Bedside Ultrasonography Research Articles

Evaluation of Etiopathogenesis, Clinical Profile and Lrinec Scoring in Necrotising Soft Tissue Infections

Necrotising soft-tissue infections can be defined as infections of any of the layers within the soft tissue compartment that are associated with necrotising changes. NSTI is an uncommon but life-threatening. To resolve this, some authors have developed different diagnostic adjuncts such as finger tests, skin biopsies, bedside ultrasounds and laboratory parameters in distinguishing NSTI from other soft-tissue infections (LRINEC laboratory risk indicator for necrotizing fasciitis score). Material and Method : An observational study was conducted in 50 patients (clinically diagnosed necrotising soft tissue infection). clinical observations supported by relevant investigations were documented on the attached proforma and the data so obtained was statistically analysed. Observation and result : The results suggested that maximum number of affected individuals are males, middle aged individuals. Majority of patients had normal pulse with mean body temperature of 37.3°C, normal blood pressure,INR, normal serum level of sodium, potassium and bilirubin. High level of RBS (more than 200mg/dl). Tenderness was the most commonly elicited clinical sign of NSTI, crepitus was noted in only 20% patients. Maximum number of patients were found to be infected by streptococcus pyogenes (42%). The mean level was -hemoglobin -10.2+2.3 g/dl, WBC -13,340 + 6116 /mm3, serum creatinine value of s 1.6mg/l. High discrepancy noted in value of CRP. High prevalence of NSTI involving the extremities ranging from 64.39% to 93.The mean value of LRINEC score is 6±2.92 36 % of patients having <6 score and 64% patients having score >6. Conclusion : It can be concluded that the local clinical findings are of paramount importance rather than clinical features of systemic toxicity such as fever and tachycardia.

Effects of a Preoperative Carbohydrate-Rich Drink Before Ambulatory Surgery: A Randomized Controlled, Double-Blinded Study.

BackgroundThe guidelines recommend oral carbohydrates up to 2 hr before elective surgery. The objective of this study was to explore the safety and feasibility of preoperative carbohydrate drink in patients undergoing ambulatory surgery.Material/MethodsPatients undergoing ambulatory surgery under general anesthesia were enrolled. They were fasted from midnight and randomly assigned to a study group (200 mL of a carbohydrate beverage) or the control group (pure water) and received the assigned drink 2 hr before surgery. Bedside ultrasonography was performed to monitor gastric emptying at T0 (before liquid intake), T1 (5 min after intake), T2 (1 hr after intake), and T3 (2 hr after intake). Subjective feelings of thirst, hunger, anxiety, and fatigue were assessed 1 hr after liquid intake using the visual analogue scale (VAS).ResultsIn both groups, gastric antrum cross-sectional area, gastric content volume, and weight-corrected gastric content volume increased at T1 and returned to baseline at T3. These parameters were significantly higher in the study group at T2 (6.28±1.38 vs. 4.98±0.78, 67.22±29.49 vs. 49.04±15.4, 1.10±0.51 vs. 0.85±0.37, P<0.05). Thirst and hunger VAS scores were reduced in both groups. The study group suffered significantly less hunger (28.44±10.41 vs. 36.03±14.42, P<0.05). Blood electrolytes (sodium, potassium, calcium) and glucose concentration levels were similar in both groups at T2. No gastric regurgitation or pulmonary aspiration was recorded.ConclusionsAdministration of 200 mL of oral carbohydrate beverage 2 hr before ambulatory surgery is safe, effective, and can be used for preoperative management of fasting patients.

Accuracy of Bedside Ultrasound Femoral Vein Diameter Measurement by PICU Providers.

Perform a needs assessment by evaluating accuracy of PICU provider bedside ultrasound measurement of femoral vein diameter prior to utilization of the catheter-to-vein ratio for central venous catheter size selection. Prospective observational cohort study. PICU within a quaternary care children's hospital. PICU patients greater than 30 days and less than 6 years without a femoral central venous catheter. None. Gold-standard femoral vein diameter measurements were made by a radiologist, sonographer, or bedside ultrasound expert. PICU providers then repeated the femoral vein diameter measurements, and results were compared by Bland-Altman analysis with a priori accuracy goal of limits of agreement ± 15%. Among recruited patients (n = 27), the median age was 1.1 years (interquartile range 0.5-2.3 yr), weight was 9.0 kg (interquartile range 7.0-11.5 kg), and reference femoral vein diameter was 0.36 cm (interquartile range 0.28-0.45 cm). Providers performed 148 femoral vein diameter measurements and did not meet goal accuracy when compared with the reference measurement with a bias of 4% (95% of limits of agreement -62% to 70%). A majority of patients would have a catheter-to-vein ratio greater than 0.5 using either age-based central venous catheter size selection criterion (14/27) or the provider bedside ultrasound femoral vein diameter measurement (18/27). PICU provider measurement of femoral vein diameter by bedside ultrasound is inaccurate when compared with expert reference measurement. Central venous catheter size selection based on age or PICU provider femoral vein diameter measurement can lead to a catheter-to-vein ratio greater than 0.5 and potentially increase the risk of catheter-associated venous thromboembolism. Structured bedside ultrasound training with assessment of accuracy is necessary prior to implementation of venous thromboembolism reduction efforts based on catheter-to-vein ratio recommendations.

Treatment of Skin Abscesses in the Emergency Department

Treatment of Skin Abscesses in the Emergency Department Abstract. Skin abscesses are a common cause for presentation in the emergency department and are in most cases treated by incision and drainage. The diagnosis is usually based upon clinical manifestation. If there is uncertainty regarding the presence of an abscess, bedside ultrasonography is suggested to identify the presence, size and location of the abscess. Uncomplicated abscesses < 5 cm in diameter often can be treated under local or regional anesthesia with or without additional procedural sedation within the emergency department. Sufficient anesthesia and analgesia are essential to avoid undertreatment of the abscess. Certain abscess localizations or conditions require referral to a surgeon and / or operation of the abscess in the operating room. Alternative to the classic incision and drainage the minimal invasive Loop Drainage Technique may be considered. A postoperative systemic antibiotic treatment is only indicated under certain conditions.

Focused ultrasonography for septic shock resuscitation.

Severe sepsis with septic shock is the most common cause of death among critically ill patients. Mortality has decreased substantially over the last decade but recent data has shown that opportunities remain for the improvement of early and targeted therapy. This review discusses published data regarding the role of focused ultrasonography in septic shock resuscitation. Early categorization of the cardiovascular phenotypes with echocardiography can be crucial for timely diagnosis and targeted therapy of patients with septic shock. In the last few years, markers of volume status and volume responsiveness have been investigated, serving as valuable tools for targeting volume therapy in the care of both spontaneously breathing and mechanically ventilated patients. In tandem, investigators have highlighted findings of extravascular volume with ultrasonographic evaluation to compliment de-escalation of resuscitation efforts when appropriate. Furthermore, special attention has been given to resuscitation efforts of patients in septic shock with right ventricular failure. Severe sepsis with septic shock is an insidious disease process that continues to take lives. In more recent years, data have emerged suggesting the utility of bedside ultrasonography for early cardiovascular categorization, goal directed resuscitation, and appropriate cardiovascular support based on its changing phenotypes.

Pre-anaesthesia ultrasonography of the subclavian/infraclavicular axillary vein for predicting hypotension after inducing general anaesthesia: A prospective observational study.

Bedside sonography of the inferior vena cava has been demonstrated to be a reliable tool for assessing intravascular volume status. Subclavian vein (SCV) assessment was proposed as a reasonable adjunct for measuring the inferior vena cava. We examined whether the preoperative diameter and collapsibility index of the SCV or the infraclavicular axillary vein could predict the incidence of hypotension after induction of general anaesthesia in patients undergoing laparoscopic cholecystectomy. Prospective, observational study. Tertiary university hospital. Adults scheduled for laparoscopic cholecystectomy. Sonographic evaluation of the SCV or the axillary vein (SCV-AV) before induction of anaesthesia. The main outcome was the association between the SCV-AV measurements (diameter an collapsibility index) and intra-operative hypotension (IOH) after induction of anaesthesia. Patients who developed IOH had a higher collapsibility index of the SCV-AV during spontaneous breathing (P = 0.009) and deep inspiration (P = 0.002). After adjusting for confounding variables, the collapsibility index of the SCV-AV during spontaneous breathing was not a significant predictor of a decrease in mean arterial blood pressure (MAP) after inducing anaesthesia (P = 0.127), whereas the collapsibility index of the SCV-AV during deep inspiration was a significant predictor (P < 0.001). The collapsibility index of the SCV-AV during deep inspiration was a significant predictor of IOH occurrence and the percentage decrease in MAP after inducing anaesthesia. Further studies in patients with higher collapsibility index are needed to confirm our findings, before the collapsibility index of the SCV-AV can be recommended unequivocally for clinical use. This trial was registered on 8 September 2017 at the Clinical Trial Registry of Korea (https://cris.nih.go.kr/cris/index.jsp; Identifier: KCT0001078KCT0002457), and the first patient was enrolled on 14 October 2017.

Use of Bedside Ultrasound to Assess Muscle Changes in the Critically Ill Surgical Patient.

Critical illness causes hypercatabolism, loss of lean body mass (LBM), and poor outcomes. Evaluating LBM in the critically ill is challenging, and it is uncertain whether nutrition support (NS) impacts LBM. This study measured quadriceps muscle layer thickness (QMLT) by bedside ultrasound (US) to estimate LBM changes in surgical intensive care unit (SICU) patients and healthy controls (HCs). Trained RDNs measured QMLT via US at the midpoint and one-third distance between the superior margin of the patella and the anterior superior iliac spine. QMLT measurements were taken upon enrollment and repeated 1-2 times over 10 days. Fifty-two SICU patients and 15 HCs were enrolled. Average SICU percent QMLT loss per day at the midpoint and one-third landmarks was 3.2 ± 3.8 (P < 0.001) and 2.9 ± 5.7 (P = 0.001); and QMLT loss was higher between the second and third measurements (4.0 ± 8.0, P = 0.005 and 4.3 ± 9.8, P = 0.017 at the midpoint and one-third landmarks) compared with that at the first and second measurements (1.7 ± 9.2, P = 0.20 & 1.7 ± 9.4, P = 0.22). Changes were not associated with NS received. No significant QMLT change was found in HCs. SICU patients significantly lost QMLT over 10 days, with greater losses occurring after 5 days. These results support RDNs performing USs to detect QMLT changes and suggest this technique could be valuable to evaluate LBM changes in critically ill patients.

Bedside Ultrasound for Weaning from Mechanical Ventilation: The Diaphragm Is Not Enough!

Bedside Ultrasound for Weaning from Mechanical Ventilation: The Diaphragm Is Not Enough!

Determination of normal values of optic nerve sheath diameter in newborns with bedside ultrasonography

ObjectivesBedside sonographic opthalmic ultrasound measurement of optic nerve sheath diameter (ONSD) is an easy, portabl, noninvasive and a radiation free technique to determine increased intracranial pressure. This prospective, multicenter study was aimed to establish the range of normal values for ONSD in preterm and term newborns with a large study population. MethodsNewborns without intracranial pathology in the Newborn Intensive Care Units and in Obstetrics and Gynecology Departments were enrolled in the study. ONSD was measured at 3 mm distance behind of the right optic nerve head. As 3 mm distance was beyond the optic nerve head in some of the premature newborns, we had also measurements at 2 and 2.5 mm. ResultsONSD was measured in 554 newborns. Mean ONSD of preterm babies at 2, 2.5 and 3 mm distances were 3.2 ± 0.3 mm (range 2.0–4.2 mm), 3.3 ± 0.3 mm (range 2.2–4.5 mm) and 3.6 ± 0.2 mm (range 2.9–4.5 mm), (p2.0–2.5 mm < 0.001, p 2.5–3.0mm < 0.001, p2.0–3.0 mm < 0.001) respectively. Mean ONSD of term babies at 3 mm was higher than the mean ONSD of preterm babies in 33 weeks 0 day- 37 weeks 0 days group (p < 0.001). In correlation analysis, a significant, strong and positive correlation was found between ONSD measurements and gestational age, weight, height and head circumference at 2, 2.5 and 3 mm distances. ConclusionThe normal values reported by the present study may be used for evaluating the ONSD of newborns with different conditions with increased incracranial pressure.

A Clinical Study of Noninvasive Assessment of Lung Lesions inPatients with Coronavirus Disease-19 (COVID-19) by Bedside Ultrasound.

This study was conducted to explore the clinical value of noninvasive assessment of bedside ultrasound in the diagnosis of lung lesions of Coronavirus Disease-19. In this retrospective study, 30 patients with Coronavirus Disease-19 admitted to our hospital from January 18 to February 5, 2020, were selected as the research subjects. All cases were examined by lung ultrasound and CT. Lung lesions were reviewed by blinded observers, with imaging scores being used to analyze the ultrasound findings of lung lesions in patients with Coronavirus Disease-19 and with chest CT being used as the reference standard. The clinical value of ultrasound in the noninvasive assessment of lung lesions was evaluated. Lung ultrasound signs in patients with Coronavirus Disease-19 were mainly manifested as interstitial pulmonary edema (90.0 %, 27/30) and pulmonary consolidations (20.0 %, 6/30). The lung lesions were mainly distributed in the subpleural and peripheral pulmonary zones. The lower lobe and the dorsal region had a greater tendency to be involved. There was moderate agreement (Kappa = 0.529) between the noninvasive assessment of bedside ultrasound for lung lesions in patients with Coronavirus Disease-19 and CT. The ultrasound scores to evaluate mild, moderate and severe lung lesions exhibited sensitivity of 68.8 % (11/16), 77.8 % (7/9), 100.0 % (2/2), specificity of 85.7 % (12/14), 76.2 % (16/21), 92.9 % (26/28), and diagnostic accuracy of 76.7 % (23/30), 76.7 % (23/30), 93.3 % (28/30), respectively. The follow-up dynamic ultrasound examination showed that the condition of all patients worsened gradually, with the ultrasound scores of lung lesions increasing to varying degrees. Though the diagnostic efficacy of bedside ultrasound is relatively low for mild to moderate patients, it is high for severe patients. Bedside ultrasound has important clinical significance for noninvasive assessment and dynamic observation of lung lesions in patients with Coronavirus Disease-19, which is worth further consideration.

Diaphragm ultrasound: A novel approach to assessing pulmonary function in patients with traumatic rib fractures.

Rib fractures following blunt trauma are a major cause of morbidity. Various factors have been used for risk stratification for complications. Ultrasound (US) measurements of diaphragm thickness (Tdi) and related measures such as thickening fraction (TF) have been verified for use in the evaluation of diaphragm function. In healthy individuals, Tdi by US is known to have a positive and direct relationship with lung volumes including inspiratory capacity (IC). However, TF has not been previously been described in, or used to assess, pulmonary function in rib fracture patients. We examined TF and IC to elucidate the association between acute rib fractures and respiratory function. We hypothesized that TF and IC were related. Secondarily, we examined the relationship of TF in rib fractures patients, in the context of values reported for healthy controls in the literature. We prospectively enrolled adults with acute blunt traumatic rib fractures within 48 hours of admission to a level 1 trauma center. Patients requiring a chest tube or mechanical ventilation at time of consent were excluded. Inspiratory capacity was determined via incentive spirometry. Thickening fraction was determined by bedside US measurements of minimum and maximum Tdi during tidal breathing (TFtidal) or deep breathing (TFDB) was calculated (TF = [TdimaxTdi - TdiminTdi]/TdiminTdi). TFDB values were also compared with previously reported mean ± SD values of 2.04 ± 0.62 in healthy males and 1.70 ± 0.89 in females. Univariate and multivariate analyses were performed. A total of 41 subjects (58.5% male) with a median age of 64 years (interquartile range [IQR], 53-77 years) were enrolled. Diaphragm US demonstrated a median TFtidal of 0.30 (IQR, 0.24-0.46). Median IC was 1,750 mL (IQR, 1,250-2,000 mL). As compared with previously reported controls, our mean ± SD TFDB in males 0.90 ± 0.51 and 0.88 ± 0.89 in females were significantly lower. Multivariate analysis revealed a significant inverse correlation (-0.439, p = 0.004) between TFtidal and IC, and no relationship between TFDB and IC. To our knowledge, this is the first report of TF in rib fracture patients. The significant inverse association between TFtidal and IC, along with lower than normal TFDB ranges, suggests that, in the setting of rib fractures, there are alterations in the diaphragm-chest cage mechanics, whereby other muscles may play more prominent roles. Diagnostic tests or criteria, Level III.

Percutaneous dilational tracheostomy: current techniques and evidence of safety

Tracheostomy has transitioned from being the complete domain of surgeons, as described by Chevalier Jackson in early 20th century, to a procedure shared by intensivists and interventional pulmonologists in form of percutaneous dilatational tracheostomy. This procedure is commonly performed in intensive care units to facilitate long-term mechanical ventilation for chronic respiratory failure, but other less frequent indications also exist. The commonly practiced techniques for percutaneous dilational tracheostomy rely on passage of tools over a guidewire, with the Ciaglia technique being the most popular and having the best safety profile. Adjunctive techniques include use of bronchoscopy, bedside ultrasonography, and laryngeal mask airway (LMA). In properly selected patients, percutaneous dilational tracheostomy carries a good safety profile, but some patient characteristics may increase the risk of complications; thus, the procedure is complimentary to surgical tracheostomy (ST) and not a complete replacement. Bedside ultrasound and bronchoscopy are routinely available instruments in most intensive care units, although there is limited evidence of improved safety with these adjuncts. In properly selected patients, percutaneous dilational tracheostomy can be a safe and cost-effective alternative to ST.

Does Pre‐Clerkship physician assistant POCUS training improve Knowledge and confidence in Clerkship?

IntroductionWith the technological progress of different types of portable Ultrasound machines, there is a growing demand for all health care providers to perform bedside Ultrasonography, also known as Point of Care Ultrasound (POCUS). This technique is becoming extremely useful as part of the Clinical Skills/Anatomy teaching in the undergraduate Medical field curriculum.Teaching/training health care providers how to use these portable Ultrasound machines can complement their physical examination findings and help in a more accurate diagnosis, which leads to a faster diagnosis and better patient outcomes. In addition, using portable Ultrasound machines can add more safety measurements to every therapeutic/diagnostic procedure when it is done under an Ultrasound guide. Ultrasound is one of the different imaging modalities that health care providers depend on to reach their diagnosis, while also being the least invasive methodAimTo assess the effect of pre‐clerkship POCUS training on their knowledge and confidence of POCUS training during their clerkshipMethodThe research we report in this manuscript is a preliminary qualitative study. It provides the template for future models for teaching hands on Ultrasound for all health care providers in different learning institutions.The McMaster Physician Assistant program is a two‐year course; we introduce POCUS training to the first and second year Physician Assistant curriculum. We have a total of 24 Physician Assistant students at each level of the program; at each level we divide them into three equal groups, supervised by a tutor. Each group uses one portable General Electric Ultrasound machine, which is projected onto a large plasma screen. We dim the room lights to get better quality screen images. Our session lasts for 90 minutes, the first 20 minutes being an introduction to how to use the machine and probe orientation, as well as some anatomy landmarks. Every student will have the chance to scan their peers at least one time during our session.Our objective is a pure “hands on” scanning of the neck and the abdomen performed by the students. With the correlations to their anatomy background knowledge, they were able to identify normal Thyroid Glands and major neck vessels, Liver, abdominal Aorta, inferior vena cava, Gall Bladder, and the Kidneys.ResultA questionnaire was handed to the second year (clerkship) Physician Assistant students to evaluate their hands on ultrasound session experience. And the effect of their previous POCUS training at pre‐clerkship level in enhancing more confidence on their most recent training. Answers were collected and data was analyzed into multiple graphs (as illustrated in this poster).Discussion and ConclusionThese results illustrate the importance of the prior POCUS training for Physician Assistant students at their pre‐clerkship level, to build up more confidence in their scanning ability, improve the orientation of their ultrasound images, and to better understand the relation of the probe’s position to the corresponding images during their clerkship POCUS training.Support or Funding InformationEducation program anatomy, McMaster University

798 Introduction of Bedside Echocardiography by Mid-level Providers into Burn Intensive Care

Abstract Introduction Point-of-care ultrasound (US) has been shown to be a useful adjunct in assessment of various shock states and has been utilized to guide both resuscitation and post-resuscitation de-escalation. We aimed to characterize the use of bedside ultrasound examinations performed by advance practice providers (APPs) and attending physicians in a burn intensive care unit (BICU). Methods We introduced routine US by an APP into our BICU and evaluated our experience under an approved PI project. Daily beside US exams were performed utilizing a portable US machine with a cardiac probe and tissue filter. US exams included focused transthoracic echocardiography, assessment of inferior vena cava diameter with distensibility/collapsibility indices, and pulmonary evaluation. The images were archived to a centralized repository and reviewed daily during multi-disciplinary rounds. US data were utilized in conjunction with physical exam, radiographic, and laboratory findings for medical management decision making. Results Thirty-four exams of 34 patients have been conducted to date. 91% of US findings corresponded to physical, laboratory, and radiographic findings, and contributed positively to medical decision making. 9% of US findings either did not contribute to medical decision making or conflicted with physical exam, radiographic, or laboratory findings. Conclusions Our results demonstrate the feasibility of routine US by an APP in the BICU, and indicate that bedside US helps guide both resuscitative and post-resuscitative care. Applicability of Research to Practice It is well known that positive fluid balance is associated with worse clinical outcomes. We believe point-of-care US is a viable tool in preventing over-resuscitation as well as to guide post-resuscitative diuresis.

Preoperative bedside ultrasound assessment of gastric volume and evaluation of predisposing factors for delayed gastric emptying: a case-control observational study.

Perioperative pulmonary aspiration of gastric content is a serious complication. Fasting guidelines try to ensure an empty stomach before intervention. Certain medications or pathologies may cause delayed gastric emptying. Bedside ultrasonography is a useful tool when gastric content status is unclear or in emergency situations where fasting is not feasible. The aim of this prospective case-control observational study was to assess differences in gastric fluid volume between fasted patients with or without predisposing factors for delayed gastric emptying. Patients were preoperatively scanned. Antral cross-sectional area was measured by two tracing methods and total gastric clear fluid volumes were calculated. Data was recorded from September 2018 to March 2019 in a university hospital setting in Barcelona, Spain. Fifty-three patients were enrolled, 23 with delayed gastric emptying predisposing factors (DGEF) and 30 without non-DGEF. Ultrasound-estimated gastric clear fluid volume was 35.21 ± 32.69mL in the DGEF versus 53.50 ± 30.72mL in the non-DGEF group (p = 0.08). Average volume per unit of weight was 0.61 ± 0.46mL/kg. Only 1 patient in the DGEF group had a volume that posed a higher risk of aspiration (1.57mL/kg). Perfect correlation (R = 0.91; p < 0.01) and concordance (0.91; 95% CI 0.83; 0.95) was found between tracing methods. Minimal gastric content was observed in scheduled surgery in spite of predisposing factors for delayed gastric emptying. Ultrasound clear gastric volume estimation was useful to assess preoperative bedside gastric content.

Sonographic Assessment of Intravascular Fluid Estimate (SAFE) Score by Using Bedside Ultrasound in the Intensive Care Unit.

Objective The objective of the study was to use an ultrasound-based numerical scoring system for assessment of intravascular fluid estimate (SAFE) and test its validity. Methods A prospective, observational study was carried out in the surgical intensive care unit (ICU) of an urban tertiary care teaching hospital. Patient's intravascular volume status was assessed using the standard methods of heart rate, blood pressure, central venous pressure, cardiac output, lactate and saturation of venous oxygen, and others. This was compared with assessment using bedside ultrasound evaluation of the cardiac function, inferior vena cava, lungs, and the internal jugular vein. Applying a numerical scoring system was evaluated by Fisher's exact testing and multinomial logistic model to predict the volume status based on ultrasound scores and the classification accuracy. Results 61 patients in the ICU were evaluated. 21 (34.4% of total) patients diagnosed with hypovolemia, and their ultrasound volume score was −4 in 14 (66.7%) patients, −3 in 5 (23.8%) patients, and 0 in 2 (9.5%) patients (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and −1 in 1 (5.6%) patient (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and −1 in 1 (5.6%) patient (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and −1 in 1 (5.6%) patient (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and −1 in 1 (5.6%) patient (Conclusion Using the SAFE scoring system to identify the IVV status in critically ill patients significantly correlates with the standard measures. A SAFE score of −4 to −2 more likely represents hypovolemia, −1 to +1 more likely represents euvolemia, and +2 to +4 more likely to be hypervolemia.

Pericardial effusion with tamponade: bedside ultrasonography saves another life

In these video clinical images, the authors present the cause for an elderly gentleman’s shortness of breath. It was presumed to be an exacerbation of chronic obstructive pulmonary disease, a condition for which he was in the process of being evaluated. However, bedside ultrasonography revealed a large pericardial effusion with tamponade. This timely diagnosis resulted in the patient being taken expeditiously to the operating room and saving his life.

The relationship between inferior vena cava diameter measured by bedside ultrasonography and central venous pressure value

The relationship between inferior vena cava diameter measured by bedside ultrasonography and central venous pressure value

Rapid Diagnosis of A Palmar Artery Pseudo-Aneurysm with Bedside Ultrasonography in Emergency Department

Aneurysms are abnormal dilations in the vessel wall due breakdown in connective tissue. Aortic aneurysms are a common presentation in the emergency department (ED) and their incidence increases with age and associated risk factors. However, palmar artery aneurysms are a rare presentation. The increasing use of point of care ultrasound (PoCUS) has facilitated early diagnosis of aneurysms in the ED and has expedited their management. In this report we describe a case of palmar artery aneurysm in a 87 year old patient which was diagnosed with PoCUS in the ED.

A woman with knife In situ of chest

The violence can be physical, psychological or sexual. Physical violence can be by the use of sharp objects. Chest stab wounds with retained penetrating objects are rare. Here, we have reported a case with a knife impaled in her upper back who was treated successfully without any complications. A 35-year-old woman presented to our emergency department with an in situ knife at T4–T5 level. Neurologic examination revealed normal and bed side sonography reveals no free fluid in the abdomen, but lung sliding was disrupted on the left hemithorax without evidence of tamponade. A portable chest-x ray showed that the knife passes through an oblique track from right to left. The patient transferred to the operating room and the 50 cm knife removed without traumatic force. Limited thoracotomy with chest tube placement was done. We have reported a case report of an in situ knife at the upper back of a young woman who was successfully treated. The patient was stabbed in the upper back due to her husband's violence and the knife passes through an oblique track from right to left without any vascular injury. We stabilized the patient and used bedside sonography as a modality for diagnosis and decision making.