Robert R. Ehrman

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.

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%.

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.

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)