Ozcan Yavasi

Ultrasonography by emergency medicine and radiology residents for the diagnosis of small bowel obstruction.

Objective Our objective was to study the accuracy of emergency medicine [(EM) bedside ultrasonography (BUS)] and radiology residents performed ultrasonography (RUS) in patients with suspected mechanical small bowel obstruction (SBO). Methods After a 6-h training program, from January to June 2009, four EM residents used BUS to prospectively evaluate the patients presenting to the emergency department with suspected SBO. Then, patients underwent RUS. Outcome was determined by surgical findings if they were operated upon or self-reported the condition upon telephone follow-up at 1-month. BUS and RUS results were compared with χ2 testing. Results Of the 174 enrolled patients, 90 patients were BUS-positive. Of these, surgical findings agreed with the BUS findings in 84 patients. In 78 cases, BUS was negative, and 76 of these patients had benign clinical courses. Six patients were excluded from the study. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio for BUS were 97.7, 92.7, 93.3, 97.4, and 13.4%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value for RUS were 88.4, 100, 100, and 89.1%, respectively. The diagnostic accuracy of BUS and RUS were not statistically different from each other (κ=0.81). The presence of dilated small bowel loops (>25 mm in jejunum or >15 mm in ileum) was the most sensitive (94%) and specific (94%) sonographic finding for SBO. Conclusion Abdominal sonography for the diagnosis of SBO is a new application of BUS in the emergency department. EM residents can diagnose SBO using BUS with a high-degree of accuracy, comparable with that of radiology residents.

Transorbital Ultrasonographic Measurement of Optic Nerve Sheath Diameter for Intracranial Midline Shift in Patients with Head Trauma

OBJECTIVE Measurement of the optic nerve sheath diameter (ONSD) by using sonography is a straightforward, noninvasive technique to detect an increased intracranial pressure, which can even be conducted at the bedside. However, the correlation between ONSD and intracranial midline shift has not been studied. METHODS The authors performed a prospective, blinded observational study in an intensive care unit. Forty-five patients were divided into groups. Of those, 19 patients had a midline shift, whereas 26 had no intracranial pathology or shift and served as control individuals. RESULTS Spearman rank correlation coefficient of difference of ONSD and midline shift was 0.761 (P < 0.0005), demonstrating a significant positive correlation between patients with midline shift and control group. CONCLUSIONS Despite small numbers and selection bias, this study suggests that bedside ultrasound may be useful in the diagnosis of midline intracranial shift by measurement of ONSD.

Bedside assessment of central venous pressure by sonographic measurement of right ventricular outflow-tract fractional shortening.

Objectives We aimed to assess the suitability of right ventricular outflow tract (RVOT) fractional shortening for estimating low central venous pressure (CVP). To the best of our knowledge, there have been no similar studies in the English language literature. Methods In this cross-sectional study, the emergency physicians measured the RVOT fractional shortening on parasternal short-axis view. A receiver operating characteristic curve analysis was conducted to identify the threshold that maximized the sensitivity and specificity for discriminating normal and low CVPs by the RVOT fractional shortening value. The sensitivity, specificity, and the positive and the negative likelihood ratios of RVOT fractional shortening to truly estimate CVP were calculated. Results Fifty-eight consecutive patients had invasive CVP monitoring. Nine patients with high CVP and eight for other reasons were excluded. Forty-one patients were enrolled in the study, of whom 21 were in low CVP group and 20 were in normal CVP group. RVOT diastolic diameters, RVOT systolic diameters, and RVOT fractional shortening were lower in low CVP group and this difference was statistically significant (P<0.001). The cutoff value for RVOT fractional shortening to differentiate the low and normal CVPs using the highest sensitivity and specificity was 26.44%. Area under the receiver operating characteristic curve was 0.933 (0.810–0.987) with a P value of less than 0.001. The sensitivity and specificity of RVOT fractional shortening to truly estimate CVP were 95 (75–99) and 80% (58–94), respectively. Conclusion In the hands of emergency physicians, a RVOT fractional shortening measurement is a good predictor of low CVP.

Paramedic-performed Focused Assessment with Sonography in Trauma (FAST) in the emergency department.

BACKGROUND Our objective was to evaluate the accuracy of paramedic-performed Focused Assessment with Sonography in Trauma (PFAST) for detection of free fluid in patients admitted to the Emergency Department (ED) following trauma. METHODS After four hours of didactic and four hours of hands-on training, four paramedics prospectively evaluated trauma patients. Our gold standard was the official radiologist reports of ultrasonography and computerized abdominal tomography (CAT). The sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of PFAST were calculated and analyzed using SPSS 15.0 with ?2 testing. RESULTS One hundred and twenty-seven patients were evaluated by the paramedics. Fourteen patients had positive free fluid in the abdomen. Of these, 11 were corroborated by radiology reports and CAT (true positives), and three were found to be negative (false positives). In 113 cases, PFAST was negative for free fluid. Of these, 111 were determined not to have free fluid (true negatives), whereas free fluid was detected by CAT in 2 (false negatives). The sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of PFAST were 84.62, 97.37, 32.15, 0.16, and 203.50, respectively. CONCLUSION Our study shows that paramedics can perform FAST in hospital Eds with a high degree of accuracy.

Acute airway compromise due to ruptured inferior thyroid artery aneurysm

A cervical hematoma secondary to the spontaneous rupture of an aneurysm is an uncommon but catastrophic life-threatening condition because it can potentially obstruct the airway. Inferior thyroid artery aneurysm and rupture is a very rare clinical entity and only a limited number of cases have been reported in the literature. In this article, we present the case of a female patient who suffered from a rapidly enlarging cervical mass followed by a rapid onset of dyspnea as a result of rupture of an inferior thyroid artery aneurysm. The diagnosis was confirmed by magnetic resonance angiography, and delayed surgery resulted in an uneventful outcome. We aim to draw the attention of emergency physicians to this rare condition.

Pneumomediastinum Associated with Pneumopericardium and Epidural Pneumatosis

Spontaneous pneumomediastinum is a relatively rare benign condition. It may rarely be associated with one or combination of pneumothorax, epidural pneumatosis, pneumopericardium, or subcutaneous emphysema. We present a unique case with four of the radiological findings in a 9-year-old male child who presented to our emergency department with his parents with complaints of unproductive cough, dyspnea, and swelling on chest wall. Bilateral subcutaneous emphysema was palpated on anterior chest wall from sternum to midaxillary regions. His anteroposterior and lateral chest radiogram revealed subcutaneous emphysema and pneumomediastinum. His thorax computed tomography to rule out life-threatening conditions revealed bilateral subcutaneous, mediastinal, pericardial, and epidural emphysema without pneumothorax. He was transferred to pediatric intensive care unit for close monitorization and conservative treatment. He was followed-up by chest radiographs. He was relieved from symptoms and signs around the fifth day and he was discharged at the seventh day. Diagnosis of pneumomediastinum is often made based on physical findings and plain radiographs. It may not be as catastrophic as it is seen. Close cardiopulmonary monitorization is mandatory for complications and accompanying conditions. Most patients with uncomplicated spontaneous pneumomediastinum respond well to oxygen and conservative management without any specific treatment.

Isolated abducens nerve palsy due to pituitary apoplexy after mild head trauma.

Pituitary apoplexy is a relatively rare condition. Cranial nerve palsies may develop due to compression of the surrounding structures by the rapidly expanding tumor. While the most commonly affected nerve is the oculomotor nerve, abducens nerve palsy may also occur less commonly. A 68-year-old male patient was admitted to the emergency department with complaints of severe headache, nausea, vomiting, and diplopia after head trauma due to falling. His magnetic resonance imaging evaluation demonstrated a large pituitary adenoma and bleeding into the tumor, which was acutely expanding and leading to compression of the abducens nerve laterally. Isolated abducens palsy due to posttraumatic pituitary apoplexy is a rare clinical condition, and as the symptoms and signs are nonspecific, it can commonly remain clinically undiagnosed. In this article, our aim was to draw attention to a clinical condition in which unfavorable complications may develop if the diagnosis is overlooked.

Incidental finding in a headache patient: intracranial lipoma.

A 60 year old female, with a history of atrial fibrillation who was on warfarin therapy, presented to our emergency department with chief complaint of the most severe headache that she ever had. Her vital signs, systemic and neurological examinations were normal. She had emergency computed tomography (CT) of the brain with suspicion of intracranial hemorrhage that revealed a lesion in fat dansity in the lateral ventricle and interhemispheric fissure (Figure a). Her international normalized ratio was 3,2. She underwent cranial magnetic resonance imaging (MRI) that revealed a hyperintense lesion in T1 and T2 sequances in the lateral ventricles, pericallosal area and interhemispheric fissure that did not show contrast enhancement (Figure b and c). After the symptomatic relief by analgesics she was discharged from the emergency department for out-patient follow-up. Figure Image (a) shows cranial computed tomography. There is a homogenously hypodense lesion measuring 33 mm × 30 mm in the lateral and third ventricles with about −101 to −110 Hounsefield unit. Image (b) and (c) show magnetic resonance ... Intracranial lipomas are rare and benign congenital malformations accounting for 0,1% to 0,46% of all intracranial tumors.1 Since half of all cases are asymptomatic, they are usually an incidental finding during neuroimaging studies. Headache is the most common symptom in adults if it becomes symptomatic.2 The deep interhemispheric fissure, especially the corpus callosum, is the most common localization of intracranial lipomas.1 Intracranial lipomas are often associated with other malformations of the central nervous system, such as callosal agenesis or hypogenesis, spina bifida or a cranium bifidum.1,3 Noncontrast cranial CT and brain MRI allow definitive diagnosis. The appearance of the corpus callosum lipoma on the cranial CT scan is quite typical, with the low attenuation seen only in adipose tissue, which ranges from −40 to −100 hounsfield units.4,5 In the brain MRI the lesion presents characteristics of fatty tissue, with a hyperintense signal in both T1 and T2-weighted studies.6 Most lipomas are treated conservatively and rarely requires neurosurgical treatment because of their benign nature.1 Our patient did not have any accompanying lesion and was discharged to follow-up as an out-patient.

Ability of Emergency Physicians to Detect Early Ischemic Changes of Acute Ischemic Stroke on Cranial Computed Tomography

Objective: The objective of this study was to evaluate the ability of emergency physicians (EPs) to diagnose early ischemic changes due acute ischemic stroke on cranial computed tomography (CT). Subjects and Methods: Three EPs interpreted CT scans obtained within 3 h of symptom onset in 50 patients with acute stroke. The CT scans were interpreted by the EPs and compared to official neuroradiologist reports as a gold standard. ĸ statistics were calculated to determine agreement among the three readers. Sensitivities and specificities were analyzed for each reader. Results: The EPs’ sensitivities were 50, 45.5, and 45.5%, and specificities were 64.3, 82.1, and 64.3%, respectively. Focal parenchymal hypodensity was the criterion for which the EPs were the most sensitive (77.3%). The ability of EPs to recognize early ischemic changes on CT scans in acute ischemic stroke was moderate based on sensitivities. Conclusion: Based on this study, EPs must be trained especially for recognizing early ischemic changes in acute ischemic stroke to improve their accuracy of interpretation.

Do we routinely need cranial computed tomography for mild head injuries in Turkey

The objectives of this study were to determine the role of clinical parameters in detecting intracranial injury and to find out whether cranial computed tomography (CT) is routinely needed for mild head injury (MHI) in Turkey. This retrospective study was conducted by reviewing the records of patients with MHI who underwent cranial CT in our emergency department. We carried out multiple logistic regression analysis, and odds ratios with 95% confidence intervals were calculated by using SPSS 15.0. This study included 923 patients. Positive cranial CT findings were determined in 17 patients (1.8%) and six of them (0.6%) underwent surgery. Statistically significant correlations were found among headache, presence of clinical findings of skull fracture, focal neurological deficit and positive cranial CT findings. Although the incidence of the intracranial lesions, especially those requiring surgery, is low in MHI, the liberal use of CT scanning in MHI seems to be justified in countries such as Turkey.