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2.
Am J Emerg Med ; 72: 223.e1-223.e4, 2023 10.
Article in English | MEDLINE | ID: mdl-37524634

ABSTRACT

Low back pain is among one of the most common presentations to the emergency department (ED). Regional anesthesia has recently gained traction as an option for analgesia in ED patients, especially in the wake of the opioid epidemic. Data on lumbar application of the ESPB in the setting of acute, refractory low back pain in the ED is scarce. We describe a series of three cases of patients who presented to the ED with severe low back pain refractory to traditional therapy, successfully treated using lumbar ESPB. Lumbar ESPB may be an effective approach to achieving rapid analgesia in patients who present with low back pain who may otherwise be poor candidates for more traditional therapy, such as with opioids or NSAIDs, or who may have refractory pain despite use of these medications.


Subject(s)
Acute Pain , Low Back Pain , Humans , Low Back Pain/drug therapy , Lumbosacral Region , Acute Pain/therapy , Pain Management , Analgesics, Opioid , Ultrasonography, Interventional , Pain, Postoperative
4.
Am J Emerg Med ; 69: 219.e3-219.e6, 2023 07.
Article in English | MEDLINE | ID: mdl-36933988

ABSTRACT

Radicular pain due to sciatica is a common occurrence with a lifetime incidence of up to 40%. Typical approaches to treatment vary and may include topical and oral analgesics, such as opioids, acetaminophen, and non-steroidal anti-inflammatory drugs (NSAIDs); however, these medications may be contraindicated in some or result in untoward effects in others. The use of ultrasound-guided regional anesthesia is an important component of multimodal analgesia in the emergency department. Transgluteal sciatic nerve block has been described as an effective method to treat patients with sciatica but carries risk of injury and falls due to its resultant loss of motor function and potential for systemic toxicity when higher volumes are used. Ultrasound-guided peripheral nerve hydrodissection with D5W has been shown to be an effective treatment of various compressive neuropathies in the outpatient setting. Here we present 4 cases of patients who presented to the emergency department with severe acute sciatica and were treated successfully using an ultrasound guided transgluteal sciatic nerve hydrodissection (TSNH). This technique may offer a safe and effective approach to treating patients with sciatica, but more studies are needed to assess its utility on a larger scale.


Subject(s)
Nerve Block , Sciatica , Humans , Sciatica/therapy , Nerve Block/methods , Sciatic Nerve/diagnostic imaging , Ultrasonography, Interventional/methods , Emergency Service, Hospital
5.
J Am Coll Emerg Physicians Open ; 1(5): 1119-1120, 2020 Oct.
Article in English | MEDLINE | ID: mdl-33145570
6.
J Emerg Med ; 59(3): 403-408, 2020 09.
Article in English | MEDLINE | ID: mdl-32712031

ABSTRACT

BACKGROUND: The novel coronavirus SARS-CoV-2 has caused a pandemic, overwhelming health care systems around the world. Hospitals around the world, including the United States, have been struggling to adapt to the influx of patients with COVID-19, the illness caused by SARS-CoV2, given limited resources and high demand for medical care. OBJECTIVES: This article seeks to provide emergency physicians with a guide to sonographic findings in COVID-19 and an algorithm by which point-of-care lung ultrasound may assist emergency physicians caring for these patients during the SARS-CoV-2 pandemic. DISCUSSION: The studies currently being published have established a typical set of ultrasound findings in COVID-19. Point-of-care lung ultrasound is rapid and accessible in most emergency departments in the United States, and even in many resource-poor settings. CONCLUSION: Point-of-care ultrasound provides numerous benefits to emergency providers caring for patients with COVID-19, including decreasing resource utilization, assisting in diagnosis, guiding management of the critically ill patient, and aiding in rapid triage of patients under investigations for COVID-19.


Subject(s)
Coronavirus Infections/diagnostic imaging , Coronavirus Infections/epidemiology , Emergency Service, Hospital/organization & administration , Pneumonia, Viral/diagnostic imaging , Pneumonia, Viral/epidemiology , Point-of-Care Systems/organization & administration , Severe Acute Respiratory Syndrome/diagnostic imaging , Ultrasonography, Doppler/statistics & numerical data , COVID-19 , Delivery of Health Care/organization & administration , Disease Transmission, Infectious/prevention & control , Female , Humans , Infection Control/methods , Male , Occupational Health , Pandemics/prevention & control , Pandemics/statistics & numerical data , Patient Safety , Severe Acute Respiratory Syndrome/epidemiology , Severe Acute Respiratory Syndrome/physiopathology , Ultrasonography, Doppler/methods
8.
Am J Emerg Med ; 35(11): 1738-1742, 2017 Nov.
Article in English | MEDLINE | ID: mdl-28927949

ABSTRACT

Ultrasound is an ideal modality in the emergency department (ED) to assess for pneumothorax given its rapid availability, portability, and repeatability to assess clinical status changes. Certain patient populations and clinical circumstances may present challenges to the performance of this examination. In this article, we review patterns of the presence or absence of lung sliding in the commonly utilized sonographic modes in the ED setting. We also describe a novel technique to evaluate lung sliding using tissue Doppler.


Subject(s)
Lung/diagnostic imaging , Pleura/diagnostic imaging , Pneumothorax/diagnostic imaging , Ultrasonography, Doppler/methods , Emergency Service, Hospital
9.
J Emerg Med ; 53(2): 241-247, 2017 Aug.
Article in English | MEDLINE | ID: mdl-28372830

ABSTRACT

BACKGROUND: Although air has traditionally been considered a barrier to sonographic imaging, when encountered in unusual settings it can serve as an important indicator of various pathologic states as well. Clinician recognition and thorough understanding of the characteristic pattern of artifacts generated by air are critical for making a number of important diagnoses. CASE SERIES: We present five emergency department cases in which air was visualized in a pathologic location. Pneumothorax, pneumoperitoneum, necrotizing fasciitis, or Fournier's gangrene, and subcutaneous emphysema and pneumomediastinum, can be rapidly and easily identified on ultrasound by the presence of air artifacts. The relevant sonographic findings are described and discussed in this article. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to its inherent impedance mismatch with other human tissues, air has a characteristic appearance on ultrasound that includes irregular hyperechoic structures, "dirty shadowing," A-lines, and decreased visualization of deeper structures. Knowledge of the sonographic appearance of air artifacts can assist the physician in making a diagnosis, selecting appropriate additional imaging, and enlisting specialist consultation.


Subject(s)
Air/analysis , Ultrasonography/methods , Adult , Aged , Fasciitis, Necrotizing/diagnosis , Fasciitis, Necrotizing/physiopathology , Female , Fournier Gangrene/diagnosis , Fournier Gangrene/physiopathology , Humans , Male , Mediastinal Emphysema/diagnosis , Mediastinal Emphysema/physiopathology , Middle Aged , Pneumoperitoneum/diagnosis , Pneumoperitoneum/physiopathology , Pneumothorax/diagnosis , Pneumothorax/physiopathology , Point-of-Care Systems/trends , Subcutaneous Emphysema/diagnosis , Subcutaneous Emphysema/physiopathology
11.
J Emerg Med ; 53(1): 91-97, 2017 Jul.
Article in English | MEDLINE | ID: mdl-28351511

ABSTRACT

BACKGROUND: Corrected flow time (FTc) measured via sonography of the carotid artery is a novel method that has shown promising results for predicting fluid responsiveness in shock states. It is a rapid and noninvasive examination that can be taught to emergency physicians with ease. However, its reliability has not been assessed, and the effects of several variables, including respiration and side of evaluation, are unclear. OBJECTIVES: The objectives were to compare carotid FTc during different phases of the respiratory cycle, (at end-inspiration and end-expiration), to compare FTc reproducibility among providers, and to compare FTc on the right and left sides in a given individual. METHODS: The FTc of both the right and left carotid arteries was measured in 16 healthy volunteers during an inspiratory hold and an expiratory hold. Examinations were completed by three sonographers blinded to previous results and were analyzed for reliability and reproducibility. RESULTS: Reliability and reproducibility were poor when comparing sonographers under all circumstances. No significant differences were found when comparing left vs. right sides of measurement regardless of respiratory phase. CONCLUSION: Although this method for predicting fluid responsiveness has many promising aspects, reproducibility between sonographers was found to be poor. No significant difference was found between the two sides of the body or respiratory phase.


Subject(s)
Blood Flow Velocity/physiology , Carotid Arteries/pathology , Respiratory Mechanics/physiology , Carotid Arteries/diagnostic imaging , Female , Functional Laterality , Humans , Male , Prospective Studies , Reproducibility of Results , Ultrasonography/methods
12.
J Clin Ultrasound ; 45(9): 589-591, 2017 Nov 12.
Article in English | MEDLINE | ID: mdl-28186626

ABSTRACT

Injury to the penis resulting from zipper entrapment is a painful condition that presents a unique anesthetic challenge to the emergency physician and may even require procedural sedation for removal. In this case report, we describe successful removal of zipper entrapment from the penis of a 34-year-old patient after the application of an ultrasound-guided dorsal penile nerve block. We discuss the anatomy, sonographic features, and steps required for the nerve block procedure. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:589-591, 2017.


Subject(s)
Foreskin/diagnostic imaging , Foreskin/injuries , Nerve Block/methods , Penile Diseases/pathology , Pudendal Nerve/diagnostic imaging , Ultrasonography, Interventional/methods , Adult , Anesthetics, Local/administration & dosage , Anti-Bacterial Agents/therapeutic use , Bacitracin/therapeutic use , Foreskin/pathology , Humans , Lidocaine/administration & dosage , Male , Necrosis , Penile Diseases/diagnosis , Penile Diseases/drug therapy , Penis/diagnostic imaging , Penis/injuries , Penis/innervation , Pudendal Nerve/drug effects
14.
J Emerg Med ; 51(4): 411-417, 2016 Oct.
Article in English | MEDLINE | ID: mdl-27614538

ABSTRACT

STUDY OBJECTIVES: In a patient with dyspnea and suspected CHF, the evaluation of diastolic function involves: tissue Doppler of the mitral annulus and 2) pulsed wave Doppler of the mitral inflow. We aimed to 1) determine the inter-rater reliability for overall diastolic function and 2) evaluate the reliability of the individual Doppler measurements. METHODS: A convenience sample of adult emergency department patients was prospectively enrolled by 8 EPs who had participated in a 1-hour didactic session. Patients were selected if they had a history of CHF or suspected abnormal diastolic function due to chronic hypertension. Diastolic function was considered to be abnormal if Tissue Doppler of the septal e' was <8 cm/s and if the lateral e' was <10 cm/s. In cases of discordance, the E/e' ratio was calculated with ≤8 considered normal and >8 considered abnormal. A Kappa coefficient. Bland-Altman plot and a fixed effect regression model were used in the analysis. RESULTS: Thirty-two patients were enrolled, and 3 (9.4%) were excluded due to technical inadequacy. The inter-rater reliability among sonographers for overall interpretation was very good: κ = 0.86 (95% CL [0.67, 1.0]). Based on the Bland-Altman plot, was no consistent bias between readers. There was no evidence to conclude that the readings differed among sonographers: septal e' (p = 0.77), lateral e' (p = 0.89) and E (p = 0.15). CONCLUSION: EP sonographers obtained similar Doppler measurements for diastolic function evaluation with very good inter-rater reliability for the assessment of overall diastolic function.


Subject(s)
Echocardiography, Doppler , Heart Failure/diagnostic imaging , Heart Failure/physiopathology , Mitral Valve/diagnostic imaging , Mitral Valve/physiopathology , Diastole , Emergency Service, Hospital , Humans , Observer Variation , Prospective Studies , Reproducibility of Results
15.
J Emerg Med ; 51(3): 331-2, 2016 Sep.
Article in English | MEDLINE | ID: mdl-27372374
16.
Am J Emerg Med ; 34(9): 1779-82, 2016 Sep.
Article in English | MEDLINE | ID: mdl-27324854

ABSTRACT

BACKGROUND: Point-of-care ultrasound may be used to facilitate foreign body (FB) localization and removal. We hypothesized that injection of normal saline adjacent to an FB may make it easier to detect. METHODS: The study was performed on one embalmed human cadaver. Potential FB sites were created of wood (24), metal (24), and null (24). Two sonographers evaluated each of the 72 sites both before and after a 25-gauge needle was inserted into each incision and 3 cc of normal saline was injected. Accuracy, sensitivity, and specificity were calculated both before and after injection of normal saline. Binomial tests were used to determine the statistical significance of FB detection before and after injection. A 2-tailed Student's t test was used to determine if there was a statistically significant difference between the 2 methods. RESULTS: Preinjection, 116 (81%) of the 144 interpretations (P≤ .001) were correct in their assessment of whether or not an FB was present, with a sensitivity of 81% (95% confidence interval [CI], 72%-88%) and a specificity of 79% (95% CI, 65%-90%). Postinjection, 119 (83%) of these 144 interpretations (P≤ .001) were correct in their assessment of whether or not an FB was present, with a sensitivity of 85% (95% CI, 77%-92%) and a specificity of 77% (95% CI, 63%-88%). This difference was not significant (P=.08; 95% CI, -0.04 to 0.01). DISCUSSION: Ultrasound was reasonably accurate, sensitive, and specific in identifying 1-cm metal and wood FBs. Although accuracy and sensitivity did improve after normal saline injection, this difference was not significant.


Subject(s)
Foreign Bodies/diagnostic imaging , Metals , Subcutaneous Tissue/diagnostic imaging , Ultrasonography , Wood , Cadaver , Humans , Point-of-Care Systems , Prospective Studies , Sensitivity and Specificity , Sodium Chloride
19.
J Emerg Med ; 49(5): 686-92, 2015 Nov.
Article in English | MEDLINE | ID: mdl-26293413

ABSTRACT

BACKGROUND: M-mode or "motion" mode is a form of ultrasound imaging that is of high clinical utility in the emergency department. It can be used in a variety of situations to evaluate motion and timing, and can document tissue movement in a still image when the recording of a video clip is not feasible. OBJECTIVES: In this article we describe several straightforward and easily performed applications for the emergency physician to incorporate M-mode into his or her practice, including the evaluation for: 1) pneumothorax, 2) left ventricular systolic function, 3) cardiac tamponade, and 4) hypertrophic cardiomyopathy. DISCUSSION: The emergency physician and other point-of-care ultrasound providers can use this versatile function in the evaluation of patients for a number of critical cardiopulmonary diagnoses. CONCLUSION: A great deal of important information may be obtained with M-mode imaging through views and measurements that are relatively easy to obtain.


Subject(s)
Cardiac Tamponade/diagnostic imaging , Cardiomyopathy, Hypertrophic/diagnostic imaging , Emergency Medicine/methods , Heart Ventricles/diagnostic imaging , Pneumothorax/diagnostic imaging , Emergency Service, Hospital , Heart Ventricles/physiopathology , Humans , Point-of-Care Systems , Ultrasonography/methods , Ventricular Function, Left
20.
Am J Emerg Med ; 33(10): 1454-7, 2015 Oct.
Article in English | MEDLINE | ID: mdl-26234585

ABSTRACT

INTRODUCTION: The placement of a central venous catheter (CVC) remains an important intervention in the care of critically ill patients in the emergency department, and bedside ultrasound can be used for procedural guidance as well as conformation of placement. Microbubble contrast-enhanced ultrasound may facilitate CVC tip position localization, and the addition of autologous blood can significantly increase its echogenicity. The purpose of this study was to describe the preferences of a group of resident physicians regarding the performance of various concentrations of air-blood-saline sonographic microbubble contrast agents. METHODS: Institutional Animal Care and Use Committee approved prospective study. A CVC was inserted into the right internal jugular vein of a 20-kg Yorkshire swine under general anesthesia. Contrast mixtures were created with air, saline, and varying amounts of blood and were injected while echocardiographic video clips were recorded and reviewed by 25 physician sonographers. RESULTS: All reading physicians reported increased overall echogenicity, a higher peak echogenicity, and greater personal preference for blood containing solutions. Nearly all reading physicians preferred the lower percentage blood containing mixtures over the higher percentage blood containing mixture. CONCLUSION: The inclusion of 1 to 3 parts of 10 of the patient's blood in the preparation of a sonographic contrast mixture increased the echogenicity of the contrast, resulted in better visualization of both the contrast and the endocardial border and was the preferred mixture among the resident physicians studied.


Subject(s)
Catheterization, Central Venous/methods , Contrast Media , Critical Care/methods , Emergency Service, Hospital , Jugular Veins/diagnostic imaging , Practice Patterns, Physicians' , Air , Animals , Blood , Echocardiography/methods , Heart Atria/diagnostic imaging , Microbubbles , Models, Animal , Prospective Studies , Sodium Chloride , Swine
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