Faculty Bibliography

Study Objective: Abdominal pain is a common complaint and comprises approximately 25% of all patients who present to the emergency department (ED). More than 25% of patients presenting to the ED with uncomplicated abdominal pain have computed tomography (CT) scans during their visit. The radiology literature has shown that despite the large number of CTs performed on patients in the ED presenting with abdominal pain, less than half (48%) are actually diagnostic. The objective of this study is to determine if performing a bedside screening ultrasound (US) on patients who present to the ED with undifferentiated abdominal pain can result in a reduction in CT scan usage. We hypothesize that performing a bedside US will decrease the use of CT imaging in the ED by 15% in patients with abdominal pain. Methods: This is a preliminary prospective observational study of ED patients at two urban academic medical centers beginning December 2014. Inclusion criteria include all patients between the ages of 18 and 65 who present with abdominal pain and have a CT of the abdomen and pelvis performed. Patients with an extensive abdominal surgical history or those who end up not having a CT are excluded. Emergency physician co-investigators trained in US, blinded to CT results, performed the following studies: a Focused Assessment with Sonography in Trauma (FAST) exam, right upper quadrant US, bilateral renal US, an abdominal aorta US, and a right lower quadrant US. All US results were discussed with the treating physician and any changes in management were documented. Medical records were reviewed for the final results of all CTs. Results: We calculated a sample size of 200 patients in order to reduce CT scan usage from 25% to 10%. Our preliminary data identified 31 eligible patients of which 28 were enrolled in the study. Three patients have been dropped due to the CT being canceled. Twenty-five patients received both the US and CT in the ED and were included in the analysis. Eleven patients (44%) had a normal US and no significant findings on a subsequent CT. Four patients (16%) had a normal US, but a positive CT. Two of these four had mild hydronephrosis on CT that was missed on US and two had more complicated diagnoses of fistulizing Crohn's and diverticulitis. Ten patients (40%) had a positive US, of which eight had the same diagnosis confirmed on CT and two patients (8%) had CT findings that differed from the US: one had acute appendicitis on US, but renal colic on CT and one had a possible SBO on US but a rectus muscle hematoma on CT. Ultrasound could have theoretically reduced CT utilization in 32% of patients. Although three patients were dropped, two of these had the CT scan canceled and a change in management based on US findings. The two diagnoses were appendicitis and cholelithiasis and both had subsequent radiology US confirming the findings. Therefore, our preliminary total theoretical and actual CT usage reduction is 40%. Conclusions: These preliminary findings suggest that ED performed bedside US in patients with uncomplicated abdominal pain may significantly reduce CT utilization. Bedside US will not replace CT in all patients and subsequent imaging may still be required. However, incorporating US into an abdominal pain algorithm may reduce radiation exposure, length of stay and costs associated with unnecessary CT usage in the ED

BACKGROUND: Optic neuritis is an inflammatory demyelinating condition of the optic nerve that causes subacute visual loss. It is often the result of an underlying systemic condition, such as multiple sclerosis. Due to the possible long-term morbidity associated with this condition, it is essential that the emergency physician recognizes the diagnosis and expedites treatment. OBJECTIVE: This case report describes optic neuritis diagnosed at the bedside by emergency physician-performed ultrasound. CASE REPORT: This is a case report of a young man presenting with unilateral painful vision loss. Optic neuritis must be considered in the differential diagnosis of any young patient who presents with visual complaints without any other neurologic findings. This report is unique because there are very few cases describing the findings of optic neuritis on emergency physician-performed bedside ultrasound in the literature. CONCLUSIONS: This article presents the case, describes diagnostic modalities, especially the use of ultrasound in its diagnosis, and the course of treatment for this particular condition.

STUDY OBJECTIVE: The objective of this study was to determine the diagnostic performance of right ventricular dilatation identified by emergency physicians on bedside echocardiography in patients with a suspected or confirmed pulmonary embolism. The secondary objective included an exploratory analysis of the predictive value of a subgroup of findings associated with advanced right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, McConnell's sign). METHODS: This was a prospective observational study using a convenience sample of patients with suspected (moderate to high pretest probability) or confirmed pulmonary embolism. Participants had bedside echocardiography evaluating for right ventricular dilatation (defined as right ventricular to left ventricular ratio greater than 1:1) and right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, or McConnell's sign). The patient's medical records were reviewed for the final reading on all imaging, disposition, hospital length of stay, 30-day inhospital mortality, and discharge diagnosis. RESULTS: Thirty of 146 patients had a pulmonary embolism. Right ventricular dilatation on echocardiography had a sensitivity of 50% (95% confidence interval [CI] 32% to 68%), a specificity of 98% (95% CI 95% to 100%), a positive predictive value of 88% (95% CI 66% to 100%), and a negative predictive value of 88% (95% CI 83% to 94%). Positive and negative likelihood ratios were determined to be 29 (95% CI 6.1% to 64%) and 0.51 (95% CI 0.4% to 0.7%), respectively. Ten of 11 patients with right ventricular hypokinesis had a pulmonary embolism. All 6 patients with McConnell's sign and all 8 patients with paradoxical septal motion had a diagnosis of pulmonary embolism. There was a 96% observed agreement between coinvestigators and principal investigator interpretation of images obtained and recorded. CONCLUSION: Right ventricular dilatation and right ventricular dysfunction identified on emergency physician performed echocardiography were found to be highly specific for pulmonary embolism but had poor sensitivity. Bedside echocardiography is a useful tool that can be incorporated into the algorithm of patients with a moderate to high pretest probability of pulmonary embolism.

BACKGROUND: Paget-Schroetter syndrome, or an upper-extremity deep venous thrombosis (UEDVT), occurs in young people after strenuous repetitive activity involving the upper extremity. The long-term morbidity and mortality of this condition is similar to the effects of lower-extremity DVT and therefore, its early diagnosis and treatment are essential. OBJECTIVES: This case report describes Paget-Schroetter syndrome (effort thrombosis) diagnosed at the bedside by Emergency Physician performed ultrasound. CASE REPORT: This is a case report of an uncommon but potentially dangerous disease that carries high morbidity if not diagnosed and treated early. Emergency Physicians should be aware of this condition in any young patient who presents with upper-extremity complaints with a history of repetitive use. Although the role of ultrasound in the diagnosis of lower-extremity DVT is well described, this case report is unique because it illustrates the diagnosis of Paget-Schroetter syndrome completed at the bedside. CONCLUSION: This article presents the case and discusses the incidence, potential causes, predisposing factors, diagnostic modalities, and the course of treatment for this particular diagnosis.

Lung sonography has rapidly emerged as a reliable technique in the evaluation of various thoracic diseases. One important, well-established application is the diagnosis of a pneumothorax. Prompt and accurate diagnosis of a pneumothorax in the management of a critical patient can prevent the progression into a life-threatening situation. Sonographic signs, including 'lung sliding', 'B-lines' or 'comet tail artifacts', 'A-lines', and 'the lung point sign' can help in the diagnosis of a pneumothorax. Ultrasound has a higher sensitivity than the traditional upright anteroposterior chest radiography (CXR) for the detection of a pneumothorax. Small occult pneumothoraces may be missed on CXR during a busy trauma scenario, and CXR may not always be feasible in critically ill patients. Computed tomography, the gold standard for the detection of pneumothorax, requires patients to be transported out of the clinical area, compromising their hemodynamic stability and delaying the diagnosis. As ultrasound machines have become more portable and easier to use, lung sonography now allows a rapid evaluation of an unstable patient, at the bedside. These advantages combined with the low cost and ease of use, have allowed thoracic sonography to become a useful modality in many clinical settings.

BACKGROUND: The extrauterine migration of an intrauterine device (IUD) can be life threatening and require emergent surgical intervention and treatment. Migration is usually the result of IUD expulsion or uterine perforation. OBJECTIVE: This case report describes a presentation of extrauterine migration of an IUD due to probable perforation. CASE REPORT: This is a case report of an uncommon but potentially dangerous outcome of IUD placement and use. The potential migration of an IUD and resultant uterine perforation must be considered in the differential diagnosis of any woman using this type of contraception who presents with abdominal pain. This report is unique due to the subtle presentation of a potentially life-threatening diagnosis. CONCLUSION: This article presents the case, discusses the incidence, potential causes, predisposing factors, diagnostic modalities, and the course of treatment for this particular diagnosis.

OBJECTIVE: This study sought to correlate the presence of pleural-based B-lines seen by emergency department ultrasound performed with the linear transducer with B-type natriuretic peptide (BNP) level in patients with suspected congestive heart failure. METHODS: The study was a prospective convenience sample on adult patients in an academic, urban emergency department with over 100,000 annual patient visits. Adult patients with a BNP level ordered by the treating physician were prospectively enrolled by one of four physicians, blinded to the BNP level. The enrolling physicians included an emergency ultrasound director, two emergency ultrasound fellows, and a senior emergency medicine resident. Bedside ultrasound was performed using a 3-12 MHz linear broadband transducer in four lung fields. The serum BNP level was correlated with bilateral B-lines, defined as three or more comet-tail artifacts arising from the pleural line extending to the far field without a decrease in intensity on the right and left thorax. RESULTS: Sixty three patients were consented and enrolled during a four-month period. Fifteen patients had the presence of bilateral B-lines. The median BNP in patients with bilateral B-lines was 1560 pg/mL (95% confidence interval (CI) 1141-3706 pg/mL), compared with 538 pg/mL (95% confidence interval 310-1917 pg/mL) in patients without B-lines. The distributions in the two groups differed significantly (p=0.0006). Based on the threshold level of BNP 500 pg/mL, the sensitivity of finding bilateral B-lines on ultrasound was 33.3% (95% CI: 0.19-0.50), and the specificity was 91.7% (95% CI: 0.73-0.99). In addition, bilateral B-lines were absent in all patients with a BNP<100 pg/mL. CONCLUSION: The presence of bilateral B-lines identified with the linear probe is associated with significantly higher BNP levels than patients without B-lines. In our patient population, the presence of B-lines was specific but not sensitive for BNP>500. Further research may show that it can be applied to quickly assess patients with undifferentiated dyspnea.

The emergence of prothrombotic agents (e.g. activated factor VII) to treat traumatic brain injury (TBI) requires a better understanding of the association of coagulopathy with isolated head injury (IHI). OBJECTIVE: To investigate the association of IHI and coagulopathy. METHODS: Prospective, observational study in an urban level I trauma center. Inclusion criteria: Adult (> or = 13 years of age) patients with IHI. Exclusion criteria: patients with known coagulopathies or on anticoagulant therapy. Predictor Variables: TBI (head abbreviated injury severity score > 2, or brain hematoma on CT scan), age, gender, mechanism of injury, Glasgow Coma Score (GCS), and loss of consciousness (LOC). Outcome variables: coagulopathy defined as elevated International Normalized Ratio (INR > 1.3) or activated partial thromboplastin time (PTT) greater than 34 s. We divided IHI subjects into two groups of patients with and without TBI. Statistical Analysis: Fisher's exact test and Mann-Whitney U were used to compare data where appropriate (alpha: 0.05, two-tailed). RESULTS: From July 2005 to December 2006, 276 patients with IHI were studied. The median age was 35 years (interquartile range: 25-52) with a 79% male predominance and 88% blunt trauma. Eight percent (95% CI, 5-12%) of patients had coagulopathy. The rate of coagulopathy in TBI patients (17%) was significantly higher than non-TBI patients (6%) (11% difference, 95% CI, 3-20%]. The relative risk of coagulopathy in TBI patients was 2.9 (95% CI, 1.3-6.6). CONCLUSION: Coagulopathy as defined by elevated INR and/or PTT is associated with TBI after isolated head injury.