Faculty Bibliography

BACKGROUND: Focused, proximal compression ultrasound (FPCUS) is a commonly used point-of-care study in the Emergency Department (ED). Pelvic vein deep venous thrombosis (DVT) is a rare presentation, and Emergency Physicians need to be aware of the limitations and pitfalls of FPCUS. OBJECTIVE: A case of external iliac vein DVT diagnosed in the ED is presented, with a focus on subtle signs seen during FPCUS that led to the diagnosis and additional ultrasound techniques to aid in appropriate point-of-care diagnosis. CASE REPORT: We describe a patient who presented with lower-extremity pain and was subsequently diagnosed with external iliac DVT. A FPCUS study by Emergency Physicians was performed and demonstrated subtle findings that led to further investigation and appropriate diagnosis. CONCLUSION: Emergency physicians using FPCUS in the evaluation of lower-extremity pain or swelling need to be aware of the pitfalls, limitations, and advanced techniques to avoid misdiagnosis while evaluating for DVT.

BACKGROUND: Long-bone fractures represent one of the most commonly sustained injuries following trauma and account for nearly 4% of emergency department visits in the United States each year. These fractures are associated with a significant risk of bleeding and neurovascular compromise. Delays in their identification and treatment can lead to loss of limb and even death. Although emergency physicians currently rely predominantly on radiography for the examination of long-bone injuries, emergency ultrasound has several advantages over radiography and may be useful in the identification of long-bone fractures. Ultrasound is rapid, noninvasive, and cost-effective. Unlike radiography, ultrasound does not expose children to ionizing radiation, which has been linked to cancer. OBJECTIVE: The goal of this study was to assess the agreement between emergency physicians' and radiologists' final assessments of suspected long-bone fractures using emergency ultrasound and radiography, respectively, in the pediatric population. METHODS: This is a prospective study involving a convenience sample of pediatric patients (<18 years of age) who presented to the emergency department of a university-affiliated, level I trauma center between March 2008 and January 2009 with at least 1 suspected long-bone fracture. Suspected fractures were characterized by swelling, erythema, and localized pain. Patients who had a history of fracture, extremity deformity, orthopedic hardware in the traumatized area, or an open fracture were excluded from this study. Each investigator received limited, focused training in the use of ultrasonography for fracture identification and localization. This training consisted of a brief didactic session and video review of normal and fractured long-bones. RESULTS: A total of 53 subjects (mean age, 10.2 [SD, 3.8] years; 56.6% were male) were enrolled, which corresponded to 98 ultrasound examinations. Sixty-nine scans (70.4%) involved bones of the upper extremity, and 29 (29.6%) the lower extremity. Radiography identified a total of 43 fractures. The sensitivity and specificity of ultrasound in the detection of long-bone fractures were 95.3% (95% confidence interval [CI], 82.9%-99.2%) and 85.5% (95% CI, 72.8%-93.1%), respectively, and the positive and negative predictive values were 83.7% (95% CI, 68.8%-92.2%) and 96% (95% CI, 84.9%-99.3%), respectively. Overall, ultrasound detected 100.0% of diaphyseal fractures and 27 (93.1%) of 29 end-of-bone or near-joint fractures.Radiography revealed 6 displacements that met the published criteria for reduction, all of which were also revealed by ultrasound. The overall sensitivity and specificity for ultrasound identifying the need for reduction were 100.0% (95% CI, 51.7%-100.0%) and 97.3% (95% CI, 84.2%-99.9%), respectively, and positive and negative predictive values were 85.7% (95% CI, 42.0%-99.2%) and 100.0% (95% CI, 88.0%-100.0%), respectively. CONCLUSIONS: Emergency department physician-performed focused ultrasound was more accurate in detecting diaphyseal fractures than in detecting fractures in the metaphysis and/or epiphysis. The high sensitivity and specificity of ultrasound in the detection of long-bone fractures and the need for reduction support the use of ultrasound in the evaluation of suspected long-bone fractures in children.

Background: The standard evaluation of patients with right upper quadrant (RUQ) abdominal pain consists of a history and physical examination, laboratory analysis, and radiological investigation. Given the increasing availability of bedside ultrasound in the Emergency Department (ED), a growing proportion of Emergency Physicians are now performing their own ultrasound examinations in patients with RUQ abdominal pain to circumvent diagnostic delays and improve patient care. Objective: To determine the economic 'opportunity' costs of additional radiographic testing after identification of acute cholecystitis by focused ED ultrasound performed by registered diagnostic medical sonographer (RDMS)-certified personnel. Methods: A retrospective analysis of a consecutive sample of patients with 'positive' focused ED ultrasounds of the RUQ that were significant for cholecystitis, who presented from June 1, 2005 through February 30, 2006. Cost analysis was performed using standard Medicare compensation indices for radiological examinations of the abdomen/hepatobiliary system. Results: There were 37 patients enrolled; 32 patients exhibited RUQ pain with a focused ED ultrasound significant for cholecystitis. Eight (25%) patients received no further radiographic tests and exhibited positive pathology. Twenty-four (75%) patients had additional diagnostic examinations; 22 (92%) showed positive pathology. Based upon Medicare compensation indices, an opportunity cost of $6885.34 was incurred at our institution over 9 months due to additional examinations. Using nationally comparable indices, this was extrapolated to an opportunity cost of $63 million (95% confidence interval $48.3-$78.9 million) per year across the nation, assuming that 50% of patients with cholecystitis present to the ED and receive an ultrasound examination by an RDMS-certified Emergency Physician. Conclusions: In this small sample, additional radiological testing after ED ultrasounds significant for acute cholecystitis led to sizable economic costs on a local and national level. Formal cost-benefit analyses are needed to evaluate the full economic and patient care implications of ED ultrasound use in this setting

OBJECTIVE: The diagnosis of cholecystitis or biliary tract disease in children and adolescents is an uncommon occurrence in the emergency department and other acute care settings. Misdiagnosis and delays in diagnosing children with cholecystitis or biliary tract disease of up to months and years have been reported in the literature. We discuss the technique and potential utility of point-of-care ultrasound evaluation in a series of pediatric patients with suspected cholecystitis or biliary tract disease. METHODS: We present a nonconsecutive case series of pediatric and adolescent patients with abdominal pain diagnosed with cholecystitis or biliary tract disease using point-of-care ultrasound. The published sonographic criteria is 3 mm or less for the upper limits of normal gallbladder wall thickness and is 3 mm or less for normal common bile duct diameter (measured from inner wall to inner wall) in children. Measurements above these limits were considered abnormal, in addition to the sonographic presence of gallstones, pericholecystic fluid, and a sonographic Murphy's sign. RESULTS: Point-of care ultrasound screening detected 13 female pediatric patients with cholecystitis or biliary tract disease when the authors were on duty over a 5-year period. Diagnoses were confirmed by radiology imaging or at surgery and surgical pathology. CONCLUSIONS: Point-of-care ultrasound to detect pediatric cholecystitis or biliary tract disease may help avoid misdiagnosis or delays in diagnosis in children with abdominal pain

Over the past 25 years, research performed by emergency physicians (EPs) demonstrates that bedside ultrasound (US) can improve the care of emergency department (ED) patients. At the request of the Council of Emergency Medicine Residency Directors (CORD), leaders in the field of emergency medicine (EM) US met to delineate in consensus fashion the model "US curriculum" for EM residency training programs. The goal of this article is to provide a framework for providing US education to EM residents. These guidelines should serve as a foundation for the growth of resident education in EM US. The intent of these guidelines is to provide minimum education standards for all EM residency programs to refer to when establishing an EUS training program. The document focuses on US curriculum, US education, and competency assessment. The use of US in the management of critically ill patients will improve patient care and thus should be viewed as a required skill set for all future graduating EM residents. The authors consider EUS skills critical to the development of an emergency physician, and a minimum skill set should be mandatory for all graduating EM residents. The US education provided to EM residents should be structured to allow residents to incorporate US into daily clinical practice. Image acquisition and interpretation alone are insufficient. The ability to integrate findings with patient care and apply them in a busy clinical environment should be stressed.

Hypertrophic pyloric stenosis (HPS) is an acute abdominal emergency in infants that often presents to Emergency Departments. The clinical diagnosis of HPS relies on palpation of an olive-sized mass in the right upper quadrant of an infant with a history of projectile vomiting. However, studies have shown that clinicians cannot detect the olive in 11% to 51% of cases. Ultrasonography is the imaging modality of choice to diagnose HPS. HPS has a highly characteristic sonographic appearance that makes it readily identifiable on ultrasound. To our knowledge, there have been no reports documenting the ability of Emergency Physicians to diagnose HPS using point-of-care ultrasound. We present a multi-center case series (n = 8) of HPS diagnosed by Emergency Physician-performed ultrasound. We review the technique of incorporating point-of-care ultrasound into the physical examination of infants with suspected HPS and discuss the possible role of point-of-care ultrasound in the management of these patients

The internal jugular vein (IJV) is an optimal location for obtaining central venous access due to its superficial location. However, there are many potential pitfalls of using the landmark technique, including aberrant anatomy of the IJV, proximity to the carotid artery and cupola of the lung, body habitus, and prior neck surgery. Our case study demonstrates how the use of ultrasound greatly simplified cannulation of an aberrant IJV in a dialysis patient