Emergency Department Ultrasound Research Articles

Dysphagia in a young healthy female in the ED: why sometimes you do need to work them up

The authors describe a thyroid nodule diagnosed on emergency department ultrasonography as the culprit for dysphagia.

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.

Undifferentiated Dyspnea with Point-of-Care Ultrasound, Primary Emergency Physician Compared with a Dedicated Emergency Department Ultrasound Team.

Emergency physicians (EPs) perform critical actions while operating with diagnostic uncertainty. Point-of-care ultrasound (POCUS) is useful in evaluation of dyspneic patients. In prior studies, POCUS is often performed by ultrasound (US) teams without patient care responsibilities. This study evaluates the effectiveness of POCUS in narrowing diagnostic uncertainty in dyspneic patients when performed by treating EPs vs. separate US teams. This multicenter, prospective noninferiority cohort study investigated the effect of a POCUS performing team in patient encounters for dyspnea. Before-and-after surveys assessing medical decision-making were administered to attending physicians. Primary outcome was change in most likely diagnosis after POCUS. This was assessed for noninferiority between encounters where the primary or US team performed POCUS. Secondary outcomes included change in differential diagnosis, confidence in diagnosis, interventions considered, and image quality. There were 156 patient encounters analyzed. In the primary team group, most likely diagnosis changed in 40% (95% confidence interval 28-52%) of encounters vs. 32% (95% confidence interval 22-41%) in the US team group. This was noninferior using an a priori specified margin of 20% (p < .0001). Post-POCUS differential decreased by a mean 1.8 diagnoses and was equivalent within a margin of 0.5 diagnoses between performing teams (p = 0.034). Other outcomes were similar between groups. POCUS performed by primary teams was noninferior to POCUS performed by US teams for changing the most likely diagnosis, and equivalent when considering mean reduction in number of diagnoses. POCUS performed by treating EPs reduces cognitive burden in dyspneic patients.

Penile Dorsal Vein Rupture Identified by Emergency Department Ultrasound.

Case PresentationWe present the case of a young male with high clinical suspicion of a penile fracture found to have dorsal vein rupture by emergency department point-of-care ultrasound. This false form of penile fracture was subsequently confirmed intraoperatively.DiscussionPenile fracture is a rare clinical entity that may be separated into true vs false penile fracture, with only true fracture requiring surgery. The images submitted here add to the sparse literature evidence that point-of-care ultrasound can be used to differentiate between these two clinical entities. Additionally, this case report highlights an opportunity for further research into and application of point-of-care ultrasound to the evaluation of suspected penile fractures.

The feasibility of bedside transvaginal ultrasonography in non-pregnant women in the emergency department.

We recorded data on the routine use of point-of-care transvaginal ultrasound (POC TVUS) for the evaluation of non-pregnant women with pelvic complaints in the Emergency Department (ED), and sought to determine how it altered the diagnostic impression and management. This was a prospective observational study. Adult non-pregnant women with pelvic complaints undergoing POC TVUS were enrolled. Pre and post ultrasound, the treating physician completed a data collection form indicating the most likely cause of the patient's pain, current treatment plan, and expected ultrasound findings. Immediately after the ultrasound, the treating physician completed another form to indicate details about the sonographic process and findings, and whether a radiologyperformed TVUS was planned. Of 113 women enrolled, 79% had both ovaries visualized and the POC TVUS led to changes in plan in 43% of patients, including 3 emergent/urgent interventions; 48% of patients had unexpected findings. Of the 25% who had an additional radiology exam, there were no instances of discordant findings when both ovaries were assessed to be normal on ED Ultrasound. The ultrasound added <10 minutes in 92% of patients. With an ED ultrasound only (n = 85), the median length of stay (LOS) was 282 (IQR 197-323) minutes, compared to 437 (IQR 367-500) minutes when a radiology ultrasound was required (n = 28) (median difference,170 minutes [95% CI 122-212 min]). In this study, emergency physicians were able to efficiently obtain and interpret POC TVUS images that changed assessment of non-pregnant women with pelvic pain without significantly increasing the ED length of stay.

174 Evaluation of Undifferentiated Dyspnea with Point of Care Ultrasound Performed by Primary Emergency Department Physician Compared to a Dedicated Emergency Department Ultrasound Team

Undifferentiated dyspnea is among the most challenging emergency department (ED) presentations. Emergency physicians (EP) must often perform critical actions while operating with diagnostic uncertainty. Point of care ultrasound (POCUS) has been shown to be highly beneficial in the initial evaluation of dyspneic patients but prior studies often study POCUS performed by experts or a dedicated physician ultrasound (US) team. Performance of POCUS by the primary treating team is often limited by the time and workflow constraints. This study aims to evaluate the effectiveness of POCUS in narrowing diagnostic uncertainty and guiding initial management of acutely dyspneic patients when performed by treating EP compared to a dedicated US team. This is a multi-center, prospective non-inferiority cohort study investigating the effect of POCUS on the differential diagnosis of patients presenting with undifferentiated dyspnea. During the initial evaluation of these patients, the primary attending provider completed a survey evaluating initial differential diagnosis and treatment plan. The provider team or a separate US team then performed targeted POCUS on the patient. After POCUS, the treating provider completed a second survey to evaluate changes in differential and management. The primary outcome was change in the most likely diagnosis and was assessed for non-inferiority between primary and US team performed POCUS using an a priori specified non-inferiority margin of 20%. Secondary outcomes included change in number of diagnoses considered, change in confidence in diagnosis assessed on a Likert-like scale, and change in interventions. We enrolled physicians evaluating 156 patients presenting with undifferentiated dyspnea at a university affiliated ED or a community hospital ED. In 40% (95% CI, 28 - 52%) of studies performed by the primary team the most likely diagnosis changed compared to 32% (95% CI, 22 - 41%) for studies performed by the US team. This was declared non-inferior using a margin of 20% (p < .0001). Post-POCUS differentials decreased by a mean 1.8 diagnoses and this change was equivalent within a margin of 0.5 diagnoses between primary and US team performed studies (p = 0.034). Secondary outcomes were also notable for a modest change in any management being considered (34% primary team vs 32% US team), an increase in post-POCUS confidence in diagnosis (0.7 vs 0.6-point increase), and 3 cases of cardiac tamponade were found when COPD or CHF was the initial suspected diagnosis. POCUS performed both by the primary team and a dedicated US team resulted in a significant narrowing of the differential diagnosis, a change in the primary diagnosis and an increase in confidence of diagnosis. The change in primary diagnosis was non-inferior when comparing primary to US team performed studies and the two groups were equivalent when considering change in confidence in diagnosis as well as mean reduction in number of diagnoses. There was also no significant difference in effect between performing sites. POCUS is a valuable tool for limiting the cognitive burden in the initial evaluation of undifferentiated dyspneic ED patients when performed in a targeted fashion.

An Evaluation of a Community Hospital’s Emergency Department Ultrasonography Processes for the Diagnosis of Acute Pediatric Appendicitis

CONTEXTSince the 1980s, the use of ultrasonography for suspected acute pediatric appendicitis has become increasingly common. Multiple studies have suggested that ultrasound of the appendix has consistently high sensitivity and specificity when the appendix can be clearly visualized. The authors’ primary objective for this study was to retrospectively evaluate their community-based healthcare system’s processes for detecting acute pediatric appendicitis using ultrasonography.METHODSThis was a retrospective medical chart review study of data over a five-year 2014-2018 period at Mercy Health Muskegon in Muskegon, Michigan. All patients aged 3-18 years who had received an appendix ultrasound during this period were identified using the McKesson Radiology (MS) PACS-Lite computer program. Pediatric appendix ultrasound cases were collected and analyzed for sensitivity, specificity, positive predictive value, negative predictive value with 95% confidence intervals. Acute appendicitis cases had been confirmed based on pathology reports. Secondary measures including white blood cell, body mass index, and body temperature were also included in analyses.RESULTSIn this sample, the overall sensitivity at detecting acute pediatric appendicitis using ultrasonography was relatively low at approximately 42% (95% CI: 21.1 - 66.0%). On the other hand, sample specificity was quite high at 97% (95% CI: 89.9 – 99.5%). The overall positive predictive value (PPV) was 80% (95% CI: 44.2-96.5%) and the negative predictive Value (NPV) was 86% (95% CI: 75.7-92.4%). The occurrence for false positives was 20% (95% CI: 3.5-55.8%). False negatives were 14% (95% CI: 7.6-24.3%).CONCLUSIONSThe use of ultrasonography at the authors’ institution less often accurately identified cases of later-confirmed pediatric appendicitis compared to some earlier published studies. The authors concluded that this could be due to seeing a lower number of more complex/ambiguous cases of pediatric appendicitis or lack of hospital personnel’s pediatric-specific training and/or experience compared to specialty children’s hospitals. It is possible that imaging improvements could be achieved by either or a combination of: offering training sessions for general ultrasound technicians, offering training session for radiologists, and visiting pediatric physicians and ultrasound technicians. A valuable follow-up study would be to track anticipated improvements and lead to formulation of an acute pediatric appendicitis care protocol within the authors’ healthcare system.

Effect of Initial Bedside Ultrasonography on Emergency Department Skin and Soft Tissue Infection Management

We examine the utility of emergency department (ED) ultrasonography in treatment of skin and soft tissue infections. We enrolled ED patients with skin and soft tissue infections and surveyed clinicians in regard to their pre-ultrasonography certainty about the presence or absence of an abscess, their planned management, post-ultrasonography findings, and actual management. We determined sensitivity and specificity of ultrasonography and clinical evaluation, and assessed appropriateness of management changes based on initial clinical assessment and outcomes through 1-week follow-up. Among 1,216 patients, clinicians were uncertain of abscess presence in 105 cases (8.6%) and certain for 1,111 cases (91.4%). Based on surgical exploration and follow-up through 1 week, sensitivity and specificity for abscess detection by clinical evaluation were 90.3% and 97.7%, and by ultrasonography were 94.0% and 94.1%, respectively. Among 1,111 cases for which the clinician was certain, sensitivity and specificity of clinical evaluation were 96.6% and 97.3% compared with ultrasonographic evaluation sensitivity and specificity of 95.7% and 96.2%, respectively. Of 105 uncertain cases, sensitivity and specificity of ultrasonography were 68.5% and 80.4%. Ultrasonography changed management in 13 of 1,111 certain cases (1.2%), appropriately in 10 of 13 (76.9%) and inappropriately in 3 of 13 (23.1%). Of 105 uncertain cases, ultrasonography changed management in 25 (23.8%), appropriately in 21 of 25 (84.0%) and inappropriately in 4 of 25 (16.0%). Ultrasonography rarely changed management when clinicians were certain about the presence or absence of an abscess. When they were uncertain, ultrasonography changed drainage decisions in approximately one quarter of cases, of which most (84%) were appropriate.

An Exploratory Study of Sectra Table Visualization Improves the Effectiveness of Emergency Bedside Echocardiography Training.

Echocardiography is an essential tool in emergency medicine, and its training is the most challenging of all types of bedside ultrasound (US) training. This study investigated the effectiveness of the Sectra Table (Sectra AB, Linköping, Sweden), an anatomy visualization and collaboration tool, in improving the quality of echocardiography training for emergency medicine physicians. We conducted an exploratory prospective observational study from 2015 to 2017 and enrolled 66 trainees who participated in a 2.5-day bedside US course organized by the emergency department (ED) of Peking Union Medical College Hospital. The study participants underwent 2 different training programs: the first group received standard training, and the second group was trained with Sectra Table experiences integrated into the echocardiography training curriculum. After the training sessions, both groups were evaluated for their hands-on echocardiography performance. The new training program with the Sectra Table significantly increased trainees' self-confidence in performing bedside echocardiography. The Sectra Table trainees had a higher performance rating than the trainees in the traditional program, with a mean total assessment score of 40.5 versus 26.5 for traditional training (P < .01). The improved performance was evident for all subcategories of echocardiography. The higher performance rating of the Sectra Table trainees was also statistically significant after adjusting for confounders, including prior training experiences, baseline confidence in independently performing ED US examinations, the number of ED US examinations performed, years in ED practice, and physician seniority. Our analysis suggests that integrating the Sectra Table into echocardiography training may improve the effectiveness of training programs.

Emergency Department Patient Perceptions of Transvaginal Ultrasound for Complications of First-Trimester Pregnancy.

Emergency department (ED) transvaginal ultrasound (US) is underused in clinical practice. This study assessed pregnant women's perceptions of ED transvaginal US in terms of pain, embarrassment, anxiety, and willingness to receive the procedure. Secondary variables include physicians' perceptions of patients' experiences. Women undergoing US examinations for complications of first-trimester pregnancy were prospectively surveyed before any US and after ED and/or radiology transvaginal US. Patients' and physicians' assessments of pain, embarrassment, and anxiety were measured with visual analog scales (0-100). A total of 398 women were enrolled. In the pre-US survey, the median anxiety score was 14 (interquartile range, 3-51), and 96% of patients were willing to have an ED transvaginal US if necessary. Of those who had ED transvaginal US, 96% would agree to have another examination. Patients reported minimal pain/embarrassment, and there was no difference if performed in the ED versus radiology (median pain, 11.5 versus 13; P = .433; median embarrassment, 7 versus 4; P = .345). Of the 48 who had both ED and radiology transvaginal US, 85% thought the ED transvaginal US was worthwhile. Physicians accurately assessed patient's embarrassment and pain (mean differences, 3.5 and -1.9, respectively; P > .25 for both); however, they overestimated them relative to the pelvic examination (mean difference for embarrassment, 12.8; P < .0001; pain, 8.0; P = .01). Pregnant ED patients report low levels of anxiety, pain, and embarrassment, and after ED transvaginal US, 96% would agree to have the examination again. There is no difference in pain/embarrassment between ED and radiology transvaginal US. Emergency department physicians accurately assessed patients' pain and embarrassment with ED transvaginal US but overestimated them compared to the pelvic examination.

Heated Ultrasound Gel and Patient Satisfaction with Bedside Ultrasound Studies: The HUGS Trial.

IntroductionOur goal was to determine if heated gel for emergency department (ED) bedside ultrasonography improves patient satisfaction compared to room-temperature gel.MethodsWe randomized a convenience sample of ED patients determined by their treating physician to require a bedside ultrasound (US) study to either heated gel (102.0° F) or room-temperature gel (82.3° F). Investigators performed all US examinations. We informed all subjects that the study entailed investigation into various measures to improve patient satisfaction with ED US examinations but did not inform them of our specific focus on gel temperature. Investigators wore heat-resistant gloves while performing the examinations to blind themselves to the gel temperature. After completion of the US, subjects completed a survey including the primary outcome measure of patient satisfaction as measured on a 100-mm visual analogue scale (VAS). A secondary outcome was patient perceptions of sonographer professionalism measured by an ordinal scale (1–5).ResultsWe enrolled 124 subjects; 120 completed all outcome measures. Of these, 59 underwent randomization to US studies with room-temperature gel and 61 underwent randomization to heated US gel. Patient 100-mm VAS satisfaction scores were 83.9 among patients undergoing studies with room-temperature gel versus 87.6 among subjects undergoing studies with heated gel (effect size 3.7, 95% confidence interval −1.3–8.6). There were similarly no differences between the two arms with regard to patient perceptions of sonographer professionalism.ConclusionThe use of heated ultrasound gel appears to have no material impact on the satisfaction of ED patients undergoing bedside ultrasound studies.

History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis.

Acute cholecystitis (AC) is a common differential for patients presenting to the emergency department (ED) with abdominal pain. The diagnostic accuracy of history, physical examination, and bedside laboratory tests for AC have not been quantitatively described. We performed a systematic review to determine the utility of history and physical examination (H&P), laboratory studies, and ultrasonography (US) in diagnosing AC in the ED. We searched medical literature from January 1965 to March 2016 in PubMed, Embase, and SCOPUS using a strategy derived from the following formulation of our clinical question: patients-ED patients suspected of AC; interventions-H&P, laboratory studies, and US findings commonly used to diagnose AC; comparator-surgical pathology or definitive diagnostic radiologic study confirming AC; and outcome-the operating characteristics of the investigations in diagnosing AC were calculated. Sensitivity, specificity, and likelihood ratios (LRs) were calculated using Meta-DiSc with a random-effects model (95% CI). Study quality and risks for bias were assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Separate PubMed, Embase, and SCOPUS searches retrieved studies for H&P (n=734), laboratory findings (n=74), and US (n=492). Three H&P studies met inclusion/exclusion criteria with AC prevalence of 7%-64%. Fever had sensitivity ranging from 31% to 62% and specificity from 37% to 74%; positive LR [LR+] was 0.71-1.24, and negative LR [LR-] was 0.76-1.49. Jaundice sensitivity ranged from 11% to 14%, and specificity from 86% to 99%; LR+ was 0.80-13.81, and LR- was 0.87-1.03. Murphy's sign sensitivity was 62% (range= 53%-71%), and specificity was 96% (range= 95%-97%); LR+ was 15.64 (range= 11.48-21.31), and LR- was 0.40 (range= 0.32-0.50). Right upper quadrant pain had sensitivity ranging from 56% to 93% and specificity of 0% to 96%; LR+ ranged from 0.92 to 14.02, and LR- from 0.46 to 7.86. One laboratory study met criteria with a 26% prevalence of AC. Elevated bilirubin had a sensitivity of 40% (range= 12%-74%) and specificity of 93% (range= 77%-99%); LR+ was 5.80 (range= 1.25-26.99), and LR- was 0.64 (range= 0.39-1.08). Five US studies with a prevalence of AC of between 10% and 46%. US sensitivity was 86% (range= 78%-94%) and specificity was 71% (range= 66%-76%); LR+ was 3.23 (range= 1.74-6.00), and LR- was 0.18 (range= 0.10-0.33). Variable disease prevalence, coupled with limited sample sizes, increases the risk of selection bias. Individually, none of these investigations reliably rule out AC. Development of a clinical decision rule to include evaluation of H&P, laboratory data, and US are more likely to achieve a correct diagnosis of AC.

Clinical information available during emergency department imaging order entry and radiologist interpretation.

The objective of this study was to evaluate the proportion of Emergency Department (ED) radiology examinations ordered or interpreted prior to a documented clinical assessment. We collected 600 retrospective consecutive ED cases consisting equally of patients whose first ED imaging examination was computed tomography (CT), radiography (XR), or ultrasonography (US). For each patient, the following times were documented: ED arrival, ED departure, ED length of stay (LOS), imaging order entry, image availability, radiology report availability, triage note, ED provider note, and laboratory results. Mean age was 44.2, 66.5% female, and mean ED LOS was 326.2min. ED LOS was longer for patients who received CT versus XR (343.9 vs. 311.3; p=0.029). In 25.5% of XR, 10% of CT, and 8% of US cases, the imaging exam was completed before the ED provider note was started. In 20.5% of XR, 6.5% of CT, and 6% of US cases, the radiologist did not have the ED provider note available prior to completing their diagnostic interpretation. In 33.4% of all cases and 57.5% of XR cases, incomplete clinical documentation (triage note, provider note, lab results) was available during radiology report creation. CT and US exams more frequently had clinical data available prior to radiologist interpretation than XR (p<0.0001). Radiologist turn-around-time was unaffected by clinical information availability. Eight percent of ED CT and 10% of ED US examinations were ordered and completed before documented clinical assessment. Thirty-three percent had incomplete clinical assessment performed prior to image interpretation. Further investigation is needed to determine impact on interpretation accuracy.

Downstream Imaging Utilization After Emergency Department Ultrasound Interpreted by Radiologists Versus Nonradiologists: A Medicare Claims–Based Study

ObjectiveTo study differences in imaging utilization downstream to initial emergency department (ED) ultrasound examinations interpreted by radiologists versus nonradiologists. MethodsUsing 5% Medicare Research Identifiable Files from 2009 to 2014, we identified episodes where the place of service was “emergency room hospital” and the patient also underwent an ultrasound examination. We determined whether the initial ultrasound was interpreted by a radiologist or nonradiologist and then summed all additional imaging events occurring within 7, 14, and 30 days of each initial ED ultrasound. For each year and each study window, we calculated the mean number of downstream imaging procedures by specialty group. ResultsOf 200,357 ED ultrasound events, 163,569 (81.6%) were interpreted by radiologists and 36,788 (18.4%) by nonradiologists. Across all study years, ED patients undergoing ultrasound examinations interpreted by nonradiologists underwent 1.08, 1.22, and 1.34 additional diagnostic imaging studies at 7, 14, and 30 days, respectively (P < .01) compared with when the initial ultrasound examination was interpreted by a radiologist. From 2010 to 2014, the volume of downstream imaging for both radiologists and nonradiologists significantly decreased, with each year resulting in 0.08 fewer imaging examinations (P < .001) 14 days after the ED ultrasound event. Despite that decline, differences in downstream imaging between radiologists and nonradiologists persisted over time. ConclusionDownstream imaging after an initial ED ultrasound is significantly reduced when the ultrasound examination is interpreted by a radiologist rather than a nonradiologist.

Emergency Department Imaging Modality Effect on Surgical Management of Nephrolithiasis: A Multicenter, Randomized Clinical Trial

In the emergency department ultrasonography is emerging as an alternative to computerized tomography for diagnosing patients with nephrolithiasis. In this multicenter randomized clinical trial we examined rates of urological referral and intervention to elucidate whether the initial diagnostic imaging modality affected the management of nephrolithiasis. Patients 18 to 76 years old who presented to the emergency department with renal colic across 15 diverse treatment centers were randomized to receive abdominal ultrasonography by an emergency department physician or a radiologist, or abdominal computerized tomography. We analyzed the 90-day followup for patients diagnosed with nephrolithiasis to assess subsequent urological evaluation, procedure type and time to intervention. Of 1,666 patients diagnosed with nephrolithiasis in the emergency department 241 (14.5%) had a consultation with urology at initial presentation, 503 (30%) saw a urologist in followup and 192 (12%) underwent at least 1 urological procedure. Median time to outpatient procedure and type of procedure performed did not vary significantly among imaging groups. Most patients (78%) had computerized tomography performed before elective intervention. Patients with ultrasonography performed by an emergency department physician were 2.6 times more likely to undergo computerized tomography before intervention than those who had ultrasonography performed by a radiologist. Patients undergoing a urological intervention who had ultrasonography as initial imaging do not experience a significant delay to intervention or different procedure types, but the majority ultimately undergoes computerized tomography before surgery. Formal ultrasonography by a radiologist may encourage less computerized tomography preoperatively.

Screening for occult penetrating cardiac injuries.

To determine the sensitivity of emergency department ultrasonography (US) in the diagnosis of occult cardiac injuries. Internationally, US has become the investigation of choice in screening patients for a possible cardiac injury after penetrating chest trauma by detecting blood in the pericardial sac. Patients presenting with a penetrating chest wound and a possible cardiac injury to the Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 were prospectively evaluated. All patients were hemodynamically stable, had no indication for emergency surgery, and had an US scan followed by subxiphoid pericardial window exploration. There were a total of 172 patients (median age = 26 years; range, 11-65 years). The mechanism of injury was stab wounds in 166 (96%) and gunshot wounds in 6. The sensitivity of US in detecting hemopericardium was 86.7%, with a positive predictive value of 77%. There were 18 false-negatives. Eleven of these false-negatives had an associated hemothorax and 6 had pneumopericardium. A single patient had 2 negative US examinations and returned with delayed cardiac tamponade. The sensitivity of US to detect hemopericardium in stable patients was only 86.7%. The 2 main factors that limit the screening are the presence of a hemothorax and air in the pericardial sac. A new regimen for screening of occult injuries to make allowance for this is proposed.

The utility of transvaginal ultrasound in the ED evaluation of complications of first trimester pregnancy

BackgroundFor patients with early intrauterine pregnancy (IUP), the sonographic signs of the gestation may be below the resolution of transabdominal ultrasound (TAU); however, it may be identified by transvaginal ultrasound (TVU). We sought to determine how often TVU performed in the emergency department (ED) reveals a viable IUP after a nondiagnostic ED TAU and the impact of ED TVU on patient length of stay (LOS). MethodsThis was a retrospective cohort study of women presenting to our ED with complications of early pregnancy from January 1, 2007 to February 28, 2009 in a single urban adult ED. Abstractors recorded clinical and imaging data in a database. Patient imaging modality and results were recorded and compared with respect to ultrasound (US) findings and LOS. ResultsOf 2429 subjects identified, 795 required TVU as part of their care. Emergency department TVU was performed in 528 patients, and 267 went to radiology (RAD). Emergency department TVU identified a viable IUP in 261 patients (49.6%). Patients having initial ED US had shorter LOS than patients with initial RAD US (median 4.0 vs 6.0 hours; P < .001). Emergency department LOS was shorter for women who had ED TVU performed compared with those sent for RAD TVU regardless of the findings of the US (median 4.9 vs 6.7 hours; P < .001). There was no increased LOS for patients who needed further RAD US after an indeterminate ED TVU (7.0 vs 7.1 hours; P = .43). There was no difference in LOS for those who had a viable IUP confirmed on ED TAU vs ED (median 3.1 vs 3.2 hours, respectively; P < .32). ConclusionWhen an ED TVU was performed, a viable IUP was detected 49.6% of the time. Emergency department LOS was significantly shorter for women who received ED TVU after indeterminate ED TAU compared with those sent to RAD for TVU, with more marked time savings among those with live IUP diagnosed on ED TVU. For patients who do not receive a definitive diagnosis of IUP on ED TVU, this approach does not result in increased LOS.

Abdominal aortic aneurysm screening for high-risk cardiac patients in the emergency department

Background: The prevalence of abdominal aortic aneurysm (AAA) is 1-2 percent in the general population, and is as high as 6 percent in groups with risk factors. Objectives: The aim of this study was to determine the prevalence of AAA amongst high-risk cardiac patients in the emergency department (ED). Methods: A prospective study was conducted to evaluate the prevalence of AAA in a high-risk population presenting to the ED. Inclusion criteria included male gender, Caucasian race, age over 50 years, history of smoking, and presentation to the ED with chest pain requiring admission. Patients enrolled in the study were screened for AAA by ultrasound (US) scan. Study subjects were excluded if there was inadequate imaging. Results: One hundred and nine patients were recruited into the study. Nineteen patients were excluded by the ED US Director secondary to inadequate imaging. Of the remaining 90 patients, eight patients were found to have AAA (n = 8; 8.9%; CI 3.9 - 16.8%). Of the eight patients with an AAA, four had diagnosed cardiovascular disease during their hospital admission. There was no statistically significant difference in secondary risk factors such as hypertension, diabetes, dyslipidemia or previous history of coronary artery disease between those with AAA and those without AAA. Conclusions: This study found that in a single ED, the prevalence of AAA in high-risk cardiac patients admitted to rule out acute coronary syndrome who could be adequately visualized with ultrasound was over 8 percent. With such a high prevalence, this population could be a potential screening group.

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.

National specialty trends in billable diagnostic ultrasound in the ED: analysis of Medicare claims data

ObjectiveTo assess recent national specialty trends in the use of diagnostic ultrasound (US) services in the Emergency Department (ED) setting. MethodsWe searched aggregated 1998-2012 Medicare Part B Master Files for ED diagnostic US studies, excluding cardiac and ophthalmic examinations. Studies were classified by body part and interpreting specialty. Subsequent analysis was performed for higher-volume services rendered by emergency physicians for which discrete codes were present longitudinally for complete vs limited examinations. National trends were analyzed. ResultsFrom 1998 to 2012, paid ED US studies interpreted by radiologists, emergency physicians, and all other physicians increased by 332% (from 221 712 to 735 858 examinations), 4454% (from 561 to 24 992), and 251% (from 26 961 to 67 787), respectively. The fraction of ED US examinations interpreted remained around 90% for radiologists, increased from 0.2% to 3% for emergency physicians, and decreased from 11% to 8% for other physicians. The fraction of complete abdominal and complete retroperitoneal studies interpreted by emergency physicians remained less than 1% from 1998 through 2012. However, emergency physicians experienced disproportionate growth in limited examinations (from 1% to 9% for abdominal studies and from <1% to 20% for retroperitoneal studies). Likewise, the fraction of (typically targeted) chest studies interpreted by emergency physicians increased from less than 1% to 63%. ConclusionFrom 1998 to 2012, there was substantial growth in ED US studies for Medicare beneficiaries interpreted by radiologists and emergency physicians alike. For more commonly performed services distinguishable as complete vs limited in nature, growth in services by emergency physicians was most dramatic for less complex services.