Bedside Emergency Research Articles

How we started an elective in emergency bedside ultrasound

The expanding use of bedside ultrasonography in the practice of emergency medicine and other specialties is accompanied by the need to train medical students in its applications and interpretation of its results. In this article, the authors describe their successful design, launch, and management of the ultrasound elective at the University of Maryland School of Medicine. Because the course has been so well received, the authors are now exploring ways of presenting its content and skills-building opportunities in more venues, including the Introduction to Clinical Medicine course.

Emergency Bedside Ultrasound to Identify Pediatric Appendicitis

Investigators at a single academic institution prospectively evaluated the accuracy of emergency department ultrasound for identifying acute appendicitis in children. After attending a 45-minute lecture and performing five studies under supervision, one pediatric emergency medicine attending physician and 12 fellows performed bedside ultrasound studies. A positive study result was defined as visualization …

Emergency bedside ultrasound in a case of chest pain and collapse

Emergency bedside ultrasound in a case of chest pain and collapse

Emergency department diagnosis of pulmonary hypertension in a patient with left atrial sarcoma.

Pulmonary hypertension is a disease with many etiologies and is responsible for 200,000 admissions and 25,000 hospitalizations in the United States each year. We report the case of a previously healthy 58-year-old woman who presented to the emergency department with a months-long history of worsening dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Despite the severity of her symptoms, she had no corroborative physical exam findings, including jugular venous distension or peripheral edema. Bedside emergency department ultrasonography revealed a dilated right ventricle and bowing of the intraventricular septum into the left ventricle, consistent with pulmonary hypertension. CT angiography of the chest performed in the emergency department revealed a large left atrial mass, found on pathology to be a left atrial sarcoma. This case illustrates how severely symptomatic pulmonary hypertension can have few to no physical exam findings and the utility of bedside emergency department ultrasound in making the presumptive diagnosis.

TF-12 Critical Actions in Common Floor Emergencies: A Multi-Disciplinary, Multimodality Course for Incoming First Year Residents

TF-12 Critical Actions in Common Floor Emergencies: A Multi-Disciplinary, Multimodality Course for Incoming First Year Residents

Diagnostic accuracy of emergency physician performed graded compression ultrasound study in acute appendicitis: a prospective study.

Accurate early diagnosis of appendicitis can decrease its complications and minimize the mortality, morbidity and costs. This prospective study evaluates the accuracy of bedside emergency physician performed ultrasound study diagnosis in acute appendicitis. Patients who were suspicious to have appendicitis based on their clinical findings were included and underwent emergency physician performed ultrasound study. Then they were followed up until the recognition of final diagnosis based on pathology report or identification of an alternative diagnosis. Ultrasound studies were done by post-graduate year three emergency medicine residents or emergency medicine attending physicians who were attended in a 4h didactic and practical course and with 7.5MHz linear probe both in longitudinal and axial axes. Ninety-seven patients were included and analyzed. 27 (27.8%) of patients had appendicitis according to the results of emergency physicians performed ultrasound studies. 19 (70.37%) of them had appendicitis according to their pathologic reports too. Forty-three (44.3%) of patients had appendicitis according to pathology reports. Only 19 (44.18%) of them were diagnosed by emergency physicians. Emergency physician performed ultrasound study had a sensitivity of 44.18%, specificity of 85.18%, positive predictive value of 70.37%, negative predictive value of 65.71% and overall accuracy of 67.01% in diagnosing appendicitis in patients clinically suspicious to have acute appendicitis. Emergency physician performed bedside ultrasound has an acceptable overall accuracy but its sensitivity is low thus it can help emergency physicians to diagnose the acute appendicitis when used in conjunction with other clinical and para-clinical evaluations but not per se.

Abstract 209: The Safety of Emergent Bedside Gastrointestinal Endoscopy in Patients with Moderate and Severe Aortic Stenosis in the Cardiac Intensive Care Unit

Purpose: Recent advances in the management of aortic stenosis (AS) including the availability of percutaneous valve therapies have resulted in the evaluation of patients with increased co-morbidities. AS is associated with an increased risk of Gastrointestinal (GI) bleeding which is further increased by antithrombotic and antiplatelet treatment that often accompany hospitalization. The aim of our study was to determine the safety of emergent bedside endoscopies in patients with moderate to severe AS in the Cardiac Intensive Care Unit (CICU) setting presenting with acute GI bleeding. Objective and Methods: We identified all patients with moderate to severe AS who were admitted to the CICU at the Cleveland Clinic and experienced GI bleeding requiring emergent bedside endoscopies between Jan 2011 and Jan 2013. Data collection included demographics, indication for admission to the CICU, indication for bedside endoscopy, etiologies of GI bleeding, and intra procedural as well as post procedural hemodynamic instability and respiratory distress. AS was defined as moderate for aortic valve area (AVA) in the range 1.5-1.00 cm square and severe for AVA < 1.00 cm square. Result: 17 patients (10 males) with a mean age 78.4 ± 10.6 years were identified. Overall 4 patients had moderate AS while 13 had severe AS. The peak gradient across the aortic valve was 53.8 ± 24.8 with a mean AVA 0.74 ± 0.25 cm square. Indication for urgent bedside endoscopies included episodes of acute melena, hematemesis, acute anemia of an undetermined etiology, in addition to evaluation of acute anemia in the perioperative period. 88% of patients were on either antiplatelet or anticoagulation or both. The patients underwent a total of 20 bedside endoscopies: 16 upper endoscopies and 4 colonoscopies. IV fentanyl and midazolam were used for sedation in patients not previously intubated. The etiologies of GI bleeding were peptic ulcer disease (n=5), hemorrhagic gastritis (n=5), esophagitis with esophageal ulcer (n=3), GI angiodysplasias (n=3), and diverticulitis (n=1). None of the patients developed acute hemodynamic instability or acute respiratory distress during or after the endoscopy. Conclusion: The etiologies of acute bleeding in patients with AS are diverse. Emergent bedside GI endoscopies done in the CICU for the diagnosis and management of acute GI bleeding is a safe procedure in patients with moderate to severe AS.

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.

Optic Neuritis Diagnosed by Bedside Emergency Physician−Performed Ultrasound: A Case Report

BackgroundOptic neuritis is an inflammatory demyelinating condition of the optic nerve that causes subacute visual loss. It is often the result of an underlying systemic condition, such as multiple sclerosis. Due to the possible long-term morbidity associated with this condition, it is essential that the emergency physician recognizes the diagnosis and expedites treatment. ObjectiveThis case report describes optic neuritis diagnosed at the bedside by emergency physician−performed ultrasound. Case ReportThis is a case report of a young man presenting with unilateral painful vision loss. Optic neuritis must be considered in the differential diagnosis of any young patient who presents with visual complaints without any other neurologic findings. This report is unique because there are very few cases describing the findings of optic neuritis on emergency physician−performed bedside ultrasound in the literature. ConclusionsThis article presents the case, describes diagnostic modalities, especially the use of ultrasound in its diagnosis, and the course of treatment for this particular condition.

Hold the Stroke Alert! Acute Axillary Artery Embolus Unmasked by Emergency Bedside Ultrasound

Objective —To describe a case of axillary artery embolus detected by emergency physician- performed bedside ultrasound. Case Report —A patient presented with a possible stroke but was diagnosed correctly with acute axillary artery embolus. The axillary artery embolus was detected by the emergency physician by the use of bedside ultrasound. Results —An acute axillary artery embolus was detected rapidly by emergency physician-performed bedside ultrasound. This led to rapid definitive vascular surgical care. Conclusion —Rapid bedside emergency ultrasound of the upper extremity arterial system can accurately detect life- and limb-threatening pathology and expedite, as this case demonstrates, definitive limb-saving surgical care.

Obstetrics and Gynecology Ultrasound Topics in Emergency Medicine Resident Training

ABSTRACT The evaluation of abdominal or pelvic pain and/or vaginal bleeding using pelvic ultrasound is a common practice of the emergency physician. In fact, the American College of Emergency Physicians (ACEP) in 2008 published guidelines listing evaluation of pregnancy as a core application and evaluation of the adnexa as a secondary application for emergency bedside pelvic ultrasound. In 2012 the Accreditation Council of Graduate Medical Education (ACGME) along with the American Board of Emergency Medicine (ABEM) introduced milestones into residency programs to provide a framework of cognitive and behavioral performance standards, including procedure-based skills. The milestones are the knowledge, skills, attitudes and other attributes for each of the ACGME competencies that monitor resident performance throughout the residency and range from less to more advanced levels. Goal-directed focused ultrasound is one of twenty-three specific milestones that will be measured during emergency medicine training. Discussion will focus on how to teach focused goaldirected pelvic ultrasound based on the five levels within this milestone. How to cite this article Greer VL, Brosseit MW. Obstetrics and Gynecology Ultrasound Topics in Emergency Medicine Resident Training. Donald School J Ultrasound Obstet Gynecol 2014;8(1):35-43.

Application of emergency bedside focused assessment with sonography for trauma together with regional organ focused ultrasonography in closed abdominal trauma

Objective To investigate the value of emergency bedside focused assessment with sonography for trauma (FAST) in combination with regional organ focused ultrasonography in patients with closed abdominal trauma.Methods Two hundred and thirty-seven patients with closed abdominal trauma underwent bedside ultrasonography in the Emergency Department at General Hospital of Chengdu Military Command.In patients with unstable hemodynamics or severe craniocerebral injury,ultrasonography was ended immediately after FAST screening.In patients with stable vital signs,the focused regional organ injury after FAST screening was determined based on the mechanism of trauma,action location and direction of external force,abdominal symptoms,and signs.The results of operation and CT scanning were considered as golden criteria and used to compare with those of ultrasonography.Results (1) The diagnostic sensitivity of FAST to abdominal organ rupture and ascites due to abdominal organ rupture calling for emergency operation was 79.3％ and 100％,respectively.The total specificity of FAST was 98.2％,positive predictive value 93.9％,and negative predictive value 86.7％.(2) The diagnostic accordance rate of single visceral injury examined by regional organ focused ultrasonography was 91.2％ and that of multiple visceral injury was 63.6％.The missed diagnoses were predominantly contusion and microlaceration.Conclusions FAST can quickly screen out the patients with unstable hemodynamics due to abdominal organ rupture calling for emergency management.Regional organ focused ultrasonography can increase the rate of correct diagnosis of visceral injury and decrease the rate of missed diagnosis. Key words: Abdominal injuries ; Ultrasonography ; Emergency treatment

Sensitivity of Emergency Bedside Ultrasound to Detect Hydronephrosis in Patients with Computed Tomography-proven Stones

IntroductionNon-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasound is a sign of a ureteral stone, and has a reported sensitivity of 72–83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number.MethodsThis was a structured, explicit, retrospective chart review. Two blinded investigators used reviewed charts of all adult patients over a 6-month period with a final diagnosis of renal colic. Of these charts, those with CT evidence of renal calculus by attending radiologist read were examined for results of bedside ultrasound performed by an emergency physician. We included only those patient encounters with both CT-proven renal calculi and documented bedside ultrasound results.Results125 patients met inclusion criteria. The overall sensitivity of ultrasound for detection of hydronephrosis was 78.4% [95% confidence interval (CI)=70.2–85.3%]. The overall sensitivity of a positive ultrasound finding of either hydronephrosis or visualized stones was 82.4% [95%CI: 75.6%, 89.2%]. Based on a prior assumption that ultrasound would detect hydronephrosis more often in patients with larger stones, we found a statistically significant (p=0.016) difference in detecting hydronephrosis in patients with a stone ≥6 mm (sensitivity=90% [95% CI=82–98%]) compared to a stone <6 mm (sensitivity=75% [95% CI=65–86%]). For those with 3 or more stones, sensitivity was 100% [95% CI=63–100%]. There were no patients with stones ≥6 mm that had both a negative ultrasound and lack of hematuria.ConclusionIn a population with CT-proven urolithiasis, ED bedside ultrasonography had similar overall sensitivity to previous reports but showed better sensitivity with increasing stone size and number. We identified 100% of patients with stones ≥6 mm that would benefit from medical expulsive therapy by either the presence of hematuria or abnormal ultrasound findings.

Emergency bedside ultrasound for the diagnosis of pediatric intussusception: a retrospective review.

Ultrasound diagnosis of pediatric intussusception is feasible with limited operator training. The authors report the test characteristics of bedside ultrasound (BUS) for the diagnosis of pediatric intussusception at a single institution. Inclusion criteria were: 1) patients of 0-18 years old were seen in the pediatric emergency department (ED) with a clinical presentation suspicious for intussusception; 2) BUS was performed to identify intussusception and bedside impression documented in the medical record; 3) a "formal" diagnostic study (such as computed tomography, ultrasound, or barium enema) was performed by the radiology department after BUS was completed. Electronic medical record and ED BUS archive were screened for potentially eligible ED visits between January 1(st) 2009 to October 3(rd) 2012. These records were then reviewed to identify patients for inclusion in the study. All emergency physicians who performed the BUS had undergone a minimum of 1-hour didactic training on the use of BUS to diagnose pediatric intussusception. A total of 1 631 charts were reviewed, with 49 meeting inclusion criteria. Five of those were later excluded for incomplete documentation or lack of saved BUS images. The prevalence of intussusception was 23%. The mean age of the subjects was 31 months. BUS was 100% sensitive (95%CI 66%-100%) and 94% specific (95%CI 79%-99%) for detection of pediatric intussusception compared to radiology study results. Positive and negative likelihood ratios were 16.5 (95%CI 4.30%-63.21%) and 0 (95%CI 0-0) respectively. BUS is an accurate means of diagnosing acute intussusception in pediatric patients. Further study might be indicated to confirm such benefits.

A Novel Method for the Management of Post‐Thyroidectomy or Parathyroidectomy Hematoma: A Single‐Institution Experience after over 4,000 Central Neck Operations

Cervical hematoma is a rare but serious complication of thyroid and parathyroid surgery that has historically required inpatient monitoring. With improved surgical technique and experience, operations are being performed increasingly as outpatient procedures. Therefore, a safe and systematic approach to cervical exploration of a postoperative hematoma needs to be defined. From 1996 to 2013, a retrospective review was performed of 4,140 thyroid and parathyroid operations. Surgical outcomes data were recorded, specifically including the occurrence of a cervical hematoma, time interval to presentation, and methods of management. A total of 18 patients (0.43 %) developed a postoperative cervical hematoma that required surgical intervention. The occurrence of hematoma was 0.66 % (n = 11) for bilateral thyroid procedures, 0.21 % (n = 3) for unilateral thyroid procedures, and 0.13 % (n = 1) for parathyroid procedures. There were 3 (1.69 %) patients who had combined unilateral thyroid and parathyroid procedures and developed hematomas. Emergent bedside decompression was required for only two patients, both of whom suffered respiratory arrest in the postoperative anesthesia recovery unit. The remaining 16 patients were explored in the operating room, utilizing initial local anesthesia in the semi-upright position in 11 patients (69 %). From our experience, hematomas that caused significant airway compromise leading to respiratory arrest occurred in the postoperative anesthesia recovery room, and hematoma presentation after this time did not require emergent bedside decompression. Hematoma, when it occurs, can otherwise be managed safely in the operating room after inpatient or outpatient procedures using initial local anesthesia with the patient in the semi-upright position for hematoma evacuation.

Symptomatic Floor-of-Mouth Swelling with Neck Extension in a 14-Year-Old Girl

A plunging ranula is a soft-tissue mass stemming from a mucous extravasation cyst of the sublingual gland which can herniate through the mylohyoid muscle. We describe a case in which a 14-year-old girl presented with a rapidly expanding mass on the floor of her mouth affecting her ability to swallow and speak and causing tracheal compression. The patient was initially managed conservatively with antibiotics and steroids; however, the mass continued to expand necessitating emergent bedside incision and drainage and subsequent surgical intervention. The pathophysiology and management options for ranulas are also discussed herein.

Emergency medical equipment storage: benefits of visual cues tested in field and simulated settings.

We tested the effectiveness of an illustrated divider ("the divider") for bedside emergency equipment drawers in an intensive care unit (ICU). In Study I, we assessed whether the divider increases completeness and standardizes the locations of emergency equipment within the drawer. In Study 2, we investigated whether the divider decreases nurses' restocking and retrieval times and decreases their workload. Easy access to fully stocked emergency equipment is important during emergencies. However, inefficient equipment storage and cognitively demanding work settings might mean that drawers are incompletely stocked and access to items is slow. A pre-post-post study investigated drawer completeness and item locations before and after the introduction of the divider to 30 ICU drawers. A subsequent experiment measured item restocking time, item retrieval time, and subjective workload for nurses. At 2 weeks and 10 weeks after the divider was introduced, the completeness of the drawer increased significantly compared with before the divider was introduced. The divider decreased the variability of the locations of the 17 items in the drawer to 16% of its original value. Study 2 showed that restocking times but not retrieval times were significantly faster with the divider present For both tasks, nurses rated their workload lower with the divider. The divider improved the standardization and completeness of emergency equipment. In addition, restocking times and workload were decreased with the divider. Redesigning storage for certain equipment using human factors design principles can help to speed and standardize restocking and ease access to equipment.

Does This Patient Have Pericardial Effusion?

Emergency department diagnosis of pericardial effusion is critical. The presence of a pericardial effusion may be suggested on history and physical examination. Transthoracic echocardiography is recommended in patients with suspected pericardial effusion. However, the indications for an emergent echocardiogram based on clinical findings are not clearly defined. The purpose of this study was to investigate the presenting clinical features of patients with pericardial effusion to determine the need for an emergent bedside ultrasound examination. A retrospective review of all point-of care cardiac ultrasound examinations performed at two urban academic emergency departments. The point-of-care ultrasound examinations were reviewed for the presence of a pericardial effusion by an emergency physician with advanced training in bedside US. Medical records were then reviewed for history and physical exam findings suggestive of pericardial effusion. Descriptive statistics are presented along with 95% confidence intervals (CI). A total of 814 POC cardiac US examinations were reviewed. Fifty pericardial effusions were identified for an estimated prevalence of 6.1%. Three patients were excluded from the analysis because of lack of appropriate documentation. Sixteen patients had a moderate to large pericardial effusion. Five patients required emergent pericardiocentesis. The presenting symptoms of patients with pericardial effusions were: shortness of breath (65.2%), chest pain (34.7%), syncope (10.8%) and altered mental status (10.8%). Tachycardia or hypotension was present in 72.3% of patients. None of the patients with pericardial tamponade were found to have Beck's triad. Sensitivity of Beck's triad for pericardial tamponade was therefore 0% (95% CI, 0, 7.5%). Sensitivity for one finding of Beck's triad was 55% (95% CI, 40.1, 69.8). Despite limited numbers, our study illustrates the limitations of clinical criteria in determining the need for an echocardiogram in diagnosing a pericardial effusion and supports liberal use of bedside ultrasound when evaluating patients with shortness of breath and chest pain.

Evaluating the Redesign of an ICU Bedside Emergency Equipment Drawer

Patient safety can be improved by redesigning how medication and bedside equipment is stored in the intensive care unit (ICU). Grundgeiger (2011) noted that an ICU emergency bedside drawer often was not fully stocked. He used human factors principles to design an illustrated and divided drawer that significantly improved drawer restocking compliance and is still in use in the ICU. In two studies we set out to clarify exactly why Grundgeiger’s redesign succeeded. In Experiment 1 we tested the redesigned vs. old drawer design using stationery contents and psychology student participants. In Experiment 2 we used the tests developed in Experiment 1 to compare ICU nurses’ performance with the redesigned vs. old drawer design. Both experiments indicate that the divided and illustrated drawer leads to faster restocking times and overwhelmingly positive user acceptance.

Emergency Bedside Ultrasound Diagnosis of Superior Mesenteric Artery Dissection Complicating Acute Aortic Dissection

BackgroundA timely diagnosis of aortic dissection is associated with lower mortality. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, there is limited literature regarding the use of bedside ultrasound to identify superior mesenteric artery dissection, a known high-risk feature of aortic dissection. ObjectiveOur aim was to present a case of superior mesenteric artery dissection identified by bedside ultrasound and review the utility of bedside ultrasound in the diagnosis of aortic emergencies. Case ReportWe report a case of superior mesenteric artery dissection found on emergent bedside ultrasound in a 46-year-old male complaining of abdominal pain with a history of cocaine abuse and prior aortic dissection. Bedside ultrasound in the emergency department revealed an intimal flap in the descending aorta with extension into the superior mesenteric artery prompting early surgical consultation before computed tomography because of concern for acute mesenteric ischemia. ConclusionSuperior mesenteric artery dissection is a high-risk feature of aortic dissection and can be identified with emergent bedside ultrasound.