Ninfa Mehta

Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review

OBJECTIVES Understanding history, physical examination, and ultrasonography (US) to diagnose extremity fractures compared with radiography has potential benefits of decreasing radiation exposure, costs, and pain and improving emergency department (ED) resource management and triage time. METHODS The authors performed two electronic searches using PubMed and EMBASE databases for studies published between 1965 to 2012 using a strategy based on the inclusion of any patient presenting with extremity injuries suspicious for fracture who had history and physical examination and a separate search for US performed by an emergency physician (EP) with subsequent radiography. The primary outcome was operating characteristics of ED history, physical examination, and US in diagnosing radiologically proven extremity fractures. The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2). RESULTS Nine studies met the inclusion criteria for history and physical examination, while eight studies met the inclusion criteria for US. There was significant heterogeneity in the studies that prevented data pooling. Data were organized into subgroups based on anatomic fracture locations, but heterogeneity within the subgroups also prevented data pooling. The prevalence of fracture varied among the studies from 22% to 70%. Upper extremity physical examination tests have positive likelihood ratios (LRs) ranging from 1.2 to infinity and negative LRs ranging from 0 to 0.8. US sensitivities varied between 85% and 100%, specificities varied between 73% and 100%, positive LRs varied between 3.2 and 56.1, and negative LRs varied between 0 and 0.2. CONCLUSIONS Compared with radiography, EP US is an accurate diagnostic test to rule in or rule out extremity fractures. The diagnostic accuracy for history and physical examination are inconclusive. Future research is needed to understand the accuracy of ED US when combined with history and physical examination for upper and lower extremity fractures.

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

BACKGROUND 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. OBJECTIVES This was a systematic review of the literature for the operating characteristics of emergency department (ED) ultrasonography for AAA. METHODS 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. RESULTS 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%). CONCLUSIONS 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.

Systematic review: is real-time ultrasonic-guided central line placement by ED physicians more successful than the traditional landmark approach?

Introduction The superiority of ultrasonic-guided compared with landmark-guided central venous catheter (CVC) placement is not well documented in the Emergency Department. Objective To systematically review the literature comparing success rates between ultrasonic- and landmark-guided CVC placement by ED physicians. Methods PubMed and EMBASE databases were searched for randomised controlled trials from 1965 to 2010 using a search strategy derived from the following PICO formulation: Patients: Adults requiring emergent CVC placement except during cardiopulmonary resuscitation. Intervention CVC placement using real-time ultrasonic guidance. Comparator: CVC placement using anatomical landmarks. Outcome: Comparison of success rates of CVC placement between ultrasonic- versus landmark-guided techniques. Analysis: Success rates between CVC placement methods using a Forest Plot (95% CI) calculated by Review Manager Version 5.0. Results Search identified 944 articles of which 938 were excluded by title/abstract relevance, two not randomised, one cardiac arrest, one no landmark control, one success rate not calculated. A single study of 130 patients (65 ultrasonic- vs 65 landmark-guided) selected for internal jugular vein placement remained. Successful internal jugular CVC was significantly (p=0.02) more likely in the ultrasound-guided (93.9%) compared with landmark-guided (78.5%) techniques with an OR of 1.2 (95% CI 1.0 to 1.4). Complications rates were significantly (p=0.04) lower in ultrasonic (4.6%) versus landmark (16.9%) technique, OR=3.7 (95% CI 1.1 to 12.5). Conclusion Only one single high quality study illustrating that ED ultrasound- versus landmark-guided internal jugular catheter placement had higher success rates with lower complication rates.

Sonographic diagnosis of bilateral pneumothorax following an acupuncture session

We present the case of a 57‐year‐old woman who presented with the acute onset of chest pain and dyspnea, which started while undergoing acupuncture for neck pain. A bedside ultrasound revealed bilateral pneumothoraces, which were confirmed radiographically. We discuss the details of the case, the sonographic features of pneumothorax, and the role of bedside ultrasonography in the assessment of an acutely dyspneic patient.

Serial Sonographic Assessment of Pulmonary Edema in Patients With Hypertensive Acute Heart Failure

Objective measures of clinical improvement in patients with acute heart failure (AHF) are lacking. The aim of this study was to determine whether repeated lung sonography could semiquantitatively capture changes in pulmonary edema (B‐lines) in patients with hypertensive AHF early in the course of treatment.

Is there a correlation of sonographic measurements of true vocal cords with gender or body mass indices in normal healthy volunteers

Background: Ultrasound is a readily available, non-invasive technique to visualize airway dimensions at the patients bedside and possibly predict difficult airways before invasively looking; however, it has rarely been used for emergency investigation of the larynx. There is limited literature on the sonographic measurements of true vocal cords in adults and normal parameters must be established before abnormal parameters can be accurately identified. Objectives: The primary objective of the following study is to identify the normal sonographic values of human true vocal cords in an adult population. A secondary objective is to determine if there is a difference in true vocal cord measurements in people with different body mass indices (BMIs). The third objective was to determine if there was a statistical difference in the measurements for both genders. Materials and Methods: True vocal cord measurements were obtained in healthy volunteers by ultrasound fellowship trained emergency medicine physicians using a high frequency linear transducer orientated transversely across the anterior surface of the neck at the level of the thyroid cartilage. The width of the true vocal cord was measured perpendicularly to the length of the cord at its mid-portion. This method was duplicated from a previous study to create a standard of measurement acquisition. Results: A total of 38 subjects were enrolled. The study demonstrated no correlation between vocal cord measurements and patients characteristics of height, weight, or BMIs. When accounting for vocal cord measurements by gender, males had larger BMIs and larger vocal cord measurements compared with females subjects with a statistically significant different in right vocal cord measurements for females compared with male subjects. Conclusion: No correlation was seen between vocal cord measurements and persons BMIs. In the study group of normal volunteers, there was a difference in size between the male and female vocal cord size.

Successful Thrombolysis of Massive Pulmonary Embolism

A 52-year-old man with a medical history significant only for hypertension presented to the emergency department (ED) after a syncopal episode. He was walking to work and experienced the sudden onset of severe chest pain followed by a syncopal episode, during which he sustained minor head trauma after falling to the ground. He awoke shortly thereafter with intense back pain and arrived in the ED in severe distress with the following vital signs: blood pressure 73 ⁄ 45 mm Hg, pulse 120 beats ⁄ min, respirations 38 breaths ⁄ min, temperature 99.0 F, and an oxygen saturation of 82% on 100% oxygen delivered via face mask. He was diaphoretic and anxious, his lungs were clear, and his exam was otherwise remarkable only for abrasions to his face, a small left lip laceration, and a moderate occipital scalp hematoma. After intravenous access was obtained, the patient was intubated for severe hypoxemia and agitation. During the initial stabilization and assessment, the treating emergency physician performed a bedside cardiac ultrasound using a 5–1 MHz phased array transducer (SonoSite MTurbo, Bothell WA). This demonstrated marked right ventricular enlargement with severely impaired right ventricular systolic function and preservation of right apical systolic function (McConnell’s sign, Video Clip S1). The patient’s condition then deteriorated quickly into pulseless electrical activity, with return of spontaneous circulation after chest compressions and one dose of intravenous epinephrine. Suspicious of massive pulmonary embolism, a limited compression ultrasound of the lower extremities was performed using a 10–5 MHz linear transducer. This demonstrated a noncompressible right popliteal vein with visible echogenic thrombus within the vein. (Figure 1, Video Clip S2). The patient experienced two subsequent cardiac arrests, with return of spontaneous circulation within 2 minutes of each arrest. Despite the evidence of head trauma, the patient was treated with a 2-hour infusion of 100 mg of tissue plasminogen activator given the high suspicion for massive pulmonary embolism with severe hypotension and multiple cardiac arrests. A dopamine infusion was initiated and the patient was admitted to the intensive care unit in critical condition. The emergency physician performed a repeat bedside echocardiogram with the intensivists on hospital day 2 (Video Clip S3), which demonstrated normal right and left ventricular function. A comprehensive echocardiogram by the cardiology department the following day confirmed these findings. The patient was extubated on hospital day 3 and was discharged from the hospital neurologically intact and with no cardiorespiratory symptoms on hospital day 6.

“My Arm Looks Like Popeye's”: A Case Report of Bicep Tendon Rupture

A 76-year-old right-hand-dominant man presented with a 3-week history of right arm pain and swelling. He was disembarking from a train when his suitcase fell, and as the patient caught it, he felt a pop and lancing pain in his right upper arm and elbow. He also noted a marked swelling of the right upper arm. The patient denied paresthesias, but reported decreased strength to hold objects with his right arm. On physical examination there was a deformity of his right upper arm located near the distal end of the humerus (Figure 1). His sensation and pulses were intact and he had full range of motion at the shoulder, elbow, and wrist joint. Elbow flexion and supination/pronation strength were 4 out of 5. No pain was elicited with flexion of the shoulder to 90 against downward resistance (Speed’s test); no pain was appreciated with the elbow flexed to 90 and resistance applied during supination (Yergason’s test); and no pain was elicited when the armwas passively flexed with the thumb facing down while stabilizing the scapula (Neer’s test). X-ray studies of the elbow, humerus, and shoulder were taken, and Orthopedics was consulted for operative repair.