Bedside echocardiography by emergency physicians.

STUDY OBJECTIVE: Timely diagnosis of a pericardial effusion is often critical in the emergency medicine setting, and echocardiography provides the only reliable method of diagnosis at the bedside. We attempt to determine the accuracy of bedside echocardiography as performed by emergency physicians to detect pericardial effusions in a variety of high-risk populations. METHODS: Emergency patients presenting with high-risk criteria for the diagnosis of pericardial effusion underwent emergency bedside 2-dimensional echocardiography by emergency physicians who were trained in ultrasonography. The presence or absence of a pericardial effusion was determined, and all images were captured on video or as thermal images. All emergency echocardiograms were subsequently reviewed by the Department of Cardiology for the presence of a pericardial effusion. RESULTS: During the study period, a total of 515 patients at high risk were enrolled. Of these, 103 patients were ultimately deemed to have a pericardial effusion according to the comparative standard. Emergency physicians detected pericardial effusion with a sensitivity of 96% (95% confidence interval [CI] 90.4% to 98.9%), specificity of 98% (95% CI 95.8% to 99.1%), and overall accuracy of 97.5% (95% CI 95.7% to 98.7%). CONCLUSION: Echocardiography performed by emergency physicians is reliable in evaluating for pericardial effusions; this bedside diagnostic tool may be used to examine specific patients at high risk. Emergency departments incorporating bedside ultrasonography should teach focused echocardiography to evaluate the pericardium.

Three common presentations of ascariasis infection in an urban Emergency Department.

In the United States, approximately 4 million people per year are infected with Ascaris lumbricoides. We reviewed the common presentations of complications of Ascariasis infection in the Emergency Department (ED) and the diagnostic tools and treatment available. This was a retrospective case review conducted on all patients diagnosed with Ascariasis (using ICD-9 codes) over a 6-year period at Los Angeles County and University of Southern California Medical Center. Three patients with distinct complications secondary to Ascariasis were chosen, and all ED and inpatient records were reviewed. The patient's age, sex, race, presenting symptoms, data, outcome, and ED course and diagnosis were recorded. The three cases included a periappendiceal abscess, Loeffler's syndrome, and biliary colic/choledocholithiasis. The first patient underwent a computed tomography-guided drainage of the abscess. The second patient received supportive care and antibiotic therapy secondary to a superimposed bacterial pneumonia. The third patient underwent endoscopic retrograde cholangiopancreatography with sphincterotomy. All three patients had a stool ova and parasites positive for A. lumbricoides, and all received a 3-day course of mebendazole. Symptomatic cases of Ascariasis may present to EDs in the United States. Important diagnostic tools for the ED include chest X-ray, X-ray of the kidney-ureter-bladder and ultrasonography. Single-dose medications given in the ED are very effective in eradicating A. lumbricoides infection, thus avoiding hospitalization.

Emergency department presentations of typhoid fever.

Typhoid fever, a systemic infectious disease caused by Salmonella typhi, is classically characterized by fever, paradoxical bradycardia, abdominal pain, and a rose colored rash. This was a retrospective review of 21 confirmed cases over a 5-year period. Mean age was 32.6 years (range 2-60 years), and Mexico (7/21) and El Salvador (3/21) represented the most common countries of origin. Recent travel to an endemic area was noted in 14 patients. The most common complaints were fever (15/21), headache (10/21), abdominal pain (9/21), and diarrhea (6/21). Average duration of symptoms before presentation to the Emergency Department (ED) was 7.9 days. High fever associated with bradycardia was noted in 12 patients. Leukopenia was present in 7 patients. Blood culture was the most sensitive confirmatory test while the Widal test was positive in 7 out of 11 cases. Fever of unknown origin (12/21), followed by presumed typhoid fever (3/21) were the most common ED diagnoses. It is important to recognize that patients with typhoid fever may present to EDs in the US and this disease should be included in the differential diagnosis of febrile patients from Latin America or those with a history of recent travel to endemic countries.

Leprosy in the emergency department.

OBJECTIVES: Los Angeles County-University of Southern California Medical Center, like many large urban hospitals, has a large immigrant population from regions of the world where leprosy is endemic. Emergency physicians (EPs) in these settings can expect to encounter leprosy patients. This study reviewed the emergency department (ED) course of patients with confirmed leprosy in an attempt to describe the most common presenting patterns so that future cases can be more easily recognized. METHODS: This was a retrospective chart review of all patients followed in the Hansen's disease clinic. Demographics, leprosy type, clinical presentations to the ED, and medications were recorded. RESULTS: Of the total number of patients (415), most were of Mexican (52%), Filipino (15%), Vietnamese (14%), and Chinese (5%) origin. Leprosy was classified as lepromatous (56%), borderline (40%), and tuberculoid (4%). There were a total of 118 ED visits by 74 patients. The mean age was 46 years, with 51% male and 49% female. Dermatologic (68%), neurologic (23%), and ophthalmologic (9%) complaints were the most common reasons for ED presentation related to leprosy. The EP did not elicit a history of leprosy in 34% of those patients followed in the leprosy clinic. The ED diagnosis of leprosy was made in 3 of 15 (20%) undiagnosed cases. Of the 63 patients prescribed medications in the leprosy clinic at the time of their ED visits, 22 (35%) ED charts did not report leprosy drugs. CONCLUSION: Patients with leprosy present to U.S. EDs, and new cases can be identified. Early recognition is important given leprosy's devastating consequences, major drug side effects of medications used for treatment, and improved prognosis with multidrug therapy. A history of leprosy and associated medications are often not documented in the ED chart, which may reflect a continued fear of stigmatization among these patients.

Common presentations of amebic liver abscess.

STUDY OBJECTIVE: The most common extraintestinal manifestation of Entamoeba histolytica, the agent of amebiasis, is a hepatic abscess. This infection is common throughout the world and can be associated with life-threatening consequences. Given the often nonspecific nature of the complaints related to an amebic abscess, a retrospective review of patients with confirmed disease was done to recognize the most common patterns of presentation. METHODS: A retrospective case series was conducted of all patients with confirmed amebic liver abscess over a 5-year period. All available emergency department and inpatient records were reviewed. Age, sex, country of origin, chief complaint (including duration), vital signs, and physical and laboratory findings were recorded. The use of ultrasonography, computed tomography scan, chest radiograph, and serum antibodies was noted, as well as the final ED diagnosis. RESULTS: Seventy-five patients were reviewed; mean patient age was 35.5 years, 80% were male, and Mexico was the country of origin for 64%. The most common complaint was fever (77%), followed by abdominal pain (72%), which was most often located in the right upper quadrant. Cough (16%), chest pain (19%), and chest radiographic abnormalities (57%) were also common. The majority of patients (69%) had symptoms for less than 13 days. The WBC count was the most consistent laboratory abnormality (83%), whereas the liver aminotransferase, alkaline phosphatase, and bilirubin levels were often normal. Most patients received their diagnoses on the basis of ultrasonography (85%), followed by a confirmatory serum antibody titer (88%). The diagnosis of amebic liver abscess was correctly made in the ED in 31.5% of the patients, with the most common misdiagnoses being cholecystitis (16.4%), hepatitis (12.3%), and pneumonia (9.6%). CONCLUSION: Patients with amebic liver abscess do present to EDs in the southwestern United States, especially in areas with a high immigrant population from endemic areas. Patients with complaints of fever and right upper quadrant abdominal pain, especially men of Hispanic origin, warrant a high degree of vigilance. Whereas most laboratory studies are unhelpful, the diagnosis can often be made in the ED by means of a bedside ultrasonographic test. Treatment should be initiated with metronidazole with disposition to an inpatient medical service.

Brown-Sequard syndrome due to isolated blunt trauma.

Blunt trauma without associated fracture or ligamentous injury is a rare cause of Brown-Sequard syndrome. We report a case of Brown-Sequard syndrome after a direct blow to the cervical spine that did not cause injury to adjacent bone or ligaments. Characteristic neurologic findings, including a unilateral hemiparesis with associated contralateral sensory findings, were noted at the time of presentation. High-dose steroids were instituted after recognition of the patient's injury, and magnetic resonance imaging of the cervical spine revealed a unilateral cord contusion with no associated fractures. After 1 month, the patient had recovered much of his function and was able to ambulate unassisted.

Bedside emergency department ultrasonography plus radiography of the kidneys, ureters, and bladder vs intravenous pyelography in the evaluation of suspected ureteral colic.

OBJECTIVE: To determine the role of bedside renal ultrasonography (US) and plain radiography of the kidneys, ureters, and bladder (KUB) as the initial investigative modality for those patients presenting to the ED with unilateral flank pain and hematuria. The hypothesis was that the renal US + KUB may obviate the need for emergent i.v. pyelography (i.v.P) in a majority of patients. METHODS: Prospective study over an 8-month period of all consecutive adult patients between the ages of 18 and 65 years presenting with unilateral flank pain and hematuria to the ED at LAC + USC Medical Center. Patients received KUB followed by a 500-mL bolus of normal saline. Bedside US was then performed by emergency physicians (EPs). Hydronephrosis of the kidney was graded as mild, moderate, or severe. All patients then underwent i.v.P. The results of the bedside US + KUB were then compared with those of i.v.P (the criterion standard). RESULTS: Of a total of 139 eligible patients, 108 were enrolled. The combination of US and KUB correctly identified pathology consistent with nephroureterolithiasis with a sensitivity of 97.1% (95% CI = 93.1-100%) when compared with i.v.P. The KUB + US results were falsely positive in 16 patients, resulting in a specificity of 58.9% (95% CI = 43.5-74.3%). The positive predictive value of the combined modality was 80.7%, the negative predictive value was 92.0%, and the overall accuracy was 83.3%. CONCLUSION: The bedside US + KUB has a high sensitivity and can be performed rapidly at the bedside by the EP when compared with i.v.P. This combined modality is an effective screening tool in the initial evaluation of ureteral colic.