Emergency diagnostic paracentesis to determine intraperitoneal fluid identity discovered on bedside ultrasound of unstable patients

Procedural Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.

A Delayed Diagnosis of Hemorrhagic Shock in a Patient with Alcoholic Cirrhosis and Ascites on Bedside Ultrasound

Undifferentiated shock is a common and challenging problem in critical care. We present a case of hemorrhagic shock due to splenic and hepatic lacerations diagnosed by bedside paracentesis, initially misclassified as septic shock due to suspected spontaneous bacterial peritonitis (SBP). Case. A 47-year old man with a history of reported alcoholic cirrhosis and ongoing heavy alcohol use was brought to the emergency room after a syncopal event. He was found to be anemic (hemoglobin 9.9 g/dl) and hypotensive with a blood pressure of 64/34. Despite crystalloid infusion he remained hypotensive and required vasopressor support with norepinephrine. Bedside ultrasound revealed moderate ascites and as there was no evidence of active bleeding, his shock was attributed to sepsis due to SBP. A bedside paracentesis was performed which revealed gross blood. A repeat hemoglobin returned at 4.4 g/dl. Massive transfusion protocol was initiated and interventional radiology was emergently consulted due to concerns for intraabdominal hemorrhage; general surgery deemed the patient too unstable for surgical intervention. Angiogram revealed a splenic laceration and possible hepatic laceration, both embolized successfully. Internal medicine practitioners should keep the differential of hemorrhagic shock due to intraabdominal organ injury in mind for patients with undifferentiated shock.

Use of Focused Assessment with Sonography in Trauma Examination Skills in the Evaluation of Non-trauma Patients

Study objectives

Although the focused assessment with sonography in trauma (FAST) examination was initially developed for rapid evaluation of trauma patients, the basic skillset required to perform a FAST examination provides valuable information that may alter a non-trauma patient’s clinical course. The objective of this study was to determine the utility of the FAST examination in the emergency department management of non-trauma patients.

Methods

Cases in which the FAST examination was used to direct care in non-trauma patients were retrospectively reviewed. Following the completion of the patient's care, emergency physicians were asked to complete a questionnaire indicating how information from the FAST examination was utilized to direct care of their non-trauma patients.

Results

A total of 63 non-trauma cases with average age of 48 years (range 16-94 years) were enrolled. The FAST examination positively impacted care in 57/63 (90.5%) cases. In 18/63 (28.6%) cases, the patient’s ultimate disposition changed because of FAST examination findings. In 9/63 (14.3%) cases, paracentesis was avoided by obtaining a FAST examination, and in 8/63 cases (12.7%) paracentesis was performed due to FAST examination results. In 16/63 (25.4%) cases, anticipated imaging changed due to FAST examination findings and 4/63 (6.3%) cases did not receive the anticipated computed tomography (CT) scan.

Conclusions

Although initially developed for evaluation of trauma patients, the FAST examination can provide valuable information that can positively impact care in non-trauma patients. The FAST examination can provide information to determine appropriate patient disposition, obtain appropriate additional imaging, ensure timely consultation, and eliminate risk from unnecessary procedures.

Point-of-Care Ultrasound in Acute Neonatal Ascites

We present a 4-week-old neonate with acute onset of bloody stools and abdominal distention. Point-of-care ultrasound performed in the emergency department allowed for rapid diagnosis of a large amount of free intra-abdominal fluid, which together with the physical findings, prompted emergent operative exploration revealing chylous ascites. Although no areas of active volvulus were identified intraoperatively, findings in the case were suggestive of small bowel volvulus and deemed as the most likely etiology for this patient's presentation. In this report, we review the relevant aspects of ultrasonography for ascites and discuss the diagnosis of chylous ascites.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Overview of point-of-care abdominal ultrasound in emergency and critical care

Point-of-care abdominal ultrasound (US), which is performed by clinicians at bedside, is increasingly being used to evaluate clinical manifestations, to facilitate accurate diagnoses, and to assist procedures in emergency and critical care. Methods for the assessment of acute abdominal pain with point-of-care US must be developed according to accumulated evidence in each abdominal region. To detect hemoperitoneum, the methodology of a focused assessment with sonography for a trauma examination may also be an option in non-trauma patients. For the assessment of systemic hypoperfusion and renal dysfunction, point-of-care renal Doppler US may be an option. Utilization of point-of-care US is also considered in order to detect abdominal and pelvic lesions. It is particularly useful for the detection of gallstones and the diagnosis of acute cholecystitis. Point-of-case US is justified as the initial imaging modality for the diagnosis of ureterolithiasis and the assessment of pyelonephritis. It can be used with great accuracy to detect the presence of abdominal aortic aneurysm in symptomatic patients. It may also be useful for the diagnoses of digestive tract diseases such as appendicitis, small bowel obstruction, and gastrointestinal perforation. Additionally, point-of-care US can be a modality for assisting procedures. Paracentesis under US guidance has been shown to improve patient care. US appears to be a potential modality to verify the placement of the gastric tube. The estimation of the amount of urine with bladder US can lead to an increased success rate in small children. US-guided catheterization with transrectal pressure appears to be useful in some male patients in whom standard urethral catheterization is difficult. Although a greater accumulation of evidences is needed in some fields, point-of-care abdominal US is a promising modality to improve patient care in emergency and critical care settings.

A Novice User of Pediatric Emergency Point-of-Care Ultrasonography Avoids Misdiagnosis in a Case of Chronic Abdominal Distention

A 13-year-old adolescent girl with chronic abdominal distention was referred to the pediatric emergency department after the outpatient workup suggested moderate ascites. Point-of-care ultrasonography performed by the emergency physicians ruled out ascites, instead demonstrating a well-circumscribed cystic mass subsequently identified as an ovarian mucinous cystadenoma.

Focused assessment with sonography in nontraumatized dogs and cats in the emergency and critical care setting

OBJECTIVE

To evaluate the use of abdominal- and thoracic-focused assessment with sonography for trauma (AFAST and TFAST) in nontraumatized dogs and cats in the emergency and critical care setting and to compare prevalence of free fluid identified via these techniques between stable and unstable patients.

DESIGN

Prospective observational study.

SETTING

University Distributed Veterinary Learning Community.

ANIMALS

One hundred client-owned dogs and cats presenting to an emergency service with no evidence of trauma.

INTERVENTIONS

AFAST and TFAST performed within 12 hours of presentation.

MEASUREMENT AND MAIN RESULTS

Free fluid was identified on AFAST or TFAST in 33% of dogs and cats in this study. Free fluid was identified in 27 of 36 (75%) cardiovascularly unstable or dyspneic patients, compared to 6 of 64 (9%) stable patients. A significantly greater proportion of unstable patients had free fluid compared to stable patients (P < 0.0001).

CONCLUSIONS

Results of this study support the use of AFAST and TFAST to detect free fluid in nontraumatized dogs and cats in the emergency and critical care setting, particularly patients that are unstable on presentation.

The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll

The RUSH exam (Rapid Ultrasound in SHock examination), presented in this article, represents a comprehensive algorithm for the integration of bedside ultrasound into the care of the patient in shock. By focusing on a stepwise evaluation of the shock patient defined here as "Pump, Tank, and Pipes," clinicians will gain crucial anatomic and physiologic data to better care for these patients.