Echocardiographic diagnosis and clinical implications of wide-open tricuspid regurgitation for evaluating right ventricular dysfunction in the emergency department.

The tricuspid regurgitation pressure gradient (TRPG) reflects the difference in pressure between the right ventricle and right atrium (ΔPRV-RA). Its estimation by echocardiography correlates well with that obtained using right-heart catheterization. An elevated TRPG is an important marker for identifying right ventricular dysfunction in both the acute and chronic settings. However, in the "wide-open" variant of TR, the TRPG counterintuitively falls. Failure to recognize this potential pitfall and underlying pathophysiology can cause underestimation of the severity of right ventricular dysfunction. This could lead to erroneous fluid tolerance assessments, and potentially harmful resuscitative and airway management strategies. In this manuscript, we illustrate the pathophysiology and potential pitfall of wide-open TR through a series of cases in which emergency physicians made the diagnosis using cardiac point-of-care ultrasound. To our knowledge, this clinical series is the first to demonstrate recognition of the paradoxically-low TRPG of wide-open TR, which guided appropriate management of critically ill patients in the emergency department.

Point of Care Ultrasound Diagnosis of Maxillary Artery Pseudoaneurysm in the Emergency Department.

A pseudoaneurysm results from a tear in a vessel wall. This leads to extravasation of blood into adjacent tissue and eventual formation of a fibrous sac that maintains continuity with the lumen. These vascular injuries very rarely occur in deeper vessels of the face (e.g. maxillary artery) due to protection from structures like the bony mandible and parotid gland. If left untreated, these pseudoaneurysms can lead to infection, thromboembolism, hemorrhage, and compression of surrounding structures such as facial nerve branches. Pseudoaneurysms are typically diagnosed by advanced imaging techniques including computed tomography angiography and magnetic resonance angiography. However, these tests require time to perform and interpret, are costly, and take place outside the patient care area. Computed tomography also confers ionizing radiation. Fortunately, point of care ultrasound (POCUS) is a readily available, dynamic imaging tool that can be performed at the bedside. Here we present the first known case report of a maxillary artery pseudoaneurysm diagnosed by POCUS in the emergency department. Early differentiation from a typical hematoma led to rapid management in the form of a compression bandage, as well as expedited consultation to the appropriate services.

Invasive Fungus Balls Diagnosed by Point-of-Care Ultrasound in the Emergency Department.

BACKGROUND: Genitourinary tract fungus balls are a rare complication of urinary tract infections (UTI). They arise from dense aggregations of hyphae that combine with surrounding urothelial cells and debris. Symptoms can progress to urosepsis and systemic dissemination. Unfortunately, fungus balls may remain unrecognized. Even with computed tomography (CT) and magnetic resonance imaging, fungus balls can be mistaken for malignancies, urinary calculi, or blood clots. CASE REPORT: A 54-year-old man with past medical history of type 2 diabetes mellitus presented to the Emergency Department (ED) reporting urinary retention for one week. He had undergone Foley catheter insertion three separate times for this symptom over the past five weeks. The emergency physicians expected that point-of-care ultrasound (POCUS) would show a distended, anechoic bladder. Instead, there were multiple discrete, gravitationally-dependent, circular echogenic masses without posterior acoustic shadowing, floating freely within a mosaic-like background of mixed echogenicity urine. These findings, together with the CT scan subsequently ordered, raised concern for fungus balls. Instead of being discharged with antibiotics for UTI, the patient was admitted for antifungal coverage, with contingency plans for bladder irrigation and antifungal instillation as needed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This is the first known case report in which emergency physicians used POCUS to diagnose invasive fungus balls in the ED. POCUS findings led to further CT imaging and specialist consultation that otherwise would not have occurred. Rather than discharge with antibiotics, goal-directed management and appropriate disposition mitigated the risk of systemic decompensation in an immunocompromised patient.