Critical Point-of-care Ultrasound Diagnosis of Fournier's Gangrene: A Case Report.

INTRODUCTION: Fournier's gangrene is a severe, necrotizing, and potentially fatal, soft tissue infection of the perineum that can be difficult to diagnose clinically. Point-of-care ultrasound (POCUS) has established a critical role in emergency medicine as a quick diagnostic tool due to its safety, accuracy, and cost effectiveness. CASE REPORT: We present a case in which POCUS was used to rapidly confirm diagnosis in an unstable, severely septic patient presenting to the emergency department with Fournier's gangrene. CONCLUSION: Point-of-care ultrasound can be used to make the diagnosis of Fournier's gangrene in critical patients when other diagnostic modalities are not feasible due to a patient's clinical state.

Abdominal Pain in the Elderly Patient: Point-of-care Ultrasound Diagnosis of Small Bowel Obstruction.

CASE PRESENTATION: A 67-year-old female presented to the emergency department (ED) complaining of generalized abdominal pain, nausea, and vomiting. Point-of-care ultrasound (POCUS) demonstrated dilated bowel loops measuring up to 4.1 centimeters and localized free fluid, consistent with a small bowel obstruction (SBO). A nasogastric tube was placed without complications. The patient was admitted to the hospital and conservatively managed with an uncomplicated course. DISCUSSION: In elderly patients with abdominal pain, POCUS is an excellent initial imaging modality to assist emergency physicians in rapid and accurate diagnosis of a variety of pathologies to expedite management. Point-of-care ultrasound can be used to rule out and evaluate for conditions encountered in emergency medicine, including acute cholecystitis, renal colic, abdominal aortic aneurysm, and intraperitoneal free fluid. As demonstrated in our case presentation, POCUS had an integral role in the early diagnosis and management of a SBO.

Gonococcal Tenosynovitis Diagnosed with the Aid of Emergency Department Bedside Ultrasound.

BACKGROUND: Gonorrhea is the second most common sexually transmitted infection. Disseminated gonococcal infection (DGI) consists of gonococcal infection plus one or more of the triad of arthritis, tenosynovitis, and dermatitis. Diagnosis in the emergency department (ED) must be suspected clinically, as confirmatory tests are often not available. Point-of-care ultrasound (POCUS) can aid in diagnosis and appropriate management by identifying tenosynovitis and excluding arthritis. CASE REPORT: A 26-year-old man with multiple recent sex partners presented to the ED with slowly progressing right wrist pain and swelling over 5 days. His dorsal right wrist was swollen, with slightly decreased range of motion owing to mild pain, and no warmth, tenderness, erythema, or drainage. Multiple hemorrhagic, gray-purple blisters were noted over both hands. Serum white blood cell count was 12 × 103/µL; C-reactive protein was 30.3 mg/L. POCUS of the dorsal right wrist found no joint effusion; the extensor tendon sheath contained a large anechoic space with clear separation of the extensor tendons, suggesting a tendon sheath effusion/tenosynovitis. DGI was suspected, without septic arthritis. The patient was admitted and treated with ceftriaxone and azithromycin. Gonococcus grew from blood cultures and pharyngeal swabs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: DGI must be suspected clinically, as confirmatory tests are often not available in the ED. Not all patients present with arthritis, tenosynovitis, and dermatitis. It is often difficult to differentiate tenosynovitis from arthritis. POCUS can aid in diagnosis by identifying tenosynovitis (vs. arthritis or simple soft-tissue swelling), allowing timely appropriate DGI diagnosis and management, and, importantly, averting unnecessary arthrocentesis.

Point-of-Care Ultrasound for the Diagnosis of Skull Fractures in Children Younger Than Two Years of Age.

OBJECTIVES: To determine the accuracy of skull point-of-care ultrasound (POCUS) for identifying fractures in children younger than 2 years of age with signs of head trauma, and the ability of POCUS to identify the type and depth of fracture depression. STUDY DESIGN: This was a multicenter, prospective, observational study of children younger than 2 years of age with nontrivial mechanisms of injury and signs of scalp/skull trauma. Patients were enrolled if they underwent computed tomography (CT). Patients underwent clinical evaluation, in addition to a cranial POCUS in the emergency department (ED). From the POCUS examinations, we documented whether fractures were present or absent, their location, characteristics, and depth. POCUS and CT findings were compared to calculate the diagnostic accuracy. RESULTS: We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures. Agreement between POCUS and CT to identify the type of fracture as linear, depressed, or complex was 84.4% (97 of 115) with a kappa of 0.75 (95% CI 0.70-0.84). CONCLUSIONS: POCUS performed by emergency physicians may identify the type and depth of fractures in infants with local physical signs of head trauma with substantial accuracy. Emergency physicians should consider POCUS as an adjunct to clinical evaluation and prediction rules for traumatic brain injuries in children younger than 2 years of age.

Ultrasound-Assisted Removal of A Fishbone Stuck in A Tongue in the Emergency Department.

BACKGROUND: Foreign body (FB) impaction in the oropharyngeal region-and specifically the tongue-is a common problem in the emergency department that often requires specialty consultation and admission for operative intervention. Over the years, the use of point of care ultrasound (POCUS) has increased ease and success of FB removal in other anatomic regions, but is only rarely reported for extraction of FB from the tongue outside of the operating room. CASE REPORT: This case demonstrates a unique case of ultrasound-guided removal of a fishbone from the tongue in the emergency department after blind attempts failed. Operative intervention and admission were initially avoided; however, because of initial failed attempts and blind dissection before the use of POCUS, the patient presented a day later requiring admission for postprocedural tongue swelling and edema. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware that POCUS may assist in FB localization in the tongue.

Saline Flush Test: Can Bedside Sonography Replace Conventional Radiography for Confirmation of Above-the-Diaphragm Central Venous Catheter Placement?

OBJECTIVES: Resuscitation often requires rapid vascular access via central venous catheters. Chest radiography is the reference standard to confirm central venous catheter placement and exclude complications. However, radiographs are often untimely. The purpose of this study was to determine whether dynamic sonographic visualization of a saline flush in the right side of the heart after central venous catheter placement could serve as a more rapid confirmatory study for above-the-diaphragm catheter placement. METHODS: A consecutive prospective enrollment study was conducted in the emergency departments of 2 major tertiary care centers. Adult patients of the study investigators who required an above-the-diaphragm central venous catheter were enrolled during the study period. Patients had a catheter placed with sonographic guidance. After placement of the catheter, thoracic sonography was performed. The times for visualization of the saline flush in the right ventricle and sonographic exclusion of ipsilateral pneumothorax were recorded. Chest radiography was performed per standard practice. RESULTS: Eighty-one patients were enrolled; 13 were excluded. The mean catheter confirmation time by sonography was 8.80 minutes (95% confidence interval, 7.46-10.14 minutes). The mean catheter confirmation time by chest radiograph availability for viewing was 45.78 minutes (95% confidence interval, 37.03-54.54 minutes). Mean sonographic confirmation occurred 36.98 minutes sooner than radiography (P< .001). No discrepancy existed between sonographic and radiographic confirmation. CONCLUSIONS: Confirmation of central venous catheter placement by dynamic sonographic visualization of a saline flush with exclusion of pneumothorax is an accurate, safe, and more efficient method than confirmation by chest radiography. It allows the central line to be used immediately, expediting patient care.

Emergency evaluation and management of the sore throat.

Although sore throat is a very common complaint in the emergency department and is often associated with benign conditions, such as pharyngitis, it can be the early onset of something much more serious and even life threatening. A thorough history and examination are vital to the correct diagnosis but a high index of suspicion must be maintained to diagnose less common but serious pathology, such as epiglottitis and retropharyngeal abscess. Airway management is paramount to survival, and aggressive means should be taken early when epiglottitis is considered.

Emergency evaluation and management of vaginal bleeding in the nonpregnant patient.

Evaluation of the nonpregnant patient presenting to the emergency department with vaginal bleeding requires the emergency physician to be aware of the potential for a variety of underlying causes. Patients with vaginal bleeding may have non-life-threatening problems such as fibroids, endometriosis, or treatable sexually transmitted diseases such as gonorrhea and chlamydial infection. However, care must be taken to differentiate these from more serious causes of pelvic pain and bleeding such as ectopic pregnancy, hemorrhagic cyst, ovarian torsion, and rare complications from fibroids such as intraperitoneal hemorrhage. Abnormal bleeding unrelated to structural problems could have an anovulatory or ovulatory cause.