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Background McConnell's sign (right ventricular [RV] free wall hypokinesis with apical sparing on echocardiography) is often described as very specific for the diagnosis of pulmonary embolism (PE). We present the case of a patient who, despite manifesting a classic McConnell's sign, was not found to have a PE. Case report A 58-year-old woman presented to the emergency department with a cough, dyspnea, and leg swelling. A bedside focused cardiac ultrasound revealed hypokinesis of the RV free wall, with apical sparing, in the apical four-chamber view. A computed tomography angiogram for PE was negative. Ultrasounds of both lower extremities were negative for deep venous thrombosis, and a D-dimer was only marginally elevated. The patient was ultimately diagnosed with pulmonary hypertension due to chronic obstructive pulmonary disease and systemic lupus erythematosus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware that McConnell's sign is not completely specific for acute right heart strain from PE.

Background In patients with pulmonary embolism (PE), right ventricular strain (RVS) on transthoracic echocardiography by Cardiology has been shown to be an independent predictor of 30-day adverse outcomes. However, it is not known how emergency practitioner-performed point-of-care focused cardiac ultrasound (FOCUS) with assessment for RVS compares with other prognostic methods in the Emergency Department (ED). Objectives To determine whether RVS on FOCUS is a significant predictor of in-hospital adverse outcomes when compared to other risk factors and scoring systems. Methods Retrospective chart review of patients who were diagnosed with PE and had a FOCUS examination during January 1, 2007 through January 1, 2011 in an urban, academic center with a well-developed ultrasound program. Adverse outcomes were defined as shock, respiratory failure requiring intubation, death, recurrent venous thromboembolism, transition to higher level of care, or major bleeding during hospital admission. Statistical analysis included univariate and multivariate analysis to assess for prognostic significance. Results One hundred sixty-one patients were included in the final analysis. A total of 25 (16%) patients had an adverse outcome during hospitalization. On univariate analysis, only the presence of altered mental status conferred a higher positive likelihood ratio (6.4 vs. 4.0) than RVS, whereas absence of RVS had the lowest negative likelihood ratio (0.45). On multivariate analysis, RVS and cardiopulmonary disease were the only predictors of adverse outcomes that achieved statistical significance, with odds ratio of 9.2 and 3.4, respectively. Conclusion In this retrospective chart review, a FOCUS examination for RVS performed by emergency care practitioners of varying experience level was a significant predictor of in-hospital adverse outcomes among patients diagnosed with PE in the ED. Future research should be directed at exploring ways to incorporate RVS assessment into ED prognostic models for pulmonary embolism.

Over 1.4 million patients present annually to United States (US) emergency departments with minor head trauma. Many undergo unnecessary head computed tomography (HCT).We sought to determine the diagnostic accuracy of S100B, a central nervous system peptide, to screen for HCT+ head injury.This study was a prospective observational study of adults with minor head trauma. Patients presenting within 6h of injury and undergoing HCT for evaluation were eligible. All HCTs were blindly reviewed for presence of a priori defined intracranial injury (HCT+). Quantitative S100B levels were determined by enzyme-linked immunosorbent assay.A total of 346 patients were enrolled over 12 months, mean age 48 years (± 23 years), 62% male. Twenty-two (6.4%) were HCT+. Vomiting, headache, anterograde amnesia, Glasgow Coma Scale score15, nausea, and loss of consciousness were associated with HCT+ results. Median S100B levels were significantly elevated in HCT+ (115 ng/dL) vs. HCT- (56.0 ng/dL) patients (p=0.032). Receiver operator characteristic analysis demonstrated an area under the curve of 0.643. Sensitivity and specificity were 86% (95% confidence interval [CI] 67-96) and 37% (95% CI 29-45%) at 42 ng/dL, 91% (95% CI 72-98%) and 24% (95% CI 17-31%) at 32 ng/dL, and 96% (95% CI 78-100%) and 13% (95% CI 9-20%) at 24 ng/dL, respectively.The study demonstrates that S100B may be a sensitive but non-specific marker of HCT+ injury.

Background: Subcutaneous myiasis, a maggot infiltration of human tissue, is common in tropical countries. However, physicians in the United States may be unlikely to consider this etiology of dermatologic abnormalities even when a travel history suggests the diagnosis should be included in the differential. Case Report: We report the case of a patient who returned from Sierra Leone with an infestation of a maggot of Cordylobia anthropophaga (tumbu fly) that was diagnosed and appropriately treated based on ultrasound findings. Conclusion: As international travel increases, clinicians should maintain a high level of suspicion for tumbu fly infestation in returned travelers from endemic areas. The increasing use of ultrasound in the Emergency Department for evaluation of skin and soft tissue infections may aid the physician in making the diagnosis of subcutaneous myiasis.

Background Point-of-care ultrasound (PoC US) is now taught and used in nearly all academic emergency departments (EDs), but prior surveys have shown that adoption in the community ED setting is much lower. Objective Our aim was to characterize the current practice of emergency physician (EP)–performed PoC US in Connecticut. Methods We conducted a 20-question online survey of all ED directors in Connecticut to determine how PoC US is utilized. The questions addressed ED demographics, ownership of ultrasound (US) equipment, frequency of PoC US performance in general and by examination type, credentialing patterns, quality assurance methods, and billing patterns. Results The response rate was 83% (25 of 30). Almost all (96%) respondent EDs owned at least one US machine, and 24% used US regularly for diverse applications according to 2008 American College of Emergency Physicians (ACEP) guidelines. PoC US was most commonly used for Focused Assessment with Sonography in Trauma examinations, procedural guidance, and assessing the aorta for an abdominal aortic aneurysm. Although 64% reported hospital ultrasonography privileges, 40% did not keep any record of PoC US performed in the ED. More than half (56%) required an over-read by radiology, and 36% required an over-read by another EP (e.g., ED Ultrasound Director). Only 8% of EDs billed for PoC US. Conclusions Most Connecticut EDs own an US machine and have hospital privileges for PoC US. However, a minority use or bill for PoC US regularly for diffuse applications, and most do not have a quality assurance program as described by ACEP guidelines.

Laparoscopy has become an established approach with diverse applications in both diagnostic and therapeutic surgical procedures. In general, the procedure is safe and effective and offers the advantage of being less invasive than conventional surgery. Complications after laparoscopy are uncommon but among them major vascular injury is potentially the most fatal, with recognition or mortality typically occurring intra-operatively or in the immediate post-operative period. We report the case of a delayed emergency department presentation of a major vascular injury after an elective laparoscopic tubal ligation. The prevalence, diagnosis, pathophysiolgy and management of major vascular injury after laparoscopic surgery is discussed.