Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department.

Importance: Ocular symptoms represent approximately 2% to 3% of all emergency department (ED) visits. These disease processes may progress to permanent vision loss if not diagnosed and treated quickly. Use of ocular point-of-care ultrasonography (POCUS) may be effective for early and accurate detection of ocular disease. Objective: To perform a large-scale, multicenter study to determine the utility of POCUS for diagnosing retinal detachment, vitreous hemorrhage, and vitreous detachment in the ED. Design, Setting, and Participants: A prospective diagnostic study was conducted at 2 academic EDs and 2 county hospital EDs from February 3, 2016, to April 30, 2018. Patients who were eligible for inclusion were older than 18 years; were English- or Spanish-speaking; presented to the ED with ocular symptoms with concern for retinal detachment, vitreous hemorrhage, or vitreous detachment; and underwent an ophthalmologic consultation that included POCUS. Patients with ocular trauma or suspicion for globe rupture were excluded. The accuracy of the ultrasonographic diagnosis was compared with the criterion standard of the final diagnosis of an ophthalmologist who was masked to the POCUS findings. Seventy-five unique emergency medicine attending physicians, resident physicians, and physician assistants performed ocular ultrasonography. Exposure: Point-of-care ultrasonography performed by an emergency medicine attending physician, resident physician, or physician assistant. Main Outcomes and Measures: Sensitivity and specificity of POCUS in identifying retinal detachment, vitreous hemorrhage, and vitreous detachment in patients presenting to the ED with ocular symptoms. Results: Two hundred twenty-five patients were enrolled. Of these, the mean age was 51 years (range, 18-91 years) and 135 (60.0%) were men; ophthalmologists diagnosed 47 (20.8%) with retinal detachment, 54 (24.0%) with vitreous hemorrhage, and 34 (15.1%) with vitreous detachment. Point-of-care ultrasonography had an overall sensitivity of 96.9% (95% CI, 80.6%-99.6%) and specificity of 88.1% (95% CI, 81.8%-92.4%) for diagnosis of retinal detachment. For diagnosis of vitreous hemorrhage, the sensitivity of POCUS was 81.9% (95% CI, 63.0%-92.4%) and specificity was 82.3% (95% CI, 75.4%-87.5%). For vitreous detachment, the sensitivity was 42.5% (95% CI, 24.7%-62.4%) and specificity was 96.0% (95% CI, 91.2%-98.2%). Conclusions and Relevance: These findings suggest that emergency medicine practitioners can use POCUS to accurately identify retinal detachment, vitreous hemorrhage, and vitreous detachment. Point-of-care ultrasonography is not intended to replace the role of the ophthalmologist for definitive diagnosis of these conditions, but it may serve as an adjunct to help emergency medicine practitioners improve care for patients with ocular symptoms.

Successful Retrograde Intubation After Failed Fiberoptic Intubation and Percutaneous Cricothyrotomy.

BACKGROUND: An obstructive neck lesion presents an airway challenge for any emergency physician. Retrograde intubation is an infrequently used airway alternative that can be employed in the difficult airway algorithm that requires little training and is less invasive than surgical cricothyrotomy. CASE REPORT: We report a case of a 31-year-old male patient who presented with respiratory distress progressing to respiratory failure from upper airway obstruction. The patient had significant tracheal thickening at the level of the thyroid gland based on a computed tomography report from 3 weeks prior to his presentation. Awake upright fiberoptic intubation and subsequent percutaneous cricothyrotomy were unsuccessful secondary to obstructive neck mass. We performed a retrograde intubation via tracheal approach and secured the airway via manipulation of a small-diameter endotracheal tube over the guidewire using visualization with video laryngoscopy. This case describes a combination of difficult airway techniques utilizing retrograde intubation with a Glidescope (Verathon Inc., Bothell, WA) as a rescue maneuver for a difficult airway secondary to a tracheal obstruction and supraglottic and subglottic stenosis. Follow-up confirmed the patient's diagnosis as granulomatosis with polyangiitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In cases of supraglottic and subglottic narrowing or mass lesions, retrograde intubation can be a life-saving technique that is an important consideration in the difficult airway algorithm. This technique may be combined with other difficult airway techniques and is especially relevant and potentially life-saving for patients in whom an open cricothyrotomy is undesirable, such as patients with a potentially vascular neck mass, subglottic stenosis, localized neck trauma, or morbid obesity.

Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) protocol.

OBJECTIVES: The primary goal of this study was to determine accuracy for diagnosing acutely decompensated heart failure (ADHF) in the undifferentiated dyspneic emergency department (ED) patient using a lung and cardiac ultrasound (LuCUS) protocol. Secondary objectives were to determine if US findings acutely change management and if findings are more accurate than clinical gestalt. METHODS: This was a prospective, observational study of adult patients presenting to the ED with undifferentiated dyspnea. The intervention consisted of a 12-view LuCUS protocol performed by experienced emergency physician sonographers. The primary objective was measured by comparing US findings to the final diagnosis independently determined by two physicians blinded to the LuCUS result. Acute treatment changes based on US findings were tracked in real time through a standardized data collection form. RESULTS: Data on 99 patients were analyzed; ADHF was the final diagnosis in 36%. The LuCUS protocol had sensitivity of 83% (95% confidence interval [CI] = 67% to 93%), specificity of 83% (95% CI = 70% to 91%), positive likelihood ratio of 4.8 (95% CI = 2.7 to 8.3), and negative likelihood ratio of 0.20 (95% CI = 0.09 to 0.42). Forty-seven percent of patients had changes in acute management, and 42% had changes in acute treatment. Observed agreement for the LuCUS protocol was 93% between coinvestigators. Overall, accuracy improved by 20% (83% vs. 63%, 95% CI = 8% to 31% for the difference) over clinical gestalt alone. CONCLUSIONS: The LuCUS protocol may accurately identify ADHF and may improve acute clinical management in dyspneic ED patients. This protocol has improved diagnostic accuracy over clinical gestalt alone.

Aspirin resistance: biological and clinical implications.

Cardiovascular events are the leading causes of mortality and morbidity in the United States. This development has prompted the rise of aspirin therapy in the prevention of atherothrombotic events. However, not all patients benefit to the same extent from aspirin therapy and many continue experiencing atherothrombotic complications. Researchers have labeled this phenomenon aspirin resistance, and despite drawing much attention from both researchers and lay people the cause remains unknown. Much needs to be clarified and standardized regarding the phenomenon of aspirin resistance, including the prevalence, definition, appropriate measurement methods, mechanisms, and, most important, linking low response to aspirin with worsened clinical outcomes.