Pacemaker lead related myocardial perforation.

Permanent pacemaker (PPM) insertion is widely used to treat cardiac rhythm disorders; approximately 600,000 pacemakers are implanted annually in the US. Almost 9% of patients who receive a permanent pacemaker, however, experience a variety of medical complications such as infections, battery problems, programming issues, lead migration, or lead fracture. Moreover 1-2% of these patients will encounter severe lead-related problems within 30 days of their pacemaker insertion. In this report, we focus on an uncommon but serious complication of PPM insertion: right ventricular lead perforation leading to a pericardial effusion. Although lead perforation is a relatively rare occurrence, this event can be life-threatening, and should be considered in the differential diagnosis when patients present to the emergency department (ED) with relevant symptoms and recent PPM insertion. Specifically, patients who experience complications from pacemaker insertion may present to the ED with a variety of symptoms such as chest pain, syncope, dyspnea, or even dizziness. Pacemaker complications include pneumothorax, pleural and/or pericardial effusions, and infection, placing the patient at serious risk for significant harm. The evaluation of a lead-related issue typically involves chest radiography to visualize abnormal lead placement and check for a pneumothorax or pleural effusion, and a 12­lead electrocardiogram (ECG) to detect pacing errors. We present the case of a patient who presented to the ED three days after his pacemaker insertion with chest pain and dyspnea; he was subsequently diagnosed with a lead perforation into the pericardial space resulting in a pericardial effusion.

Valproic Acid Overdose: Case Report and Literature Review.

BACKGROUND: Valproic acid (VPA) is a common antiepileptic drug that is also used routinely for various psychiatric disorders. VPA toxicity typically manifests as central nervous system depression, while hyperammonemic encephalopathy and hepatotoxicity are potentially life-threatening complications. CASE REPORT: We describe the case of a 56-year-old man who presented to the emergency department after an intentional VPA overdose, was found to have hyperammonemia, and was treated with L-carnitine exclusively. He was subsequently admitted to the hospital for monitoring and serial laboratory testing. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although VPA toxicity has conventionally been managed by gastric decontamination, L-carnitine, and, in severe and refractory cases, extracorporeal removal, recent literature supports the use of carbapenem antibiotics, particularly meropenem. Thus, we report the details of current treatment modalities for VPA toxicity by reviewing current literature.

eFAST exam errors at a level 1 trauma center: A retrospective cohort study.

OBJECTIVES: Extended Focused Assessment with Sonography for Trauma (eFAST) ultrasound exams are central to the care of the unstable trauma patient. We examined six years of eFAST quality assurance data to identify the most common reasons for false positive and false negative eFAST exams. METHODS: This was an observational, retrospective cohort study of trauma activation patients evaluated in an urban, academic Level 1 trauma center. All eFAST exams that were identified as false positive or false negative exams compared with computed tomography (CT) imaging were included. RESULTS: 4860 eFAST exams were performed on trauma patients. 1450 (29.8%) were undocumented, technically limited, or incomplete (missing images). Of the 3410 remaining exams, 180 (5.27%) were true positive and 3128 (91.7%) were true negative. 27 (0.79%) exams were identified as false positive and 75 (2.19%) were identified as false negative. Of the false positive scans, 7 had no CT scan and 8 had correct real-time trauma paper documentation of eFAST exam results when compared to CT and were excluded, leaving 12 false positive scans. Of the false negative scans, 11 were excluded for concordant documentation in real-time trauma room paper documentation, 20 were excluded for no CT scan, and 2 were excluded as incomplete, leaving 42 false negative scans. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam were the most common source of errors. CONCLUSION: The eFAST exams in trauma activation patients are highly accurate. Unfortunately poor documentation and technically limited/incomplete studies represent 29.8% of our eFAST exams. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam are the most common source of errors.

Resource utilisation among patients with syncope presenting to the emergency department.

BACKGROUND: Syncope is a common problem encountered in the emergency department (ED) and a significant source of ED resource utilisation, including advanced imaging modalities. Current guidelines do not recommend routine Computed Tomography (CT) imaging of the head for patients seen in the ED due to syncope. OBJECTIVE: In this study, we investigate resource allocation in the ED for syncope-related visits, including advanced imaging modalities using a large national database. OUTCOMES ANALYSIS: Data from the CDC's National Hospital Ambulatory Medical Care Survey (NHAMCS) for years 2008-2017 were compiled and analysed. Intrinsic survey and constructed variables were utilised to identify and investigate all syncope-related ED visits in the United States during the study period that met study criteria. Appropriate bivariate and multivariate statistical analyses were applied in order to identify and compare the resource utilisation, demographics, and ED visit dynamics of syncope and non-syncope-related ED visits. RESULTS: During the study period, there were over 15 million ED visits for syncope. A high percentage of syncope visits received head CT compared with non-syncope visits (34% vs. 4.5%, P > .001). When investigated by age-grouping utilisation of head CT ranged from 26.5 (95% CI 18.9-27.5) for ages 18-40 to as high as 40.2% (95% CI 33.8-47.1) for ages 80 and higher. Compared with non-syncope ED visits, syncope-related ED visits were older and more likely to have Medicare or private insurance. CONCLUSION: Syncope continues to be a large and growing share of visits to US EDs. Despite well-supported, evidence-based recommendations that do not recommend routine utilisation of head CT in syncope-related ED visits, these data suggest that emergency physicians routinely over-utilise this modality. More specific guidelines may be required to help reduce the use of imaging studies for patients who present to the ED with syncope.

Point of care ultrasound and ocular injuries: A case of lens dislocation and a comprehensive review of the literature.

Point-of-care ultrasound (POCUS) can help the clinician diagnose different ocular pathologies including retinal detachment, vitreous detachment, lens dislocation, and intraocular foreign bodies. Ocular pathologies such as blurry vision, double vision, loss of vision, and eye trauma are common chief complaints and require a comprehensive evaluation in order to determine the etiology and choose the correct treatment. Specifically ultrasound can help the clinician decide whether an urgent ophthalmology consult is appropriate. We present a case in which a lens dislocation was diagnosed using POCUS and review the available literature.

A randomized trial of ultrasound-guided peripheral IV catheter placement in difficult access patients using a guidewire approach.

OBJECTIVE: The purpose of this pilot study was to investigate whether use of a guidewire improves successful placement of ultrasound-guided peripheral IVs (PIV) in difficult intravenous access patients in the emergency department (ED). METHODS: This was an unblinded, prospective, randomized trial performed by emergency medicine (EM) clinicians at a single academic ED. Eligible participants were randomized to ultrasound-guided PIV placement with or without the use of a guidewire. PIV access was obtained using the Accucath™ 20 gauge × 5.7 cm catheters by way of deployment or non-deployment of the guidewire. Primary outcome measure was first-pass success rate and secondary outcomes included number of attempts, complication rates, and clinician reported ease of insertion. RESULTS: Seventy patients were enrolled and 69 were included in the final analysis. Thirty-four participants were randomized to use of guidewire and 35 to no guidewire. First-pass success rates were similar with and without guidewire use, 47.1% vs. 45.7%, (p = 0.9). There were no differences found in median number of attempts between the two techniques, 2 (IQR 1-2) vs 2 (IQR 1-2), (p = 0.60). The complication rates were similar, 15% vs. 29% (p = 0.25). Clinicians reported no difference in ease of insertion between methods on a 5-point Likert Scale, mean 2.6 vs 2.7 (p = 0.76). DISCUSSION: In this pilot study comparing ultrasound-guided PIV placement in ED patients using an integrated guidewire versus no guidewire, there was no significant difference in first-pass success, number of attempts, or complication rates. This study provides preliminary data for further investigations.

Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients.

AIMS: Pulmonary congestion is a common and important finding in heart failure (HF). While clinical examination and chest radiography are insensitive, lung ultrasound (LUS) is a novel technique that may detect and quantify subclinical pulmonary congestion. We sought to independently relate LUS and clinical findings to 6-month HF hospitalizations and all-cause mortality (composite primary outcome). METHODS: We used LUS to examine 195 NYHA class II-IV HF patients (median age 66, 61% men, 74% white, ejection fraction 34%) during routine cardiology outpatient visits. Lung ultrasound was performed in eight chest zones with a pocket ultrasound device (median exam duration 2 min) and analysed offline. RESULTS: In 185 patients with adequate LUS images in all zones, the sum of B-lines (vertical lines on LUS) ranged from 0 to 13. B-lines, analysed by tertiles, were associated with clinical and laboratory markers of congestion. Thirty-two per cent of patients demonstrated ≥3 B-lines on LUS, yet 81% of these patients had no findings on auscultation. During the follow-up period, 50 patients (27%) were hospitalized for HF or died. Patients in the third tertile (≥3 B-lines) had a four-fold higher risk of the primary outcome (adjusted HR 4.08, 95% confidence interval, CI 1.95, 8.54; P < 0.001) compared with those in the first tertile and spent a significantly lower number of days alive and out of the hospital (125 days vs. 165 days; adjusted P < 0.001). CONCLUSIONS: Pulmonary congestion assessed by ultrasound is prevalent in ambulatory patients with chronic HF, is associated with other features of clinical congestion, and identifies those who have worse prognosis.

Bradycardia caused by intravenous nicardipine in an elderly patient with acute ischemic infarct.

Nicardipine is a dihydropyridine calcium-channel blocker that is frequently used in the acute treatment of hypertension in the emergency department (ED). Reflex sympathetic tachycardia is a well-described side effect of this medication. Two experimental studies and 1 anesthesia case report, however, have previously described nicardipine-induced bradycardia as a very rare side effect. We report the case of an elderly patient with an acute ischemic stroke who developed nicardipine-induced bradycardia in the ED.

Point-of-Care Ultrasound Diagnosis of a Catheter-Associated Atrial Thrombus.

BACKGROUND: Emergency physicians can utilize point-of-care thoracic ultrasound to aid in the diagnosis of a variety of cardiovascular and respiratory complaints. CASE REPORT: An emergency physician utilized point-of-care cardiac ultrasound to identify catheter-associated atrial thrombi in a hemodialysis patient presenting with dyspnea. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Based on this case, point-of-care ultrasound can be utilized in patients with central venous catheters, to identify intracardiac thrombi as the cause of dyspnea, thereby facilitating appropriate consultation and treatment.

High Body Mass Index is Strongly Correlated with Decreased Image Quality in Focused Bedside Echocardiography.

BACKGROUND: There is a well-established relationship between obesity, as measured by body mass index (BMI), and overall health risk. The presence of body fat is a known limitation to ultrasound, but it is unknown whether any decrease in quality due to obesity limits the interpretability of focused bedside echocardiography (FBE). OBJECTIVES: To correlate obesity, as measured by BMI, with image quality and interpretability of (FBE) performed by an emergency physician. METHODS: We conducted a prospective observational study in a convenience sample of adults presenting to two academic emergency departments (EDs) and a bariatric surgery outpatient clinic. Twenty patients were enrolled in each of three BMI categories, <30, 30-39, and ≥40 kg/m(2). FBE was performed in multiple views in two positions. Images were rated for ability to discern the pericardial myocardial interface (PMI) and the endocardial border of the left ventricle (ELV). RESULTS: There were 23 males and 37 females enrolled. The median age was 49 years and the median BMI was 35.6 kg/m(2). There was a significant difference in the percentage of technically limited examinations between BMI categories for both PMI and ELV. There was an overall negative linear correlation between BMI and image quality for both PMI and ELV. CONCLUSION: There is an overall decrease in the quality of focused bedside echocardiographic images as BMI increases. This relationship exists for visualization of both the PMI and the ELV. Emergency physicians should be aware of the potential limitations of focused bedside echocardiography in this patient population.

Diagnosis and reduction of a hernia by bedside ultrasound: a case report.

BACKGROUND: Emergency physicians can utilize bedside ultrasound to aid in the diagnosis of abdominal wall hernias and in the reduction of incarcerated hernias. OBJECTIVES: To review the sonographic appearance and diagnostic criteria of abdominal wall hernias and to describe the potential use of ultrasound as an aid in hernia reduction. CASE REPORT: An emergency physician utilized bedside ultrasound to confirm the diagnosis of an incarcerated ventral abdominal wall hernia and to assist in its successful reduction. CONCLUSIONS: A physician trained in bedside ultrasound can diagnose an abdominal wall hernia and facilitate the appropriate treatment of an incarcerated hernia.

Point-of-care ultrasound in a patient with perforated appendicitis.

We present the case of an 8-year-old girl with two emergency department visits for constipation and abdominal pain. Her medical history and physical examination noted by the emergency physician did not reveal a clear etiology of her symptoms until the second visit, when a point-of-care ultrasound was performed. The sonographic findings were consistent with a fecalith surrounded by fluid concerning for appendiceal rupture. A computerized tomographic scan of the abdomen confirmed these findings in addition to two large abscesses in the lower pelvis, which subsequently required percutaneous drainage. This case illustrates the utility of point-of-care ultrasound in the evaluation of the pediatric patient with abdominal pain when appendicitis is a concern, as well as the ability of the emergency physician to use this technology to guide treatment and care of pediatric patients.

Bedside ultrasound diagnosis of vitreous hemorrhage and traumatic lens dislocation.

We report a case where an emergency physician using bedside ocular ultrasound was able to diagnose vitreous hemorrhage and lens dislocation in an elderly patient. Bedside ultrasound performed by a physician trained in this imaging modality can diagnose ocular emergencies, facilitating appropriate consultation and treatment.

Point-of-Care Ultrasound of Post-acute COVID-19 Syndrome: A Prospective Cohort Study.

Introduction Acute COVID-19 patients can suffer from chronic symptoms known as post-acute sequelae of SARS-CoV-2 infection (PASC). Point-of-care ultrasound (POCUS) is established in acute COVID, but its utility in PASC is unclear. We sought to determine the incidence of cardiac and pulmonary abnormalities with POCUS in patients with PASC in a COVID-19 recovery clinic. Methods This prospective cohort study included adults (>18 years old) presenting with cardiopulmonary symptoms to the COVID-19 recovery clinic. A lung ultrasound and standard bedside echocardiogram were performed by ultrasound-trained physicians. Images were interpreted in real time by the performing sonographer and independently by a blinded ultrasound faculty member. Discrepancies in interpretation were addressed by consensus review. A modified Soldati score was calculated by the sum of the scores in each of the 12 lung zones, with each zone score ranging from 0 to 3 (maximum score of 36). The score was then compared to clinical outcomes and outpatient testing.  Results Between April and July 2021, 41 patients received POCUS examinations, with 24 of those included in the study. In all, 15 out of 24 (62.5%) had a normal lung ultrasound. Of the nine subjects with lung abnormalities, the median modified Soldati score was 2. Three patients had trivial pericardial effusions, and all had normal left and right ventricular size and function. Conclusion The majority (62.5%) of patients presenting to the PASC clinic had a normal pulmonary ultrasound, and the vast majority (87.5%) had normal cardiac ultrasounds. These findings suggest that cardiopulmonary symptoms in PASC may be from etiologies not well evaluated by POCUS.

An Interdisciplinary Approach to the Introduction of Point-of-Care Ultrasound in an Urban Academic Primary Care Center.

Introduction Limited guidance exists for primary and urgent care ultrasound applications. This study sought to identify the most useful applications for providers in these clinical settings, to create and implement a structured interdisciplinary point-of-care ultrasound (POCUS) curriculum, and to assess the effectiveness of the course.  Methods This prospective cohort study took place at an urban academic medical center. After a needs-based assessment of ultrasound applications in primary and urgent care, the Emergency Medicine ultrasound faculty and fellows were paired with a primary or urgent care provider (N = 6). The pairings met for scanning sessions in the emergency department to practice image acquisition, documentation, and incorporation of ultrasound into the workflow. Participants were given POCUS pre-work to review before each session. The final bedside session included a formal Objective Standard Clinical Examination (OSCE) to assess learner proficiency to be cleared for independent imaging. The program was assessed using pre- and post-training surveys.  Results The survey results demonstrated that renal, gallbladder, and soft tissue scans were the most interesting and useful to primary and urgent care providers after completion of the training course.  Conclusion The course was effective, and efficient, simple, high-yield POCUS applications should be included in future programs and organizational guidelines for primary and urgent care POCUS education.

Emergency ultrasound diagnosis of ovarian hyperstimulation syndrome: case report.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy. It is a known complication of ovarian stimulation in patients undergoing treatment for infertility. As assisted reproductive technology and the use of ovulation induction agents expands, it is likely that there will be more cases of OHSS presenting to the Emergency Department (ED). OBJECTIVES: OHSS has a broad spectrum of clinical manifestations, from mild abdominal pain to severe cases where there is increased vascular permeability leading to significant fluid accumulation in body cavities and interstitial space. Severe cases may present to the ED with ascites, pericardial effusions, pleural effusions, and lower extremity edema. Through a case report, we review OHSS with an emphasis on early diagnosis by Emergency Physician (EP)-performed bedside ultrasonography. CASE REPORT: We present a case of a patient undergoing treatment for infertility who presented to the ED with shortness of breath and abdominal pain. The diagnosis of severe OHSS was made, largely based on EP-performed bedside ultrasonography showing peritoneal free fluid and bilateral pleural effusions, as well as multiple ovarian follicles. CONCLUSIONS: This report reviews the pathophysiology of OHSS, its clinical features, and pertinent diagnostic and management issues. This report emphasizes the importance of early EP-performed bedside ultrasonography.