Atraumatic splenic rupture secondary to granulocyte-colony stimulating factor medication exposure.

Hematopoietic hormones such as granulocyte-colony stimulating factors are commonly used prevent neutropenia in patients undergoing chemotherapy and to prepare patients for bone marrow donations. In rare cases, splenic injury can result from exposure to this medication. We present the case of a 30-year-old man who presented to the emergency department the day after a bone marrow donation procedure complaining of severe, acute onset left upper quadrant abdominal pain, radiating to the shoulder. Neither the patient nor his family reported any abdominal trauma prior to or following the marrow donation procedure. An initial bedside ultrasound examination was positive for peritoneal fluid and distortion of the normal splenic architecture, raising suspicion for possible intraabdominal or splenic injury. An emergent confirmatory CT with contrast of the abdomen confirmed the initial ultrasound examination suspicion of an atraumatic splenic rupture and with evidence of venous bleeding but without active arterial extravasation. An emergent trauma surgery consultation was placed, and he underwent embolization with an uneventful recovery. This case report highlights the need for a high index of suspicion for atraumatic splenic rupture in patients exposed to these types of granulocyte-colony stimulating factors.

Rapid Education Event: A Streamlined Approach to Ultrasound Guided Nerve Block Procedural Training.

In the Emergency Medicine Residency setting, procedural ultrasound education often takes place at the bedside when the procedure becomes clinically necessary. As ultrasound technology and its applications continue to gain more importance, there is a greater need for effective and standardized educational models for teaching ultrasound-guided procedures. This pilot program aimed to demonstrate that residents and attending physicians can achieve procedural competence in fascia iliaca nerve block following a rapid and compact procedural education event. Our curriculum covered anatomy identification, procedural knowledge, and technical skills of probe manipulation. After completing our new curriculum, more than 90% of participants demonstrated adequate learning through the pre- and post-assessments and direct observation of procedural performance on a gel phantom model.

Atraumatic Bi-femoral Axillary Bypass Graft Non-anastomotic Disruption With Pseudoaneurysm Formation Detected by Doppler Ultrasound.

Bi-femoral axillary bypass graft placement is a well-known and typically safe procedure. It is generally indicated for patients with advanced peripheral vascular disease, aortoiliac occlusive disease, or infectious artery disease. In rare cases, the graft can be fractured or dislodged after placement, though most often, this occurs almost exclusively at the anastomosis site, secondary to blunt trauma. Using ultrasonic imaging is a reliable method of detecting these fractures. We present a case of a bi-femoral axillary bypass graft fracture in a 68-year-old male with the development of a pseudoaneurysm in the right lateral abdominal wall. The patient reported spontaneous development of a "strange" sensation in his right lower abdomen and a "painful lump" upon waking. Physical examination showed a small right lower quadrant outpouching which was pulsatile on palpation. The initial workup included a bedside ultrasound which showed a fractured graft with the fluid collection and a Doppler signal. Vascular surgery was immediately consulted for evaluation, and the patient was taken to the operating room for emergent surgical repair. CT angiography confirmed a successful operation in which an 8 mm graft was placed to anastomose the original bypass graft fracture site. The patient remained stable postoperatively and was discharged without further complications. This report highlights the importance of using ultrasonography for the immediate identification of potential graft complications to prevent serious complications and expedite definitive management.

Traumatic atrial septal defect diagnosed by bedside point-of-care ultrasound.

Atrial septal defects (ASD) caused by traumatic events, specifically blunt cardiac trauma, are considered an infrequent occurrence, yet their true prevalence has been difficult to ascertain. The general lack of knowledge is likely due to the pathology being severely understudied. We present the case of a 21-year-old male who was diagnosed with ASD following a motor vehicle accident. Initial assessment utilizing the point-of-care ultrasound (POCUS) technique - focused assessment with sonography for trauma (FAST) was found to be negative for free intraperitoneal or pericardial fluid. Subsequent computed tomography displayed multiple injuries but agreed with the FAST exam findings of no fluid within the abdomen or pericardium. Later in the patient's care a dedicated POCUS transthoracic echocardiogram was performed which identified right sided heart dilatation. The patient was managed in the intensive care unit (ICU) for an extensive period but recovered sufficiently to be discharged. The plan was to repair the ASD on a non-emergent basis. This case highlights the importance and diagnostic utility of bedside POCUS. Categories: Emergency Medicine.

Point-of-care ultrasound utilized for foreign body in a toe: A case report of botfly larvae.

BACKGROUND: Myiasis, as defined by the Centers for Disease Control and Prevention, is infection with fly larvae commonly occurring in tropical and subtropical areas. Whereas the presentation of skin infection with organisms such as Dermatobia hominis (human botfly) is more easily recognized in these regions, identification of myiasis in the United States is difficult due to its rarity. Due to unspecific signs and symptoms, myiasis may initially be mistaken for other conditions, like cellulitis. CASE REPORT: This case details a patient with pain, swelling, drainage, and erythema of the right second toe. The patient recently returned from Belize and reported an insect bite to the area approximately 1 month prior. She had been seen by health care professionals twice prior to presenting to our Emergency Department (ED) due to increasing pain. At those visits, the patient was prescribed antibiotics, failing to improve her symptoms. In the ED, point-of-care ultrasound (POCUS) of the soft tissue was performed and showed evidence of a foreign body consistent with cutaneous myiasis. Given the patient's history of travel to Belize and known insect bite, it is prudent to have an increased suspicion for cutaneous myiasis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To prevent a delay in diagnosis and unnecessary antibiotics, clinicians should have a high level of suspicion for botfly if a patient reports recent travel in an endemic region and pain disproportionate to an insect bite. POCUS contributes to a more efficient recognition of the disease.

Point-of-care ultrasound findings in the diagnosis and management of Superior Mesenteric Artery (SMA) syndrome.

Superior mesenteric artery (SMA) syndrome is a potentially fatal condition that can be difficult to diagnose for emergency medicine physicians due to its rarity and vague gastrointestinal symptom presentation. Patients arriving at the emergency department (ED) with this condition may encounter delays in proper supportive care and treatment. We present the case of a 21-year-old female who was seen in the ED for nausea, non-bloody vomiting, and rapid weight loss. Through point-of-care ultrasound (POCUS) findings, she was diagnosed with SMA syndrome and received appropriate, supportive care for her condition before catastrophic complications could occur. This case demonstrates the utility of POCUS in SMA syndrome and the importance of considering this diagnosis despite its rarity.

BEE FIRST: A standardized point-of-care ultrasound approach to a patient with dyspnea.

Dyspnea is a common complaint in patients who present to the emergency department and can be due to numerous etiologies. This case report details a 90-year-old female with a history significant for hypertension, hyperlipidemia, and new diagnosis of ovarian malignancy whose symptoms increased over the past three days. Point-of-care Ultrasonography showed multiple B-lines, a plethoric IVC without respiratory variation, a markedly low EF and a lack of RV dilation. There was also no evidence of effusion which led the emergency medicine team to the diagnosis of acute decompensated heart failure. This quick diagnosis was possible due to using the standardized POCUS approach guided by the BEE FIRST algorithm. BEE FIRST can help physicians remember: B-lines are indicative of interstitial thickening, Effusion such as pericardial or pleural should be checked for, Ejection Fraction is useful in assessing for heart failure, IVC/Infection/Infarct correlates with central venous pressure, and can be used to assess volume status, check for enlargement, evidence of pneumonia, subpleural consolidation "shred sign", hepatization of lung, and/or pulmonary infarction related to pulmonary embolism, Right Heart Strain can indicate pulmonary embolism or pulmonary hypertension, Sliding Lung can assess for pneumothorax and pleural characteristics, and lastly, Thrombosis/Tumor can assess for myxoma and interrogation of lower extremities for deep vein thrombosis can aid in dyspnea differentiation. In this report, we demonstrate how the framework BEE FIRST offers a standardized stepwise approach to the utilization of POCUS in a patient with acute dyspnea in the ED setting.

Hemoperitoneum identified by focused assessment with sonography for trauma following cardiopulmonary resuscitation.

It is generally recognized that lives are saved by administering high-quality cardiopulmonary resuscitation (CPR) to patients in cardiac arrest. A focused assessment with sonography for trauma (FAST) examination is an effective and non-invasive method for detecting rare complications of CPR, such as hemorrhage from abdominal visceral injury. We report the case of a 56-year-old female suffering from intra-abdominal hemorrhage caused by a liver laceration following CPR. The hemoperitoneum was diagnosed by a FAST examination. Although severe complications of CPR are rare, they can be easily detected with the use of a FAST examination. A FAST examination should be considered as a post-resuscitation approach to assess for life-threatening complications in all patients following cardiopulmonary resuscitation.

A ruptured ectopic pregnancy in a patient with an intrauterine device: A case report.

Intrauterine devices (IUDs) are used worldwide. The 2 types that are used are the levonorgestrel IUD and a copper containing IUD. This is a case study of a 30-year-old female with a levonorgestrel IUD who was diagnosed with a ruptured ectopic pregnancy in the emergency department (ED). Point-of-care urine pregnancy test and point-of-care ultrasound (POCUS) were vital in making this diagnosis and should be utilized in patients assigned female at birth who present with abdominal pain.

Detection of Central Retinal Artery Occlusion by Point-of-Care Ultrasound in the Emergency Department: A Case Series.

Central retinal artery occlusion (CRAO) is a rare, but serious, diagnosis that can lead to blindness, most often due to thromboembolic disease. In the emergency department (ED), CRAO can present as acute, painless loss of vision. Physicians need quick ways to rule in this diagnosis due to the time-sensitive nature of the event. We describe two patients in this cases series who present to the same ED with unilateral painless vision loss and histories that include notable risk factors such as thromboembolic and atherosclerotic disease. Upon arrival, point-of-care ultrasound (POCUS) done at the bedside allowed for quick determination of CRAO. â€‹â€‹â€‹â€‹â€‹â€‹â€‹The importance of this case series is to emphasize the efficacy of POCUS in evaluating patients with painless vision loss in the ED setting.

Point-of-Care Ultrasound Assists in Rapid Diagnosis of T-cell Lymphoblastic Lymphoma in a Young Boy.

T-cell lymphoblastic lymphoma (T-cell LBL) is an uncommon diagnosis for acute dyspnea in pediatric emergencies. This case details a 13-year-old boy presenting to the ED with dyspnea, who was diagnosed with T-cell LBL. It was a unique presentation in which there was no obvious mediastinal mass on the examination or primary imaging. As a safe and cost-effective modality for a patient that was too unstable to transfer to the radiology department for computed tomography, point-of-care ultrasound (POCUS) was useful in the patient's rapid assessment for suspected pericardial and pleural effusion. This case highlights the advantage of early utilization of POCUS for pediatric patients with dyspnea.

Point of care ultrasound facilitated diagnosis of right ventricular mass as the etiology of syncope; A case report of intravenous leiomyomatosis.

Syncope is a common emergency department (ED) chief complaint. Rarely, syncope can be the result of right ventricular outflow obstruction from an intracardiac tumor, such as an intracardiac extension of intravenous leiomyomatosis (IVL). Typically, this type of tumor is confined to the pelvic veins, but in very rare cases, it can extend through the inferior vena cava into the right atrium. Point-of-care ultrasound (POCUS) can be a crucial tool in the ED for identifying intracardiac tumors presenting as syncope and expediting clinical management. We present the case of a 39-year-old female with no prior medical history that presented to the ED having experienced dyspnea on exertion and two syncopal episodes prior to ED admission. POCUS use in the ED elucidated the presence of a right atrial mass and further imaging showed a mass on the patient's uterus. After surgical removal of a portion of the atrial mass, a subsequent biopsy revealed it had leiomyoma-like features; as such, the patient was diagnosed with IVL. This case illustrates the importance of using POCUS in the ED to help determine the etiology of syncope. Although intracardiac extensions of IVL are rare, it is important for emergency physicians to keep this diagnosis in the differential in patients with symptoms or risk factors suggestive of IVL with intracardiac extension.

A Case of Bedside Ultrasound in COVID-19 to Prognosticate Functional Lung Recovery.

Introduction. The fight against COVID-19 poses questions as to the clinical presentation, course, diagnosis, and treatment of the condition. This case study presents a patient infected with COVID-19 and suggests with additional research, that bedside ultrasound may be used to diagnose severity of disease and potentially, prognosticate functional lung recovery without using unnecessary resources and exposing additional healthcare professionals to infection. Case Report. A 46-year-old male presented to the emergency department (ED) with cough, fever, and shortness of breath. Chest X-ray showed patchy airspace opacities bilaterally. Rapid testing resulted positive for SARS-CoV-2. Bedside ultrasound showed abnormal lung parenchyma, with diffuse comet tail artifacts, consistent with interstitial pulmonary edema. Following a prolonged intubation, patient's abnormal lung ultrasound findings are resolved.

Point-of-care ultrasound, anchoring bias, and acute pulmonary embolism: A cautionary tale and report.

Emergency physicians often rely on heuristics to facilitate clinical decisions due to the large volume of patients they see daily. Consequently, they are vulnerable to error and bias. We report the case of a 69-year-old male that presented to the emergency department (ED) with shortness of breath, productive cough, and dyspnea on exertion. One day prior to ED admission, he was diagnosed with bronchitis; however, point-of-care ultrasound (POCUS) in the ED identified acute pulmonary embolism. This case illustrates the potential dangers of anchoring bias and shows the benefits of using point-of-care ultrasound of the lungs and heart to assist in the diagnosis of acute pulmonary embolism.

Lung point-of-care (POCUS) ultrasound in a pediatric COVID-19 case.

The World Health Organization categorized coronavirus disease 2019 (COVID-19) as a pandemic due to its high contagion rate and widespread infectivity in February 2020. In the United States, one of the public health concerns is the adequacy of resources to treat infected cases. We describe a case of a previously well, 9-year-old obese boy who presented to the emergency department with shortness of breath, fever, abdominal pain, and cough with chest pain. He was diagnosed with COVID-19 through significant family contact, confirmed by polymerase chain reaction and found to be at high risk of venous thromboembolism due to abnormal d-dimer. Lung point-of-care ultrasound (POCUS) in the emergency department observed significant lung pathology, including pleural thickening, consolidation, and B lines. A chest X-ray found bilateral ground glass opacities and interstitial prominences consistent with viral pneumonia. Our case suggests that lung POCUS can provide adequate and rapid imaging to assess lung pathology of COVID-19 in a pediatric patient. As there is limited literature on use of lung POCUS in pediatric patients infected with SARS-CoV-2, our case emphasizes its function as a potentially efficient modality in bedside assessment.

Emergency Medicine Gender-specific Education.

The 2014 Academic Emergency Medicine consensus conference has taken the first step in identifying gender-specific care as an area of importance to both emergency medicine (EM) and research. To improve patient care, we need to address educational gaps in this area concurrent with research gaps. In this article, the authors highlight the need for sex- and gender-specific education in EM and propose guidelines for medical student, resident, and faculty education. Specific examples of incorporating this content into grand rounds, simulation, bedside teaching, and journal club sessions are reviewed. Future challenges and strategies to fill the gaps in the current education model are also described.

Unique method of ocular ultrasound using transparent dressings.

BACKGROUND: Utilizing bedside ocular ultrasound to aid in diagnosing pathology such as retinal detachment, lens disruption, ocular foreign bodies, or increased intracranial pressure is becoming more pervasive in the Emergency Department. To eliminate an air interface, one must apply ultrasound gel between the patient's skin and the probe. In ocular ultrasound, this practice results in discomfort for the patient as gel seeps into their eyes. To limit patient discomfort, many physicians do not apply a sufficient amount of gel for the examination. This can result in decreased image quality and may cause the ultrasonographer to apply greater pressure to the eye to obtain a satisfactory image. This can be harmful to patients with a ruptured globe and may also be painful to the patient. DISCUSSION: Traditionally, the first step in ocular ultrasound is to place a generous amount of water-soluble ultrasound gel on the eyelid to eliminate the air interface. The authors promote a different and simple technique. A transparent dressing is placed over a closed eye. A generous amount of ultrasound gel is applied to the dressing. A linear ultrasound probe is then placed on the gel and a standard ultrasound scan is obtained. Transparent dressings, which are used as sterile coverings for i.v. sites, have been found to allow satisfactory ultrasound transmission. These products remove the air interface between the eyelid and the dressing. This allows ultrasound gel to be placed on the transparent dressing and not directly on the eyelid, potentially eliminating discomfort for the patient, and creating an easier cleanup. Because a generous amount of ultrasound gel is applied, the ultrasonographer is able to apply minimal pressure on the eye to complete the study, which may decrease harm to the patient's eye. When finished, the transparent dressing is removed. There is no cleanup or patient irritation. CONCLUSION: This article demonstrates a unique method of ocular ultrasound. The technique can be easily incorporated into emergency bedside ocular ultrasound.