Sarah E. Frasure

Impact of patient positioning on lung ultrasound findings in acute heart failure

Aim: The purpose of this study was to compare lung ultrasound findings in both the supine and upright positions in heart failure patients presenting with dyspnea or chest pain. Methods and results: We performed lung ultrasonography on 50 heart failure patients in the emergency department. Each subject underwent eight-zone lung sonography in the seated upright position, followed by a repeat ultrasound in the supine position. Each ultrasound video clip was later assigned a score (0–2 B-lines=0 points, 3–7 B-lines=1 point, >7 B-lines=2 points) by a physician who was blinded to patient position, chest zone, and clinical information. The median B-line score on eight-zone lung ultrasound was significantly higher in the supine (6, interquartile range (IQR) 2–10) vs the sitting position (5, IQR 1–8; p<0.001). Subjects with vascular congestion or pulmonary edema on chest x-ray (CXR) (n=29) also had higher median eight-zone B-line scores in the supine position (6, IQR 4–10) compared to the sitting position (5, IQR 2–8; p=0.002). Subjects without any acute pulmonary findings on CXR (n=19) had similar median eight-zone B-line scores in sitting (4, IQR 1–7) and supine positions (4, IQR 1–9, p=0.093). Conclusion: Our findings suggest that patient positioning may impact the number of B-lines on lung ultrasound in a heart failure population. A consistent approach to patient positioning during lung ultrasonography may be necessary in order to monitor dynamic changes in heart failure.

Diagnosis and Reduction of a Hernia by Bedside Ultrasound: A Case Report

BACKGROUND Emergency physicians can utilize bedside ultrasound to aid in the diagnosis of abdominal wall hernias and in the reduction of incarcerated hernias. OBJECTIVES To review the sonographic appearance and diagnostic criteria of abdominal wall hernias and to describe the potential use of ultrasound as an aid in hernia reduction. CASE REPORT An emergency physician utilized bedside ultrasound to confirm the diagnosis of an incarcerated ventral abdominal wall hernia and to assist in its successful reduction. CONCLUSIONS A physician trained in bedside ultrasound can diagnose an abdominal wall hernia and facilitate the appropriate treatment of an incarcerated hernia.

Point-of-care ultrasound in a patient with perforated appendicitis.

Abstract We present the case of an 8-year-old girl with two emergency department visits for constipation and abdominal pain. Her medical history and physical examination noted by the emergency physician did not reveal a clear etiology of her symptoms until the second visit, when a point-of-care ultrasound was performed. The sonographic findings were consistent with a fecalith surrounded by fluid concerning for appendiceal rupture. A computerized tomographic scan of the abdomen confirmed these findings in addition to two large abscesses in the lower pelvis, which subsequently required percutaneous drainage. This case illustrates the utility of point-of-care ultrasound in the evaluation of the pediatric patient with abdominal pain when appendicitis is a concern, as well as the ability of the emergency physician to use this technology to guide treatment and care of pediatric patients.

Bedside ultrasound diagnosis of a spontaneous splenic hemorrhage after tissue plasminogen activator administration

Emergency physicians (EPs) can use bedside ultrasound to diagnosis of intraabdominal free fluid in a variety of clinical scenarios.The purpose of this study is to review the sonographic appearance of intraabdominal free fluid and incidence of spontaneous splenic rupture. An EP used bedside ultrasound to diagnose spontaneous splenic rupture in a patient who had received tissue plasminogen activator for suspected acute ischemic stroke. Bedside ultrasound by a physician trained in basic ultrasound and the focused assessment with sonography for trauma can diagnose intraabdominal free fluid, facilitating appropriate and more rapid consultation, advanced imaging, and treatment.

Emergency department patients with small bowel obstruction: What is the anticipated clinical course?

BACKGROUND Emergency physicians (EPs) often care for patients with acute small bowel obstruction. While some patients require exploratory laparotomy, others are managed successfully with supportive care. We aimed to determine features that predict the need for operative management in emergency department (ED) patients with small bowel obstruction (SBO). METHODS We performed a retrospective chart review of 370 consecutive patients admitted to a large urban academic teaching hospital with a diagnosis of SBO over a two-year period. We evaluated demographic characters (prior SBO, prior abdominal surgery, active malignancy) and clinical findings (leukocytosis and lactic acid) to determine features associated with the need for urgent operative intervention. RESULTS Patients with a prior SBO were less likely to undergo operative intervention [20.3% (42/207)] compared to those without a prior SBO [35.2% (57/162)]. Abnormal bloodwork was not associated with need for operative intervention. 68% of patients with CT scan findings of both an SBO and a hernia, however, were operatively managed. CONCLUSIONS Patients with a history of SBO were less likely to require operative intervention at any point during their hospitalization. Abnormal bloodwork was not associated with operative intervention. The CT finding of a hernia, however, predicted the need for operative intervention, while other findings (ascites, duodenal thickening) did not. Further research would be helpful to construct a prediction rule, which could help community EPs determine which patients may benefit from expedited transfer for operative management, and which patients could be safely managed conservatively as an initial treatment strategy.

Adult Female With Chest Pain

A 64-year-old woman with a history of coronary artery disease and non–ST-segment elevation myocardial infarction presented to the emergency department with severe substernal chest pain radiating to her back. Her blood pressure was 85/57 mm Hg and her pulse rate was 85 beats/min. She had a regular rate and rhythm; no rubs or gallops were audible. Her lungs were clear to auscultation. Her extremities were cool and mottled. ECG showed a normal sinus rhythm with 0.5-mm ST-segment elevations in V1-4, similar to her previous ECG. Her troponin level was elevated. The patient was resuscitated with intravenous fluids and began receiving a norepinephrine drip. The emergency physician performed cardiac ultrasonography and noted akinesis of the left ventricular apex and a reduced estimated ejection fraction of 30% to 35% (Figure 1, Video 1 [available online at http://www.annemergmed.com]). A cardiology consultation was obtained and the patient underwent a cardiac catheterization, in which she was found to have no obstructive coronary artery disease (Figure 2).

Accuracy of abdominal ultrasound for the diagnosis of small bowel obstruction in the emergency department

BACKGROUND Emergency physicians frequently encounter patients with acute small bowel obstructions (SBO). Although computed tomography (CT) imaging is the current gold standard in the assessment of patients with suspected SBO in the emergency department, a few studies have examined the use of ultrasound as an alternative imaging technique. METHODS We evaluated the accuracy of ultrasound performed in the ED by a variety of providers (physicians with various levels of training, physician assistants) compared to CT imaging in 47 patients with suspected SBOs. RESULTS Our data demonstrated a sensitivity of 93.8% and a specificity of 93.3% when compared to abdominal CT, and a sensitivity of 94.3% and specificity of 95.2% using a composite endpoint of abdominal CT and discharge diagnosis. CONCLUSION Ultrasound can play an important role in the identification of small bowel obstructions in ED patients.

Ten Strategies for Optimizing Ultrasound Instruction for Group Learning

Ultrasound use is rapidly increasing in clinical care and as an educational modality. While there is widespread interest in training health-care professionals to incorporate ultrasound into their daily practice, there are few resources available to guide instructors in the design of impactful and efficient training sessions. We present 10 practical strategies to optimize the educational value of ultrasound workshops for any audience.

Adult Female with a Headache

CASE REPORT A 38 year old female with a history of a right foot drop after medial facetectomies (L4-L5, L5-S1) and microdiscectomy (L4-L5) eight weeks prior presented to the emergency department (ED) with two weeks of headache and neck pain. She denied fever or chills. In the ED, her vital signs were stable and her physical exam demonstrated an area of fluctuance along a well-healed surgical incision at L4-S1 that was most prominent when she sat upright. There was no overlying erythema or tenderness to palpation. The emergency physician ordered blood work, pain medication, and performed a point-of-care ultrasound along the area of fluctuance with a linear transducer (5-12 MHz). The ultrasound images demonstrated a large, hypoechoic fluid collection that tracked to the spine (Image 1, Video). A magnetic resonance image (MRI) of the lumbosacral spine confirmed the suspected diagnosis (Image 2).

Use of Ultrasound to Diagnose Pneumonia

CASE REPORT A 31-year-old female with a history of intravenous drug use presented to the emergency department with three days of fever, cough, and pleuritic pain. She denied orthopnea, leg swelling, chest pain, back pain, urinary frequency, sore throat, exotic travel, or recent hospitalization. Her vital signs were notable for tachycardia to 140 beats per minute. Her physical exam demonstrated left basilar crackles and a systolic murmur in the left upper sternal border. The emergency physician performed a point-of-care thoracic ultrasound (Image 1), and subsequently ordered a plain film of the chest (Image 2), which confirmed the diagnosis.