Point-Of-Care Ultrasound Use for Detection of Multiple Metallic Foreign Body Ingestion in the Pediatric Emergency Department: A Case Report.

Foreign body ingestions are common complaints in the pediatric emergency department that can be difficult to diagnose in patients with vague symptoms. Magnetic foreign body ingestion can cause significant morbidity and mortality in children. Point-of-care ultrasound (POCUS) is an imaging modality that can be used to readily diagnose emergent abdominal pathology in a timely matter at the patient's bedside. In the case described in the report below, a 6-year-old male swallowed multiple round magnets, causing severe abdominal pain. This was detected on POCUS. An abdominal radiograph also confirmed the POCUS findings of multiple hyperechoic round foreign bodies. Key clinical features and sonographic findings are discussed that may help clinicians using POCUS to identify ingested foreign bodies in Pediatric Emergency Departments. Topics: Point-of-care ultrasound, pediatric emergency medicine, foreign body ingestion.

Agreement on Interpretation of Point-of-Care Ultrasonography for Cardiac Tamponade Among Emergency Physicians.

STUDY OBJECTIVE: Cardiac tamponade is an impending calamitous disorder that emergency physicians need to consider and diagnose rapidly. A pericardial effusion with right atrial systolic collapse (earliest sign) or right ventricular diastolic collapse (most specific sign) and a plethoric inferior vena cava are indicators of cardiac tamponade physiology and may be identified with point-of-care ultrasonography (POCUS). The goal of this study is to assess the agreement among emergency physicians with varying levels of sonographic training and expertise in interpreting echocardiographic signs of cardiac tamponade in adult patients.  Methods: Emergency physicians at different levels of training as sonographers were surveyed at didactic conferences at three major academic medical centers in northern New Jersey. Two cardiologists were also included in the study for comparison. Survey respondents were shown 15, 20-second video clips of patients who had presented to the emergency department (ED) with or without significant pericardial effusions and were asked to rate whether tamponade physiology was present or not. Data were collected anonymously on Google Forms (Google LLC, Mountain View, CA) and included self-reported levels of POCUS expertise and level of training. Data were analyzed using Fleiss' kappa (k). All patients had an echocardiogram performed by the department of cardiology within 24 hours of the POCUS, and the results are presented in the paper.  Results: There were 97 participant raters, including attendings, fellows, and resident physicians specializing in adult emergency medicine and two cardiologists. There was a fair degree of inter-rater agreement among all participants in interpreting whether tamponade physiology was present or not. This low level of agreement persisted across self-reported training levels and self-reported POCUS expertise, even at the expert level in both emergency medicine and cardiology specialties. CONCLUSION: According to the results of our study, there appears to be a low level of agreement in the interpretation of cardiac tamponade in adult patients. The lack of agreement persisted across specialties, self-reported training levels, and self-reported ultrasonographic expertise. This low level of agreement seen among both specialists indicates that emergency physicians are not limited in their ability to determine cardiac tamponade on POCUS. This highlights the technical nature of POCUS clips and strengthens the importance of physical exam findings when diagnosing cardiac tamponade in emergency department patients. Further research utilizing POCUS for the diagnosis of tamponade is warranted.

Imaging Findings of Small Bowel Diverticulitis: A Case Report.

Small bowel diverticulitis is an uncommon subset of acute diverticulitis and can mimic many other intra-abdominal processes. As a result, imaging modalities such as ultrasound and computed tomography (CT) scan are especially important for timely recognition of diverticulitis and can expedite diagnosis and treatment and reduce complications. In the case described in this report, an 81-year-old male with history of esophageal cancer and recurrent diverticulitis with history of multiple bowel resections presented to the emergency department (ED) with right lower quadrant abdominal pain and constipation. Findings on ultrasound were suggestive of diverticulitis, and findings on CT of the abdomen and pelvis showed ileitis with phlegmon and micro-abscess suspicious for small bowel diverticulitis. ED providers should familiarize themselves with ultrasound findings of diverticulitis and be aware that diverticulitis can also present in the small bowel. Treatment of small bowel diverticulitis is similar to colonic diverticulitis. Topics: Ileitis, small bowel diverticulitis, abdominal ultrasound.

Bilateral Common Iliac Artery Aneurysm, a Case Report.

Patient is a 72-year-old male who presented with abdominal pain and hypertension. Through bedside point-of-care ultrasound (POCUS), patient was found to have markedly enlarged bilateral iliac artery aneurysms with signs of impending rupture, which was confirmed on computed tomography (CT) angiogram of the abdomen/pelvis. Patient was immediately taken to the operating room for emergent repair of aneurysm, and was discharged from the hospital the next day. Point-of-care ultrasound is critical in diagnosis and guiding treatment in patients in the emergency department and should be considered in those with undifferentiated abdominal pain. Topics: Abdominal pain, iliac artery aneurysm, point-of-care ultrasound.

Hydroceles-Not Just For Men.

BACKGROUND: Hydroceles develop in females through the canal of Nuck. This canal is formed when the processes vaginalis fails to obliterate during development. The canal of Nuck can lead to the formation of not only hydroceles, but hernias as well. Although physicians typically think of hydroceles occurring in males, on rare occasions, they do occur in females because of this defect. They are often mistaken for incarcerated hernias, making ultrasound an excellent tool to distinguish between them and guide further treatment. CASE REPORT: We report a rare case of a 46-year-old female with the chief complaint of a painful groin mass. A diagnosis of a hydrocele was made by point of care ultrasonography in the emergency department after being misdiagnosed by computed tomography scan on two previous occasions. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Point of care ultrasound (POCUS) is a valuable tool for emergency physicians and can lead to quick diagnoses and appropriate management of the patient. Using ultrasound in conjunction with other imaging modalities can improve diagnostic accuracy. POCUS is portable and a powerful tool for immediate answers, and continues to prove its utility for clinical decision making.

Prevalence of the "double-line" sign when performing focused assessment with sonography in trauma (FAST) examinations.

The double-line sign (DLS) is a wedge-shaped hypoechoic area in Morison's pouch bounded on both sides by echogenic lines. It represents a false-positive finding for free intraperitoneal fluid when performing focused assessment with sonography in trauma examinations. The purpose of this study was to determine the prevalence of DLS. Secondarily, the study will further investigate the relationship between the presence of a DLS and body mass index (BMI). This was a prospective study that enrolled patients over a 7-month period. Inclusion criteria were patients ≥ 18 years of age presenting to the Emergency Department (ED) requiring a FAST examination as part of the patient's standard medical care. Each examination was performed by one of six experienced ultrasonographers. Presence or absence of the DLS was established in real time and gender, height, weight, and BMI were recorded for each patient. The overall prevalence rate of DLS and the corresponding 95 % confidence interval were calculated, as well as the prevalence rates broken down by BMI characterized as underweight, normal weight, overweight, and obese; and age category (18-29, 30-64, and 65+). The Chi-square test and a Fisher's exact test for BMI category were used to compare the prevalence rates of positive DLS among the different demographic groups. 100 patients were enrolled in the study; the overall prevalence was 27 %. There was no statistical significance among the different demographic groups or BMI. The DLS is a prevalent finding. We believe this sign has become more apparent due to improved imaging technology and resolution.