Emergency Department Bedside Ultrasonography Research Articles

Acute Pericardial Effusion from Pacemaker Lead Perforation of Right Ventricle Identified on Bedside Emergency Department Ultrasonography

Introduction and Objective Cardiac pacemakers and Implantable Cardioverter-Defibrillators (ICD) are devices used to treat a range of cardiac dysrhythmias. Symptomatic cardiac perforation may occur in as many as 4.2% of pacemaker or ICD placements with 1.2% of pacemaker or ICD placements leading to clinically significant pericardial effusion. Acute onset of symptoms within 24 hours of device placement due to cardiac perforation is particularly rare, with a paucity of reported cases. This report describes a case of bedside Emergency Department (ED) ultrasound identifying an acute onset of pericardial effusion following cardiac pacemaker placement in an 85-year-old woman who experienced pleuritic and oscillating chest pain. Case Presentation An 85-year-old woman with a past medical history of hypertension, diabetes and dual-chamber pacemaker placement two days ago presented to the ED with pleuritic and oscillating chest pain. Initial bedside Point of Care Ultrasound (POCUS) exam, performed by the emergency department attending, revealed a moderate pericardial effusion with evidence of a pacemaker lead perforation through the right ventricular myocardium. Lead perforation and effusion were confirmed via formal transthoracic echocardiogram. Minutes later, the patient was treated with a right ventricle lead repositioning procedure and recovered uneventfully. Conclusion Symptomatic cardiac perforation due to pacemaker or ICD placement is rare, with a range of potential complications which typically occur weeks to months after placement. This case demonstrates the utility of POCUS exam for patients presenting to the ED for non-specific chest pain as it facilitated the timely diagnosis of an atypical presentation of ICD-induced wall perforation.

Emergency Department Bedside Ultrasonography for Diagnosis of Acute Cholecystitis; a Diagnostic Accuracy Study

Emergency Department Bedside Ultrasonography for Diagnosis of Acute Cholecystitis; a Diagnostic Accuracy Study

Gonococcal Tenosynovitis Diagnosed with the Aid of Emergency Department Bedside Ultrasound

BackgroundGonorrhea is the second most common sexually transmitted infection. Disseminated gonococcal infection (DGI) consists of gonococcal infection plus one or more of the triad of arthritis, tenosynovitis, and dermatitis. Diagnosis in the emergency department (ED) must be suspected clinically, as confirmatory tests are often not available. Point-of-care ultrasound (POCUS) can aid in diagnosis and appropriate management by identifying tenosynovitis and excluding arthritis. Case ReportA 26-year-old man with multiple recent sex partners presented to the ED with slowly progressing right wrist pain and swelling over 5 days. His dorsal right wrist was swollen, with slightly decreased range of motion owing to mild pain, and no warmth, tenderness, erythema, or drainage. Multiple hemorrhagic, gray-purple blisters were noted over both hands. Serum white blood cell count was 12 × 103/μL; C-reactive protein was 30.3 mg/L. POCUS of the dorsal right wrist found no joint effusion; the extensor tendon sheath contained a large anechoic space with clear separation of the extensor tendons, suggesting a tendon sheath effusion/tenosynovitis. DGI was suspected, without septic arthritis. The patient was admitted and treated with ceftriaxone and azithromycin. Gonococcus grew from blood cultures and pharyngeal swabs. Why Should an Emergency Physician Be Aware of This?DGI must be suspected clinically, as confirmatory tests are often not available in the ED. Not all patients present with arthritis, tenosynovitis, and dermatitis. It is often difficult to differentiate tenosynovitis from arthritis. POCUS can aid in diagnosis by identifying tenosynovitis (vs. arthritis or simple soft-tissue swelling), allowing timely appropriate DGI diagnosis and management, and, importantly, averting unnecessary arthrocentesis.

Emergency Department Bedside Ultrasonography for Diagnosis of Acute Cholecystitis; a Diagnostic Accuracy Study.

Using bedside ultrasound in diagnosing acute cholecystitis in the emergency department (ED) can save time, help the decision making process and allocate resources wisely. This study aimed to evaluate the diagnostic accuracy of bedside right upper quadrant (RUQ) ultrasonography in detection of acute cholecystitis. In this diagnostic accuracy study, patients presenting to ED, suffering from RUQ pain in favor of acute cholecystitis underwent RUQ ultrasonography in emergency and radiology departments and interrater agreement between reports was calculated. 342 patients with the mean age of 53.92 ± 11.18 (20 - 83) years were studied (63.2% female). The number of patients with at least one sonographic finding of acute cholecystitis were 53 (15.50%) and 48 (14.00%) based on ED and radiology reports (Kappa = 0.826). Sensitivity, specificity, positive and negative predictive values, as well as positive and negative likelihood ratios of bedside sonography were 89.58 (95%CI: 76.55 - 96.10), 96.59 (95%CI: 93.63 - 98.29), 81.13 (95%CI: 67.58 - 90.11), 98.26 (95%CI: 95.77 - 99.36), 4.30 (95%CI: 2.42 - 7.62) and 0.017 (95%CI: 0.007 - 0.041), respectively. There was a very good agreement between ED and radiology departments' sonography reports regarding the presence or absence of acute cholecystitis. Sensitivity and specificity of bedside RUQ sonography were 89.58 and 96.59, respectively.

55 History, Physical Exam, and Emergency Department Bedside Ultrasound for the Diagnosis of Acute Appendicitis in Pediatric Patients

55 History, Physical Exam, and Emergency Department Bedside Ultrasound for the Diagnosis of Acute Appendicitis in Pediatric Patients

Computerized Diagnostic Assistant for the Automatic Detection of Pneumothorax on Ultrasound: A Pilot Study.

IntroductionBedside thoracic ultrasound (US) can rapidly diagnose pneumothorax (PTX) with improved accuracy over the physical examination and without the need for chest radiography (CXR); however, US is highly operator dependent. A computerized diagnostic assistant was developed by the United States Army Institute of Surgical Research to detect PTX on standard thoracic US images. This computer algorithm is designed to automatically detect sonographic signs of PTX by systematically analyzing B-mode US video clips for pleural sliding and M-mode still images for the seashore sign. This was a pilot study to estimate the diagnostic accuracy of the PTX detection computer algorithm when compared to an expert panel of US trained physicians.MethodsThis was a retrospective study using archived thoracic US obtained on adult patients presenting to the emergency department (ED) between 5/23/2011 and 8/6/2014. Emergency medicine residents, fellows, attending physicians, physician assistants, and medical students performed the US examinations and stored the images in the picture archive and communications system (PACS). The PACS was queried for all ED bedside US examinations with reported positive PTX during the study period along with a random sample of negatives. The computer algorithm then interpreted the images, and we compared the results to an independent, blinded expert panel of three physicians, each with experience reviewing over 10,000 US examinations.ResultsQuery of the PACS system revealed 146 bedside thoracic US examinations for analysis. Thirteen examinations were indeterminate and were excluded. There were 79 true negatives, 33 true positives, 9 false negatives, and 12 false positives. The test characteristics of the algorithm when compared to the expert panel were sensitivity 79% (95 % CI [63–89]) and specificity 87% (95% CI [77–93]). For the 20 images scored as highest quality by the expert panel, the algorithm demonstrated 100% sensitivity (95% CI [56–100]) and 92% specificity (95% CI [62–100]).ConclusionThis novel computer algorithm has potential to aid clinicians with the identification of the sonographic signs of PTX in the absence of expert physician sonographers. Further refinement and training of the algorithm is still needed, along with prospective validation, before it can be utilized in clinical practice.

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.

Acute Hematogenous Osteomyelitis of the Rib Identified on Bedside Ultrasound

BackgroundOsteomyelitis is a challenging and commonly considered diagnosis in the emergency department. Early recognition and treatment with appropriate antibiotic therapy is crucial to prevent complications. ObjectiveThis case reviews relevant literature and typical ultrasound features of osteomyelitis. It highlights a previously undescribed and practical application of emergency department bedside ultrasonography, adding to the diagnostic armamentarium for this disease process. Case ReportA 48-year-old woman presented with fever and left chest wall pain. She had been seen previously for a right axillary abscess requiring incision and drainage. Examination revealed a focal area of chest tenderness without cutaneous changes. Chest x-ray study and laboratory evaluation were nondiagnostic. Bedside ultrasound diagnosed acute hematogenous osteomyelitis of a rib. ConclusionsBedside ultrasound holds great promise in investigating osteomyelitis when suspicion is high and traditional initial testing is nondiagnostic. Further study is required to quantify this benefit in the emergency department setting and explore utility of negative results.

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 Department Bedside Ultrasound Diagnosis of Retinoblastoma in a Child

A 30-month-old boy presented to a Haitian emergency department with proptosis, periorbital edema, and progressive blindness. Bedside ultrasound examination revealed bilateral ocular masses with dense calcifications pathognomonic for retinoblastoma. This case illustrates the diagnostic utility of bedside ultrasound for an advanced case of retinoblastoma in a resource-poor setting. Ocular ultrasound technique is also reviewed.

Subcapsular Liver Hematoma after Colonoscopy Diagnosed by Emergency Department Bedside Ultrasonography

BackgroundHepatic subcapsular hematoma is an uncommon cause of right upper quadrant pain in the Emergency Department. It must be recognized early, as large volumes of acute blood loss and rupture into the peritoneum carry significant morbidity and mortality. In the absence of gallbladder disease, the differential diagnosis should include liver pathology. Bedside ultrasonography can be used to identify such lesions. ObjectivesTo discuss the presentation, evaluation, and management options of hepatic subcapsular hematoma. Case ReportWe report a case of a 30-year-old woman who presented with the chief complaint of right upper quadrant pain radiating to the right scapula 6 h after a screening colonoscopy for intestinal polyps. Emergency physician-performed bedside ultrasound revealed a large hyperechoic mass in the right lobe of the liver. Radiology-performed comprehensive ultrasound and subsequent computed tomography scan of her abdomen and pelvis revealed a subcapsular hematoma without intestinal perforation. ConclusionIn a patient with undifferentiated right upper quadrant abdominal pain, bedside ultrasonography is a rapid and effective modality in the diagnosis of liver masses, including subcapsular hematoma.

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.

Fibroelastoma as a culprit of syncope.

We present a case of a valvular mass diagnosed by emergency department bedside ultrasonography in a young patient with syncope. Bedside ultrasound has become a valuable tool in the evaluation of patients with syncope in the emergency department. This patient was believed to have a fibroelastoma on ultrasound that was confirmed by magnetic resonance and ultimately by postsurgical pathological evaluation. The indications and findings of using ultrasonography as part of the workup of syncope in the emergency department are discussed.

Ultrasound Diagnosis of a Left Atrial Myxoma in the Emergency Departmnet

A 61-year-old male with a 1-year history of bilateral lower extremity swelling and a chronic cough was referred to the emergency department (ED) for an abnormal echocardiogram. The patient also reported experiencing intermittent episodes of chest pressure. He stated that he was referred from his doctor after he received a cardiac echocardiography examination that showed possible mitral valve vegetations. On review of systems, he also admitted to intermittent chest palpitations. On physical examination, his vital signs included a blood pressure of 127/75 mmHg, heart rate of 80 per minute and regular, respiratory rate of 18 per minute, pulse oximetry of 98% and temperature of 98.0°F. The rest of the physical examination was normal. An electrocardiogram demonstrated normal sinus rhythm and the chest radiograph was unremarkable. ED bedside ultrasound (EUS) showed evidence of a cardiac mass moving into the mitral valve (Video). Cardiology was consulted and formal echocardiography confirmed a left atrial myxoma measuring 4.4 cm × 3.2 cm that was attached to the mitral valve near the annulus. Severe mitral regurgitation was present and the left atrium was dilated in size. The patient was admitted to the cardiothoracic surgery service and subsequently underwent successful surgical removal of the myxoma.

Emergency department ultrasonography guided long-axis antecubital intravenous cannulation: How to do it.

An 85-year-old woman with a past medical history of severe peripheral vascular disease and right below knee amputation presented to the emergency department with a 1-day history of non-positional dizziness and weakness. The patient required intravenous access to work up her dizziness and weakness. The patient had multiple failed blind ED peripheral IV attempts performed in the past. Emergency department bedside ultrasonography with a high frequency linear array vascular probe was used to guide antecubital brachial vein cannulation on the first attempt using the long-axis approach.

Bedside emergency department ultrasonography availability and use for blunt abdominal trauma in Canadian pediatric centres

To quantify the current availability and use of bedside emergency department ultrasonography (EDUS) for blunt trauma at Canadian pediatric centres and to identify any perceived barriers to the use of bedside EDUS in such centres. An electronic survey was sent to 162 pediatric emergency physicians and 12 site directors from the 12 pediatric emergency departments across Canada. Ninety-two percent (11 of 12) of centres completed the survey. The individual physician response rate was 65% (106 of 162), with 100% of site directors responding. Ultrasound machines were available in 45% (5 of 11) of centres. Forty-two percent (32 of 77) of emergency physicians working in equipped pediatric centres used bedside EDUS to evaluate blunt abdominal trauma (BAT). In the subgroup of staff who also worked at adults sites, the frequency of ultrasonography use for the evaluation of pediatric BAT was 75%. In the 55% (6 of 11) of centres without ultrasonography, 88% of staff intend to incorporate its use in the future and 81% indicated that they believed the incorporation of ultrasonography would have a positive impact on patient care. The main perceived barriers to the use of ultrasonography in the evaluation of BAT were a lack of training (41%) and a lack of equipment (26%). Bedside EDUS is currently used in almost half of pediatric trauma centres, a frequency that is significantly lower than adult centres. Physicians in pediatric centres who use ultrasonography report that it has a high utility, and a great majority of physicians at pediatric centres without EDUS plan to incorporate it in the future. The main reported barriers to its use are a lack of training and a lack of equipment availability.

Role of Bedside Ultrasound in CMV Retinitis: A Case Report

We present a case of retinal detachment diagnosed by emergency department bedside ultrasonography in a patient with CMV retinitis. The indications and findings of ocular ultrasonography are discussed.

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

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

A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis

Ultrasound Quarterly: December 2010 - Volume 26 - Issue 4 - p 228 doi: 10.1097/01.RUQ.0000391062.25405.06

The Learning Curve of Resident Physicians Using Emergency Ultrasonography for Cholelithiasis and Cholecystitis

Emergency department bedside ultrasonography (EUS) can expedite treatment for patients. However, it is unknown how much experience is required for competency in the sonographic diagnosis of cholelithiasis and cholecystitis. The objective was to assess the learning curve of physicians training in right upper quadrant (RUQ) EUS. This was a prospective study at an urban, academic emergency department from August 1999 to July 2006. Patients with suspected biliary tract disease underwent RUQ EUS followed by abdominal ultra sonography (AUS) by the Department of Radiology. Results of EUS were compared to AUS using a predesigned, standardized data sheet. A total of 1,837 patients underwent EUS by 127 physicians. The overall sensitivity and specificity of EUS for cholelithiasis were 84% (95% confidence interval [CI] = 81% to 86%) and 86% (95% CI = 83% to 88%), respectively. The overall sensitivity of EUS for ductal dilation, gallbladder wall thickening, pericholecystic fluid, and sludge were each < 60%. When analyzing the EUS test characteristics, for every increase in 10 examinations up to 50 examinations, there was no significant improvement in the sensitivity or specificity for any of these sonographic findings. Moreover, on probit regression analysis, accounting for clustering or correlation among the examinations performed by each of the operators, there was no improvement for detecting any of the sonographic findings except for pericholecystic fluid for every 10 additional examinations performed. When adjusting for operator dependence, performing up to 50 EUS examinations appears to have little effect on the accuracy of RUQ EUS. Rather than simply requiring an arbitrary number of examinations, another method of competency assessment may be necessary.