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BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has pushed us to find better ways to accurately diagnose what can be an elusory disease, preferably in a way that limits exposure to others. The potential for home diagnosis and monitoring could reduce infectious risk for other patients and health care providers, limit use of finite hospital resources, and enable better social distancing and isolation practices.Case reportWe report a case of an otherwise healthy emergency physician diagnosed with COVID-19 at home using portable ultrasound, pulse oximetry, and antibody testing. Her clinical picture and typical lung findings of COVID-19 on ultrasound, combined with a normal echocardiogram and negative deep vein thrombosis study, helped inform her diagnosis. She then monitored her clinical course using pulse oximetry, was able to self-isolate for 4 weeks, and had an uneventful recovery. Her diagnosis was confirmed with a positive IgG antibody test after 3 weeks.ConclusionsNovel times call for novel solutions and our case demonstrates one possible path for home diagnosis and monitoring of COVID-19. The tools used, namely ultrasound and pulse oximetry, should be familiar to most emergency physicians. Ultrasound in particular was helpful in eliminating other potential diagnoses, such as pulmonary embolus.

Background: Pediatric tendon injuries to the finger are rare, and their diagnosis can be challenging due to the difficulty in sensorimotor assessment in pediatric patients. Point-of-care ultrasound (POCUS) has currently been used for identifying tendon injury in adult acute care, but reports of its use in pediatric emergency departments are scarce., Case Report: A previously healthy 14-year-old male patient visited our emergency department due to a finger laceration that occurred when he was cutting sausages using a knife. Physical examination revealed a 1.5 cm laceration over the palmer surface of the left fifth proximal phalanx. Tendon exposure was unremarkable, and the peripheral perfusion and sensation of the injured finger were intact. Flexion of the proximal and distal interphalangeal joints was limited due to pain. POCUS showed the disruption of the tendon structure over the laceration site, suggesting the flexor tendon rupture. Wound exploration by the orthopedic team revealed a transected flexor digitorum superficialis and flexor digitorum profundus and a tendon repair was performed. The patient was discharged with immobilization of the injured hand. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pediatric tendon injuries to the finger are rare, and their diagnosis can be challenging to diagnose due to the difficulty in sensorimotor assessment in pediatric patients. POCUS can directly visualize a tendon structure without procedural sedation or radiation exposure, empowering physicians to diagnose tendon injuries and optimize patient care., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Immunoglobulin A vasculitis, historically known as Henoch-Schönlein purpura, is a rare form of autoimmune-induced vasculitis most common in children. This disease is characterized by a purpuric rash, arthritis, digestive tract complication, and renal inflammation (Hopkins)., Case Report: We present the case of a 78-year-old man in the emergency department with findings of weakness, abdominal pain, and bloody diarrhea for 3 days and a new-onset bilateral lower extremity rash. Diagnostic imaging and labs diagnosed this patient with immunoglobulin A vasculitis (IgAV) with associated acute kidney injury and abdominal mesenteric edema. Why Should an Emergency Physician be Aware of This? Recognition of IgAV by emergency physicians and assessment of multiple organ involvement is critical to expedite treatment and minimize complications. Particularly, physicians should consider and recognize the increased severity and different presentation of IgAV in adults in comparison with the more widely known manifestation in children., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality., Case Report: An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination < 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital. Why Should an Emergency Physician Be Aware of This? Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Cardiac tamponade is associated with high mortality, and making the diagnosis is a core skill of emergency physicians. Proper diagnosis relies on specific clinical and echocardiographic findings. It is not known whether expert sonographers consistently recognize echocardiographic signs of tamponade., Objectives: To assess whether expert sonographers agree on echocardiographic signs of tamponade., Methods: A 20-question survey consisting of 18 cine loops and 2 still images was distributed to the Academy of Emergency Ultrasound Section of the Society for Academic Emergency Medicine. Respondents answered "yes" or "no" to whether there was echocardiographic evidence of tamponade. Subgroup analyses of demographics and echocardiographic views were reported. The data were analyzed using Krippendorff's alpha (α) to assess interrater reliability (IRR) between respondents., Results: Eighty-four physicians responded and 56 completed the survey. All partial and completed surveys were analyzed. The overall IRR was poor (α = 0.60, 95% confidence interval [CI] 0.44-0.76). Residency graduation within 5 years (α = 0.66, 95% CI 0.5-0.8) was associated with higher IRR compared with those > 5 years (α = 0.53, 95% CI 0.37-0.69). The highest IRR was observed when images of mitral valve inflow pulse-wave Doppler (α = 0.81, CI 0.70-0.92) were used and the poorest IRR was on images from the parasternal short view (α = 0.28, 95% CI 0.05-0.49)., Conclusion: There was poor agreement among expert emergency medicine sonographers in identifying echocardiographic signs of cardiac tamponade from a single cine loop or clip without clinical context. Further investigation is warranted to understand differences in recognition of clinical tamponade., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Pneumothorax is a common issue in the intensive care unit and emergency department, often diagnosed using lung ultrasound. The absence of lung sliding and the presence of the lung point sign are characteristic findings for pneumothorax. We describe a case of left pneumothorax diagnosed incidentally while performing a cardiac ultrasound through a new variant of the lung point sign., Case Report: A 60-year-old patient with a medical history of diabetes, stroke, and right colon cancer underwent urgent surgical treatment for intestinal sub-occlusion. In the intensive care unit, the patient required mechanical ventilation due to shock unresponsive to fluid administration, and hemodynamic monitoring was performed using echocardiography. During systole in an apical four-chamber view, the abrupt vanishing of the heart was observed. When evaluating the tricuspid annular plane systolic excursion (TAPSE) using M-mode, the interposition of the stratosphere sign during mid-systole prevented the visualization of the TAPSE peak. Lung ultrasound revealed the absence of lung sliding and the presence of the lung point sign on the left side of the thorax, confirming the diagnosis of pneumothorax. A chest x-ray study further confirmed the diagnosis, and urgent drainage was performed. The patient showed improvement in hemodynamic and respiratory conditions and was successfully weaned from mechanical ventilation, and eventually discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: By incorporating the lung ultrasound findings, including this new variant of the lung point sign, into their diagnostic approach to pneumothorax, emergency physicians can promptly initiate appropriate intervention, such as chest tube insertion, leading to improved patient outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Eye-related symptoms are a common presentation in the emergency department (ED). The cases range from simple viral conjunctivitis to trauma-related eye injuries. One pathological condition that could lead to vision loss is retinal artery occlusion (RAO). Evaluating a patient with an eye symptom requires thorough eye examination and advanced imaging in certain instances. Consultation with an ophthalmologist is also necessary for cases that require treatment recommendations and further testing. In the ED, point-of-care ultrasound (POCUS) is a commonly used diagnostic tool that can be used for ocular examination., Case Report: We reported a case of a 60-year-old man who presented with painless partial right-eye vision loss. POCUS showed decreased flow in the right central retinal artery with an area of the pale retina seen on the image from the retinal camera, suggesting a possible branch RAO. Further examination with POCUS showed plaque formation at the carotid bifurcation, a potential cause of the patient's symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians and other providers should be encouraged to use POCUS to diagnose eye symptoms accurately and promptly. Abnormal findings will prompt immediate specialty consult and early appropriate management. Our case and other reported cases highlight POCUS's reliability and rapid diagnostic ability., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Ocular emergencies comprise 2-3% of emergency department (ED) visits, with retinal detachment requiring emergency surgery. Two-dimensional ultrasound is a rapid bedside tool but is highly operator dependent., Objective: We determined three-dimensional ultrasound (3DUS) feasibility, acceptability, and usability in eye pathology detection using the ophthalmologist examination as reference standard., Methods: We performed a prospective, blinded cohort study of a 3DUS-enabling device in 30 eye clinic and ED patients with visual symptoms and calculated 3DUS performance characteristics. Two expert readers interpreted the 3DUS images for pathology. All participants completed surveys., Results: 3DUS sensitivity was 0.81, specificity 0.73, positive predictive value 0.54, negative predictive value 0.91, and likelihood ratio (LR)+/LR- 3.03 and 0.26, respectively. Novice and expert sonographers had "substantial" agreement in correct diagnosis of abnormal vs. normal (κ = 0.68, 95% confidence interval 0.48-0.88). Most patients indicated that 3DUS is fast, comfortable, helps them understand their problem, and improves provider interaction/care, and all sonographers agreed; 4/5 sonographers felt confident performing ultrasound. Expert readers correctly identified an abnormal eye in 83/120 scans (76%) and correct diagnosis in 72/120 scans (65%), with no statistical difference between novice (79%; 69%) and expert (72%; 61%) sonographers (p = 0.39, p = 0.55), suggesting reduced operator dependence. Reader diagnosis confidence and image quality varied widely. Image acquisition times were fast for novice (mean 225 ± 83 s) and expert (201 ± 51) sonographers, with fast expert reader interpretation times (225 ± 136)., Conclusions: A 3DUS-enabling device demonstrates a sensitivity of 0.81 and specificity of 0.73 for disease detection, fast image acquisition, and may reduce operator dependence for detecting emergent retinal pathologies. Further technological development is needed to improve diagnostic accuracy in identifying and characterizing retinal pathology., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The adoption of point-of-care ultrasound (POCUS) has greatly improved the ability to rapidly evaluate unstable emergency department (ED) patients at the bedside. One major use of POCUS is to obtain echocardiograms to assess cardiac function., Objectives: We developed EchoNet-POCUS, a novel deep learning system, to aid emergency physicians (EPs) in interpreting POCUS echocardiograms and to reduce operator-to-operator variability., Methods: We collected a new dataset of POCUS echocardiogram videos obtained in the ED by EPs and annotated the cardiac function and quality of each video. Using this dataset, we train EchoNet-POCUS to evaluate both cardiac function and video quality in POCUS echocardiograms., Results: EchoNet-POCUS achieves an area under the receiver operating characteristic curve (AUROC) of 0.92 (0.89-0.94) for predicting whether cardiac function is abnormal and an AUROC of 0.81 (0.78-0.85) for predicting video quality., Conclusions: EchoNet-POCUS can be applied to bedside echocardiogram videos in real time using commodity hardware, as we demonstrate in a prospective pilot study., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest Daniel J. Kim is on the medical advisory board of Clarius Mobile Health. The remaining authors disclose no conflicts.

Background: Hypertrophic pyloric stenosis is a common cause of nonbilious vomiting in infants younger than 6 months. Its history, physical examination, and point-of-care ultrasound (POCUS) have not been compared for their diagnostic test accuracy., Objective: The aim of this systematic review was to quantify and compare the diagnostic test accuracy of a history of vomiting, a pyloric mass on palpation, and POCUS., Methods: We performed three searches of the literature from 1977 to March 2022. We evaluated bias using the QUADAS-2 (Quality Assessment Tool for Diagnostic Accuracy-2) tool. We performed a bivariate analysis., Results: From 5369 citations, we identified 14 studies meeting our inclusion criteria. We quantified three diagnostic elements: POCUS, a pyloric mass on palpation, and vomiting. We identified five studies that analyzed POCUS, which included 329 patients. POCUS had a sensitivity of 97.7% (95% confidence interval (CI) 93.1-99.3%) and a specificity of 94.1% (95% CI 88.7-97.1%) for detecting pyloric stenosis. We identified six studies that analyzed the presence of a pyloric mass, which included 628 patients. The palpation of a pyloric mass had a sensitivity of 73.5% (95% CI 62.6-82.1%) and a specificity of 97.5% (95% CI 93.8-99.0%). We identified four studies that analyzed vomiting, which included 355 patients. Vomiting had a sensitivity of 91.3% (95% CI 82.1-96.0) and a specificity of 60.8% (95% CI 8.5-96.3). Both POCUS and palpation of a pyloric mass had a high positive likelihood ratio (LR+: 17 and 33, respectively). The LR+ for vomiting was 5.0., Conclusions: Both POCUS and palpable mass had high specificity and positive LR, whereas vomiting provided the lowest diagnostic test measures., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Real-time ultrasound (US)-guided venipuncture has become the standard of care due to its reduced complications and higher success rate. There are various techniques for US-guided cannulation of the internal jugular vein (IJV); the transversal and longitudinal views are the most widely used. There is a less commonly used technique that combines the benefits of both methods., Discussion: Two main techniques for central line US-guided cannulation of the IJV are based on the location of the probe relative to the vessel and are known as the transversal view and the longitudinal view. The transversal view may make it difficult to identify the tip of the needle as it enters the vein, and the longitudinal view may not allow for visualization of surrounding structures. A third and less commonly used technique, the short axis in-plan view, aims to combine the benefits of both previous methods. In this technique, the entire needle can be tracked in real time as it enters the IJV, while also providing visualization of surrounding structures., Conclusions: The short axis in-plane view technique for central venous line placements allows for real-time US-guided needle venipuncture with simultaneous visualization of surrounding structures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Cardiopulmonary ultrasound (CPUS) is commonly used to assess cardiac function and preload status in patients with septic shock. However, the reliability of CPUS findings at the point of care is unknown., Objective: To assess interrater reliability (IRR) of CPUS in patients with suspected septic shock between treating emergency physicians (EPs) vs emergency ultrasound (EUS) experts., Methods: Single-center, prospective, observational cohort enrolling patients (n = 51) with hypotension and suspected infection. Treating EPs performed and interpreted CPUS for cardiac function parameters (left ventricular [LV] function and right ventricular [RV] function and size) and preload volume parameters (inferior vena cava [IVC] diameter and pulmonary B-lines). The primary outcome was IRR (assessed by Kappa values [κ] and intraclass correlation coefficient [ICC]) between EP and EUS-expert consensus. Secondary analyses examined the effects on IRR of operator experience, respiratory rate, and known difficult views on a Cardiology-performed echocardiogram., Results: IRR was fair for LV function, κ = 0.37, 95% confidence interval (CI) 0.1-0.64; poor for RV function, κ = -0.05, 95% CI -0.6-0.5; moderate for RV size, κ = 0.47, 95% CI 0.07-0.88; and substantial for B-lines, κ = 0.73, 95% CI 0.51-0.95 and IVC size, ICC = 0.87, 95% CI 0.2-0.99. Involvement of ultrasound-trained faculty was associated with improved IRR of RV size (p = 0.002), but not other CPUS domains., Conclusions: Our study demonstrated high IRR for preload volume parameters (IVC size and presence of B-lines), but not for cardiac parameters (LV function and RV function and size) in patients presenting with concern for septic shock. Future research must focus on determining sonographer and patient-specific factors affecting CPUS interpretation in real-time., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Morel-Lavallée lesions, also known as an internal degloving injuries, occur hours to months after high-speed shearing trauma, usually in the peri-trochanteric region. These are uncommon injuries, and are often missed as part of the trauma examination. Failure to diagnose or treat these lesions may result in complications, such as infected seromas, chronic cosmetic deformities, capsule formation, or skin necrosis. There are no formalized societal guidelines for management, but smaller studies have recommended compression alone for asymptomatic lesions, aspiration for small symptomatic lesions, and open debridement for large lesions., Case Report: A young woman presented with swelling, fluctuance, and paresthesia to her right hip after falling off her bicycle 1 week earlier. Physical examination showed a fluctuant and hypoesthetic area over the greater trochanter and point-of-care ultrasound showed a hypoechoic and compressible fluid collection between a fascial layer and a subcutaneous layer, confirming the diagnosis of a Morel-Lavallée lesion (internal degloving injury). Symptoms did not improve with compression alone, but did improve after fluid aspiration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Morel-Lavallée lesions are frequently missed traumatic injuries. Morel-Lavallée lesions can be diagnosed quickly and cost-effectively in the emergency department through the combination of a thorough history, physical examination, and bedside ultrasound. Although there are no formal societal guidelines, limited studies suggest management strategies, including compression, aspiration, and open debridement, with treatments varying by symptom severity and lesion size., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Clinicians trained in point-of-care ultrasound (POCUS) use the tool to enhance diagnostic capabilities at the bedside, often excluding or diagnosing conditions that are suspected based on the history and physical examination. Thoracic outlet syndrome (TOS) involves compression of arteries and nerves between the clavicle and first rib causing pain and paresthesia in the affected limbs. To our knowledge, use of POCUS to diagnose TOS in the literature has not been described., Case Report: A 46-year-old man presented with left upper extremity (LUE) edema, pain, and paresthesia, which was progressive over 3 weeks. Examination of the LUE revealed diffuse swelling without erythema and a left radial pulse present on Doppler only. A subsequent POCUS examination of the LUE was performed to exclude a deep vein thrombosis, and enlarged and turbulent veins distal to the internal jugular vein were found, which suggested venous compression external to the veins. Additional imaging confirmed narrowing of the subclavian vein and a diagnosis of venous thoracic outlet syndrome (vTOS) was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Failure to promptly diagnose and treat TOS can lead to long-term chronic upper extremity pain and even permanent disability. Diagnosis of vascular TOS is often made using computed tomography to identify impinged vessels, although color Doppler sonography can be an excellent choice for initial imaging in patients with suspected vTOS. Although POCUS is being used increasingly as a diagnostic tool and for procedural guidance, our case represents a novel application of POCUS in the diagnosis of vTOS., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Previous investigators have assessed United States Case Law to evaluate the medicolegal risk surrounding point-of-care ultrasound applications. These studies have suggested that nonperformance is the primary source of an allegation of medical malpractice., Objectives: The objective of this study is to update the literature regarding medical malpractice cases involving ultrasound applications that could be used at the point of care, and assess the risk conveyed to advanced practice providers and by application of emerging applications of ultrasound., Methods: Authors reviewed the Westlaw database for medical malpractice cases involving point-of-care ultrasound applications between December 2012 and January 2021. Cases were included if there was an allegation of misconduct by an emergency provider and if an ultrasound included in the American College of Emergency Physicians investigators core, extended, emerging, or adjunct applications was discussed to any degree. Investigators independently reviewed the cases for inclusion. Authors abstracted the case information, type of ultrasound performed, and the specific allegation of misconduct., Results: Nineteen cases met inclusion criteria. Seven cases involved core applications of emergency ultrasound and 13 involved extended, emerging, or adjunct applications. One case was included in both categories as it included elements of both core and extended applications. The most common primary allegation was failure to perform an ultrasound. No cases clearly alleged misinterpretation of a point-of-care ultrasound., Conclusion: As previous studies have suggested, nonperformance of ultrasound seems to convey the greatest medicolegal risk. Extended, emerging, or adjunct applications of ultrasound may convey a slightly higher risk., (Copyright © 2022. Published by Elsevier Inc.)

Background: Chest injury can result in life-threatening complications like tension pneumothorax, in which rapid deterioration can occur without decompression. Traditionally, the second intercostal space (ICS) along the mid-clavicular line is taught as the site for decompression. However, this has been questioned due to high rates of treatment failure. The fifth ICS on the mid-axillary line (MAL) is hypothesized to have a shorter distance from skin to pleura based on recent studies., Objective: The purpose of this study was to use point-of-care ultrasound (POCUS) to compare chest wall thickness at these two locations. The primary objective was to evaluate the distance from skin to pleura line at the second ICS along the mid-clavicular line and the fifth ICS along the MAL. Secondarily, we aimed to evaluate inter-rater reliability of the two assessments., Methods: This was a single-center, observational, pilot study. POCUS was performed using a linear transducer. Measurements of skin to pleura line were obtained at the right second ICS and fifth ICS. These measurements were then repeated by a blinded second ultrasonographer. Intraclass correlations (ICCs) for each measurement site were calculated to determine the inter-rater reliability., Results: Ninety-three percent of volunteers had a smaller chest wall distance at the fifth ICS-MAL. The median distance at the second and fifth ICS was 2.28 cm and 1.80 cm. The ICC for second ICS was 0.75 (95% CI 0.54-0.87), and 0.90 for the fifth ICS (95% CI 0.81-0.95), both indicating good reliability., Conclusions: The data support that patients have a smaller chest wall distance at the fifth ICS vs. the second ICS. We support performing needle decompression at the fifth ICS and believe POCUS can be used to determine the optimal location for decompression., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Press-through packs (PTPs) are widely used for storing drugs. The number of cases involving improper swallowing and esophageal foreign bodies (EFBs) has increased with the increasing use of PTPs. Studies have reported the utility of point-of-care ultrasound (POCUS) for evaluating EFBs. The application of POCUS for esophageal PTPs has not been reported., Case Report: An 83-year-old woman complaining of neck pain and odynophagia that occurred after improperly swallowing 2 PTPs was admitted to the emergency department. EFBs were suspected, and POCUS revealed a hyperechoic material, suggestive of a PTP, in the cervical esophagus. Endoscopy was immediately performed, and the PTPs were successfully removed without complications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This study was significant because it documented the application of POCUS to detect esophageal PTPs. POCUS is a simple and noninvasive technique for identifying EFBs without radiation exposure. © 2022 Elsevier Inc., (Copyright © 2022. Published by Elsevier Inc.)

Background: Point-of-care ultrasound (POCUS) is an optimal imaging modality for the risk stratification of patients presenting to the emergency department (ED) with inguinal and femoral hernias, allowing for better evaluation of clinical presentations and guiding appropriate treatment. The lack of ultrasound classification for inguinal and femoral hernias has led to inconsistent use and often underuse of POCUS in this patient population. Several groin hernia classifications are available, but most are complex and often targeted toward surgical management., Objectives: The objective of this study is to review the use of POCUS in the diagnosis of inguinal and femoral hernias, providing a synopsis of critical ultrasound findings in determining signs of incarceration, strangulation, and small bowel obstruction, and suggesting a simple and educative sonographic classification for inguinal or femoral hernias., Discussion: POCUS can reliably confirm the presence of groin hernias and can uniquely identify specific ultrasound findings predictive of complications, such as aperistaltic nonreducible bowel loops, free fluid in the hernia sac, and lack of color doppler in the entrapped mesentery and bowel walls. POCUS can also aid in determining the presence of small bowel obstruction by detecting dilated loops of bowel >25 mm adjacent and proximal to the hernia site., Conclusions: In the ED, POCUS can confirm the presence of a hernia sac and identify and predict surgical emergencies, such as bowel incarceration or strangulation, which are the most important elements in the management of patients presenting with possible inguinal or femoral hernias., (Copyright © 2022. Published by Elsevier Inc.)

Background: Hemorrhagic cholecystitis is a rare cause of abdominal pain. Most often described in the setting of blunt abdominal trauma, anticoagulation use, coagulopathy (such as cirrhosis or renal failure), and malignancy (biliary angiosarcoma), this rare condition can be difficult to identify unless high on the differential. With point-of-care ultrasound becoming more commonplace in the emergency department (ED), this tool can be successfully used to make a timely diagnosis in the correct clinical context., Case Report: A 64-year-old man with a past medical history of paroxysmal atrial fibrillation status post ablation on rivaroxaban, myelodysplastic syndrome, nonalcoholic steatohepatitis, gastroesophageal reflux disease, clonal cytopenias of undetermined significance, hypertension, and chronic pain presented to the ED with complaints of right upper quadrant pain in the setting of a recent transjugular liver biopsy. Using point-of-care ultrasound, the patient was diagnosed with hemorrhagic cholecystitis. This is an incredibly rare entity, with 87 documented cases in the literature, only two of which are in the setting of transjugular liver biopsy. The patient was ultimately managed conservatively until he had worsening symptoms, and a laparoscopic cholecystectomy was performed. The patient tolerated the procedure well and recovered. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hemorrhagic cholecystitis is a rare pathology that can be easily recognized during point-of-care ultrasound examination. This allows for rapid diagnosis and surgical consultation to provide the patient with timely definitive management., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Myiasis, as defined by the Centers for Disease Control and Prevention, is infection with fly larvae commonly occurring in tropical and subtropical areas. Whereas the presentation of skin infection with organisms such as Dermatobia hominis (human botfly) is more easily recognized in these regions, identification of myiasis in the United States is difficult due to its rarity. Due to unspecific signs and symptoms, myiasis may initially be mistaken for other conditions, like cellulitis., Case Report: This case details a patient with pain, swelling, drainage, and erythema of the right second toe. The patient recently returned from Belize and reported an insect bite to the area approximately 1 month prior. She had been seen by health care professionals twice prior to presenting to our Emergency Department (ED) due to increasing pain. At those visits, the patient was prescribed antibiotics, failing to improve her symptoms. In the ED, point-of-care ultrasound (POCUS) of the soft tissue was performed and showed evidence of a foreign body consistent with cutaneous myiasis. Given the patient's history of travel to Belize and known insect bite, it is prudent to have an increased suspicion for cutaneous myiasis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To prevent a delay in diagnosis and unnecessary antibiotics, clinicians should have a high level of suspicion for botfly if a patient reports recent travel in an endemic region and pain disproportionate to an insect bite. POCUS contributes to a more efficient recognition of the disease., (Copyright © 2022. Published by Elsevier Inc.)

Background: Abdominal pain and constipation are common presenting symptoms of pediatric patients presenting to the emergency department. Sometimes these symptoms are related to uncomplicated constipation from stool burden, and other cases may be secondary to more serious pathologies, including obstruction from intra- or extra-intestinal compression. Point-of-care ultrasound (PoCUS) can be helpful in discerning the etiology for this undifferentiated symptomatology., Case Report: A 14-year-old girl presented with 3 days of constipation and abdominal pain. This was similar to previous symptoms that resolved with laxatives. This time, however, her symptoms were associated with one episode of vomiting. PoCUS expanded a narrow differential with the discovery of a large ovarian cyst. This finding helped to expedite her transfer to a pediatric hospital for definitive treatment in the operating room. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Constipation is one of the leading reasons pediatric patients present to the ED with abdominal pain. PoCUS can detect uncommon causes of constipation, especially pathologies associated with large volumes of fluid, such as a large ovarian cyst, bladder outlet obstruction, or small bowel obstruction., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: An accurate estimation of fetal gestational age is essential for the management of pregnant patients who present to the emergency department (ED). Point-of-care-ultrasound (POCUS) is an integral part of emergency medicine training and includes measurement of fetal gestational age by the biparietal diameter (BPD) method., Objectives: In this study we performed a quantitative assessment of emergency physician (EP)-performed BPD estimate of gestational age to identify the percentage of studies performed in our department that had an estimated gestational age within 14 days of an adjusted radiological or obstetrical estimation., Methods: We performed a chart review of our ED ultrasound database and electronic medical records for cases where a BPD measurement was performed by an EP. We recorded the ED gestational age estimate in days and the radiological or obstetrical estimate of gestational age in days. We then calculated the difference in days between the two examinations. We used a normal binomial approximation to calculate 95% confidence intervals. A secondary analysis looked at the quality of the images based on measurement placement and the view obtained., Results: Seventy-four cases met eligibility criteria; of those, 67 (91%) had a gestational age estimation within 14 days of the adjusted radiological or obstetrical estimate (95% confidence interval 81-96%)., Conclusion: This study shows that EP-performed BPD measurements for gestational age are quantitatively accurate, with 91% of estimates within 14 days of a standard radiological or obstetrical estimation., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Priapism can be categorized as low flow or high flow. Low flow priapism is a compartment syndrome and requires immediate treatment to avoid long-term ischemic damage. Alternatively, high flow priapism is not an emergent condition and can be managed as an outpatient. The diagnosis has traditionally been made via cavernosal blood gas analysis; however, this is painful and can cause iatrogenic harm., Case Report: We present a case of high flow priapism whereby point-of-care ultrasound (POCUS) identified the presence of pulsatile cavernosal arterial flow to confirm the diagnosis. This is the first case report in the emergency medicine literature to highlight the utility of POCUS in the diagnosis and management of high flow priapism. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Low flow priapism accounts for 95% of cases and is a urologic emergency requiring immediate invasive intervention. High flow priapism is much less common and does not require emergent management. While blood gas analysis can differentiate between high and low flow priapism, POCUS is a rapid, noninvasive, accurate diagnostic means to identify the presence or absence of cavernosal pulsatile arterial flow., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Hemorrhage from ruptured ectopic pregnancy is the leading cause of first trimester mortality in North America., Objectives: Our objective was to compare patients with a ruptured ectopic pregnancy who had an emergency department (ED) point-of-care ultrasound (PoCUS) with those who received a radiology department-performed ultrasound (RADUS). Four time intervals were measured: ED arrival to ultrasound interpretation, obstetric consultation, operating room (OR) arrival, and ultrasound interpretation to OR arrival., Methods: This was a retrospective cohort study of patients with ruptured ectopic pregnancy seen between February 2012 and September 2018 at an urban tertiary care hospital. Patients who received an ultrasound in the ED, went directly to the OR, and had confirmed rupture were included., Results: Of 262 patients diagnosed with ectopic pregnancy during the study period, 36 (14%) were ruptured and 32 were enrolled. Comparing times between PoCUS (n = 10) and RADUS (n = 22) groups, the mean time from ED arrival to ultrasound interpretation was 15 vs. 138 min (difference 123, 95% confidence interval [CI] 88-158), from ED arrival to obstetric consultation was 35 vs. 150 min (difference 115, 95% CI 59-171), from ED arrival to OR arrival was 160 vs. 381 min (difference 222, 95% CI 124-320), and from ultrasound interpretation to OR arrival was 145 vs. 243 min (difference 98, 95% CI 12-184)., Conclusion: ED patients with a ruptured ectopic pregnancy who received a PoCUS first had shorter times to diagnosis, obstetric consultation, and OR arrival compared with those who received RADUS., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Intussusception is a common pediatric emergency. The two types of intussusception are ileocolic intussusception (ICI) and small bowel-small bowel intussusception (SB-SBI), and neither are easily distinguished clinically. ICI requires radiology personnel and potentially surgical assistance for its reduction. SB-SBI is managed expectantly, as many resolve spontaneously. Differentiating between ICI and SB-SBI through point-of-care ultrasound (POCUS) requires an understanding of their salient features. Identification of the correct type of intussusception immediately assists decision making and patient disposition., Objective of the Review: Our objective was to provide guidance on POCUS technique for intussusception identification, and to review the ultrasound literature differentiating ICI from SB-SBI., Methods: We systematically searched 3 separate databases and gray literature to identify articles that met our criteria and assessed them for final review. The final articles were graded for quality using The National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies., Results: A total of 858 articles were identified. Six articles were included in the final review. All studies were conducted in pediatric patients in different countries. Most were found to have a fair quality of evidence. The linear transducer is used when evaluating intussusception. Both ICI and SB-SBI are identified easily on POCUS, but they differ sonographically with respect to region within the abdomen, intussusception parameters, lymph nodes, and other salient features seen on real-time video., Conclusions: ICI and SB-SBI can be identified and differentiated using several sonographic features. POCUS is capable of expeditiously aiding the emergency physician's decision making and disposition when managing intussusception., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Emergency physicians frequently evaluate patients with postoperative wound issues. The differential is broad, but obviously includes postoperative site infections. We present a case where a suspected postoperative abscess was evaluated with bedside ultrasound prior to incision and drainage. Suture material was recognized, shifting our approach to treatment of the lesion., Case Report: A 24-year-old female patient presented with pain, swelling, and drainage from a left lower quadrant abdominal wound that had been present since undergoing a laparoscopic appendectomy 1 year prior. A computed tomography scan was performed, which was negative for foreign bodies. Prior to incision and drainage, a bedside ultrasound was performed to evaluate the lesion, which was notable for sonographic findings consistent with suture material. Suture granuloma was diagnosed, and ultrasound was then used to successfully guide retrieval of the suture. To our knowledge, this is the first published case where ultrasound was used to both diagnose and dynamically remove the offending suture material. We briefly discuss suture granulomas, their sonographic appearance, and management. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently perform ultrasound on suspected abscesses prior to incision and drainage and should be aware of the sonographic appearance of suture material as it would change management if present. If a suture granuloma is suspected due to swelling at a postoperative site, ultrasound use should be strongly considered for evaluation., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Psoas muscle abscess (PMA) is a collection of pus in the psoas muscle. It is considered a rare clinical entity and is often misdiagnosed due to highly vague symptoms. We report that point-of-care ultrasound (POCUS) serves as a useful and noninvasive tool for early detection of PMA., Case Report: Our patient was a 35-year-old man without any past medical illness who visited the emergency department due to right lower back pain and hematuria for 8 months. He denied fever, trauma, or recreational drug use. On arrival, the patient's vital signs were stable and had no fever. Laboratory tests showed white blood cell count 12,800/μL with neutrophil segment 83.2%, C-reactive protein 0.2 mg/dL, and normal renal function. Urine routine showed red blood cells > 100/high-power field. Kidney-ureter-bladder radiograph revealed a positive psoas sign on the right. POCUS showed a mixed echogenic mass adjacent to the right kidney. Subsequently, contrast abdominal computed tomography revealed T10-T11 collapsed vertebral bodies with disc erosion and right psoas muscle abscess at the right kidney level. The patient received open drainage of psoas muscle abscess and T11-T12 laminectomy. He was discharged 13 days post admission. Why ShouldanEmergency PhysicianBe Aware of This? Early and accurate diagnosis of PMA is important because, if left untreated, mortality rate can reach 100%. A potential pitfall in our case is the presence of hematuria with flank pain that could lead to incorrect diagnosis of renal calculi, a much more common condition. This case illustrates the importance of using POCUS in any patient with back or flank pain, with or without hematuria., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Diagnostic lumbar puncture (LP) is an invasive procedure routinely performed within the emergency department (ED). LP is traditionally performed with the patient in either the lateral recumbent or sitting position. We investigated if the intervertebral space is larger in one of these positions. If one position is larger than the other, this would imply that one position offers a higher chance of a successful lumbar puncture than the other position., Objective: We sought to determine if there is a significant size difference of the L4/L5 intervertebral space in the lateral recumbent compared with the sitting position., Methods: Point-of-care ultrasound (POCUS) was performed to measure the size of each volunteer's L4/L5 intervertebral space in both the seated and lateral recumbent positions. All volunteers >18 years of age were eligible for the study. Thirty volunteers had measurements taken. Three measurements were taken by each investigator in both positions for each volunteer., Results: The median L4/L5 intervertebral space distance was 1.7511 cm in the lateral recumbent position and 1.9511 cm in the seated position with a Wilcoxon signed rank p value <.0001. The interspinous space in the seated position was found to be significantly larger than in the lateral recumbent position., Conclusion: The size of the interspinous space in the seated position on ultrasound was found to be larger than the lateral recumbent position, suggesting that LP may be more successful in the seated position., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Achilles tendon rupture is a common injury with increasing incidence due to the rising popularity of high-velocity sports, continued physical activity of the aging American population, and use of fluoroquinolones and steroid injections. The diagnosis can often be missed or delayed, with up to 20% misdiagnosed, most commonly as an ankle sprain., Objective: The aim of our study was to systematically evaluate the reported sensitivity, specificity, and likelihood ratios of ultrasound for detecting Achilles tendon rupture in patients who were treated surgically., Methods: In January 2020, we performed a literature search of MEDLINE and EMBASE databases to identify eligible articles according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were original studies with at least five patients, which reported data on the sonographic diagnosis of Achilles tendon rupture (complete or partial) compared to surgery as the reference standard., Results: A total of 15 studies with 808 patients were included in the primary analysis. The sensitivity of ultrasound for detecting complete Achilles tendon ruptures was 94.8% (95% confidence interval [CI] 91.3-97.2%), specificity was 98.7% (95% CI 97.0-99.6%), positive likelihood ratio was 74.0 (95% CI 31.0-176.8), and negative likelihood ratio was 0.05 (95% CI 0.03-0.09), in patients who underwent surgical treatment., Conclusions: The results from our study suggested that a negative ultrasound result may have the potential to rule out a complete, as well as a partial, Achilles tendon rupture., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Children with limp or hip pain often undergo radiographs and ultrasound as part of their initial evaluation. Previous research suggests that hip radiography may have limited utility, and early use of ultrasound may safely reduce the use of radiographs., Objectives: We sought to assess the utility of radiography in addition to ultrasound by evaluating the rate of bony abnormalities present on hip radiographs among children with and without effusion on ultrasound. We also assessed the agreement of point-of-care and Radiology-performed ultrasounds for the detection of effusion., Methods: This is a retrospective cohort study of children presenting to a pediatric emergency department with acute atraumatic limp or hip pain. Data from patients who received both hip ultrasound and hip radiography as part of their evaluation were analyzed. We included both point-of-care and Radiology-performed hip ultrasounds., Results: We identified 134 patients who received both hip ultrasound and hip radiographs. Sixty-eight patients (51%) had a hip effusion present on ultrasound and none of these had bony abnormalities on radiography (0%, 95% confidence interval 0-5.3%). Of the 66 patients (49%) who had no effusion on hip ultrasound, 2 patients were found to have a bony abnormality (3%, 95% confidence interval 0.4-10.5%). For patients who received both point-of-care and Radiology-performed ultrasound, the overall agreement for diagnosis of effusion was 92.6% (kappa = 0.82)., Conclusions: We observed that no children with an effusion on ultrasound had bony pathology on plain radiography, suggesting that the routine performance of hip radiography may not be indicated in all children. Future studies are needed to evaluate the negative predictive value of effusion in larger numbers of patients with known bony abnormalities., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Acute heart failure (AHF) in children is associated with significant disease burden with high rates of morbidity, mortality, and resource utilization. These children often present to the emergency department with clinical features that mimic common childhood illnesses. Cardiac point-of-care ultrasound (POCUS) can be an effective tool for rapidly identifying abnormal cardiac function., Case Reports: This case series documents 10 children presenting with AHF between 2016 and 2019 and demonstrates how pediatric emergency physicians used cardiac POCUS to expedite their diagnosis, management, and disposition. All cardiac POCUS was performed before comprehensive echocardiograms were completed. One case is described in detail; the other cases are summarized in a Table. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition of AHF is critical to reduce pediatric morbidity and mortality. With proper training, cardiac POCUS can be an effective adjunct and should be considered for the early diagnosis and treatment of infants and children with AHF., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Urethral foreign bodies (UFBs) are rare in pediatric emergency care, but require immediate diagnosis and intervention when they occur. Although radiography, computed tomography, and cystography are available for diagnosing UFBs, these modalities are undesirable because they involve radiation exposure. Point-of-care ultrasound (POCUS) is used as an alternative imaging modality for UFB detection in adult patients, but reports of its use in pediatric emergency departments are still scarce. We report a pediatric case of a UFB detected by POCUS., Case Report: A 10-year-old boy with a history of a learning disorder presented to our pediatric emergency department with a paper clip in his penis, which he had intentionally inserted during play. He denied any symptoms, such as abdominal pain, vomiting, and hematuria. Physical examination failed to reveal the tip of the FB, but showed a palpable mass in the penile urethra accompanied by mild tenderness in the area. POCUS demonstrated a hyperechoic structure with reverberation artifact extending to the bulbar urethra. Endoscopic removal was planned, but the tip of the FB emerged from the external urethral meatus with postural change. Manual removal was successfully performed, after which the hyperechoic structure in the urethra was no longer visible on ultrasonography. The patient was discharged on the same day of the procedure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS is a noninvasive procedure that can be useful for detecting UFBs in children., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Pediatric patients undergoing transabdominal pelvic ultrasound require a full bladder as an acoustic window. Patients are typically relied upon to subjectively identify bladder fullness, but inaccurate reporting often leads to delays in test results, diagnosis, and treatment., Objectives: Our aim was to objectively evaluate bladder fullness by comparing the height of the bladder to the height of the uterus on point-of-care ultrasound (POCUS). Our hypothesis was that this method would result in faster time to imaging and decrease emergency department length of stay (ED LOS)., Methods: Bladder fullness was assessed using POCUS every 30 min until the bladder was full. If the height of the bladder was equal to or greater than the height of the uterus in the sagittal view, the bladder was considered full. The POCUS group was compared with a control group that relied solely on patients' self-identified bladder fullness., Results: Females aged 8-18 years old with pelvic pain in the pediatric ED were included in the study. Forty POCUS patients were compared with a control group of 105 patients. The POCUS group demonstrated a decrease in time to pelvic imaging by 38.7 min (95% confidence interval -59.2 to -18.2; p < 0.0001) and a decrease in LOS by 49.2 min (95% CI -89.7 to -8.61; p = 0.004). There was poor overall agreement on bladder fullness between patient's subjective sensation and POCUS (k = 0.04)., Conclusion: POCUS to evaluate bladder fullness by comparing the height of the bladder with the height of the uterus reduces time to pelvic imaging and ED LOS., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Patients with coronavirus disease 2019 (COVID-19) present with diagnostic challenges because COVID-19 can cause varied end-organ failures that mimic respiratory distress of pulmonary origin. Early identification of concurrent complications can significantly alter patient management and course. Point-of-care ultrasound (POCUS) can be particularly useful in helping to differentiate concomitant complications with COVID-19. While lung POCUS findings related to COVID-19 have been published, little guidance exists on how ultrasound can be incorporated into a more comprehensive evaluation of patients under investigation for COVID-19., Objectives: We devised a pathway called COVUS that incorporates POCUS into the initial evaluation of patients under investigation for COVID-19 to guide diagnosis and management., Discussion: The pathway was derived based on a review of literature, consensus from the ultrasound faculty, as well as feedback from the entire faculty group at one academic institution with high volumes of patients with COVID-19. The scanning protocol uses a cardiac-first (rather than lung-first) approach to identify potential concomitant organ failure that may immediately alter management., Conclusions: COVUS aims to maximize identification of the most immediately life-threatening complications while minimizing time at bedside and provider risk of exposure to COVID-19., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Intussusception (INT) is a common cause of bowel obstruction in young children. Delay in diagnosis can lead to significant morbidity and mortality. There have been several studies evaluating early point-of-care ultrasound (POCUS) in the diagnosis of INT by nonradiologists., Objective: Our objective was to determine the diagnostic accuracy of POCUS by novice sonographer pediatric emergency medicine physicians (PEM-Ps) who received focused US training for diagnosing INT., Methods: We performed a prospective observational study including 17 PEM-Ps (14 attendings, 3 fellows) trained to perform abdominal US for INT. Children suspected of having INT received POCUS performed and interpreted by a PEM-P, followed by a US study performed by a certified ultrasonographer and interpreted by an attending pediatric radiologist. Diagnostic concordance between PEM-P-and radiology-performed US (RPUS) results was assessed., Results: One hundred patients were enrolled; median patient age was 24 months. There was excellent diagnostic agreement for presence or absence of INT between PEM-Ps and RPUS (97% of cases; κ = 0.826). POCUS-diagnosed INT was present in 8 of 9 patients with RPUS-diagnosed INT (sensitivity 89%; 95% confidence interval [CI] 51-99%; specificity 98%; 95% CI 92-100%; positive predictive value 80%; 95% CI 44-96%; negative predictive value 99%; 95% CI 93-100%). Likelihood ratio for INT with a positive POCUS was 40.44 (95% CI 10.07-162.36) and with a negative POCUS was 0.11 (95% CI 0.02-0.72)., Conclusions: POCUS performed by novice sonographers to diagnose INT has high diagnostic concordance with RPUS. Emergency department-performed POCUS is a rapid and accurate method for diagnosing INT., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The viral illness severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), more commonly known as Coronavirus 2019 (COVID-19), has become a global pandemic, infecting over 100 million individuals worldwide., Objectives: The objective of this study was to compare the test characteristics of point-of-care lung ultrasound (LUS) with chest x-ray study (CXR) at radiographically detecting COVID-19 pneumonia., Methods: This was a single-center, prospective, observational study at an urban university hospital with > 105,000 patient visits annually. Patients ≥ 18 years old, who presented to the Emergency Department with predefined signs and symptoms of COVID-19, were eligible for enrollment. Each patient received an LUS using a portable, handheld ultrasound followed by a single-view, portable anteroposterior CXR. Patients with an abnormal LUS or CXR underwent a non-contrast-enhanced computed tomography scan (NCCT). The primary outcome was the radiographic diagnosis of COVID-19 pneumonia on NCCT., Results: One hundred ten patients underwent LUS, CXR, and NCCT; 99 LUS and 73 CXRs were interpreted as positive; 81 NCCTs were interpreted as positive, providing a prevalence of COVID-19 pneumonia of 75% (95% confidence interval [CI] 66-83.2) in our study population. LUS sensitivity was 97.6% (95% CI 91.6-99.7) vs. 69.9% (95% CI 58.8-79.5) for CXR. LUS specificity was 33.3% (95% CI 16.5-54) vs. 44.4% (95% CI 25.5-64.7) for CXR. LUS positive predictive value and negative predictive value were 81.8% (95% CI 72.8-88.9) and 81.8% (95% CI 48.2-97.7), respectively, vs. 79.5% (95% CI 68.4-88), and 32.4% (95% CI 18-49.8), respectively, for CXR., Conclusion: LUS was more sensitive than CXR at radiographically identifying COVID-19 pneumonia., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Patients with anorectal complaints commonly present to the emergency department (ED). In patients with prior history of pelvic radiation and those with risk factors for sexually transmitted infections, proctitis is frequently on the differential diagnosis. Computed tomography (CT) scans are frequently done in patients with atypical presentations and those with broader differential diagnoses. Although in cases with suspected uncomplicated proctitis, conducting a point-of-care transperineal ultrasound (TPUS) may provide sufficient data to confirm the diagnosis and ascertain a safe plan for outpatient management, thus limiting the need for CT scan, a frequent flow-limiting step in the ED., Case Report: In this article, we present a brief case series of patients presenting to the ED with anorectal complaints in whom TPUS revealed circumferential symmetric rectal wall edema and pericolonic stranding suggestive of proctitis. History and subsequent imaging further supported these diagnoses; we also briefly detail the patients' clinical course and outcomes. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We propose the use of TPUS as the screening imaging for anorectal pathologies and those with suspected proctitis to increase its use among emergency physicians. We review the main sonographic features of proctitis alongside reports from clinical cases, as well as the potential advantages of TPUS as a first-line imaging modality as compared with CT or magnetic resonance imaging. Although the complexities of anorectal anatomy can make TPUS a more difficult ultrasound modality to master, integrating TPUS into clinical practice will prove beneficial to both physician and patient., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Choledocholithiasis complicates approximately 10% of gallstone disease. Spontaneous stone migration out of the common bile duct (CBD) may occur in as many as 20% of choledocholithiasis cases. A decrease in CBD caliber occurs in the setting of spontaneous stone passage, but to our knowledge, this finding has not been appreciated using point-of-care ultrasound (POCUS) in the emergency medicine setting., Case Report: A 49-year-old woman presented to our Emergency Department (ED) with a complaint of epigastric pain radiating to the left shoulder. On examination she was found to have epigastric tenderness to palpation, but no guarding or rebound. POCUS demonstrated a dilated common bile duct, and her liver function tests were abnormally high. She was admitted to Medicine with concern for choledocholithiasis and plan for endoscopic retrograde cholangiopancreatography (ERCP), but her pain had resolved shortly after ED arrival. A repeat ultrasound examination demonstrated a normal-caliber common bile duct approximately 3 h after the initial scan. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Choledocholithiasis often requires admission and invasive testing. Using POCUS in conjunction with liver function tests and patient assessments may obviate a need for ERCP., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: A cesarean scar pregnancy (CSP) is a clinically important form of ectopic pregnancy that carries a high risk of maternal morbidity and mortality. As the rate of cesarean sections has risen, this diagnosis is becoming an increasingly important consideration for providers caring for patients in early pregnancy., Case Report: We present three cases of CSPs in which point-of-care ultrasound expedited the diagnosis and treatment in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the risks of an undiagnosed CSP, the increasing incidence of CSP, and the number of effective treatment options available in early gestation, the prompt and accurate diagnosis of CSP remains crucial to its successful management. As such, it is an important diagnosis for the emergency physician to consider when evaluating a patient in early pregnancy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Risk stratification of patients with pulmonary embolism (PE) is essential to guide advanced interventional management and proper disposition., Objectives: In this study, we sought to assess individual echocardiographic markers of right ventricular (RV) strain and left ventricular (LV) function in patients with high-risk PE and identify their association with the need for advanced intervention (such as thrombolysis) and 30-day mortality., Methods: This was a retrospective study of ED patients with PE who were subject to a pulmonary embolism response team activation over a 5-year period. Cardiac point-of-care ultrasound studies were performed as part of patient care and later assessed for septal bowing, RV hypokinesis, McConnell sign, RV enlargement, tricuspid annular place systolic excursion, and LV systolic dysfunction. Outcome variables included need for advanced intervention and 30-day mortality., Results: The pulmonary embolism response team was activated in 893 patients, of which 718 had a confirmed PE. Of these, 90 had adequate cardiac point-of-care ultrasound images available for review. Patients who needed an advanced intervention were more likely to have septal bowing (odds ratio [OR] 8.69, 95% confidence interval [CI] 2.37-31.86), RV enlargement (OR 4.02, 95% CI 1.43-11.34), and a McConnell sign (OR 2.79, 95% CI 1.09-7.13). LV dysfunction was the only statistically significant predictor of 30-day mortality (OR 9.63, 95% CI 1.74-53.32)., Conclusion: In patients with PE in the ED, sonographic findings of RV strain that are more commonly associated with advanced intervention included septal bowing, McConnell sign, and RV enlargement. LV dysfunction was associated with a higher 30-day mortality. These findings can help inform decisions about ED management and disposition of patients with PE., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Iatrogenic femoral artery pseudoaneurysm formation after intervention of the femoral artery may present weeks after intervention. We report a case of a patient with delayed pseudoaneurysm diagnosis that was ultimately diagnosed with bedside ultrasound. Importantly, our case demonstrates a patient who had a left-sided atherectomy and angioplasty with microcatheter access of the right femoral artery., Case Report: A 68-year-old man with multiple comorbidities presented to the Emergency Department (ED) with right inguinal pain, swelling, and overlying skin changes 17 days after an interventional radiology-guided left-sided femoral artery atherectomy and angioplasty. His first postoperative ED visit at an outside hospital led to the diagnosis of a hematoma vs. abscess, with attempted bedside drainage. On presentation to our ED, a bedside ultrasound confirmed arterial pseudoaneurysm formation of the right femoral artery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In patients presenting with the constellation of symptoms after arterial site intervention of either side, iatrogenic pseudoaneurysm should be in the differential. Although the patient had atherectomy and angioplasty of the left femoral artery, it is important to highlight that both femoral arteries were accessed during intervention, and thus, both sites are at risk for pseudoaneurysm formation. Emergency sonography can be a useful tool to diagnose, expedite treatment, and avoid potentially harmful invasive procedures in patients presenting with pain and swelling after arterial site intervention., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: There is a significant variability in survival rates for cardiopulmonary resuscitation (CPR) in out of-hospital cardiac arrest (OHCA), and some data indicate that ultrasound improves CPR., Objectives: We evaluated the feasibility of ultrasound for monitoring chest compressions in OHCA., Methods: We planned a prospective study in patients with an ultrasound-integrated CPR for OHCA. Chest compressions were performed on the intermammillary line (IML), but the position was changed according to the quality of the heart squeezing, evaluated by ultrasound. End-tidal carbon dioxide (ETCO 2 ) was used as the control parameter. Then we compared the area with the highest squeezing with the position of the heart in the chest computed tomography (CT) scans of 20 hospitalized patients., Results: Chest compressions were good, partial, and inadequate on the IML in 58.4%, 48.9%, and 2.8% of cases, respectively. These percentages were 75%, 25%, and 0% after these modifications: none (47.2%), increased depth (8.3%), hands moved on the lower third of the sternum (27.8%), on left parasternal line of the lower part of the sternum (13.9%), and on the center of the sternum (1 case). Accordingly, ETCO 2 improved significantly (20.37 vs. 37.10, p < 0.0001). The CT scans showed that the larger biventricular area (BVA) was under the parasternal line of the lower third of the sternum, and the mean distance IML-BVA was 5.7 cm., Conclusions: Our study has demonstrated that CPR in OHCA can be improved using ultrasound and changing the position of the hands. This finding was connected with the ETCO 2 and confirmed by chest CT scans., (Copyright © 2020. Published by Elsevier Inc.)

Background: More than 10 million arterial lines are placed annually worldwide, many of which happen in the emergency department. Before the introduction of point-of-care ultrasound, landmark-guided palpation (LMGP) was considered standard of care., Objective: The objective of this study is to compare ultrasound-guided (USG) and LMGP of radial arterial line cannulation by novice emergency medicine interns., Methods: This was a single-center, prospective, randomized controlled trial (NCT03326739) of a convenience sample of adult patients who presented to an urban, university hospital with 100,000 visits annually. There was no funding for this study. Patients who required an arterial line were blindly randomized into LMGP or USG groups. Only novice emergency medicine interns, defined as interns with <15 previous placements, who were not blinded, performed the cannulation. Statistical analyses included t and Fisher exact tests., Results: Forty patients were enrolled with 20 patients randomized to each group. USG had a first-pass success of 75% vs. 0% for LMGP (p < 0.00001) and an overall success of 100% vs. 15% for LMGP (p < 0.00001), a mean of 1.30 attempts vs. 2.95 attempts for LMGP (a difference of 1.65; p < 0.0001), and a mean time for placement of 264 s vs. 524 s for LMGP (a difference of 260; p = 0.0025). Of the failed LMGP, USG crossover was 100% successful with a mean of 1.37 attempts (95% confidence interval 0.58-2.16) and 180 s for placement (95% confidence interval 97.92-262.08). Five percent of LMGP had a complication vs. 0% for USG (p = 1.0)., Conclusions: USG improved first-pass and overall success of radial arterial line cannulation while reducing time to access and attempts when used by novice emergency medicine interns., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Physical examination for peritonsillar abscess (PTA) has limited sensitivity. Traditional management involves blind needle aspiration, which has a false negative rate of 10-24%. A randomized controlled trial by Costantino et al. demonstrated that point-of-care ultrasound (POCUS) improves PTA management., Objectives: Compare the use and impact of POCUS between patient cohorts prior to and after the trial by Costantino et al., Methods: Retrospective cohort study of adult patients diagnosed with PTA. Cohort 1 presented to the emergency department (ED) January 2007-December 2008. Cohort 2 presented between January 2013 and December 2014. Data were separated into those with POCUS vs. without ultrasound (NUS). Primary endpoint was POCUS utilization. Secondary endpoints were successful aspiration, otolaryngology (ear, nose, and throat [ENT]) consultation, computed tomography (CT) imaging, unscheduled return visits, and length of stay (LOS). The Fisher's exact and t-tests analyzed data., Results: Cohort 1 enrolled 48 patients, vs. 114 patients for cohort 2. Twelve patients in cohort 1 had a POCUS (25%) vs 89 in cohort 2 (78%) (p < 0.0001; odds ratio [OR] 0.09 (95% confidence interval [CI] 0.04-0.20). Emergency physician (EP) successful aspiration: 89.1% POCUS vs. 24.5% NUS (p < 0.0001; OR 25 [95% CI 10-59]). Combined EP/ENT successful aspiration: 99.0% POCUS vs. 80.3% NUS (p < 0.0001; OR 24 [95% CI 3-193]). ENT consultation:12.9% POCUS vs. 65.6% NUS (p < 0.0001; OR 0.07 [95% CI 0.03-0.17]). CT usage: 23.8% POCUS vs. 37.7% NUS (p = 0.07; OR 0.51 [95% CI 0.25-1.02]). Return visits: 3.96% POCUS vs. 18.0% NUS (p = 0.004; OR 0.18 [95% CI 0.05-0.61])., Conclusion: POCUS use has increased for PTA treatment, improves aspiration, and decreases consultations, CTs, return visits, and LOS., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Although surface sonography has become an essential diagnostic tool in the evaluation of trauma patients, important limitations of this modality include the evaluation of retroperitoneal hemorrhage and mediastinal pathology, such as blunt traumatic aortic injuries (BTAI). As in other emergency applications where surface sonography can't provide the information needed, focused transesophageal echocardiography (TEE) may represent a valuable diagnostic tool in the evaluation of hemodynamically unstable trauma patients with suspected thoracic pathology such as BTAI., Case Series: We present a series of five cases that illustrate the diagnostic value of emergency physician-performed resuscitative TEE in the diagnosis of BTAI in patients presenting with blunt thoracic trauma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As the use of point-of-care TEE during resuscitation continues to expand in emergency medicine, the evaluation of patients with BTAI represents a novel application where this emerging modality can allow early diagnosis of these injuries in hemodynamically unstable patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Herpes zoster (HZV) is a painful vesicular rash that occurs after reactivation in immunosuppressed patients. Analgesia in this patient population has been notoriously difficult. The serratus anterior and erector spinae plane block have both been described as effective thoracic analgesic techniques, but data are limited on their use in HZV., Case Report: A middle-aged man with a history of hypertension and hyperlipidemia presented to the emergency department (ED) with chest and back pain associated with cutaneous rash. Traditional pain regimens were not effective; therefore, a serratus anterior plane block was performed using 25 mL of 0.25% of bupivacaine. The patient's pain decreased from 10 to 2 in 20 min and the patient was discharged without further analgesia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As opiate use decreases in prevalence and utility in the ED, alternatives to analgesia are sought. We describe the technique of regional anesthesia using a serratus anterior plane block as another modality that physicians can use to address HZV-related pain., (Copyright © 2020 Elsevier Inc. All rights reserved.)