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Aortic dissection (AD) is a rare, time-sensitive, and potentially fatal condition that can present with subtle signs requiring timely diagnosis and intervention. Although definitive diagnosis is most accurately made through computed tomography angiography, this can be a time-consuming study and the patient may be unstable, thus preventing the study’s completion. Chest radiography (CXR) signs of AD are classically taught yet have poor diagnostic reliability. Point-of-care ultrasound (POCUS) is increasingly used by emergency physicians for the rapid diagnosis of emergent conditions, with multiple case reports illustrating the sonographic signs of AD. We present a case of Stanford type B AD diagnosed by POCUS in the emergency department in a patient with vague symptoms, normal CXR, and without aorta dilation. A subsequent review of CXR versus sonographic signs of AD is described.

Introduction: In the United States, there are limited studies regarding use of prehospital ultrasound (US) by emergency medical service (EMS) providers. Field diagnosis of life-threatening conditions using US could be of great utility. This study assesses the ability of EMS providers and students to accurately interpret heart and lung US images. Methods: We tested certified emergency medical technicians (EMT-B) and paramedics (EMT-P) as well as EMT-B and EMT-P students enrolled in prehospital training programs within two California counties. Participants completed a pre-test of sonographic imaging of normal findings and three pathologic findings: pericardial effusion, pneumothorax, and cardiac standstill. A focused one-hour lecture on emergency US imaging followed. Post-tests were given to all EMS providers immediately following the lecture and to a subgroup one week later. Results: We enrolled 57 prehospital providers (19 EMT-B students, 16 EMT-P students, 18 certified EMT-B, and 4 certified EMT-P). The mean pre-test score was 65.2%±12.7% with mean immediate post-test score of 91.1%±7.9% (95% CI [22%-30%], p

Traumatic injuries to the knee are common in Emeregncy Medicine. Bedside ultrasound has benefits in the rapid initial detection of injuries to the patella. In addition, ultrasound can quickly detect injuries to the entire knee extensor mechanism, including the quadriceps tenson and inferior patellar ligament in addition to the patella, that can be difficult to diagnose with plain radiographs. While MRI remains the gold standard for diagnostic evaluation of the knee extensor mechanism, this can be difficult to obtain from the Emergency Department. Clinicans caring for patients with orthopedic injuries of the knee will benefit from incorporating of musculoskeletal bedside ultrasound into their clinical skills set.

An 86-year-old female was brought in by ambulance for severe abdominal and back pain. She was hypotensive en route and appeared to be in distress upon arrival to the emergency department. Her abdomen was tense and distended with diffuse tenderness to palpation present. A bedside abdominal ultrasound (US) was done immediately, which raised concern for free air. A portable upright chest x-ray was obtained, which confirmed the diagnosis of pneumoperitoneum (Video). Video Pneumoperitoneum. Pneumoperitoneum due to perforated viscus is an emergent diagnosis that requires immediate surgical consultation and intervention. US is a useful tool that can be done at the bedside to rapidly make the diagnosis. Both low- and high-frequency transducers may be used to detect intraperitoneal free air. With the patient in a supine position, the perihepatic space should be evaluated. The patient may also be turned to the left lateral decubitus position to facilitate the rise of free air to the RUQ.1 Findings may also be seen from the anterior abdominal wall when the patient is supine. Pneumoperitoneum can be detected on US by the enhanced peritoneal stripe sign (EPSS) in conjunction with reverberation artifacts, which have the appearance of repeating linear lines extending at equidistant distances posteriorly from the peritoneal lining.2 Comet tail artifact may also be appreciated from the peritoneal stripe. The “scissors maneuver” can increase sensitivity of US in detecting intraperitoneal free air.3 Indirect signs may also be seen on US, including thickened bowel loops or air bubbles in peritoneal free fluid.4 US has been shown to have a sensitivity of 85% and a specificity of 100% for pneumoperitoneum. It has been shown by some to have a higher sensitivity for this diagnosis as compared to plain radiography.5 Although computed tomography imaging is still the gold standard for pneumoperitoneum, US is a helpful initial diagnostic tool that can be done rapidly at the bedside.