Non-thrombotic abnormalities on lower extremity venous duplex ultrasound examinations.

INTRODUCTION: Emergency physician-performed compression ultrasonography focuses primarily on the evaluation of the proximal veins of the lower extremity in patients with suspected deep venous thrombosis (DVT). A detailed sonographic evaluation of lower extremity is not performed. The objective of this study was to determine the prevalence of non-thrombotic findings on comprehensive lower extremity venous duplex ultrasound (US) examinations performed on emergency department (ED) patients. METHODS: We performed a retrospective six-year review of an academic ED's records of adult patients who underwent a comprehensive lower extremity duplex venous US examination for the evaluation of DVT. The entire US report was thoroughly reviewed for non-thrombotic findings. RESULTS: We detected non-thrombotic findings in 263 (11%, 95% CI [9.5-11.9%]) patients. Among the non-thrombotic findings, venous valvular incompetence (81, 30%) was the most frequent, followed by cyst/mass (41, 15%), lymphadenopathy (33, 12%), phlebitis (12, 4.5%), hematoma (8, 3%), cellulitis (1, 0.3%) and other (6, 2.2%). CONCLUSION: In our study, we detected a variety of non-thrombotic abnormalities on comprehensive lower extremity venous duplex US examinations performed on ED patients. Some of these abnormalities could be clinically significant and potentially be detected with point-of-care lower extremity US examinations if the symptomatic region is evaluated. In addition to assessment of the proximal veins for DVT, we recommend sonographic evaluation of the symptomatic area in the lower extremity when performing point-of-care ultrasound examinations to identify non-thrombotic abnormalities that may require immediate intervention or close follow up.

Isolated Deep Venous Thrombosis: Implications for 2-Point Compression Ultrasonography of the Lower Extremity.

STUDY OBJECTIVE: Two-point compression ultrasonography focuses on the evaluation of common femoral and popliteal veins for complete compressibility. The presence of isolated thrombi in proximal veins other than the common femoral and popliteal veins should prompt modification of 2-point compression technique. The objective of this study is to determine the prevalence and distribution of deep venous thrombi isolated to lower-extremity veins other than the common femoral and popliteal veins in emergency department (ED) patients with clinically suspected deep venous thrombosis. METHODS: This was a retrospective study of all adult ED patients who received a lower-extremity venous duplex ultrasonographic examination for evaluation of deep venous thrombosis during a 6-year period. The ultrasonographic protocol included B-mode, color-flow, and spectral Doppler scanning of the common femoral, femoral, deep femoral, popliteal, and calf veins. RESULTS: Deep venous thrombosis was detected in 362 of 2,451 patients (14.7%; 95% confidence interval [CI] 13.3% to 16.1%). Thrombus confined to the common femoral vein alone was found in 5 of 362 cases (1.4%; 95% CI 0.2% to 2.6%). Isolated femoral vein thrombus was identified in 20 of 362 patients (5.5%; 95% CI 3.2% to 7.9%). Isolated deep femoral vein thrombus was found in 3 of 362 cases (0.8%; 95% CI -0.1% to 1.8%). Thrombus in the popliteal vein alone was identified in 53 of 362 cases (14.6%; 95% CI 11% to 18.2%). CONCLUSION: In our study, 6.3% of ED patients with suspected deep venous thrombosis had isolated thrombi in proximal veins other than common femoral and popliteal veins. Our study results support the addition of femoral and deep femoral vein evaluation to standard compression ultrasonography of the common femoral and popliteal vein, assuming that this does not have a deleterious effect on specificity.

Utility of point-of-care biliary ultrasound in the evaluation of emergency patients with isolated acute non-traumatic epigastric pain.

To determine the utility of emergency physician-performed point-of-care biliary ultrasound in the evaluation of emergency department (ED) patients with isolated acute non-traumatic epigastric pain. This was a multi-center prospective observational study of adult patients presenting to the ED with isolated acute non-traumatic epigastric pain. Patients with abdominal tenderness at any site other than the epigastric region, or with a history of gall stones, cholecystectomy, gastrointestinal bleeding, chronic abdominal pain, trauma, or altered mental status were excluded. Emergency physician investigators performed point-of-care biliary ultrasound after clinical assessment. Demographic information, history, physical examination findings, laboratory results, additional diagnostic tests, and disposition data were collected. A total of 51 patients (39 women, 12 men) were enrolled. The mean age of the patients was 36.4 years ± 13.6 (SD). All subjects had isolated epigastric tenderness. Gallstones were found in 20/51 (39%, 95% CI 26-52%) on point-of-care biliary ultrasound. Of the 20 patients who had gallstones, eight had sonographic signs of chloecystitis. The treating emergency physicians' initial evaluation did not plan to include an ultrasound in 17/20 patients with gallstones. 19/20 patients were initially given a GI cocktail by the treating emergency physicians. Point-of-care biliary ultrasound detected gall stones in more than one-third of ED patients with isolated acute non-traumatic epigastric pain. All patients presenting to the ED with non-traumatic epigastric pain should be evaluated for biliary disease with an ultrasound imaging study. Bedside ultrasound can avoid misdiagnosis and expedite management in these patients.

Pilot study to determine the utility of point-of-care ultrasound in the assessment of difficult laryngoscopy.

OBJECTIVES: Prediction of difficult laryngoscopy in emergency care settings is challenging. The preintubation clinical screening tests may not be applied in a large number of emergency intubations due to the patient's clinical condition. The objectives of this study were 1) to determine the utility of sonographic measurements of thickness of the tongue, anterior neck soft tissue at the level of the hyoid bone, and thyrohyoid membrane in distinguishing difficult and easy laryngoscopies and 2) to examine the association between sonographic measurements (thickness of tongue and anterior neck soft tissue) and difficult airway clinical screening tests (modified Mallampati score, thyromental distance, and interincisor gap). METHODS: This was a prospective observational study at an academic medical center. Adult patients undergoing endotracheal intubation for an elective surgical procedure were included. The investigators involved in data collection were blinded to each other's assessments. Demographic variables were collected preoperatively. The clinical screening tests to predict a difficult airway were performed. The ultrasound (US) measurements of tongue and anterior neck soft tissue were obtained. The laryngoscopic view was graded using Cormack and Lehane classification by anesthesia providers on the day of surgery. To allow for comparisons between difficult airway and easy airway groups, a two-sided Student's t-test and Fisher's exact test were employed as appropriate. Spearman's rank correlation coefficients were used to examine the association between screening tests and sonographic measurements. RESULTS: The mean (±standard deviation [SD]) age of 51 eligible patients (32 female, 19 male) was 53.1 (±13.2) years. Six of the 51 patients (12%, 95% confidence interval [CI] = 3% to 20%) were classified as having difficult laryngoscopy by anesthesia providers. The distribution of laryngoscopy grades for all subjects was 63, 25, 4, and 8% for grades 1, 2, 3, and 4, respectively. In this study, 83% of subjects with difficult airways were males. No other significant differences were noted in the demographic variables and difficult airway clinical screening tests between the two groups. The sonographic measurements of anterior neck soft tissue were greater in the difficult laryngoscopy group compared to the easy laryngoscopy group at the level of the hyoid bone (1.69, 95% CI = 1.19 to 2.19 vs. 1.37, 95% CI = 1.27 to 1.46) and thyrohyoid membrane (3.47, 95% CI = 2.88 to 4.07 vs. 2.37, 95% CI = 2.29 to 2.44). No significant correlation was found between sonographic measurements and clinical screening tests. CONCLUSIONS: This pilot study demonstrated that sonographic measurements of anterior neck soft tissue thickness at the level of hyoid bone and thyrohyoid membrane can be used to distinguish difficult and easy laryngoscopies. Clinical screening tests did not correlate with US measurements, and US was able to detect difficult laryngoscopy, indicating the limitations of the conventional screening tests for predicting difficult laryngoscopy.