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OBJECTIVE The main objective of this study was to evaluate the accuracy of point-of-care ultrasound (POCUS) for the diagnosis of appendicitis in a general emergency department (ED) population as performed by emergency physicians with variable ultrasound experience. METHODS We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential appendicitis presenting to the ED between July 2014 and February 2020. Each emergency physician-performed POCUS was interpreted at the bedside and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS and blinded expert interpretation compared to surgical pathology in patients undergoing appendectomy and advanced imaging in patients managed nonoperatively. RESULTS A total of 256 subjects were included in the primary analysis with an overall appendicitis prevalence of 28.1%. For the diagnosis of appendicitis, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.85 (95% confidence interval [CI] = 0.74 to 0.92), 0.63 (95% CI = 0.56 to 0.70), 2.29 (95% CI = 1.85 to 2.84), and 0.24 (95% CI = 0.14 to 0.42), respectively. Expert review yielded a lower sensitivity (0.74 [95% CI = 0.62 to 0.83]) with a similar specificity (0.63 [95% CI = 0.56 to 0.70]). CONCLUSION POCUS is moderately accurate for acute appendicitis as performed by emergency physicians with a wide range of ultrasound expertise, but lacks adequate sensitivity and specificity to function as a definitive test in an undifferentiated ED population. Further study is warranted to elucidate the optimal role of integrated POCUS in the general approach to suspected appendicitis.

Author(s): Clontz, Robert; Dang, Duc M.; Hieger, Michelle A.; Becker, Brent A. | Abstract: Introduction: Immune checkpoint inhibitors (ICI) are a class of immunotherapy drugs used increasingly in the treatment of multiple types of cancer. Major side effects include immune-related adverse effects, potentially resulting in damage to normal tissue across multiple different organ systems.Case Report: A 74-year-old woman with a history of triple negative metastatic breast cancer treated with the ICI atezolizumab presented with new-onset autoimmune diabetes in diabetic ketoacidosis.n She required fluid resuscitation, insulin infusion, vasopressors, and initial hospitalization in the intensive care unit. The patient was subsequently discharged on bolus dose insulin and remained an insulin-dependent diabetic at three-month follow-up.Conclusion: Autoimmune diabetes is a rare, but life-threatening, adverse event associated with ICIs such as atezolizumab. To our knowledge this is the only case report of atezolizumab causing autoimmune diabetes in the setting of metastatic breast cancer. As ICIs become more common in the treatment of cancer, emergency physicians should remain vigilant for the various immune-mediated complications associated with this class of immunotherapy drugs.

Objective This study sought to evaluate rates of acute kidney injury in patients undergoing contrast-enhanced computerized tomography for acute stroke in the emergency department (ED) before and after the cessation of creatinine screening. Methods This retrospective study compared ED patients receiving contrast-enhanced imaging for suspected acute stroke with and without protocolized creatinine screening. The primary outcome was CIN, defined as an increase in serum creatinine of 0.3 mg/dl within 48 hours or 50% above baseline within 7 days after contrast administration. Secondary outcomes consisted of CIN based on other definitions, renal impairment greater than 30 days from contrast administration, hemodialysis, and mortality. Outcomes were compared using difference of proportions and odds ratios with 95% confidence intervals. Results This study included 382 subjects, with 186 and 196 in the screening and post-screening cohorts, respectively. No significant differences were observed for CIN (7.0% vs 7.1%, difference 0.1% [95% CI -5.6-5.1%], OR 1.02 [95% CI 0.47–2.24]), renal impairment greater than 30 days post-contrast (8.4% vs 7.5%, OR 0.88 [0.38–2.07]), or mortality (index visit: 4.8% vs 2.6%, OR 0.51 [0.17–1.57], 90-day follow-up: 6.7% vs 4.0%, OR 0.58 [0.22–1.53]). No patients from either group required hemodialysis. Conclusions The elimination of creatinine screening prior to obtaining contrast-enhanced computerized tomography in patients with suspected acute stroke did not adversely affect rates of CIN, hemodialysis, or mortality at a comprehensive stroke center.

The study sought to evaluate changes in mortality and resource utilization in patients with low level troponin elevations following a reduction in the cutoff for normal troponin I (TnI) from 0.5 ng/mL to the 99th percentile (0.06 ng/mL).This was an interrupted time series comparing emergency department (ED) patients with possible acute coronary syndrome (ACS) and TnI values 0.06-0.5 ng/mL before and after an institutional decrease in the TnI cutoff. The primary outcome was overall mortality at 90 days. Secondary outcomes included rates of rehospitalization, subsequent ACS, and coronary intervention within 90 days, as well as rates of anticoagulation, cardiology consultation, cardiac testing, and coronary intervention during the index visit. Outcomes for the pre-cutoff change group (control) and post-cutoff change group (post) were compared using tests of proportions and odds ratios.The study included a total of 1058 subjects with 529 in each cohort. No significant differences in 90 day outcomes were observed between groups, including mortality (13.2% post vs 14.1% control, OR 0.93 [95% CI: 0.65-1.34], p = 0.705). During the index visit, the post-group demonstrated higher rates of cardiology consultation (55.4% vs 41.2%, OR 1.77 [1.39-2.26], p 0.0001) and cardiac stress testing (16.4% vs 10.6%, OR 1.66 [1.16-2.38], p = 0.006), but no significant differences in coronary intervention or short-term mortality were observed.A reduction in the TnI cutoff to the 99th percentile did not change mortality or rates of coronary intervention in ED patients with low level troponin elevations, but significantly increased the use of cardiology resources.

Background Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging. Objective The primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis. Methods We performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities. Results A total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%. Conclusion Of patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population.

Author(s): Gregory, David; Wexler, Bryan; Becker, Brent | Abstract: Case Presentation: We describe a case of an acute myocardial infarction with an atypical electrocardiogram showing a de Winter T-wave pattern suggesting the 100% proximal left anterior descending artery occlusion seen on emergent cardiac catheterization.Discussion: Timely recognition of acute myocardial ischemia is paramount for emergency providers. As highlighted in this case, It is important to be mindful of atypical electrocardiogram findings, such as de Winter T-waves, which suggest acute myocardial ischemia.

Hepatic encephalopathy (HE) is a state of cerebral dysfunction due to accumulated ammonia and other toxins in patients with underlying liver insufficiency and/or portosystemic shunting. The diagnosis is largely clinical, but the differential is extensive. Broad diagnostic testing is necessary to exclude alternative etiologies. Asterixis is a classic finding, but is not pathognomonic. Serum ammonia concentrations do not correlate well with disease severity. Providers should strongly consider cerebral edema and intracranial hypertension. Lactulose and rifaximin comprise first-line treatment, but identification and correction of precipitating factors are essential.

Author(s): Becker, Brent A; Lahham, Shadi; Gonzales, Mark A; Nomura, Jason T; Bui, Michelle K; Truong, Taylor A; Stahlman, Barbara A; Fox, John C; Kehrl, Thompson | Abstract: ObjectiveThe main objective of this study was to evaluate the accuracy of emergency physician-performed point-of-care ultrasound (POCUS) for the diagnosis of small-bowel obstruction (SBO) compared to computed tomography (CT).MethodsWe performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential SBO presenting to the emergency department (ED) between July 2014 and May 2017. Each POCUS was interpreted at the bedside by the performing emergency physician and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS, blinded expert interpretation, and specific POCUS parameters.ResultsA total of 217 subjects were included in the primary analysis with an overall SBO prevalence of 42.9%. For the diagnosis of SBO, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.88 (95% confidence interval [CI]n= 0.80 to 0.94), 0.54 (95% CIn= 0.45 to 0.63), 1.92 (95% CIn= 1.56 to 2.35), and 0.22 (95% CIn= 0.12 to 0.39), respectively. Expert review yielded a similar sensitivity (0.89 [95% CIn= 0.81 to 0.95]) with a significantly higher specificity (0.82 [95% CIn= 0.74 to 0.88]). The more sensitive sonographic parameters for both POC sonographers and expert reviewers were small-bowel dilation ≥ 25 mm (0.87 [95% CIn= 0.79 to 0.93], 0.87 [95% CIn= 0.79 to 0.93]) and abnormal peristalsis (0.82 [95% CIn= 0.72 to 0.89], 0.85 [95% CIn= 0.76 to 0.87]). The more specific parameters for both groups were transition point (0.82 [95% CIn= 0.74 to 0.89], 0.98 [95% CIn= 0.94 to 1.00]), intraperitoneal free fluid (0.82 [95% CIn= 0.74 to 0.89], 0.93 [95% CIn= 0.87 to 0.97]), and bowel wall edema (0.76 [95% CIn= 0.67 to 0.83], 0.93 [95% CIn= 0.87 to 0.97]).ConclusionPOCUS is moderately sensitive for SBO, although less specific, when performed by a diverse group of emergency physicians across multiple EDs. Interpretation of acquired POCUS images is significantly more accurate when performed by physicians with prior emergency ultrasound fellowship training and familiarity with the sonographic appearance of SBO.

The effectiveness of point of care (POC) right upper quadrant ultrasound (RUQ US) in the diagnosis of biliary disease has been well studied. Extrabiliary pathology that might remain undetected in the course of typical, focused POC RUQ US has not been directly examined.Our objective was to determine the prevalence and clinical significance of extrabiliary findings (EBFs) seen on radiology-performed, comprehensive RUQ US.We conducted a retrospective review of all adult patients undergoing radiology-performed RUQ US in the emergency department (ED) between January 2007 and April 2012. Ultrasound findings and contemporaneous laboratory values were collected. EBFs were identified and further classified by clinical significance.A total of 1579 charts were included, demonstrating a total of 1030 EBFs, with 747 (47.3% [95% confidence interval {CI}, 44.8-49.8%]) patients demonstrating ≥ 1 EBF. Of these EBFs, 184 were classified as clinically significant (CSEBFs) and 150 (9.5% [95% CI, 8.1-11.0%]) patients had ≥ 1 CSEBF. A total of 50 unspecified masses were seen in 47 (3.0% [95% CI, 2.1-3.8%]) patients, with 8 (0.5%) representing a previously undiagnosed malignancy.CSEBFs were seen in10% of ED patients undergoing comprehensive RUQ US. Nonspecific masses were seen in 3% of patients, but1% of patients were found to have a new malignancy.

Measurement of the common bile duct (CBD) has traditionally been considered an integral part of gallbladder sonography, but accurate identification of the CBD can be difficult for novice sonographers.To determine the prevalence of isolated sonographic CBD dilation in emergency department (ED) patients with cholecystitis or choledocholithiasis without laboratory abnormalities or other pathologic findings on biliary ultrasound.We conducted a retrospective chart review on two separate ED patient cohorts between June 2000 and June 2010. The first cohort comprised all ED patients undergoing a biliary ultrasound and subsequent cholecystectomy for presumed cholecystitis. The second cohort consisted of all ED patients receiving a biliary ultrasound who were ultimately diagnosed with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. Postoperative gallbladder pathology reports and endoscopic retrograde cholangiopancreatography (ERCP) reports were used as the criterion standard for final diagnosis.Of 666 cases of cholecystitis, there were 251 (37.7%) with a dilated CBD6 mm and only 2 cases (0.3%; 95% confidence interval [CI] 0.0-0.7%) of isolated CBD dilation with an otherwise negative ultrasound and normal laboratory values. Of 111 cases of choledocholithiasis, there were 80 (72.0%) with a dilated CBD and only 1 case (0.9%; 95% CI 0.0-2.7%) with an otherwise negative ultrasound and normal laboratory values.The prevalence of isolated sonographic CBD dilation in cholecystitis and choledocholithiasis is1%. Omission of CBD measurement is unlikely to result in missed cholecystitis or choledocholithiasis in the setting of a routine ED evaluation with an otherwise normal ultrasound and normal laboratory values.

Background Intraosseous (IO) access can be complicated by obesity. Successful placement of a 25 mm IO needle is unlikely when soft tissue depth exceeds 20 mm. Objectives The authors examined the relationship between body mass index (BMI), the ability to palpate the tibial tuberosity (TT), and soft tissue depth at recommended IO insertion sites. Methods Obese emergency department patients were assessed for a palpable TT and received ultrasound measurement of the soft tissue depth at recommended IO insertion sites. Linear and logistic regression were used to determine cut-off BMI values predicting soft tissue depth >20 mm. Results Seventy-five patients were enrolled with a mean BMI of 47.2. The mean soft tissue depth at the proximal humerus, proximal tibial, and distal tibial were 29.6 [95% CI 27.5-31.7] mm, 11.0 [8.9-13.0] mm, and 10.7 [9.4-12.1] mm, respectively. In 5 patients without a palpable TT the soft tissue depth exceeded 20 mm at all three anatomic sites. A BMI ≥43 and BMI ≥60 predicted a soft tissue depth >20 mm at the proximal tibia and distal tibia, respectively, while no reliable BMI cut-off was identified at the proximal humerus. Conclusions In obese adults with a palpable TT or BMI ≤43 a 25 mm IO needle is likely adequate at the proximal and distal tibial insertion sites. Empiric use of an extended 45 mm IO needle is advisable at the proximal humeral insertion site in obese patients.

Introduction: The goal of this study was to investigate the efficacy of diagnosing shoulder dislocation using a single-view, posterior approach point-of-care ultrasound (POCUS) performed by undergraduate research students, and to establish the range of measured distance that discriminates dislocated shoulder from normal. Methods: We enrolled a prospective, convenience sample of adult patients presenting to the emergency department with acute shoulder pain following injury. Patients underwent ultrasonographic evaluation of possible shoulder dislocation comprising a single transverse view of the posterior shoulder and assessment of the relative positioning of the glenoid fossa and the humeral head. The sonographic measurement of the distance between these two anatomic structures was termed the Glenohumeral Separation Distance (GhSD). A positive GhSD represented a posterior position of the glenoid rim relative to the humeral head and a negative GhSD value represented an anterior position of the glenoid rim relative to the humeral head. We compared ultrasound (US) findings to conventional radiography to determine the optimum GhSD cutoff for the diagnosis of shoulder dislocation. Sensitivity, specificity, positive predictive value, and negative predictive value of the derived US method were calculated. Results: A total of 84 patients were enrolled and 19 (22.6%) demonstrated shoulder dislocation on conventional radiography, all of which were anterior. All confirmed dislocations had a negative measurement of the GhSD, while all patients with normal anatomic position had GhSD>0. This value represents an optimum GhSD cutoff of 0 for the diagnosis of (anterior) shoulder dislocation. This method demonstrated a sensitivity of 100% (95% CI [82.4-100]), specificity of 100% (95% CI [94.5-100]), positive predictive value of 100% (95% CI [82.4-100]), and negative predictive value of 100% (95% CI [94.5-100]). Conclusion: Our study suggests that a single, posterior-approach POCUS can diagnose anterior shoulder dislocation, and that this method can be employed by novice ultrasonographers, such as non-medical trainees, after a brief educational session. Further validation studies are necessary to confirm these findings.

Cardiac arrest in the adolescent population secondary to congenital heart disease (CHD) is rare. Focused cardiac ultrasound (FoCUS) in the emergency department (ED) can yield important clinical information, aid in resuscitative efforts during cardiac arrest and is commonly integrated into the evaluation of patients with pulseless electrical activity (PEA). We report a case of pediatric cardiac arrest in which FoCUS was used to diagnose a critical CHD known as cor triatriatum sinistrum as the likely cause for PEA cardiac arrest and help direct ED resuscitation.

As bedside ultrasound (BUS) is being increasingly taught and incorporated into emergency medicine practice, measurement of BUS competency is becoming more important. The commonly adopted experiential approach to BUS competency has never been validated on a large scale, and has some limitations by design.Our aim was to introduce and report preliminary testing of a novel emergency BUS image rating scale (URS).Gallbladder BUS was selected as the test case. Twenty anonymous BUS image sets (still images and clips) were forwarded electronically to 16 reviewers (13 attendings, 3 fellows) at six training sites across the United States. Each reviewer rated the BUS sets using the pilot URS that consisted of three components, with numerical values assigned to each of the following aspects: Landmarks, Image Quality, and Annotations. Reviewers also decided whether or not each BUS set would be "Clinically Useful." Kendall τs were calculated as a measure of concordance among the reviewers.Among the 13 attendings, image review experience ranged from 2-15 years, 5-300 scans per week, and averaged 7.8 years and 60 images. Kendall τs for each aspect of the URS were: Landmarks: 0.55; Image Quality: 0.57; Annotation: 0.26; Total Score: 0.63, and Clinical Usefulness: 0.45. All URS elements correlated significantly with clinical usefulness (p0.001). The correlation coefficient between each attending reviewer and the entire group ranged from 0.48-0.69, and was independent of image review experience beyond fellowship training.Our novel URS had moderate-to-good inter-rater agreement in this pilot study. Based on these results, the URS will be modified for use in future investigations.