Thomas Mailhot

Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol.

Assessment of hemodynamic status in a shock state remains a challenging issue in Emergency Medicine and Critical Care. As the use of invasive hemodynamic monitoring declines, bedside-focused ultrasound has become a valuable tool in the evaluation and management of patients in shock. No longer a means to simply evaluate organ anatomy, ultrasound has expanded to become a rapid and noninvasive method for the assessment of patient physiology. Clinicians caring for critical patients should strongly consider integrating ultrasound into their resuscitation pathways.

Caval Sonography in Shock A Noninvasive Method for Evaluating Intravascular Volume in Critically Ill Patients

onography has traditionally been used to assess anatomic abnormalities. However, its value in evaluating physiologic characteristics has recently been recognized, particularly in the care of patients in shock. As the use of point-of-care sonography grows in critical care and emergency medicine, noninvasive assessment of intravascular volume status is increasingly being used to guide therapy of the critically ill. Although intravenous fluid is often the initial treatment in hypotensive patients, aggressive volume resuscitation may be detrimental in some patients and in certain types of shock. Accurate diagnosis of shock state can be challenging because physical findings of hypovolemic, distributive, cardiogenic, and obstructive shock often overlap. Pulmonary artery and central venous pressure catheters, which provide physiologic data such as cardiac output and right atrial pressure, are time-consuming, invasive, and carry considerable risks. Central venous pressure has long been used to guide fluid management; however, data suggest that in critically ill patients, central venous pressure may not correlate with the effective intravascular volume. 1 Furthermore, invasive hemodynamic monitoring has not been shown to benefit patients. 2 Given the importance of determining intravascular volume in shock, a rapid bedside sonographic examination can be instrumental in guiding medical management of critically ill patients. Multiple sonographic protocols now exist for the evaluation of shock, dyspnea, and cardiac arrest. 3,4 This article will describe the use of sonography of the inferior vena cava (IVC) in the evaluation of patients in shock.

Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound.

Infective endocarditis is a challenging diagnosis that is rarely made in the emergency department. As the use of focused emergency ultrasound expands into more applications, including advanced echocardiography, the diagnosis of infective endocarditis may be made earlier, potentially leading to more timely treatment. We report a case of an ill-appearing patient presenting to the emergency department with an indwelling central venous catheter, a cardiac murmur, and necrotic toes, who was diagnosed with a large tricuspid vegetation and prominent tricuspid regurgitation on bedside emergency ultrasound. A cardiologist-performed echocardiogram confirmed these findings during the patients hospital admission.

Point-of-Care Ultrasound in Diagnosing Pyomyositis: A Report of Three Cases

BACKGROUND Pyomyositis is a bacterial infection of skeletal muscle that often results in deep intramuscular abscesses. The absence of external dermatologic manifestations in the early stages of pyomyositis makes this a challenging diagnosis. In addition, physical examination findings can be difficult to distinguish from more common processes, such as soft-tissue cellulitis. Clinicians can fail to diagnose this serious disease in a timely manner, resulting in delayed treatment and potential clinical deterioration from sepsis. Although advanced imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI) provide excellent detail, ultrasound (US) can also be used to detect this disease. US can be performed expeditiously at the bedside and is less expensive than CT or MRI. It allows the clinician to examine the deeper tissue planes of muscle, in which purulent fluid collections will develop as pyomyositis advances. CASE REPORT Three patients presenting with leg pain were evaluated with point-of-care (POC) US and diagnosed with pyomyositis. The early diagnosis of this condition prompted rapid treatment with administration of appropriate antibiotics and involvement of orthopedic surgery. Aspiration of fluid allowed for detailed fluid analysis and bacterial cultures. Additional diagnostic imaging was performed, confirming the initial US diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POC US can be helpful in identifying and further delineating intramuscular abscesses and can subsequently lead to expedited and appropriate care in patients who present with extremity pain, but lack significant dermatologic changes.

Ultrasound for the Detection of Pleural Effusions and Guidance of the Thoracentesis Procedure

Objective. To review the use of ultrasound for the detection of pleural effusions and guidance of the thoracentesis procedure. Methods. Two clinical cases will be presented in which ultrasound proved beneficial in guiding the diagnosis and management of patients with pleural effusions and respiratory distress. The ultrasound techniques for the evaluation of pleural effusions and performance of the thoracentesis procedure are discussed. A review of the most current literature follows to present the known diagnostic and safety benefits of ultrasound guidance for thoracentesis. Conclusions. Ultrasound improves the diagnostic accuracy for the detection of pleural effusions over standard chest radiographs. Ultrasound can also diagnose a complicated pleural effusion that may be at higher risk for an adverse outcome during a thoracentesis. Optimally, thoracentesis should be performed under direct ultrasound guidance to decrease the complication rate and improve patient safety.

The use of ultrasound for peripheral IV placement by vascular access team nurses at a tertiary children’s hospital

Purpose Children receiving treatment in the hospital frequently require intravenous (IV) access. Placement of short peripheral catheters can be painful and challenging especially in those children who have difficult access. Many childrens hospitals have teams of specialized vascular access nurses experienced in peripheral catheter insertion, and at times use vein visualization devices, including ultrasound (US), to assist in peripheral IV placement. Our objectives were to describe the prevalence and success rate of US-guided peripheral IV placement by vascular access team nurses at a single tertiary childrens hospital. Methods We retrospectively reviewed quality assurance data kept by our institutions vascular access team between February, 2014 and March, 2014. Data extracted included: age, gender, number of attempts, if difficult, if ultimately successful and modality used to aid IV placement. Descriptive statistics and chi-square tests were used to analyze and report data. Results There were 1111 patient-nurse encounters reported for peripheral IV placement over a six-week period, and a total of 1579 attempts. Ultimately 84% of the patients had successful IV placement. Overall, visualization and palpation was the most frequently used technique (50.1%), followed by near-infrared light (40.6%), US (8.0%), and transillumination (1.3%). The success rate of US (60% overall and 59.2% difficult) was not significantly different from other advanced visualization techniques. Conclusions Vascular access team nurses use US infrequently for peripheral IV placement, including in children with difficult access. Methods to increase its skillful use in difficult access patients and improve successful IV placements should be explored.

Bedside Ultrasound in a Case of Blunt Scrotal Trauma

This case study describes a patient who suffered blunt force trauma to the scrotum. Use of bedside emergency ultrasound facilitated early diagnosis of a ruptured testicle and allowed for prompt urological consultation and timely surgical repair. The utility of bedside emergency ultrasound in the evaluation of testicular trauma, as well as the outcome of our case, is discussed here.

Diagnosis of Fournier's Gangrene on Bedside Ultrasound

A previously healthy 48 year-old male presented to the hospital with a 4-week history of “pimples” on his scrotum. This condition had progressively worsened, resulting in increased pain, swelling and redness to the genital region and buttocks. On physical examination, the patient was persistently tachycardic. The scrotum, penis, perineum and left buttock were erythematous, swollen and markedly tender to palpation. Furthermore, the patient’s suprapubic region contained an area of necrotic tissue. As part of the initial assessment, the patient received a bedside ultrasound (US) that demonstrated marked thickening of the scrotal fascia with edema, as well as discrete areas of subcutaneous gas (Video). Based on these ultrasound findings, in conjunction with the clinical evaluation, the patient was diagnosed with Fournier’s Gangrene and intravenous antibiotics were started. He was then emergently transferred to the operating room without further advanced imaging, where he received aggressive surgical therapy with a good outcome. Video Ultrasound of scrotum demonstrating thickening of scrotal fascia. Fournier’s Gangrene is defined as “an infective fasciitis of the perineal, genital or perianal regions”.1 The bacterial etiology is typically a synergistic polymicrobial infection, defined as a form of type 1 necrotizing fasciitis. 2–3 This case demonstrates that Fournier’s Gangrene remains a clinical diagnosis and that while many patients receive confirmatory advanced imaging with computed tomography and magnetic resonance imaging, an expedited bedside US can allow for the diagnostic certainty to proceed rapidly with appropriate therapy.4–5

Hepatic Portal Venous Gas: Findings on Ultrasound and CT

A 76-year-old female with a history of Parkinson’s, dementia, and hypertension presented to the emergency department with non-bilious, non-bloody vomiting and abdominal pain for 2 days. Her exam was significant for borderline hypotension without tachycardia, abdominal distension and a palpable ventral hernia. An emergency physician performed ultrasound showed free intraperitoneal air and gas in the liver (Video). A computed tomography showed pneumoperitoneum, pneumatosis intestinalis, and hepatic portal venous gas (HPVG) (Figure). At laparotomy, she was found to have a sigmoid colon perforation from adenocarcinoma, ischemic small bowel, and a colovesicular fistula. Post-operatively her clinical status worsened, and she was transitioned to comfort care and expired on hospital day 2. Figure Computed tomography without contrast of the abdomen and pelvis showing free air (asterisks), pneumatosis intestinalis (thin arrows), and hepatic portal venous gas (large arrow). HPVG was first reported in infants with necrotizing enterocolitis.1 In adults, it is most commonly associated with mesenteric ischemia and pneumatosis intestinalis, accounting for 43% of HPGV cases2 and an associated mortality of 75%.2–3 It has been reported with other diseases such as diverticulitis, inflammatory bowel disease, obstructive pyelonephritis, pancreatitis, cholangitis, uterine gangrene, and severe shock.4 HPVG is attributed to either bacterial gas production in bowel entering mesenteric circulation4 or intraluminal air entering capillaries from impaired mucosal barrier or increased intraluminal pressure.5 HPVG spreads to the periphery of the liver whereas pneumobilia collects centrally, in the direction of bile flow. Treatment is always aimed at the underlying etiology of HPVG.

Ultrasound Diagnosis of Urethral Calculi

A 35-year-old man presented to the emergency department (ED) for acute urinary retention and penile pain for 4 hours. The patient denied any significant medical history or history of trauma. Physical exam revealed testicles that were nontender, without masses. However, a tender mass was felt at the distal end of the penis, adjacent to the urethral meatus. Placement of a Foley catheter resulted in a return of 700 cc of clear yellow urine and immediate resolution of the patient’s suprapubic and penile pain. During the ED course, the Foley catheter was removed with a subsequent trial of voiding. Initially, the patient was able to void 15 cc of urine until the normal stream was abruptly cut off. The patient then complained of extreme penile pain, near the urethral meatus. A small, circular and firm mass was again palpated in the distal penile shaft. Bedside emergency ultrasound (EUS), performed with a 10 MHz linear array probe placed along long axis of penis, revealed a hyperechoic, dense and round structure with characteristic acoustic shadowing at the distal end of the urethra, with obstruction of the urinary flow (Video). The object, a 9 mm stone, was removed with forceps. Following stone removal, the patient experienced immediate pain relief and was able to spontaneously void. While urethral imaging has traditionally been performed with retrograde urethrography (RUG), more recently ultrasound has been used to minimize the pain associated with RUG and to provide clinicians more detailed information about urethral pathology.2 As demonstrated in this case, EUS allowed a prompt diagnosis of the patient’s condition with appropriate rapid treatment and removal of the urethral stone. Video. Ultrasound of dorsal surface of penis with 10 MHz linear transducer demonstrating urethral calculus at urethral meatus (audio narration included). Click here to view.(6.2M, mov)