Mark J. Favot

Strain Echocardiography in Acute Cardiovascular Diseases.

Echocardiography has become a critical tool in the evaluation of patients presenting to the emergency department (ED) with acute cardiovascular diseases and undifferentiated cardiopulmonary symptoms. New technological advances allow clinicians to accurately measure left ventricular (LV) strain, a superior marker of LV systolic function compared to traditional measures such as ejection fraction, but most emergency physicians (EPs) are unfamiliar with this method of echocardiographic assessment. This article discusses the application of LV longitudinal strain in the ED and reviews how it has been used in various disease states including acute heart failure, acute coronary syndromes (ACS) and pulmonary embolism. It is important for EPs to understand the utility of technological and software advances in ultrasound and how new methods can build on traditional two-dimensional and Doppler techniques of standard echocardiography. The next step in competency development for EP-performed focused echocardiography is to adopt novel approaches such as strain using speckle-tracking software in the management of patients with acute cardiovascular disease. With the advent of speckle tracking, strain image acquisition and interpretation has become semi-automated making it something that could be routinely added to the sonographic evaluation of patients presenting to the ED with cardiovascular disease. Once strain imaging is adopted by skilled EPs, focused echocardiography can be expanded and more direct, phenotype-driven care may be achievable for ED patients with a variety of conditions including heart failure, ACS and shock.

ANAPHYLACTIC REACTION AFTER ONGOING EXPOSURE TO HAIR GLUE: A NOVEL CASE REPORT

BACKGROUND Latex allergy is thought to be present in up to 6.5% of the general population, and can be much higher among those with chronic exposure. It is, however, uncommonly associated with severe anaphylactic reactions. Hair-care practices, such as the application of a hair weave, are a potential cause of latex-related anaphylaxis because the adhesives often contain natural rubber latex. CASE REPORT We report the first case in the emergency medicine literature of successful treatment of a patient with airway compromise secondary to hair glue exposure. This case involved a 29-year-old woman who presented to the emergency department with severe angioedema and airway compromise. The patient had recently had an adhesive substance applied to her scalp for a hair weave placement. The patient did respond initially to antihistamine and alpha-adrenergic medication, however, because the allergen could not be removed, she relapsed, was subsequently intubated, and admitted to the intensive care unit. The latex-containing hair glue was removed over a period of several hours using an oil-based hair-conditioning product. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This unique and potentially lethal situation required innovative management. Successful resolution of this case required a high degree of cultural literacy leading to the correct diagnosis and treatment, and utilization of resources outside of the health care field. Clinicians treating patients in areas where similar hair-care practices are prevalent should be aware of this pathology, and consider similar management strategies.

Can Abdominal Ultrasonography Be Used to Accurately Diagnose Acute Appendicitis

The search strategy yielded 3,306 potential references, of which 17 full-text articles met the inclusion criteria, totaling 2,778 patients. Of the 17 included studies, design was retrospective in 8, prospective in 4, and unclear in the remaining 5; only 1 trial explicitly mentioned recruitment from the emergency department (ED). All included studies had a high risk of bias. Twelve studies included adults and children, 1 included only adults, and 4 were of unclear composition. Sonographer experience was rated as high in 2 studies and low in 4 studies and was not stated in the remaining 11. One study included only women, and 3 did not report proportion of women; in the remaining 13 studies, the proportion of women ranged from 38% to 83%, with a median of 47%. None of the included studies reported the proportion of obese patients. The prevalence of acute appendicitis ranged from 38% to 93%, with a median of 76%.

A Novel Low‐Cost Ultrasound‐Guided Pericardiocentesis Simulation Model: Demonstration of Feasibility

Pericardiocentesis is a rare life‐saving procedure for patients with cardiac tamponade. Due to the infrequency of this procedure, simulation models are often used for training. Commercial models are generally expensive. Proposed homemade models offer a lower‐cost alternative but can be labor and time intensive. The purpose of this study was to determine the feasibility of a limited use, low‐cost ultrasound‐guided pericardiocentesis model as a training tool for emergency physicians. Our model proved to be a practical, easily implemented, and acceptable model for training emergency physicians, including residents and students, in ultrasound‐guided pericardiocentesis.

Three-dimensional echocardiography in acute heart failure: Can and should we do it in the emergency department?

Despite its proven superiority over two‐dimensional transthoracic echocardiography (2DTTE) for left ventricular (LV) volumes and ejection fraction, clinical use of 3DTTE remains very limited in the acute setting. 3DTTE may have significant clinical advantages in the assessment of acute heart failure. Further exploration of 3DTTE utilization may help in more precise assessment of the regional wall‐motion abnormalities, early identification of acute ischemic from nonischemic LV dysfunction with a more precise approach to the AHF management. The use of other measures, especially the right ventricular and the left atrial assessment, and 3D strain methodology may further expand the potential future utility of 3DTTE in patients with new‐onset HF.

Pathophysiology, echocardiographic evaluation, biomarker findings, and prognostic implications of septic cardiomyopathy: a review of the literature

BackgroundSepsis is a common condition encountered by emergency and critical care physicians, with significant costs, both economic and human. Myocardial dysfunction in sepsis is a well-recognized but poorly understood phenomenon. There is an extensive body of literature on this subject, yet results are conflicting and no objective definition of septic cardiomyopathy exists, representing a critical knowledge gap.ObjectivesIn this article, we review the pathophysiology of septic cardiomyopathy, covering the effects of key inflammatory mediators on both the heart and the peripheral vasculature, highlighting the interconnectedness of these two systems. We focus on the extant literature on echocardiographic and laboratory assessment of the heart in sepsis, highlighting gaps therein and suggesting avenues for future research. Implications for treatment are briefly discussed.ConclusionsAs a result of conflicting data, echocardiographic measures of left ventricular (systolic or diastolic) or right ventricular function cannot currently provide reliable prognostic information in patients with sepsis. Natriuretic peptides and cardiac troponins are of similarly unclear utility. Heterogeneous classification of illness, treatment variability, and lack of formal diagnostic criteria for septic cardiomyopathy contribute to the conflicting results. Development of formal diagnostic criteria, and use thereof in future studies, may help elucidate the link between cardiac performance and outcomes in patients with sepsis.

Hiatal Hernia Mimicking Aortic Aneurysm on Point-of-care Echocardiography

CASE PRESENTATION An 85-year-old woman presented to the emergency department (ED) with altered mental status. She appeared to be in shock with a distended abdomen. A point-of-care (POC) echocardiogram using a 4 Mhz phased array transducer revealed a large anechoic mass posterior to the left atrium concerning for an aneurysm of the descending thoracic aorta (DTA). (Image, Video) However, computed tomography revealed high-grade small bowel obstruction, associated with a hiatal hernia.

What Elements of the History, Examination, Laboratory Testing, or Point-of-Care Ultrasonography Are Most Useful in the Diagnosis of Acute Appendicitis in Children?

Fever (reported) 370 0.90 (0.67–1.21) 1.04 (0.90–1.20) Nausea/vomiting 3,186 1.30 (1.19–1.41) 0.65 (0.57–0.73) Anorexia 3,003 1.33 (1.26–1.40) 0.58 (0.52–0.65) Pain migration to RLQ 2,621 1.75 (1.58–1.94) 0.70 (0.62–0.79) Fever (in ED) 2,816 1.13 (0.99–1.29) 0.94 (0.89–1.00) Cough/hop pain 1,935 1.61 (1.42–1.83) 0.52 (0.45–0.61) RLQ rebound tenderness 3,346 2.19 (1.91–2.51) NC Guarding 1,756 2.09 (1.83–2.37) 0.47 (0.39–0.56) Periumbilical tenderness 684 1.00 (0.72–1.39) 1.00 (0.86–1.17) Rovsing’s sign 978 3.52 (2.65–4.68) 0.72 (0.66–0.78) WBC count 10,000 cells/mm 4,677 2.01 (1.86–2.17) 0.21 (0.19–0.25) Neutrophils 75% 1,603 2.02 (1.85–2.21) 0.35 (0.28–0.43) PAS 8 1,156 4.40 (3.26–5.95) 0.49 (0.42–0.57) PAS 9 1,055 5.26 (3.34–8.29) 0.72 (0.62–0.83) PAS 10 1,055 5.80 (1.97–17.11) 0.92 (0.89–0.95) Positive ED POCUS result* 461 9.24 (6.42–13.28) 0.17 (0.09–0.30)

Man With Suprapubic Pain

A 50-year-old man with an indwelling urinary catheter because of prostatic hypertrophy presented to the emergency department (ED) with 2 days of suprapubic pain after a catheter exchange. The catheter flushed appropriately with saline solution. Abdominal point-of-care ultrasonography demonstrated an inflated catheter balloon located anterior to the distended bladder (Figure 1). Under dynamic ultrasonographic guidance, the catheter balloon was deflated, withdrawn into the bladder lumen, and reinflated (Video, Figure 2), resulting in the evacuation of 400 mL of clear urine.