Bedside Emergency Research Articles

Emergency Ultrasound‐assisted Examination of Skin and Soft Tissue Infections in the Pediatric Emergency Department

The objective was to evaluate the test characteristics of clinical examination (CE) with the addition of bedside emergency ultrasound (CE+EUS) compared to CE alone in determining skin and soft tissue infections (SSTIs) that require drainage in pediatric patients. This was a prospective study of CE+EUS as a diagnostic test for the evaluation of patients 2 months to 19 years of age evaluated for SSTIs in a pediatric emergency department (ED). Two physicians clinically and independently evaluated each lesion, and the reliability of the CE for diagnosing lesions requiring drainage was calculated. Trained pediatric emergency physicians performed US following their CEs. The authors determined and compared the test characteristics for evaluating a SSTI requiring drainage for CE alone and for CE+EUS for those lesions in which the two physicians agreed and were certain regarding their CE diagnosis (clinically evident). The performance of CE+EUS was evaluated in those lesions in which the two physicians either disagreed or were uncertain of their diagnosis (not clinically evident). The reference standard for determining if a lesion required drainage was defined as pus expressed at the time of the ED visit or within 2 days by follow-up assessment. A total of 387 lesions underwent CE+EUS and were analyzed. CE agreement between physicians was fair (κ = 0.38). For the 228 lesions for which physicians agreed and were certain of their diagnoses, sensitivity was 94.7% for CE and 93.1% for CE+EUS (difference = -1.7%; 95% confidence interval [CI] = -3.4% to 0%). The specificity of CE was 84.2% compared to 81.4% for CE+EUS (difference = -2.8%; 95% CI = -9.7% to 4.1%). For lesions not clinically evident based on CE, the sensitivity of CE was 43.7%, compared with 77.6% for CE+EUS (difference = 33.9%; 95% CI = 1.2% to 66.6%). The specificity of CE for this group was 42.0%, compared with 61.3% for CE+EUS (difference = 19.3%; 95% CI = -13.8% to 52.4%). For clinically evident lesions, the addition of ultrasound (US) did not significantly improve the already highly accurate CE for diagnosing lesions requiring drainage in this study population. However, there were many lesions that were not clinically evident, and in these cases, US may improve the accuracy of the CE.

Urgent bedside echocardiography in diagnosis of acute massive pulmonary embolism presenting with cardiogenic shock – case report

Cardiologia CROATICA We are presenting the case of a 51-year-old man who has been admitted at our clinic with dyspnea, cardiogenic shock and severe pain and swelling of the left leg. At the admission he was cyanotic, severely hypotensive, with tachypnea, an oxygen saturation of 70%. An acute massive pulmonary embolism was suspected, and an emergency bedside transthoracic echocardiogram was performed. Bedside echocardiography showed significantly enlarged right ventricle (46 mm tricuspid annular size), hypokinesia of the free right ventricular wall and increased pulmonary artery size (34 mm), with signs of RV overload. There was large mobile thrombus with dimensions (34x37 mm) prolabing from right ventricle to the right atrium. Severe tricuspid regurgitation, with dilated right atrium and dilated vena cava inferior — 24 mm were found. Indirect estimation of the pulmonary hypertension with the value of the maximal velocity of the tricuspid regurgitation showed increased pulmonary pressure (estimated systolic pulmonary atrial pressure — SPAP was 59 mmHg). Color Duplex sonography of lower extremities was also performed at the bed site with the finding of non compressible left common femoral vein, which was consistent with the deep vein thrombosis. D-dimmers were significantly increased (>4.500 nq/l). Multislice computed tomography performed next day confirmed central filling defect of the left pulmonary artery consistent with acute thrombus. Based on the patient’s clinical condition and the echocardiographic findings, he has been treated with fibrinolysis therapy with alteplase. Control echocardiography performed three days after fibrinolytic therapy showed decrease in SPAP pressure from 59 mmHg to 40 mmHg, moderate tricuspid regurgitation, normal right ventricular size and function. The patient had excellent clinical recovery and was discharged from the hospital after 20 days. This case confirms the role of urgent bedside echocardiography in fast diagnosis of acute pulmonary embolism, which leads to proper management and favorable patient outcome.

Identification of Unanticipated Pelvic Pathology on Renal Bedside Ultrasound

Bedside emergency ultrasound can be a useful initial test in children who present with abdominal pain. Our case describes a teenager who presented to the emergency department with back pain and right lower quadrant pain, suspicious for nephrolithiasis. The use of bedside ultrasound enabled timely diagnosis and management of an unanticipated condition.

Dynamic Changes of Common Bile Duct Diameter During an Episode of Biliary Colic, Documented by Ultrasonography

Common bile duct stones frequently accompany gallstones and can be identified by a variety of imaging modalities. Little is known about the time course of dilatation of the common bile duct after acute obstruction or of normalization after spontaneous passage of an obstructing stone. We describe a case showing rapid fluctuations in common bile duct diameter during 72 hours in a patient presenting with epigastric pain and vomiting. Initial emergency bedside ultrasonography revealed a distended gallbladder, a dilated common bile duct (17 mm), and an obstructing stone. Five hours later, ultrasonography performed in the radiology suite showed a normal common bile duct diameter (4 mm) and no obstructing stone. The patient was admitted, and during the course of hospitalization different imaging modalities reported fluctuations in common bile duct measurements, ranging from 4 mm on computed tomography to 14 mm on endoscopic retrograde cholangiopancreatography. This case demonstrates disappearance of an obstructing stone with normalization of a highly distended common bile duct during 5 hours, highlighting that gallstone disease may be highly dynamic, with the possibility of rapid changes of common bile duct diameter. Emergency physicians, who frequently depend on ultrasonography to diagnose biliary disease, should be wary of the potential for rapid changes of sonographic findings in these patients.

Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound.

Infective endocarditis is a challenging diagnosis that is rarely made in the emergency department. As the use of focused emergency ultrasound expands into more applications, including advanced echocardiography, the diagnosis of infective endocarditis may be made earlier, potentially leading to more timely treatment. We report a case of an ill-appearing patient presenting to the emergency department with an indwelling central venous catheter, a cardiac murmur, and necrotic toes, who was diagnosed with a large tricuspid vegetation and prominent tricuspid regurgitation on bedside emergency ultrasound. A cardiologist-performed echocardiogram confirmed these findings during the patient's hospital admission.

Systematic Review: Emergency Department Bedside Ultrasonography for Diagnosing Suspected Abdominal Aortic Aneurysm

The use of ultrasound (US) to diagnose an abdominal aortic aneurysm (AAA) has been well studied in the radiology literature, but has yet to be rigorously reviewed in the emergency medicine arena. This was a systematic review of the literature for the operating characteristics of emergency department (ED) ultrasonography for AAA. The authors searched PubMed and EMBASE databases for trials from 1965 through November 2011 using a search strategy derived from the following PICO formulation: Patients-patients (18+ years) suspected of AAA. Intervention-bedside ED US to detect AAA. Comparator-reference standard for diagnosing an AAA was a computed tomography (CT), magnetic resonance imaging (MRI), aortography, official US performed by radiology, ED US reviewed by radiology, exploratory laparotomy, or autopsy results. AAA was defined as ≥ 3 cm dilation of the aorta. Outcome-operating characteristics (sensitivity, specificity, and likelihood ratios [LR]) of ED abdominal US. The papers were analyzed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) guidelines. The initial search strategy identified 1,238 articles; application of inclusion/exclusion criteria resulted in seven studies with 655 patients. The weighted average prevalence of AAA in symptomatic patients over the age of 50 years is 23%. On history, 50% of AAA patients will lack the classic triad of hypotension, back pain, and pulsatile abdominal mass. The sensitivity of abdominal palpation for AAA increases as the diameter of the AAA increases. The pooled operating characteristics of ED US for the detection of AAA were sensitivity 99% (95% confidence interval [CI] = 96% to 100%) and specificity 98% (95% CI = 97% to 99%). Seven high-quality studies of the operating characteristics of ED bedside US in diagnosing AAA were identified. All showed excellent diagnostic performance for emergency bedside US to detect the presence of AAA in symptomatic patients.

Acute, simultaneous, bilateral rhegmatogenous retinal detachment diagnosed with bedside emergency ultrasound

Acute, simultaneous, bilateral rhegmatogenous retinal detachment diagnosed with bedside emergency ultrasound

Paget-Schroetter Syndrome Diagnosed by Bedside Emergency Physician performed Ultrasound: A Case Report

BackgroundPaget-Schroetter syndrome, or an upper-extremity deep venous thrombosis (UEDVT), occurs in young people after strenuous repetitive activity involving the upper extremity. The long-term morbidity and mortality of this condition is similar to the effects of lower-extremity DVT and therefore, its early diagnosis and treatment are essential. ObjectivesThis case report describes Paget-Schroetter syndrome (effort thrombosis) diagnosed at the bedside by Emergency Physician performed ultrasound. Case ReportThis is a case report of an uncommon but potentially dangerous disease that carries high morbidity if not diagnosed and treated early. Emergency Physicians should be aware of this condition in any young patient who presents with upper-extremity complaints with a history of repetitive use. Although the role of ultrasound in the diagnosis of lower-extremity DVT is well described, this case report is unique because it illustrates the diagnosis of Paget-Schroetter syndrome completed at the bedside. ConclusionThis article presents the case and discusses the incidence, potential causes, predisposing factors, diagnostic modalities, and the course of treatment for this particular diagnosis.

Pitfalls in Emergency Department Focused Bedside Sonography of First Trimester Pregnancy

Background. Bedside sonography performed by emergency physicians is frequently utilized for real-time clinical decision-making in the emergency department (ED) setting. This includes the sonographic evaluation of pain or bleeding in the first trimester of pregnancy. The detection of intrauterine pregnancy (IUP) or life-threatening conditions, including ectopic pregnancy, is critical. Objectives. This paper will review several important pearls and avoidable pitfalls of this diagnostic modality by brief presentation of illustrative cases followed by discussion of key principles. Case Reports. Three patients evaluated in the ED for bleeding or pain occurring during the first trimester of pregnancy will be presented. Conclusions. When conducting emergency bedside ultrasound for the evaluation of first trimester pregnancy, it is important to avoid common pitfalls that can place your patient at risk.

Ultrasound Detection of a Molar Pregnancy in the Emergency Department

A 32 year-old female presented to the emergency department (ED) with complaints of mild vaginal spotting accompanied by uterine cramping. She was referred to the ED for an “abnormal pregnancy.” She was a G1P0 and her last menstrual period was 7 weeks 5 days prior. Physical examination demonstrated a well appearing female with normal vital signs. Speculum exam showed a normal appearing cervix, without active bleeding or cervical discharge. On bimanual exam, the cervical os was closed and there was no uterine or adnexal tenderness. Laboratory testing was significant for an elevated serum beta-HCG of 138,596. Bedside emergency ultrasound (EUS) was then performed and demonstrated multiple grape-like clusters within the uterus (Video). No definitive intrauterine pregnancy was detected. A radiologist performed ultrasound was then ordered and confirmed the diagnosis of a molar pregnancy.

Application of bedside emergency ERCP in the treatment of severe acute biliary pancreatitis

Application of bedside emergency ERCP in the treatment of severe acute biliary pancreatitis

Bedside Ultrasound in a Case of Blunt Scrotal Trauma

This case study describes a patient who suffered blunt force trauma to the scrotum. Use of bedside emergency ultrasound facilitated early diagnosis of a ruptured testicle and allowed for prompt urological consultation and timely surgical repair. The utility of bedside emergency ultrasound in the evaluation of testicular trauma, as well as the outcome of our case, is discussed here.

Emergency bedside-echocardiography in neonatal intensive care unit

Objective To evaluate the clinical value of emergency bedside-echocardiography in neonatal intensive care unit.Methods Six hundred and sixty-eight infants with cardiac pathological murmurs,cyanosis and shortness of breath were detected by emergency bedside echocardiography (Sonosite Micromax 1 portable ultrasound or Philips iE33 ultrasonic systems) during January 2007 to July 2011.The accuracy of emergency bedside-echocardiography in the diagnosis of neonatal heart diseases was evaluated according to the results of surgical exploration.Results Among 668 enrolled neonates with the mean age of (7.2±1.3) d,there were 347 males and 321 females,and 309 term infants [mean gestational age (39.1±0.6) weeks (37.0～42.1 weeks)] and 359 premature infants [mean gestational age (33.7±0.91) weeks (28.9～36.9 weeks)].Totally,507 cases were found cardiac abnormality by emergency bedside-echocardiography,including 268 cases of patent ductus arteriosus (232 premature and 36 term infants),115 congenital heart disease,99 persistent fetal circulation and 25 arrythmia.Surgeries were performed on 54 infants and invasive therapy was performed on one infant,and none of them received CT,magnetic resonance imaging or invasive examinations before operation; among which,51 surgeries successed and 4 infants died.Other 452 infants were treated with medications,392 infants recovered and discharged,26 infants did not recover,14 cases died and 20 cases left the hospital before recovery.The accuracy rate of Micromax 1 portable ultrasound in diagnosing congenital heart diseases was 94.5％ (52/55),while 96.4 ％ (53/55) for philips iE33 ultrasonic systems.Conclusions Emergency bedside-echocardiography could provide instant and valuable information of cardiovascular system,which would be helpful in making quick clinical decisions. Key words: Intensive care units,neonatal; Echocardiography; Medical order entry systems

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Migration to the Heart Diagnosed by Emergency Department Ultrasound

A 57-year-old man presented to our emergency department with altered mental status. He had a past medical history significant for cirrhosis and previous placement of a transjugular intrahepatic portosystemic shunt (TIPS). On cardiac auscultation, a new heart murmur and an unexpected degree of cardiac ectopy were noted. On the 12-lead electrocardiogram, the patient was noted to have multiple premature atrial contractions, corroborating the irregular heart rhythm on physicalexam. A focused bedside emergency ultrasound of the heart was then performed. This exam revealed an apparent foreign body in the right atrium. It appeared as if the patient’s TIPS had migrated from the heart into the right atrium. This case, as well as the literature describing thisunusual complication of TIPS placement, is reviewed in this case report. [West J Emerg Med. 2012;13(6):525-526]

Small Incision Fasciotomy in a Patient with Compartment Syndrome and Peripheral Arterial Occlusive Disease

An 82-year-old-man with a previous history of atrial fibrillation was admitted with acute limb ischemia. Emergent embolectomy was performed, but after the operation, the patient suffered from recurrent ischemic pain. Peripheral angiography revealed thrombosis of the distal popliteal artery due to pre-existing peripheral arterial occlusive disease. Bypass surgery of the popliteal artery and posterior tibial artery was then performed. Although peripheral blood flow was restored after the operation, he suffered from compartment syndrome the next day. The patient was treated with an emergent bed-side fasciotomy using a small incision, achieving full recovery of blood flow to the distal artery. The wound closed secondarily without surgical closure. In a patient with peripheral arterial occlusive disease, fasciotomy should be performed at a lower compartment pressure due to a lack of peripheral perfusion pressure. Emergent small incision fasciotomy was effective in this patient with an acute compartment syndrome and an ischemic limb.

Management of thoracic trauma in emergency service: Analysis of 1139 cases

Objective: Thoracic trauma is a common cause of significant morbidity and mortality. This study presents a series of thoracic trauma with the aim to assess epidemiologic features, distribution of pathologies, additional systemic injuries, diagnosis, management and outcome. Methodology: Between January 2007 and December 2011, all patients with thorax trauma admitted to the emergency service of our hospital were retrospectively reviewed with respect to age, gender, etiological factors, distribution of pathologies, additional systemic injuries, diagnosis, treatment modalities, referral and outcome. Results: A total of 1139 patients with thorax trauma were included in the study. Of these, 698 (61.3%) were male and 441 (38.7%) were female, and the average age was 54.17±17.39 years. 1090 (95.7%) of the patients had blunt trauma, whereas 49 (4.3%) had penetrating trauma. Etiological factors were falls in 792 (69.5%), motor vehicle accidents in 259 (22.8%), animal related accidents in 39 (3.4%) and penetrating injuries in 49 (4.2%) patients. It was found that 229 (20%) patients had single, 101 (8.9%) had double, 5 (3%) had three or more, 10 (0.9%) had bilateral rib fractures and 19 (1.7%) had sternal fracture. Pneumothorax was diagnosed in 58 (5.1%) patients, whereas hemothorax, hemopneuomothorax and other system injuries were diagnosed in 36 (3.2%), 38(3.3%) and 292 (25.6%) respectively. In our series, thirteen patients (mortality rate 1.1%) died as result of hemorrhagic shock (n=8), respiratory distress (n=3) and severe multiple trauma (n=2). Conclusion: Although majority of the patients with thorax trauma receive treatment as outpatients; thoracic traumas may be a life threatening condition, and should be identified and treated immediately. Mortality varies based on etiological factors, additional systemic pathologies, capabilities of the hospital especially diagnostic and treatment facilities in emergency services. We believe that a multidisciplinary approach to the patients with severe thorax trauma, and the opportunities of emergency bedside thoracotomy in emergency services will significantly reduce the morbidity and mortality.

43 A 360-Degree Approach to Teaching Emergency Bedside Procedures

Medical education continues to deemphasize cadaver-based training despite evidence that it enhances anatomy knowledge, as well as procedural skills. Once in residency, trainees are frequently faced with the responsibility of performing invasive procedures on patients without the benefit of prior experience. While a number of task trainers have been developed for procedure training, they ultimately lack the realism of working with human tissue. In response to these concerns, we have developed a 2-week elective course on emergency bedside procedures for senior medical students.

CLINICAL APPLICATION OF EMERGENCY BEDSIDE TEMPORARY CARDIAC PACING WITHOUT X-RAY FLUOROSCOPY

ObjectivesTo investigate the clinical value and safety of emergency bedside temporary cardiac pacing without X-ray fluoroscopy.Methods63 patients were selected due to ventricular rate less than or equal to 40 times/min...

Common Iliac Artery Tortuosity Simulating Aortic Dissection on Focused Abdominal Ultrasound in the Emergency Department

BackgroundBedside ultrasonography performed by the Emergency Physician is a safe procedure for evaluating patients with trauma, hypotension, chest or abdominal pain, and dyspnea of unknown origin. ObjectivesTo present a case with apparent concordance between the patient's history, symptoms, signs, and ultrasound imaging, that lead to diagnostic error. Case ReportA 74-year-old man was admitted to the hospital due to epigastric pain, radiating to the back. He reported previous detection of a small dilatation in the ascending aorta. On physical examination, the heart rate was 120 beats/min and the blood pressure was 90/60 mm Hg. These facts suggested the possibility of an aortic dissection; therefore, a bedside emergency ultrasound examination was performed. The first part of the examination focused on the ascending aorta, but the results were not significant. Then, an abdominal evaluation was performed that revealed an ovular and pulsatile anechoic mass in the infrarenal tract, with an echoic wall and an endoluminal flap. A computed tomography scan of the aorta was ordered, and it showed a regular aorta in the entire tract, with an abnormal tortuosity of iliac arteries as the basis of the false-positive ultrasound. ConclusionsThe use of ultrasound in emergency settings has improved the clinical evaluation of critical patients by Emergency Physicians, but the possibility of a false-positive diagnostic error always should be considered.

Emergency bedside cesarean delivery: lessons learned in teamwork and patient safety

BackgroundMaternal cardiovascular and pulmonary events during labor and delivery may result in adverse maternal and fetal outcome. Potential etiologies include primary cardiac events, pulmonary embolism, eclampsia, maternal hemorrhage, and adverse medication events. Remifentanil patient-controlled analgesia is an alternative when conventional neuraxial analgesia for labor is contraindicated. Although remifentanil is a commonly used analgesic, its use for labor analgesia is not clearly defined.Case presentationWe present an unexpected and unique case of remifentanil toxicity resulting in the need for an emergent bedside cesarean delivery. A 30-year-old G3P2 woman receiving subcutaneous heparin anticoagulation due to a recent deep vein thrombosis developed cardiopulmonary arrest during labor induction due to remifentanil toxicity.ConclusionA rapid discussion among the attending obstetric, anesthesia, and nursing teams resulted in consensus to perform an emergent bedside cesarean delivery resulting in an excellent fetal outcome. During maternal cardiopulmonary arrest, a prompt decision to perform a bedside cesarean delivery is essential to avoid significant maternal and fetal morbidity. Under these conditions, rapid collaboration among obstetric, anesthesia, and nursing personnel, and an extensive multi-layered safety process are integral components to optimize maternal and fetal outcomes.