Bedside Emergency Ultrasonography Research Articles

Evaluation of a Short‐term Training Program in Bedside Emergency Ultrasound in Southwestern Tanzania

To evaluate the effect of a short-term training program in emergency ultrasound on physician skills and attitudes in southwestern Tanzania. Eight registrar physicians at Mbeya Zonal Referral Hospital (Mbeya, Tanzania) underwent a 5-day course in bedside emergency ultrasound, focusing primarily on the focused assessment with sonography for trauma examination, including didactic sessions, practical sessions, and on-job training. The impact on ultrasound knowledge was assessed by pretest and posttest evaluations. Provider skill was evaluated by a standardized observed simulated patient encounter. Attitudes toward ultrasound training, utility, and self-confidence were assessed by a post-training questionnaire. All 8 physicians who began the training completed the course and successfully passed their objective structured clinical examination. There was a statistically significant improvement in written ultrasound test scores from 31% to 66% (P < .01) after the course. Most trainees felt confident performing and interpreting a basic focused assessment with sonography for trauma examination at the end of the course, and 7 of 8 stated that they would consider paying tuition for similar courses in the future. Main concerns with the course revolved around insufficient time dedicated to practicing under supervision. Registrar physicians in Tanzania can effectively learn basic emergency ultrasound skills in a short-term training program. Similar future programs may consider heavier emphasis on practical hands-on training with experts. Ongoing data collection is required to understand the true impact of such training on long-term ultrasound use and patient outcomes.

Retained Products of Conception: An Atypical Presentation Diagnosed Immediately with Bedside Emergency Ultrasound.

Background. Retained products of conception is an important diagnosis to consider in patients presenting with postpartum complaints. Bedside ultrasound is a rapid, accurate, noninvasive modality to evaluate these patients. Objective. To report an atypical case of retained products of conception diagnosed with bedside ultrasound in the emergency department. Case Report. A 27-year-old female who was 1-month postpartum presented with vaginal bleeding, pelvic pain, and no fever. At the time of initial H&P, bedside ultrasound revealed echogenic material within the endometrial cavity with blood flow seen by color Doppler consistent with retained products of conception. The bedside ultrasound rapidly narrowed the differential and allowed a definitive diagnosis immediately. Ob/Gyn was consulted and dilation and curettage was performed in the operating room. Conclusions. Retained products of conception is an important diagnosis for the emergency physician to consider in at-risk patients. The sonographic findings are easily obtained and interpreted by emergency physicians. Earlier diagnosis of this disease process should lead to more focused patient evaluations and management.

Bedside Emergency Ultrasound in a Case of Acute Parotid Duct Sialolithiasis

BackgroundSialolithiasis with salivary gland obstruction can mimic more frequently occurring illnesses such as facial and dental infection and abscess. It is often difficult to discern the etiology of facial pain and swelling on physical examination alone, requiring advanced imaging in the emergency department. Case ReportWe describe the case of a 37-year-old man who presented with 5 days of worsening unilateral facial pain and swelling. Use of bedside emergency ultrasound by an emergency physician (EP) led to an appropriate diagnosis of parotid duct sialolithiasis. Why Should an Emergency Physician Be Aware of This? Use of bedside emergency ultrasound performed by a trained EP successfully diagnosed symptomatic sialolithiasis of the parotid duct in the emergency department without the need for computed tomography. The utility of bedside emergency ultrasound in the evaluation of sialolithiasis and the outcomes of our case are discussed here.

Spontaneous Rupture of Splenic Varices: A Rare but Lethal Complication of Portal Hypertension from Cirrhosis

Intra-abdominal varices rupture is a rare but catastrophic complication in cirrhosis. We report our near-miss experience in a woman presenting with acute abdominal pain and shock. This 55-year-old cirrhotic woman presented with sudden onset of epigastric pain. On arrival, her blood pressure was 57/49 mmHg and physical examination revealed epigastric tenderness without rebounding tenderness. Emergency ultrasonography (EUS) showed intra-abdominal haemorrhage. Computed tomography revealed haemoperitoneum but no extravasation of contrast medium. She received conservative treatment first but laparotomy later for ongoing bleeding. Surgeon identified and ligated a ruptured splenic varix and she was discharged home after nine days of hospitalisation. This case report illustrates the use of bedside EUS in cirrhotic patients presenting with acute abdominal pain. (Hong Kong j.emerg.med. 2014;21:120-123)

Warfarin Induced Iliopsoas Hematoma Detected by Bedside Emergency Ultrasonography

Warfarin is frequently used as an oral anticoagulant in a variety of clinical settings, e.g. atrial fibrillation or following valvular heart disease. The most serious and common complication associated with anticoagulation using warfarin is bleeding. Hemorrhage into the iliopsoas muscle causing femoral neuropathy is an infrequent complication of anticoagulant therapy. Two women, 53 and 70 year-old, each with a history of mitral valve replacement surgery, presented at the emergency department with right hip pain. They had been taking warfarin 5 mg once a day since their operations. Physical examinations were normal except for the right hip pain,on movement and femoral nerve palsy in the second patient. Prothrombin, activated prothrombin time and international normalized ratio were prolonged. In order to make the differential diagnosis, we decided to perform bedside emergency ultrasound examination. Ultrasound examination of the patients showed an anechoic lesion in the area of the right iliopsoas muscle. They were admitted to hospital for observation and treatment. Fresh frozen plasma and vitamin K were given for treatment. The possibility of iliopsoas hematoma should be considered in any patient with hip pain undergoing anticoagulant treatment.

Warfarin Induced Iliopsoas Hematoma Detected by Bedside Emergency Ultrasonography

Warfarin Induced Iliopsoas Hematoma Detected by Bedside Emergency Ultrasonography

Procedural Applications of Bedside Emergency Ultrasound

Bedside emergency ultrasound (EUS) has been used for decades by emergency physicians and has recently begun to gain widespread acceptance in the pediatric emergency medicine arena. The use of bedside EUS for procedural assistance is a rapidly growing trend in pediatric emergency care. Its use for procedural purposes is aimed at not only improving the success rates of the procedure itself but also reducing complications and, thus, maximizing patient safety. The need to limit these unfavorable consequences resulting from necessary procedures is a powerful force, driving placement of EUS in the pediatric emergency department. Researchers continue to identify new applications for this exciting technology as practitioners are gaining expertise with proper training and education. As the range of procedural applications expands, the pediatric emergency care practitioner will need to become familiar with this evolving technology.

Bedside emergency cardiac ultrasound in children.

Bedside emergency ultrasound has rapidly developed over the past several years and has now become part of the standard of care for several applications. While it has only recently been applied to critically ill pediatric patients, several of the well-established adult indications may be applied to pediatric patients. One of the most important and life-saving applications is bedside echocardiography. While bedside emergency ultrasonography does not serve to replace formal comprehensive studies, it serves as an extension of the physical examination. It is especially useful as a rapid and effective tool in the diagnosis of pericardial effusions, tamponade and in distinguishing potentially reversible causes of pulseless electrical activity from asystole. Most recently, left ventricular function and inferior vena cava measurements have proven helpful in the assessment of undifferentiated hypotension and shock in adults and children. Future research remains to be carried out in determining the efficacy of bedside ultrasonography in pediatric-specific pathology such as congenital heart disease. This article serves as a comprehensive review of the adult literature and a review of the recent applications in the pediatric emergency department. It also highlights the techniques of bedside ultrasonography with examples of normal and pathologic images.

Thirteen-week cornual ectopic pregnancy

We present the unusual case of a 13-week cornual ectopic pregnancy with fetal movement. The patient presented with a protuberant abdomen, intoxicated with cocaine and alcohol, and in hemodynamic compromise. Bedside emergency ultrasonography led to rapid diagnosis and treatment.

269: Analysis of Lawsuits Filed Against Emergency Physicians Over Bedside Emergency Ultrasound Examination Performance or Interpretation Over a 20-Year Period

Recent increase in ultrasound (US) use by emergency physicians has led to concern regarding litigation from missed diagnosis on bedside emergency US. We sought to define the extent of lawsuits filed against emergency physicians over bedside emergency US performance and interpretation during the last 20 years nationwide.

Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience

Objectives The objective of this study was to describe diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasound (US) in an established emergency US program. Methods This was a retrospective study on patients presenting over a 2-year period performed at a level I urban academic emergency department (ED). The ED sees 78 000 patients annually and has a residency and active US program. Patients were eligible for inclusion if they were pregnant, seen in the ED for a first-trimester complication, and underwent a bedside emergency US suggesting an ectopic pregnancy. Emergency department US logs were reviewed for findings suggestive of ectopic pregnancy. Medical records were reviewed for history, physical examination findings, laboratory results, additional diagnostic testing, management, hospital course, and a discharge diagnosis by the admitting obstetric service (OB). Patients with incomplete data were excluded from analysis. Statistical analysis consisted of descriptive statistics. Results Seventy-four patients ranging in age from 16 to 39 years (mean, 25 years) were included in the study. Eight patients with incomplete data were excluded from analysis. Emergency-physician US diagnoses included definite ectopic pregnancy (6/74), probable ectopic pregnancy (28/74), and possible ectopic pregnancy (40/74). Forty-seven (64%) of these patients were eventually diagnosed with definite ectopic pregnancy by the OB. During initial consultation, the OB disagreed with the diagnosis of ectopic pregnancy in 15 (32%) of the 47 eventual patients with ectopic pregnancy, calling them miscarriages. Other eventual diagnoses included 9 (12%) patients with possible ectopic pregnancy, 11 (14%) patients with miscarriage, and 7 (9%) with intrauterine pregnancy. Emergency sonologists found tubal rings in 9 (19%) patients with eventual ectopic pregnancy, complex adnexal mass in 29 (61%) patients, and a large amount of echogenic fluid in the cul-de-sac in 10 (21%) patients. Six (13%) patients had live ectopic pregnancy. The OB ordered a radiology US in 10 cases but did not change the diagnosis or management. β-Human chorionic gonadotropin ( β-hCG) levels ranged from 41 to 59 846 mIU/mL (mean, 4602 mIU/mL), but for live ectopic pregnancy, the range was 2118 to 59 846 mIU/mL (mean, 36 341 mIU/mL). Seventeen (36%) patients had β-hCG levels of lower than 1000 mIU/mL. Of 47 eventual ectopic pregnancies, 29 (62%) patients underwent operative intervention, 17 (36%) patients received methotrexate, and 1 patient left against medical advice. Five (11%) of these patients with definite ectopic pregnancy were initially managed by emergency physicians with follow-up ED visits and serial US examinations without OB consultation. Conclusion Our study demonstrates that with increased experience, emergency sonologists can accurately diagnose ectopic pregnancy. Furthermore, patients at risk for ectopic pregnancy should not be denied US examinations if their β-hCG levels fall below an arbitrary discriminatory zone.

A Two-Year experience with bedside emergency ultrasonography for acute scrotal pain in the emergency department

Study objectives: Acute scrotal pain is a modestly common emergency department (ED) complaint. Because of increasing limitations in imaging services, emergency physicians are using their bedside ultrasonographic skills for more difficult diagnoses such as scrotal pain. We describe the practice pattern and sensitivity of bedside ED ultrasonography performed by emergency physicians for acute scrotal pain during a 2-year period. Methods: This was a retrospective quality assurance study performed at an urban ED with a residency program, an active ultrasonographic education program including an emergency ultrasonographic fellowship. The facility has an annual census of 75,000 patients. The ED quality assurance log was searched for all scrotal ultrasonographic studies performed for complaints of scrotal pain presenting within 24 hours of onset. A 12-MHz linear array transducer with pulsed wave and power Doppler capability was used to scan the scrotum. Diagnoses were verified by radiology ultrasonography, nuclear medicine, surgical evaluation, and patient follow-up. Descriptive statistics, sensitivity, and specificity with 95% confidence intervals (CIs) were calculated. Results: Eight emergency physicians performed a total of 146 scrotal ultrasonographic studies. Comparison with follow-up data with emergency physician ultrasonographic results yielded a sensitivity of 95% (95% CI 0.78% to 0.99%) and a specificity of 94% (95% CI 0.72% to 0.99%). Diagnoses included 14 (10%) testicular torsions, 41 (28%) cases of epididymitis, 16 (11%) cases of orchitis, 6 (4%) testicular fractures from trauma, 8 (6%) hernias presenting as acute scrotal pain and swelling, 21 (14%) hydroceles without other pathology, 7 (5%) cases of torsion of the appendix testes, 9 (6%) scrotal infections including Fournier's gangrene, and 24 (16%) normal examinations on which no pathology was noted. Conclusion: Emergency physicians using bedside emergency ultrasonography encounter a variety of causes of acute scrotal pain and are accurate in their diagnosis compared with traditions imaging and surgical services. Most important, they appear able to differentiate between surgical emergencies such as testicular torsion and other etiologies that require medical or supportive treatment. Study objectives: Acute scrotal pain is a modestly common emergency department (ED) complaint. Because of increasing limitations in imaging services, emergency physicians are using their bedside ultrasonographic skills for more difficult diagnoses such as scrotal pain. We describe the practice pattern and sensitivity of bedside ED ultrasonography performed by emergency physicians for acute scrotal pain during a 2-year period. Methods: This was a retrospective quality assurance study performed at an urban ED with a residency program, an active ultrasonographic education program including an emergency ultrasonographic fellowship. The facility has an annual census of 75,000 patients. The ED quality assurance log was searched for all scrotal ultrasonographic studies performed for complaints of scrotal pain presenting within 24 hours of onset. A 12-MHz linear array transducer with pulsed wave and power Doppler capability was used to scan the scrotum. Diagnoses were verified by radiology ultrasonography, nuclear medicine, surgical evaluation, and patient follow-up. Descriptive statistics, sensitivity, and specificity with 95% confidence intervals (CIs) were calculated. Results: Eight emergency physicians performed a total of 146 scrotal ultrasonographic studies. Comparison with follow-up data with emergency physician ultrasonographic results yielded a sensitivity of 95% (95% CI 0.78% to 0.99%) and a specificity of 94% (95% CI 0.72% to 0.99%). Diagnoses included 14 (10%) testicular torsions, 41 (28%) cases of epididymitis, 16 (11%) cases of orchitis, 6 (4%) testicular fractures from trauma, 8 (6%) hernias presenting as acute scrotal pain and swelling, 21 (14%) hydroceles without other pathology, 7 (5%) cases of torsion of the appendix testes, 9 (6%) scrotal infections including Fournier's gangrene, and 24 (16%) normal examinations on which no pathology was noted. Conclusion: Emergency physicians using bedside emergency ultrasonography encounter a variety of causes of acute scrotal pain and are accurate in their diagnosis compared with traditions imaging and surgical services. Most important, they appear able to differentiate between surgical emergencies such as testicular torsion and other etiologies that require medical or supportive treatment.

The role of bedside ultrasonography, urinalysis, and computed tomography in the diagnostic evaluation of flank pain

Study objectives: Numerous patients can present to the emergency department (ED) with flank pain. The diagnostic evaluation of these patients is varied but commonly includes urinalysis and an imaging modality. In this study, we evaluate the safety and utility of emergency ultrasonography for the evaluation of renal colic in patients with flank pain. Methods: This was a consecutive, prospective enrollment of afebrile patients with flank pain presenting to an ED of a tertiary care center. Exclusion criteria included trauma, recent urologic surgery, known current kidney stone, or unstable vital signs. All patients underwent identical evaluations, including urinalysis, bedside emergency ultrasonography, computed tomography (CT) scan, and a follow-up call. Ultrasonographic scans were performed by experienced emergency ultrasonographers who were blinded to the CT scan results. A percentage of the CT scans (n=44) were initially read by a radiology resident and later reread by a radiology attending physician. Final diagnosis was determined at 1-month follow-up after review of all patient records and a patient interview. Sensitivity and specificity of the ultrasonographic and initial CT scans were determined using final CT reading. To evaluate a hypothetical decision tree for the evaluation of flank pain in the ED, data were also analyzed post hoc using a set of predefined assumptions: (1) all patients undergo urinalysis; (2) ultrasonography is performed on patients with hematuria; (3) patients with hematuria and unilateral hydronephrosis (by ultrasonography) are diagnosed with renal colic and discharged; and (4) CT scans were performed on all patients with nondiagnostic urinalysis and ultrasonography. The accuracy of this decision tree was evaluated using the final diagnoses as determined by analysis of data and telephone interview at 1-month follow-up. Results: A total of 82 patients were enrolled from December 2001 to December 2003. The average age was 38.8 years, and 59% were female patients. The overall sensitivity and specificity of the emergency ultrasonography (87% and 78%, respectively) closely matched that of the initial resident-read CT scan (84% and 89%, respectively). An analysis of the flank pain decision tree shows that the combination of a positive urinalysis and ultrasonography (n=39) correctly diagnosed 97% of the patients in the study, whereas CT scan (n=43) diagnosed the remainder. Final diagnoses included renal colic (62%), urinary tract infection (6%), diverticulitis (3.6%), pneumonia (2.4%), flank pain (15%), and other (11%). Conclusion: Patients with multiple diagnoses can present with flank pain. Emergency ultrasonography of the kidney has a sensitivity and specificity similar to that of CT. A flank pain decision tree using limited bedside ultrasonography would result in a reduction of 52% of the CT scans, with no loss of diagnostic sensitivity or specificity.

Can fourth-year medical students learn bedside ultrasonography?

Study objectives: During the past decade, ultrasonography has become increasingly available in the daily practice of emergency physicians. The scope of use for bedside emergency ultrasonography is expanding daily. Emergency ultrasonographic skills and interpretation, however, are not taught in any US medical schools. We established the first emergency department (ED)–based ultrasonography medical student rotation 1 year ago. The purpose of this study is to evaluate whether fourth-year medical students can learn bedside emergency ultrasonography and whether they learn more on a 2- or 4-week rotation. Methods: A 35-question written test was designed covering the core applications of emergency ultrasonography, including diseases of the gallbladder, kidneys, vessels, eyes, reproductive organs, and trauma. An interactive DVD was also designed with live ultrasonographic video clips to accompany the examination. The questions covered ultrasonographic physics, recognition of images, and medical management of patients according to emergency ultrasonography results. Fourth-year medical students were enrolled from a number of US medical students and Europe during a 4-month period. All of the students had little or no experience in ultrasonography. The students were given the examination the first day of their rotation before they received any ultrasonography instruction. The students then spent 2- or 4-week rotations learning emergency ultrasonography. The ultrasonography course consists of 40 hours per week of clinical ultrasonography, 1 hour per week of didactic education, and 5 hours per week of quality-assurance reviewing of ultrasonography clips taped in the ED. On the final day of the rotation, the students were given the final examination. Examination results did not affect their grade for the rotation, and the students were blinded to their results. Results: Twenty-nine fourth-year medical students were enrolled in the study during a 6-month period. There were 16 students on the 2-week rotation and 13 students on the 4-week rotation. The average pretest score of all medical students on the rotation was 16.8 of 35.0, which is 48.0%, and the average posttest scores for all students was 27.7 of 35.0 (79.1%, P P =.448). The average final examination score for students on the 2-week rotation was 26.3 of 35.0 (75.1%) and for the students on the 4-week rotation was 29.4 of 35.0 (84.0%, P =.027). Conclusion: A fourth-year medical student emergency ultrasonography rotation can be an effective method of teaching emergency ultrasonography skills and interpretation. Medical students on a 4-week rotation learn more than those on a 2-week rotation.

Elevated Intracranial Pressure Detected by Bedside Emergency Ultrasonography of the Optic Nerve Sheath

Elevated Intracranial Pressure Detected by Bedside Emergency Ultrasonography of the Optic Nerve Sheath

Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath.

Patients with altered level of consciousness may be suffering from elevated intracranial pressure (EICP) from a variety of causes. A rapid, portable, and noninvasive means of detecting EICP is desirable when conventional imaging methods are unavailable. The hypothesis of this study was that ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) could accurately predict the presence of EICP. The authors performed a prospective, blinded observational study on emergency department (ED) patients with a suspicion of EICP due to possible focal intracranial pathology. The study was conducted at a large community ED with an emergency medicine residency program and took place over a six-month period. Patients suspected of having EICP by an ED attending were enrolled when study physicians were available. Unstable patients were excluded. ONSD was measured 3 mm behind the globe using a 10-MHz linear probe on the closed eyelids of supine patients, bilaterally. Based on prior literature, an ONSD above 5 mm on ultrasound was considered abnormal. Computed tomography (CT) findings defined as indicative of EICP were the presence of mass effect with a midline shift 3 mm or more, a collapsed third ventricle, hydrocephalus, the effacement of sulci with evidence of significant edema, and abnormal mesencephalic cisterns. For each patient, the average of the two ONSD measurements was calculated and his or her head CT scans were evaluated for signs of EICP. Student's t-test was used to compare ONSDs in the normal and EICP groups. Sensitivity, specificity, and positive and negative predictive values were calculated. Thirty-five patients were enrolled; 14 had CT results consistent with EICP. All cases of CT-determined EICP were correctly predicted by ONSD over 5 mm on US. One patient with ONSD of 5.7 mm in one eye and 3.7 mm in the other on US had a mass abutting the ipsilateral optic nerve; no shift was seen on CT. He was placed in the EICP category on his data collection sheet. The mean ONSD for the 14 patients with CT evidence of EICP was 6.27 mm (95% CI = 5.6 to 6.89); the mean ONSD for the others was 4.42 mm (95% CI = 4.15 to 4.72). The difference of 1.85 mm (95% CI = 1.23 to 2.39 mm) yielded a p = 0.001. The sensitivity and specificity for ONSD, when compared with CT results, were 100% and 95%, respectively. The positive and negative predictive values were 93% and 100%, respectively. Despite small numbers and selection bias, this study suggests that bedside ED US may be useful in the diagnosis of EICP.

Elevated Intracranial Pressure Detected by Bedside Emergency Ultrasonography of the Optic Nerve Sheath

Elevated Intracranial Pressure Detected by Bedside Emergency Ultrasonography of the Optic Nerve Sheath

Bedside Ultrasonography at Emergency Department - “New Kids on the Block” and “Echoes of Future”

Bedside ultrasonography is increasingly being performed by emergency physician in Hong Kong. Nearly every Accident and Emergency department in Hong Kong is equipped with an ultrasound machine. Ultrasonographic examination is a powerful clinical tool as it is non-invasive, safe, reliable and inexpensive. It has a high diagnostic accuracy in an experience hand. The practice of performing ultrasonography by local emergency physician is just at the early stage. This article aims to review the characteristic, scope and limitation of bedside ultrasonography at emergency department setting. The issue of training and certification, cost effectiveness and medico-legal implication of this tool is also discussed. The goal of bedside ultrasonography program in Hong Kong is to provide round the clock ultrasound examination and interpretation by well-trained and qualified emergency physician. Establishment of the scope of emergency ultrasound examination and implementation of quality improvement audit on the services is necessary. Training and research in the area of ultrasound imaging should be encouraged. With the maturation of our specialty and the effort of our local emergency physicians, bedside emergency ultrasonography will soon emerge as the “Echoes of the future”.