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Author(s): Gildea, Thomas H.; Anderson, Kenton L.; Niknam, Kian R.; Gharahbaghian, Laleh; Williams, Sarah R.; Angelotti, Timothy; Auerbach, Paul S.; Lobo, Viveta | Abstract: Introduction: Grayscale ultrasound (US) imaging has been used as an adjunct for confirming endotracheal tube (ETT) placement in recent years. The addition of color Doppler imaging (CDI) has been proposed to improve identification but has not been well studied. The aim of this study was to assess whether CDI improves correct localization of ETT placement.Methods: A convenience sample of emergency and critical care physicians at various levels of training and experience participated in an online assessment. Participants viewed US video clips of patients, which included either tracheal or esophageal intubations captured in grayscale or with CDI; there were five videos of each for a total of 20 videos. Participants were asked to watch each clip and then assess the location of the ETT.Results: Thirty-eight subjects participated in the online assessment. Levels of training included medical students (13%), emergency medicine (EM) residents (50%), EM attendings (32%), and critical care attendings (5%). The odds ratio of properly assessing tracheal placement using color relative to a grayscale imaging technique was 1.5 (p = 0.21). Regarding the correct assessment of esophageal placement, CDI had 1.4 times the odds of being correctly assessed relative to grayscale (p = 0.26). The relationship between training level and correct assessments was not significant for either tracheal or esophageal placements.Conclusion: In this pilot study we found no significant improvement in correct identification of ETT placement using color Doppler compared to grayscale ultrasound; however, there was a trend toward improvement that might be better elucidated in a larger study.

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.

Background Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. Objectives We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. Methods As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. Results Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). Conclusions We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.

The coronavirus disease 2019 (COVID‐19) pandemic created new emergency physician staffing challenges. Emergency physicians may be taken out of the workforce because of respiratory symptoms or pending severe acute respiratory syndrome coronavirus 2 test results. Vulnerable emergency physician populations with increased risk of serious disease and death from COVID‐19 include physicians at older ages; those with chronic medical conditions, including cardiac and pulmonary diseases and immunosuppression; and potentially pregnancy. We present our approach to planning for staffing issues through precision scheduling. We describe the actions taken to protect our vulnerable physicians and maximize our physician coverage. Measures include optimizing workforce; increasing backup call system; adjusting shifts based on patient arrival times, volume, and surge predictions; minimizing exposure to COVID‐19 and reduce personal protective equipment use through telemedicine, huddles, and, creating lower risk emergency department care areas; and standardizing intubations to limit exposure.

BackgroundCOVID-19 screening protocols rapidly evolved as a result of changing Centers for Disease Control and Prevention (CDC) and California Department of Public Health (CDPH) recommendations. These protocols led to operational improvements at one large academic medical centre using change management methods explained in Kotter’s 8-stage change model.MethodsWe reviewed all iterations of clinical process maps for identifying, isolating and assessing COVID-19 infections in paediatric and adult populations within one emergency department (ED) from 28 February 2020 to 5 April 2020. We incorporated CDC and CDPH criteria for the various roles of healthcare workers in ED patient assessment.ResultsUsing Kotter’s 8-stage change model, we outlined the chronological evolution of basic screening criteria, as well as how these were reviewed, modified and implemented during the onset and through the time of greatest uncertainty of COVID-19 in the USA. Our results demonstrate a successful creation, and subsequent execution, of rapidly changing protocols across a large workforce.ConclusionWe effectively applied a business change management framework to the hospital management response during a pandemic; we share these experiences and challenges to inform and guide future operational decision making during times of rapid change.

Introduction Hospitals commonly use Press Ganey (PG) patient satisfaction surveys for benchmarking physician performance. PG scores range from 1 to 5, with 5 being the highest, which is known as the "topbox" score. Our objective was to identify patient and physician factors associated with topbox PG scores in the emergency department (ED). Methods We looked at PG surveys from January 2015-December 2017 at an academic, urban hospital with 78,000 ED visits each year. Outcomes were topbox scores for the questions: "Likelihood of your recommending our ED to others"; and "Courtesy of the doctor." We analyzed topbox scores using generalized estimating equation models clustered by physician and adjusted for patient and physician factors. Patient factors included age, gender, race, ethnicity, and ED area where patient was seen. The ED has four areas based on patient acuity: emergent; urgent; vertical (urgent but able to sit in a recliner rather than a gurney); and fast track (non-urgent). Physician factors included age, gender, race, ethnicity, and number of years at current institution. Results We analyzed a total of 3,038 surveys. For "Likelihood of your recommending our ED to others," topbox scores were more likely with increasing patient age (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.12); less likely among female compared to male patients (OR 0.81; 95% CI, 0.70-0.93); less likely among Asian compared to White patients (OR 0.71; 95% CI, 0.60-0.83); and less likely in the urgent (OR 0.71; 95% CI, 0.54-0.93) and vertical areas (OR 0.71; 95% CI 0.53-0.95) compared to fast track. For "Courtesy of the doctor," topbox scores were more likely with increasing patient age (OR 1.1; CI, 1.06-1.14); less likely among Asian (OR 0.70; 95% CI, 0.58-0.84), Black (OR 0.66; 95% CI, 0.45-0.96), and Hispanic patients (OR 0.68; 95% CI, 0.55-0.83) compared to White patients; and less likely in urgent area (OR 0.69; 95% CI, 0.50-0.95) compared to fast track. Conclusion Increasing patient age was associated with increased likelihood of topbox scores, while Asian patients, and urgent and vertical areas had decreased likelihood of topbox scores. We encourage hospitals that use PG topbox scores as financial incentives to understand the contribution of non-service factors to these scores.

This chapter uses clinical vignettes and multiple-choice questions to explore core and advanced principles of hepatobiliary ultrasound, including cholelithiasis, cholecystitis, choledocholithiasis, cholangitis, cirrhosis, ascites, and hepatic masses. The cases assess image acquisition pearls and pitfalls, image interpretation, false positive and negative findings, and integration into patient management. Clinical vignettes include patients presenting with a wide variety of hepatobiliary pathology who are commonly seen in emergency departments and other clinics. Each case includes detailed explanations for correct and incorrect answer choices, incorporating landmark studies as well as the latest literature that clinical sonographers will find of interest.

With the advent of portable ultrasound machines, point-of-care ultrasound (POCUS) has proven to be adaptable to a myriad of environments, including remote and austere settings, where other imaging modalities cannot be carried. Austere environments continue to pose special challenges to ultrasound equipment, but advances in equipment design and environment-specific care allow for its successful use. This article describes the technique and illustrates pathology of common POCUS applications in austere environments. A brief description of common POCUS-guided procedures used in austere environments is also provided.

Introduction: The focused assessment with sonography in trauma (FAST) exam is a critical diagnostic test for intraperitoneal free fluid (FF). Current teaching is that fluid accumulates first in Morison’s pouch. The goal of this study was to evaluate the “sub-quadrants” of traditional FAST views to determine the most sensitive areas for FF accumulation. Methods: We analyzed a retrospective cohort of all adult trauma patients who had a recorded FAST exam by emergency physicians at a Level I trauma center from January 2012 – June 2013. Ultrasound fellowship-trained faculty with three emergency medicine residents reviewed all FAST exams. We excluded studies if they were incomplete, of poor image quality, or with incorrect medical record information. Positive studies were assessed for FF localization, comparing the traditional abdominal views and on a sub-quadrant basis: right upper quadrant (RUQ)1 - hepatodiaphragmatic; RUQ2 - Morison’s pouch; RUQ3 - caudal liver edge and superior paracolic gutter; left upper quadrant (LUQ)1 - splenic-diaphragmatic; LUQ2 - spleno-renal; LUQ3 – around inferior pole of kidney; suprapubic area (SP)1 - bilateral to bladder; SP2 - posterior to bladder; SP3 – posterior to uterus (females). FAST results were confirmed by chart review of computed tomography results or operative findings. Results: Of the included 1,008 scans, 48 (4.8%) were positive. The RUQ was the most positive view with 32/48 (66.7%) positive. In the RUQ sub-quadrant analysis, the most positive view was the RUQ3 with 30/32 (93.8%) positive. Conclusion: The RUQ is most sensitive for FF assessment, with the superior paracolic gutter area around the caudal liver edge (RUQ3) being the most positive sub-quadrant within the RUQ. [West J Emerg Med. 2017;18(2)270-280.]

Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.

Study objective Online educational resources such as blogs are increasingly used for education by emergency medicine clinicians. The Social Media Index was developed to quantify their relative impact. The Medical Education Translational Resources: Indicators of Quality (METRIQ) study was conducted in part to determine the association between the Social Media Index score and quality as measured by gestalt and previously derived quality instruments. Methods Ten blogs were randomly selected from a list of emergency medicine and critical care Web sites. The 2 most recent clinically oriented blog posts published on these blogs were evaluated with gestalt, the Academic Life in Emergency Medicine Approved Instructional Resources (ALiEM AIR) score, and the METRIQ-8 score. Volunteer raters (including medical students, emergency medicine residents, and emergency medicine attending physicians) were identified with a multimodal recruitment methodology. The Social Media Index was calculated in February 2016, November 2016, April 2017, and December 2017. Pearson's correlations were calculated between the Social Media Index and the average rater gestalt, ALiEM AIR score, and METRIQ-8 score. Results A total of 309 of 330 raters completed all ratings (93.6%). The Social Media Index correlated moderately to strongly with the mean rater gestalt ratings (range 0.69 to 0.76) and moderately with the mean rater ALiEM AIR score (range 0.55 to 0.61) and METRIQ-8 score (range 0.53 to 0.57) during the month of the blog post's selection and for 2 years after. Conclusion The Social Media Index's correlation with multiple quality evaluation instruments over time supports the hypothesis that it is associated with overall Web site quality. It can play a role in guiding individuals to high-quality resources that can be reviewed with critical appraisal techniques.

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

With the advent of portable ultrasound machines, point-of-care ultrasound (POCUS) has proven to be adaptable to a myriad of environments, including remote and austere settings, where other imaging modalities cannot be carried. Austere environments continue to pose special challenges to ultrasound equipment, but advances in equipment design and environment-specific care allow for its successful use. This article describes the technique and illustrates pathology of common POCUS applications in austere environments. A brief description of common POCUS-guided procedures used in austere environments is also provided.

Background Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT. Methods Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1–18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT. Results Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age >11 years, leukocytosis >15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT. Conclusions We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 42:385–394, 2014

Objective: To review the use of ultrasound (US) for the detection of free intraperitoneal fluid (ascites) and for the procedural guidance of the paracentesis procedure. Methods: Two clinical vignettes are presented to review the pertinent diagnostic, management and safety considerations associated with paracentesis. First, US techniques used for the identification of ascites and in the quantification of fluid pockets amenable to aspiration will be discussed. Next, the actual steps required for the performance of US-guided paracentesis will be covered. A review and analysis of the most current literature regarding US and paracentesis then follows. Conclusion: Current literature favors US-guided paracentesis over the traditional blind technique with a significant reduction in both the rate of unsuccessful aspiration of fluid and in the bleeding complications related to this procedure. Use of US for both the diagnostic and therapeutic management of ascites should be advocated as an essential skill for physicians and other health care providers caring for these patients.

Thoracic ultrasonography (US) has proved to be a valuable tool in the evaluation of the patient with shortness of breath, chest pain, hypoxia, or after chest trauma. Its sensitivity and specificity for detecting disease is higher than that of a chest radiograph, and it can expedite the diagnosis for many emergent conditions. This article describes the technique of each thoracic US application, illustrating both normal and abnormal findings, as well as discussing the literature. Bedside thoracic US has defined imaging benefits in a wide range of thoracic disease, and US guidance has been shown to facilitate thoracic and airway procedures.

This article reviews important literature on the FAST and E-FAST examinations in adults. It also reviews key pitfalls, limitations, and controversies. A practical "how-to" guide is presented. Lastly, new frontiers are explored.

Background Focused transthoracic echocardiography (F-TTE) is an important tool to assess hemodynamically unstable patients in the Emergency Department. Although its scope has been defined by the American College of Emergency Physicians, more research is needed to define an optimal F-TTE training program, including assessment of proficiency. Objective The goal of this study was to determine the effectiveness of current standards in post-residency training to reach proficiency in F-TTE. Methods Fourteen staff Emergency Physicians were enrolled in a standardized teaching curriculum specifically designed to meet the 2008 American College of Emergency Physicians’ guidelines for general ultrasound training applied to echocardiography. This training program consisted of 6 h of didactics and 6 h of scanning training, followed by independent scanning over a 5-month period. Acquisition of echocardiographic knowledge was assessed by an online pre- and post-test. At the conclusion of the study, a hands-on skills test assessed the trainees’ ability to perform and interpret F-TTE. Results Ninety percent of trainees passed the written post-test. Two views, the parasternal long and short axis, were easily obtainable, regardless of the level of training or the number of ultrasounds completed. Other views were more difficult to master, but strong trends toward increased competency were evident after 10 h of mixed didactic and scanning training and > 45 ultrasounds. Conclusions A short, 12-h didactic training in F-TTE provided proficiency in image interpretation and in obtaining adequate images from the parasternal window. More extensive training is needed to master the apical and subcostal windows in a timely manner.

Study objective Open educational resources such as blogs are increasingly used for medical education. Gestalt is generally the evaluation method used for these resources; however, little information has been published on it. We aim to evaluate the reliability of gestalt in the assessment of emergency medicine blogs. Methods We identified 60 English-language emergency medicine Web sites that posted clinically oriented blogs between January 1, 2016, and February 24, 2016. Ten Web sites were selected with a random-number generator. Medical students, emergency medicine residents, and emergency medicine attending physicians evaluated the 2 most recent clinical blog posts from each site for quality, using a 7-point Likert scale. The mean gestalt scores of each blog post were compared between groups with Pearson's correlations. Single and average measure intraclass correlation coefficients were calculated within groups. A generalizability study evaluated variance within gestalt and a decision study calculated the number of raters required to reliably (>0.8) estimate quality. Results One hundred twenty-one medical students, 88 residents, and 100 attending physicians (93.6% of enrolled participants) evaluated all 20 blog posts. Single-measure intraclass correlation coefficients within groups were fair to poor (0.36 to 0.40). Average-measure intraclass correlation coefficients were more reliable (0.811 to 0.840). Mean gestalt ratings by attending physicians correlated strongly with those by medical students (r=0.92) and residents (r=0.99). The generalizability coefficient was 0.91 for the complete data set. The decision study found that 42 gestalt ratings were required to reliably evaluate quality (>0.8). Conclusion The mean gestalt quality ratings of blog posts between medical students, residents, and attending physicians correlate strongly, but individual ratings are unreliable. With sufficient raters, mean gestalt ratings provide a community standard for assessment.

We report a cardiac mass detected by point-of-care ultrasound performed within the emergency department on a 65-year-old male with thymic cancer who presented with chronic cough and fever. Results from the initial emergency workup, which included blood tests, urinalysis, and a computerized tomography with angiography scan with venous phasing of the chest, did not result in a definitive diagnosis. A point-of-care echocardiogram was performed to evaluate for possible infective endocarditis, but alternatively identified a large mass in the right atria and ventricle. The mass was later confirmed to be metastatic tumor from the patient’s known thymic cancer. This case emphasizes the vital role ultrasound can play in the acute care setting.

As the use of bedside emergency ultrasound (US) increases, so does the need for effective US education.To determine 1) what pathology can be reliably simulated and identified by US in human cadavers, and 2) feasibility of using cadavers to improve the comfort of emergency medicine (EM) residents with specific US applications.This descriptive, cross-sectional survey study assessed utility of cadaver simulation to train EM residents in diagnostic US. First, the following pathologies were simulated in a cadaver: orbital foreign body (FB), retrobulbar (RB) hematoma, bone fracture, joint effusion, and pleural effusion. Second, we assessed residents' change in comfort level with US after using this cadaver model. Residents were surveyed regarding their comfort level with various US applications. After brief didactic sessions on the study's US applications, participants attempted to identify the simulated pathology using US. A post-lab survey assessed for change in comfort level after the training.Orbital FB, RB hematoma, bone fracture, joint effusion, and pleural effusion were readily modeled in a cadaver in ways typical of a live patient. Twenty-two residents completed the pre- and post-lab surveys. After training with cadavers, residents' comfort improved significantly for orbital FB and RB hematoma (mean increase 1.6, p0.001), bone fracture (mean increase 2.12, p0.001), and joint effusion (1.6, p0.001); 100% of residents reported that they found US education using cadavers helpful.Cadavers can simulate orbital FB, RB hematoma, bone fracture, joint effusion, and pleural effusion, and in our center improved the comfort of residents in identifying all but pleural effusion.

Introduction: Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement. Methods: This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigatorusing first the low-frequency (5–1 MHz) followed by the high-frequency (10–5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation ofTT placement. Results: Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10–5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode. Conclusion: Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10–5 MHz) linear transducer. [West J Emerg Med. 2012;13(4):305–311.]

ACADEMIC EMERGENCY MEDICINE 2011; 18:477–482 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT. Methods: This was a prospective observational study of consecutive children (0–17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery. Results: The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%). Conclusion: In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making.

Spontaneous pneumomediastinum is a rare disease process with no clear etiology, although it is thought to be related to changes in intrathoracic pressure causing chest pain and dyspnea. We present a case of a 17-year-old male with acute chest pain evaluated initially by bedside ultrasound, which showed normal lung sliding but poor visualization of the parasternal and apical cardiac views due to significant air artifact, representing air in the thoracic cavity. The diagnosis was later verified by chest radiograph. We present a case report on ultrasound-diagnosed pneumomediastinum, and we review the diagnostic modalities to date. [West J Emerg Med. 2015;16(2):321–324.]

Nerve gases of the organophosphate class were discovered around the time of World War II, with sarin, tabun and soman among their best known representatives. Despite the Geneva Convention of 1925 and the Chemical Weapons Convention (CWC) of 1997, chemical warfare agents, among them nerve agents like sarin, have been used in Iraq and in Japan. With an increased worldwide terrorist threat these relatively cheap but effective nerve agents have become a major concern for preparedness planners, rescue health‐care workers and security agencies. The different medical effects and physicochemical properties of these nerve agents may require a differentiated triage scenario. Early evacuation, decontamination, basic life support measures and specific pharmacologic therapy are the cornerstones of successful mass casualty management of nerve gas victims.

Abdominal pain is a common complaint among Emergency Department (ED) patients and accounts for approximately 10% of all visits. While some presentations are classic, making diagnosis and treatment expeditious, other presentations require time-intensive work-ups that yield no etiology in nearly 25%. The Emergency Physician (EP) is tasked to maintain a broad differential while ruling out surgical conditions such as acute appendicitis. Within this differential is abdominal wall pathology. We present a case of a 28 year-old female who presented with right lower quadrant pain, was diagnosed with intercostal neuritis and discharged with a non-steroidal anti-inflammatory drug (NSAID) and appendicitis precautions. Ultimately, timely diagnosis of these less emergent pathologies can improve patient satisfaction, prevent unnecessary tests and provide targeted treatment modalities.

A 64-year-old male presented to the emergency department (ED) with near syncope and worsening left flank and shoulder pain. He had undergone a difficult colonoscopy two days prior due to a tortuous colon. Initial vital signs were normal. He looked uncomfortable and had significant left upper quadrant abdominal tenderness with guarding. Thirty minutes after ED arrival, his blood pressure dropped to 73/59 mmHg, requiring aggressive fluid resuscitation. Bedside focused assessment with sonography in trauma (FAST) exam demonstrated free fluid in the abdomen with mixed echogenicity of the spleen, suggestive of splenic injury. Computed tomography (CT) demonstrated a large subcapsular splenic hematoma with active extravasation and surrounding intraperitoneal free fluid (Figure, Video). He was admitted to the surgical intensive care unit. Hemorrhage continued after interventional radiology performed embolization of the splenic artery. He then required laparoscopic splenectomy on hospital day 2 to control bleeding. He subsequently did well and was discharged on hospital day 10. Figure Splenic rupture after colonoscopy. Left image, ultrasound. Right image, computed tomography scan (CT). Video Spleen rupture case. Colonoscopy has been associated with spontaneous intra-abdominal organ injury. Jammal et al described a case of subcapsular liver hematoma associated with colonoscopy.1 Lauretta et al described a case of splenic rupture following colonoscopy that had a delayed diagnosis due to initial physician consideration of alternate pathology, specifically intestinal rupture.2 Shankar and Rowe described a case of splenic injury following colonoscopy and then reviewed the literature, finding a total of 93 cases.3 Increasing age was found to be a risk factor. The authors also emphasized that patients may present with only moderate abdominal pain. A larger case series in 2012 by Aubrey-Bassler and Sowers described 613 case of splenic rupture without known risk factors. Of these, 327 occurred as a presenting manifestation of an underlying disease. Infections were found in 143 patients, with malaria most common (65 cases) and mononucleosis second (42 cases). Medical procedures were also highly associated with splenic rupture, and 87 cases were associated with colonoscopy.4 In 2011 Fishback et al described the clinical and CT findings of 11 patients with splenic rupture after colonoscopy. CT demonstrated splenic injury with subcapsular hematoma and/or perisplenic hematoma in 10 cases and hemoperitoneum in eight cases.5 Singla et al found 102 patients with splenic injury following colonoscopy.6 The majority (73 patients) required operative intervention with 96% requiring splenectomy. This information should prompt emergency physicians to consider splenic injury in patients presenting with abdominal pain (even mild) and/or shock in those who have recently undergone a colonoscopy. Bedside point-of-care ultrasound using the FAST exam may be effective in initially identifying these patients, especially those in shock requiring immediate resuscitation and surgical consultation like the patient discussed in this case.

Focused cardiac echocardiography has become a critical diagnostic tool for the emergency physician and critical care physician caring for patients in shock and following trauma to the chest, and those presenting with chest pain and shortness of breath,. Cardiac echocardiography allows for immediate diagnosis of pericardial effusions and cardiac tamponade, evaluation of cardiac contractility and volume status, and detection of right ventricular strain possibly seen with a significant pulmonary embolus. This article addresses how to perform cardiac echocardiography using the standard windows, how to interpret a focused goal-directed examination, and how to apply this information clinically at the bedside.

Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT.Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1-18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT.Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age11 years, leukocytosis15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT.We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT.

Background Anorexia nervosa is a disease with high prevalence in adolescents and carries the highest mortality of any psychiatric disorder. Case We present a case of a 17-year-old female presenting to the emergency department with bradycardia that was subsequently diagnosed with anorexia nervosa. We also review the clinical features, diagnosis, complications, and emergency department management of this disease. Conclusions Patients with anorexia may present with multiple medical complaints, and it is imperative that the emergency physician be familiar with the syndrome so as to correctly identify and treat patients with this disease.

Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT.This was a prospective observational study of consecutive children (0-17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery.The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%).In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making.

Background: In many different health care educational models, shadowing, or observational experience, is accepted as integral to introducing students to the specifics of medical specialties. Study Objectives: We investigated whether emergency department (ED) observational experiences (EDOs) affect medical students' (MSs') interest in emergency medicine (EM). Additionally, we examined how the subjective quality of clinical exposures influences this interest and the decision to recommend EDOs to other students. Methods: This is a survey of MSs at a Level 1 tertiary care university hospital during a 2-year period. The study focused on assessing perception of ED exposure, post-EDO change in EM interest, and decision to recommend EDOs to others. Results: The majority of MSs had a change in EM interest post-EDO and recommended EDOs. Both variables correlated to ED exposure ratings. Conclusions: The EDO significantly influenced MS interest in EM by providing exposure to various aspects of the ED.

This case report describes an unusual presentation of nausea, vomiting and diarrhea, which was misdiagnosed as acute gastroenteritis in a 6-year-old girl. The patient later returned to the emergency department (ED) with severe dehydration from idiopathic central diabetes insipidus (DI). At her first visit, this previously healthy patient presented with mild dehydration, signs of acute gastroenteritis and normal urine output. Her brother had experienced similar symptoms a few days earlier. She tolerated an oral fluid challenge and was discharged from the ED with stable vital signs. Two days later, the patient returned with severe dehydration, resolving diarrhea and persistent vomiting. She was admitted to the pediatric intensive care unit. Magnetic resonance imaging illustrated an absent posterior pituitary enhancing signal, which demonstrated a loss of function in that region. There were no other abnormalities. The patient subsequently received desmopressin with improving clinical status and was discharged on the eighth hospital day. DI is a rare disease, but can be fatal if left undiagnosed. It should, therefore, be considered in the differential diagnosis of a dehydrated patient with an unexpectedly low urine specific gravity.