David C. Riley

Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol.

Assessment of hemodynamic status in a shock state remains a challenging issue in Emergency Medicine and Critical Care. As the use of invasive hemodynamic monitoring declines, bedside-focused ultrasound has become a valuable tool in the evaluation and management of patients in shock. No longer a means to simply evaluate organ anatomy, ultrasound has expanded to become a rapid and noninvasive method for the assessment of patient physiology. Clinicians caring for critical patients should strongly consider integrating ultrasound into their resuscitation pathways.

Emergency department diagnosis of a quadriceps intramuscular loculated abscess/pyomyositis using dynamic compression bedside ultrasonography

IntroductionA 73-year-old man with a past medical history of myelodysplastic syndrome and recent chemotherapy presented to the emergency department with a 1-week history of progressively increasing left thigh pain and swelling. His physical examination revealed left anterolateral diffuse thigh swelling with no erythema or warmth to palpation. The anterolateral quadriceps was markedly tender to palpation. Emergency department bedside dynamic compression ultrasonography that was performed on the left anterolateral thigh revealed a quadriceps intramuscular abscess with loculated yet movable pus.ConclusionBedside dynamic compression ultrasonography can assist the emergency or critical care physician in the diagnosis of quadriceps intramuscular abscess or pyomyositis.

Emergency department diagnosis of upper extremity deep venous thrombosis using bedside ultrasonography

A 27-year-old man presents to the emergency department with a 1-day history of severe right upper extremity pain and swelling. The patients status is post open reduction internal fixation for a left tibial plateau fracture, which was complicated by methicillin-sensitive Staphylococcus aureus osteomyelitis. A peripherally inserted central catheter (PICC) line was subsequently placed for intravenous antibiotic therapy. Emergency department bedside ultrasound examination of both the right axillary vein and subclavian vein near the PICC line tip revealed deep venous thrombosis of both veins. Bedside upper extremity vascular ultrasonography can assist in the rapid diagnosis of upper extremity deep venous thrombosis in the emergency department.

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.

Emergency Department Diagnosis of Mitral Stenosis and Left Atrial Thrombus Using Bedside Ultrasonography

A 41-year-old woman with a medical history of a heart murmur and palpitations presented to the emergency department with a 3-day history of worsening shortness of breath, nausea, palpitations, and epigastric pain. She had a syncopal episode several hours prior to her emergency department visit. Her vital signs were normal except for her heart rate, as her electrocardiogram showed atrial fibrillation with a rapid ventricular rate of 165 beats ⁄ min. Her physical examination was normal except for an irregularly irregular heart rate and rhythm; her lungs were clear and her legs were neither tender nor swollen. Her urine pregnancy test was negative. A chest x-ray revealed cardiomegaly and mild pulmonary vascular congestion. Laboratory studies were normal except for a D-dimer of 12.5 (normal 0 to 0.54 lg ⁄ mL). A bedside ultrasound of the heart was performed (see Video Clips S1 and S2), which revealed a left atrial hyperechoic thrombus versus tumor mass in the parasternal long-axis view (Figure 1). Mitral stenosis was present in the parasternal short-axis view (Figure 2). The patient was given intravenous diltiazem for rate control and IV heparin therapy in the emergency department. She had a computed tomography angiogram of the chest performed that showed a left atrial thrombus or mass and left atrial appendage thrombus and no pulmonary embolism or deep venous thrombosis. Cardiology was consulted and a formal echocardiogram revealed severe mitral stenosis, severe left atrial enlargement, and a 2.8 · 2.9-cm mass attached to the mid left atrial wall. Cardiothoracic surgery was consulted and the patient was admitted and underwent mitral valve replacement (rheumatic mitral valve pathology), left atrial thrombus (pathology confirmed) removal, and a Maze procedure for atrial fibrillation. She was discharged home postoperative day 16 on warfarin. Mitral stenosis is associated with left atrial thrombosis in 17% of patients, and the addition of atrial fibrillation doubles the risk of left atrial thrombosis. Patients with both mitral stenosis and atrial fibrillation who develop a left atrial thrombus are at risk for developing shortness of breath, syncope, and even cardiac arrest if the left atrial thrombus completely occludes the stenotic mitral valve producing obstructive shock. Most intracardiac myxomas are located in the left atrium, attached to the intraatrial septum and, although rare, may be associated with mitral stenosis. The video clips illustrate how bedside cardiac ultrasonography can assist the emergency physician in the diagnosis of left atrial thrombus and mitral stenosis. David C. Riley, MD, MS, RDMS (dr499@columbia.edu) Heidi P. Cordi, MD, MS, MPH, EMT-P Emergency Medicine Department Columbia University Medical Center New York, NY

Emergency department diagnosis of supraspinatus tendon calcification and shoulder impingement syndrome using bedside ultrasonography.

A 45-year-old woman presented to the emergency department with a 2-day history of severe left shoulder pain made worse with movement. Emergency department (ED) bedside point-of-care static and dynamic ultrasound examination of the supraspinatus tendon revealed supraspinatus tendon calcification with impingement syndrome, and the patient was urgently referred to orthopedics after ED pain control was achieved. Bedside shoulder and supraspinatus tendon evaluation with static and dynamic ultrasonography can assist in the rapid diagnosis of supraspinatus tendon calcification and supraspinatus tendon impingement syndrome in the emergency department.

Erratum to: Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point‐of‐care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pedi‐ atrics published a policy statement endorsing the use of point‐of‐care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point‐of‐care ultrasound for this specialty. This document serves as an initial step in the detailed “how to” and description of individual point‐of‐care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.