites were created of wood (24), metal (24), and null (24). Two sonographers evaluated each of the 72 sites both before and after a 25-gauge needle was inserted into each incision and 3 cc of normal saline was injected. Accuracy, sensitivity, and specificity were calculated both before and after injection of normal saline. Binomial tests were used to determine the statistical significance of FB detection before and after injection. A 2-tailed Student's t test was used to determine if there was a statistically significant difference between the 2 methods. RESULTS: Preinjection, 116 (81%) of the 144 interpretations (P≤ .001) were correct in their assessment of whether or not an FB was present, with a sensitivity of 81% (95% confidence interval [CI], 72%-88%) and a specificity of 79% (95% CI, 65%-90%). Postinjection, 119 (83%) of these 144 interpretations (P≤ .001) were correct in their assessment of whether or not an FB was present, with a sensitivity of 85% (95% CI, 77%-92%) and a specificity of 77% (95% CI, 63%-88%). This difference was not significant (P=.08; 95% CI, -0.04 to 0.01). DISCUSSION: Ultrasound was reasonably accurate, sensitive, and specific in identifying 1-cm metal and wood FBs. Although accuracy and sensitivity did improve after normal saline injection, this difference was not significant.

The Inter-rater Reliability of Echocardiographic Diastolic Function Evaluation Among Emergency Physician Sonographers.

STUDY OBJECTIVES: In a patient with dyspnea and suspected CHF, the evaluation of diastolic function involves: tissue Doppler of the mitral annulus and 2) pulsed wave Doppler of the mitral inflow. We aimed to 1) determine the inter-rater reliability for overall diastolic function and 2) evaluate the reliability of the individual Doppler measurements. METHODS: A convenience sample of adult emergency department patients was prospectively enrolled by 8 EPs who had participated in a 1-hour didactic session. Patients were selected if they had a history of CHF or suspected abnormal diastolic function due to chronic hypertension. Diastolic function was considered to be abnormal if Tissue Doppler of the septal e' was <8 cm/s and if the lateral e' was <10 cm/s. In cases of discordance, the E/e' ratio was calculated with ≤8 considered normal and >8 considered abnormal. A Kappa coefficient. Bland-Altman plot and a fixed effect regression model were used in the analysis. RESULTS: Thirty-two patients were enrolled, and 3 (9.4%) were excluded due to technical inadequacy. The inter-rater reliability among sonographers for overall interpretation was very good: κ = 0.86 (95% CL [0.67, 1.0]). Based on the Bland-Altman plot, was no consistent bias between readers. There was no evidence to conclude that the readings differed among sonographers: septal e' (p = 0.77), lateral e' (p = 0.89) and E (p = 0.15). CONCLUSION: EP sonographers obtained similar Doppler measurements for diastolic function evaluation with very good inter-rater reliability for the assessment of overall diastolic function.

Foot pain and swelling after minor traumatic injury.

Necrotizing fasciitis is a rare bacterial infection of the fascia and surrounding soft tissue, which carries a mortality rate as high as 20%, even in well-appearing patients [1]. Classically, this diagnosis must be made with computed tomography or magnetic resonance,but recent literature shows that ultrasonography, readily available in the emergency department, may be adequate for diagnosis [2]. We present a case of a 48-year-old man who presented with a painful rash. We used his clinical presentation and ultrasound to make the diagnosis,which was later corroborated with plain radiograph findings. He was taken immediately to the operating room for extensive debridement.He was discharged 8 days later in good condition.

Preferences of air-blood-saline sonographic microbubble contrast agents among emergency medicine resident physicians.

INTRODUCTION: The placement of a central venous catheter (CVC) remains an important intervention in the care of critically ill patients in the emergency department, and bedside ultrasound can be used for procedural guidance as well as conformation of placement. Microbubble contrast-enhanced ultrasound may facilitate CVC tip position localization, and the addition of autologous blood can significantly increase its echogenicity. The purpose of this study was to describe the preferences of a group of resident physicians regarding the performance of various concentrations of air-blood-saline sonographic microbubble contrast agents. METHODS: Institutional Animal Care and Use Committee approved prospective study. A CVC was inserted into the right internal jugular vein of a 20-kg Yorkshire swine under general anesthesia. Contrast mixtures were created with air, saline, and varying amounts of blood and were injected while echocardiographic video clips were recorded and reviewed by 25 physician sonographers. RESULTS: All reading physicians reported increased overall echogenicity, a higher peak echogenicity, and greater personal preference for blood containing solutions. Nearly all reading physicians preferred the lower percentage blood containing mixtures over the higher percentage blood containing mixture. CONCLUSION: The inclusion of 1 to 3 parts of 10 of the patient's blood in the preparation of a sonographic contrast mixture increased the echogenicity of the contrast, resulted in better visualization of both the contrast and the endocardial border and was the preferred mixture among the resident physicians studied.

M-Mode Ultrasound Applications for the Emergency Medicine Physician.

BACKGROUND: M-mode or "motion" mode is a form of ultrasound imaging that is of high clinical utility in the emergency department. It can be used in a variety of situations to evaluate motion and timing, and can document tissue movement in a still image when the recording of a video clip is not feasible. OBJECTIVES: In this article we describe several straightforward and easily performed applications for the emergency physician to incorporate M-mode into his or her practice, including the evaluation for: 1) pneumothorax, 2) left ventricular systolic function, 3) cardiac tamponade, and 4) hypertrophic cardiomyopathy. DISCUSSION: The emergency physician and other point-of-care ultrasound providers can use this versatile function in the evaluation of patients for a number of critical cardiopulmonary diagnoses. CONCLUSION: A great deal of important information may be obtained with M-mode imaging through views and measurements that are relatively easy to obtain.