Lawrence Haines

Ultrasound-Guided Fascia Iliaca Compartment Block for Hip Fractures in the Emergency Department

BACKGROUND Hip fracture (HFx) is a painful injury that is commonly seen in the emergency department (ED). Patients who experience pain from HFx are often treated with intravenous opiates, which may cause deleterious side effects, particularly in elderly patients. An alternative to systemic opioid analgesia involves peripheral nerve blockade. This approach may be ideally suited for the ED environment, where one injection could control pain for many hours. OBJECTIVES We hypothesized that an ultrasound-guided fascia iliaca compartment block (UFIB) would provide analgesia for patients presenting to the ED with pain from HFx and that this procedure could be performed safely by emergency physicians (EP) after a brief training. METHODS In this prospective, observational, feasibility study, a convenience sample of 20 cognitively intact patients with isolated HFx had a UFIB performed. Numerical pain scores, vital signs, and side effects were recorded before and after administration of the UFIB at pre-determined time points for 8h. RESULTS All patients reported decreased pain after the nerve block, with a 76% reduction in mean pain score at 120 min. There were no procedural complications. CONCLUSION In this small group of ED patients, UFIB provided excellent analgesia without complications and may be a useful adjunct to systemic pain control for HFx.

Tracheal rapid ultrasound saline test (T.R.U.S.T.) for confirming correct endotracheal tube depth in children.

OBJECTIVE We evaluated the accuracy of tracheal ultrasonography of a saline-inflated endotracheal tube (ETT) cuff for confirming correct ETT insertion depth. METHODS We performed a prospective feasibility study of children undergoing endotracheal intubation for surgery. Tracheal ultrasonography at the suprasternal notch was performed during transient endobronchial intubation and inflation of the cuff with saline, and with the ETT at a correct endotracheal position. Ultrasound videos were recorded at both positions, which were confirmed by fiberoptic bronchoscopy. These videos were shown to two independent blinded reviewers, who determined the presence or absence of a saline-inflated cuff. The primary outcome was accuracy of tracheal ultrasonography for appropriate ETT insertion depth. RESULTS Forty-two patients were enrolled. For correct endotracheal versus endobronchial positioning, pooled results from the reviewers revealed a sensitivity of 98.8% (95% CI=90-100%), a specificity of 96.4% (95% CI=87-100%), a PPV of 96.5% (95% CI=87-100%), a NPV of 98.8% (95% CI=89-100%), a positive likelihood ratio of 32 (95% CI=6-185), and a negative likelihood ratio of 0.015 (95% CI=0.004-0.2). Agreement between reviewers was high (kappa co-efficient=0.93; 95% CI=0.86 to 1). The mean duration of the ultrasound exam was 4.0s (range 1.0-15.0s). CONCLUSIONS Sonographic visualization of a saline-inflated ETT cuff at the suprasternal notch is an accurate and rapid method for confirming correct ETT insertion depth in children.

Clinician-performed abdominal sonography

IntroductionPoint-of-care ultrasonography is increasingly utilized across a wide variety of physician specialties. This imaging modality can be used to evaluate patients rapidly and accurately for a wide variety of pathologic conditions.MethodsA literature search was performed for articles focused on clinician-performed ultrasonography for the diagnosis of appendicitis, gallbladder disease, small bowel obstruction, intussusception, and several types of renal pathology. The findings of this search were summarized including the imaging techniques utilized in these studies.ConclusionClinician performed point-of-care sonography is particularly well suited to abdominal applications. Future investigations may further confirm and extend its utility at the bedside.

Point-of-care ultrasound detection of acute scaphoid fracture.

Abstract In cases of traumatic wrist pain, emergency physicians must maintain a high index of suspicion for scaphoid fractures due to their potential for serious complications. A growing body of literature supports the use of point-of-care ultrasonography by emergency physicians in the evaluation of potential fractures. We report a case of a pediatric scaphoid fracture that was initially not visualized on x-ray and was subsequently detected using point-of-care ultrasound in the ED.

Extension of the Thoracic Spine Sign A New Sonographic Marker of Pleural Effusion

Dyspnea is a common emergency department (ED) condition, which may be caused by pleural effusion and other thoracic diseases. We present data on a new sonographic marker, the extension of the thoracic spine sign, for diagnosis of pleural effusion.

Inflating the endotracheal tube cuff with saline to confirm correct depth using bedside ultrasonography.

Although bedside ultrasonography can accurately distinguish esophageal from tracheal intubation, it is not used to establish the correct depth of endotracheal tube insertion. As indirect sonographic markers of endotracheal tube insertion depth have proven unreliable, a method for visual verification of correct tube depth would be ideal. We describe the use of saline to inflate the endotracheal cuff to confirm correct endotracheal tube depth (at the level of the suprasternal notch) by bedside ultrasonography during resuscitation. This rapid technique holds promise during emergency intubation.

When Fever, Leukocytosis, and Right Lower Quadrant Pain Is Not Appendicitis

Abstract Mesenteric cystic lymphangioma (MCL) is an uncommon, benign, slow-growing abdominal tumor that is derived from the lymphatic vessels (World J Gastroenterol. 2012;18:6328–6332, Radiographics. 1994;14:729–737). It is most often diagnosed in the head and neck of affected children. Rarely, a lymphangioma can develop within the small bowel (Pan Afr Med J. 2012;12:7). The clinical presentation of patients with an abdominal MCL can range from asymptomatic to acute abdominal pain (J Korean Surg Soc. 2012;83:102–106). We report a case of small bowel volvulus caused by an MCL in a 3-year-old child who presented to the pediatric emergency department with right lower quadrant pain. The child was thought to have a perforated appendicitis and was taken to the operating room where an MCL was identified and resected. This case illustrates the need to consider MCL when a patient presents to the emergency department with right lower quadrant pain.

Ultrasound-guided superficial cervical plexus blockade for acute spasmodic torticollis in the ED

The ultrasound-guided superficial cervical plexus nerve block is a simple procedure that provides anesthesia to the anterior neck. It has been recently described for several indications in the emergency department including central line placement, clavicle fracture, and abscess drainage. We describe the first case in the literature of its use for acute spasmodic torticollis. We believe that this is a potentially effective intervention that warrants further study.

Does oral radiocontrast affect image quality of abdominal sonography

Objective: Emergency Department patients with abdominal pain may require both an ultrasound (US) and computed tomography (CT) for an accurate diagnosis. Patients are often asked to drink oral radiocontrast while awaiting ultrasound, in order to better expedite a CT in the case of a non‐diagnostic US. The impact of oral radiocontrast on US image quality has not been studied. We compared the quality of US images obtained before and after the ingestion of oral radiocontrast in healthy adult volunteers. Methods: This was a prospective study in which adult volunteer subjects underwent sonographic studies of the aorta, the right upper quadrant, the right lower quadrant, and the Focused Assessment with Sonography in Trauma (FAST) examination. Initial studies were performed prior to ingestion of oral radiocontrast, with subsequent imaging occurring at 1 and 2 hour post‐ingestion. All of the images from the sonographic exams were randomized and subsequently scored for quality by two emergency ultrasound fellowship trained emergency physicians with extensive experience in performing and interpreting US. Results: 638 images from 240 exams were obtained from 20 subjects at three time points. Six exams were not scored due to inadequate images. There were no significant differences in image quality for any of the US exam types after the ingestion of oral radiocontrast at 1 and 2 h. Conclusion: Ingestion of oral radiocontrast did not affect image quality of four common abdominal ultrasound examinations.

Omental torsion mimicking perforated appendicitis in a pediatric patient: emergency bedside sonography

We present the rare case of omental torsion in a pediatric patient who presented to our emergency department with both clinical and radiographic findings highly suggestive of appendicitis. In review of the medical literature and to the best of our knowledge, this is the first case of omental torsionwith both clinical and sonographic findings specific for appendicitis. Surgery and pathology reports, however, revealed a normal appendix. We also briefly discuss the role of point-of-care ultrasound in the pediatric patient presenting to the emergency department with undifferentiated abdominal pain. Omental torsion is a rare pathologic entity in which the omentum twists along its long axis to a degree whereupon the vascular flow is compromised and the omentum becomes ischemic. Because it was first described by Eitel in 1899, less than 250 cases of omental torsion have been described in the literature [1,2]. Knowledge of the entity is important for both emergency physicians and surgeons as it often mimics appendicitis and other causes of acute abdomen. Sonographic findings are not very well described in the medical literature, with some small retrospective studies reporting that ultrasound may show an echogenic and poorly definedmass in the right lower quadrant [3]. Other studies report that ultrasound may reveal free fluid in the abdomen as a result of the congested and edematous omentum, which is often mistaken for ruptured appendicitis [4]. Unfortunately, to date, there are neither sensitive nor specific sonographic findings of omental torsion making the preoperative radiographic diagnosis a challenge to providers. A 5-year-old boy presented to our emergency department with 2 days of worsening right lower quadrant pain. He also reported anorexia but denied any nausea, vomiting, diarrhea, constipation, fevers, chills, or trauma. There was no prior history of abdominal surgeries, and he was not taking any medications. On arrival, he was tachycardic with a pulse of 143 beats per minute, with the rest of his vital signs within normal limits. Physical examination was significant for localized tenderness with rebound in the right lower quadrant, but no guarding or rigidity. Complete blood count tests revealedawhitebloodcell countof10.3 (referencevalues, 4.5-15K/UL). With a high index of suspicion for appendicitis, emergency providers performed apoint-of-care ultrasoundof the right lower quadrant. Imaging revealed freefluid surrounding a noncompressible, nonperistalsing, blind-