Native-valve endocarditis detected by point-of-care echocardiography.

BACKGROUND: Infective endocarditis carries a high morbidity and mortality; therefore, a rapid diagnosis and timely treatment is crucial to improve outcomes. Diagnosis of infective endocarditis is supported on echocardiogram findings. CASE PRESENTATION: An adult male with history of long-term hemodialysis, presented with embolic manifestations (cerebral, skin) and fever. A large vegetation in the mitral valve and other in the tricuspid valve were detected by point-of-care transthoracic echocardiogram, while blood cultures subsequently resulted positive for methicillin-resistant Staphylococcus aureus. Despite therapeutic efforts, the patient developed into an irreversible shock and died. CONCLUSIONS: Point-of-care echocardiogram has a pivotal role in diagnosis and decision-making of infective endocarditis.

Pericardiocentesis: ultrasound guidance is essential.

BACKGROUND: Pericardial effusion is a common entity which may have important implications in patient's prognosis. In several cases, pericardiocentesis is indicated for diagnostic and/or therapeutic purposes. CASE PRESENTATION: A blind pericardiocentesis failed in a 95-year-old woman admitted to the emergency department with a large pericardial effusion incidentally diagnosed in the ambulatory setting. Ultrasound-guided pericardiocentesis aided in easily accessing to the pericardial cavity, without periprocedural complications. CONCLUSIONS: Ultrasound-guided pericardiocentesis is simple, safe and effective, and should replace the blind technique. This procedure should be part of the armamentarium of ultrasound-guided practices of emergency or critical care physicians.

Ultrasound-aided diagnosis of septic arthritis of the elbow in the emergency department.

Septic arthritis (SA) is an emergency orthopedic condition that carries significant patient morbidity and mortality. Clinical data and blood test analyses are fairly unreliable in making the diagnosis and, therefore, utilizing a feasible and reliable diagnostic tool is desirable, particularly in emergency settings where rapid diagnosis is pivotal. Here, we report the case of a 58-year-old male presenting to the emergency department with a swollen elbow. After demonstration of a large articular effusion with point-of-care ultrasound, the synovial fluid analysis was compatible with SA. The patient was treated with elbow arthrotomy and systemic antibiotics and discharged shortly thereafter, uneventfully. Finally, we discuss the impact of ultrasound in diagnosing SA and the many advantages that make it the first-line tool in urgent care.

Stab wound of the superficial femoral artery early diagnosed by point-of-care Doppler ultrasound.

BACKGROUND: Traumatic vascular injury of the limbs has the potential to cause substantial patient morbidity and mortality, and therefore, early recognition and treatment are crucial to improve outcomes. While patients with hard signs of arterial injury mandate for an immediate surgical intervention, patients presenting with soft signs of arterial injury need further diagnostic evaluation. CASE PRESENTATION: A 24-year-old male was admitted to the emergency department after suffering a stab wound in the anterolateral aspect of his left upper thigh. Entry wound measures approximately 3 cm × 0.7 cm; no exit wound was observed. On examination of the injured limb, the thigh was swollen and painful. Skin color was mildly pale and skin temperature was slightly diminished in his leg; leg numbness was also pointed out by the patient. Common femoral artery pulse was normal, while distal pulses were diminished. Point-of-care Doppler ultrasound (DUS) showed a subfascial hematoma in the thigh, which filled on color Doppler, corresponding to a pseudoaneurysm. On spectral Doppler, signs of distal low blood supply were noted. The patient was immediately transferred to the operating room where a 1-cm laceration was found in the anterior aspect of the superficial femoral artery. The involved artery was successfully repaired and distal flow was reestablished, as assessed by clinical examination, pulse palpation and DUS. CONCLUSIONS: Based on its several advantages, DUS should be considered as the first-line diagnostic tool in the diagnostic workup of patients with soft signs of arterial injury.

Análisis y reflexiones desde una mirada bioética, en la práctica clínica psiquiátrica, a propósito de un caso / Analysis and reflections from a look bioethics, clinical psychiatric practice, a case report

Los autores proponen reflexionar desde una mirada bioética en la práctica clínica en psiquiatría a propósito de un caso, una paciente portadora de psicosis crónica cursando embarazo con feto incompatible con la vida extrauterina. El paciente con trastorno psiquiátrico grave y con declaración de incapacidad psíquica tiene autonomía y respetarla implica un desafío para el equipo de salud. La autonomía refiere a la capacidad que se les reconoce a las personas de participar en la toma de decisiones. El trastorno psiquiátrico grave y la declaración de incapacidad no suponen la pérdida de derechos como sujetos ni como usuarios de los servicios de salud, como lo establece la Ley 18.335. En el análisis de este caso el principio de autonomía es el más comprometido; la paciente no puede consentir pero puede asentir, tomándose en cuenta su opinión para la toma de decisiones. El asentimiento tiene valor desde el punto de vista bioético pero no desde el punto de vista legal. Los avances en el diagnóstico prenatal nos enfrentan a situaciones nuevas, de implicancia bioética que es necesario conocer para proteger a poblaciones vulnerables (pacientes psiquiátricos, entre otros). Queremos enfáticamente resaltar la figura institucional de los comités de Ética Asistencial y la importancia de su creación en las instituciones que asisten pacientes con patología mental. Urge incorporar la bioética en la formación de los psiquiatras. La interdisciplina se genera como resultado de la tarea clínica de un equipo,que se configura en función del planteo de un problema, el caso clínico planteado.