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Kameda T, Ishii H, Oya S, Katabami K, Kodama T, Sera M, Takei H, Taniguchi H, Nakao S, Funakoshi H, Yamaga S, Senoo S, Kimura A. Guidance for clinical practice using emergency and point-of-care ultrasonography. Acute Med Surg 2024; 11:e974. [PMID: 38933992 PMCID: PMC11201855 DOI: 10.1002/ams2.974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/11/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.
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Affiliation(s)
- Toru Kameda
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Clinical Laboratory MedicineJichi Medical UniversityShimotsukeJapan
| | - Hiromoto Ishii
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
| | - Seiro Oya
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineShizuoka Medical CenterShizuokaJapan
| | - Kenichi Katabami
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care CenterHokkaido University HospitalSapporoJapan
| | - Takamitsu Kodama
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and General Internal MedicineTajimi City HospitalTajimiJapan
| | - Makoto Sera
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineFukui Prefectural HospitalFukuiJapan
| | - Hirokazu Takei
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineHyogo Prefectural Kobe Children's HospitalKobeJapan
| | - Hayato Taniguchi
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Advanced Critical Care and Emergency CenterYokohama City University Medical CenterYokohamaJapan
| | - Shunichiro Nakao
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Hiraku Funakoshi
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineTokyo Bay Urayasu Ichikawa Medical CenterUrayasuJapan
| | - Satoshi Yamaga
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Radiation Disaster Medicine, Research Institute for Radiation Biology and MedicineHiroshima UniversityHiroshimaJapan
| | - Satomi Senoo
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineSaiseikai Yokohamashi Tobu HospitalYokohamaJapan
| | - Akio Kimura
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical CareCenter Hospital of the National Center for Global Health and MedicineTokyoJapan
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Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med 2023; 82:e115-e155. [PMID: 37596025 DOI: 10.1016/j.annemergmed.2023.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 08/20/2023]
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Kumar K, Kumari M, Kumar V, Suman SK. Evaluation of Scrotal Pathologies by Ultrasound and Color Doppler. Cureus 2023; 15:e36776. [PMID: 37123666 PMCID: PMC10133834 DOI: 10.7759/cureus.36776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
Introduction Due to its ease of use, lack of ionizing radiation exposure, noninvasive nature, reproducibility, low cost, and ease of accessibility, ultrasound (US) is the preferred imaging modality for evaluating scrotal disease. High-resolution US and color Doppler better highlight scrotal and testicular diseases because of the scrotum's superficial anatomy. The genital organs are subjected to damaging ionizing radiation during CT, while MRI is both costly and uncommon. Aims and objectives The aim of this study is to use ultrasonography (USG) to examine various scrotal diseases and to diagnose and identify different disorders utilizing high-resolution US and color Doppler. Materials and methods The study was done on 60 patients who were referred to the Department of Radiodiagnosis by the General Surgery and Urology departments for the scrotal US and Doppler study. This study was conducted between October 2021 and March 2022 at the Indira Gandhi Institute of Medical Sciences, Patna, India. Results Out of 60 patients, hydrocele was seen in 25 cases, scrotal hernia in 12 cases, undescended testis in eight cases, varicocele and epididymal cysts in seven cases, etc. In acutely painful scrotal disorders, high-frequency US with color Doppler sonography successfully distinguishes between testicular ischemia/torsion and acute inflammatory illnesses. Eighteen cases of inflammatory scrotal pathologies and one case of testicular torsion were seen. Conclusion In detecting and assessing scrotal diseases, high-frequency USG and color Doppler sonography have good sensitivity and specificity. Furthermore, the lack of ionizing radiation, simplicity, wide availability, cost-efficiency, and reproducibility make it a highly important method for scrotal diseases.
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Haidar DA, Peterson WJ, Minges PG, Carnell J, Nomura JT, Bailitz J, Boyd JS, Leo MM, Liu EL, Duanmu Y, Acuña J, Kessler R, Elegante MF, Nelson M, Liu RB, Lewiss RE, Nagdev A, Huang RD. A consensus list of ultrasound competencies for graduating emergency medicine residents. AEM EDUCATION AND TRAINING 2022; 6:e10817. [PMID: 36425790 PMCID: PMC9677397 DOI: 10.1002/aet2.10817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/29/2022] [Accepted: 10/11/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Emergency ultrasound (EUS) is a critical component of emergency medicine (EM) resident education. Currently, there is no consensus list of competencies for EUS training, and graduating residents have varying levels of skill and comfort. The objective of this study was to define a widely accepted comprehensive list of EUS competencies for graduating EM residents through a modified Delphi method. METHODS We developed a list of EUS applications through a comprehensive literature search, the American College of Emergency Physicians list of core EUS benchmarks, and the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound consensus document. We assembled a multi-institutional expert panel including 15 faculty members from diverse practice environments and geographical regions. The panel voted on the list of competencies through two rounds of a modified Delphi process using a modified Likert scale (1 = not at all important, 5 = very important) to determine levels of agreement for each application-with revisions occurring between the two rounds. High agreement for consensus was set at >80%. RESULTS Fifteen of 15 panelists completed the first-round survey (100%) that included 359 topics related to EUS. After the first round, 195 applications achieved high agreement, four applications achieved medium agreement, and 164 applications achieved low agreement. After the discussion, we removed three questions and added 13 questions. Fifteen of 15 panelists completed the second round of the survey (100%) with 209 of the 369 applications achieving consensus. CONCLUSION Our final list represents expert opinion on EUS competencies for graduating EM residents. We hope to use this consensus list to implement a more consistent EUS curriculum for graduating EM residents and to standardize EUS training across EM residency programs.
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Affiliation(s)
- David A. Haidar
- Department of Emergency MedicineMichigan MedicineAnn ArborMichiganUSA
| | | | - Patrick G. Minges
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Jennifer Carnell
- Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
| | - Jason T. Nomura
- Department of Emergency Medicine, Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - John Bailitz
- Department of Emergency Medicine, Feinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Jeremy S. Boyd
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Megan M. Leo
- Department of Emergency MedicineBoston University School of MedicineBostonMassachusettsUSA
| | - E. Liang Liu
- Department of Emergency MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - Youyou Duanmu
- Department of Emergency MedicineStanford University School of MedicinePalo AltoCaliforniaUSA
| | - Josie Acuña
- Department of Emergency MedicineUniversity of ArizonaTucsonArizonaUSA
| | - Ross Kessler
- Department of Emergency MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Marco F. Elegante
- Department of Emergency MedicineUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Mathew Nelson
- Department of Emergency MedicineZucker Northwell School of Medicine, Northwell HealthManhassetNew YorkUSA
| | - Rachel B. Liu
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Resa E. Lewiss
- Department of Emergency Medicine, Sidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Arun Nagdev
- Department of Emergency MedicineHighland Hospital, Alameda Health SystemOaklandCaliforniaUSA
| | - Rob D. Huang
- Department of Emergency MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Small E, Ashenburg N, Schertzer K. 19-Year-Old with Sudden Onset Left Testicular Pain. Clin Pract Cases Emerg Med 2022; 6:327-329. [PMID: 36427024 PMCID: PMC9697886 DOI: 10.5811/cpcem.2022.7.56747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 07/02/2022] [Indexed: 11/19/2022] Open
Abstract
CASE PRESENTATION A previously healthy 19-year-old man presented to the emergency department with severe, sudden onset of left testicular pain. Physical exam revealed a left high-riding, horizontally oriented testicle without cremasteric reflex. Point-of-care ultrasound was used to confirm the diagnosis of testicular torsion, as well as to guide manual detorsion, verifying return of blood flow after reduction. DISCUSSION Testicular torsion is a urologic emergency in which testicular viability is time dependent. Point-of-care ultrasound can be an important and helpful tool to not only confirm suspicion but help guide adequacy of blood flow return after manual detorsion in conjunction with comprehensive ultrasound.
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Lee DY, Lee SH, Yoon JA, Kang C, Cho YC, Ahn HJ, Park JS, Ryu S, You Y, Kim SW, Lee JW, Jeong WJ. Detection of Testicular Torsion With Preserved Intratesticular Flow By Point of Care Ultrasound in the Emergency Department: A Case Report. J Emerg Med 2022; 62:e88-e90. [PMID: 35078703 DOI: 10.1016/j.jemermed.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/07/2021] [Accepted: 11/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Ultrasonography is an effective diagnostic tool for testicular torsion (TT), which is typically characterized by the absence of blood flow in the affected testicle on color Doppler mode. However, there are a few reported cases of TT with symmetrical preserved flow. We report a case of TT with the preserved intratesticular flow on color Doppler ultrasound. CASE REPORT A 14-year-old boy was admitted due to sudden-onset right scrotal pain. Point-of-care ultrasound (POCUS) revealed that the right testicle was larger than the left. The intratesticular flow in both testicles was preserved. Radiology-performed ultrasound confirmed the preserved intratesticular flow observed on POCUS, but also demonstrated a whirlpool sign of the right spermatic cord. TT was confirmed surgically. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should investigate the presence of intratesticular blood flow and the whirlpool sign of the spermatic cord or other ultrasound features suggestive of TT, even if testicular blood flow is preserved. Suspicion of TT from POCUS findings warrants further evaluation to preserve the patient's fertility.
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Affiliation(s)
- Dong Young Lee
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Sung Hyeok Lee
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Jung A Yoon
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Seung Ryu
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Seung Whan Kim
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Jin Woong Lee
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Won Joon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea.
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Nene RV, Subramony R, Macias M, Campbell C, Aminlari A. Real-time Point-of-care Ultrasound for the Diagnosis and Treatment of Testicular Torsion. POCUS JOURNAL 2021; 6:70-72. [PMID: 36895665 PMCID: PMC9979951 DOI: 10.24908/pocus.v6i2.15186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background: Testicular torsion is a surgical emergency that needs prompt diagnosis and treatment. Point-of-Care ultrasound (POCUS) can not only establish the diagnosis but also guide the Emergency Physician in evaluating the response to manual detorsion. Case Report: We describe the case of a 13-year-old male who presented with acute scrotal pain. We demonstrate how bedside ultrasound was used to make the diagnosis of testicular torsion, guide the technique for manual detorsion, and confirm adequate return of blood flow. Our case illustrates the ease with which POCUS can be used in real time to diagnose and treat organ-threatening pathology, but more importantly, it shows how real-time POCUS was used to detorse a testicle that was refractory to the standard detorsion technique. Conclusion: The acute scrotum is a time-sensitive presentation and if testicular torsion is present, the diagnosis should be made as soon as possible. Many Emergency Departments do not have 24-hour coverage of ultrasound technicians, which would delay the diagnosis and treatment. Moreover, when manual detorsion is attempted, it often does not work because the testicle may need more than the standard 180 degree medial to lateral rotation. POCUS provides real-time analysis of return of blood flow and can thus guide further rotation, or opposite direction rotation, as needed.
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Affiliation(s)
- Rahul V Nene
- Department of Emergency Medicine, University of California San Diego, CA
| | - Rachna Subramony
- Department of Emergency Medicine, University of California San Diego, CA
| | - Michael Macias
- Department of Emergency Medicine, University of California San Diego, CA
| | - Colleen Campbell
- Department of Emergency Medicine, University of California San Diego, CA
| | - Amir Aminlari
- Department of Emergency Medicine, University of California San Diego, CA
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Raml E, Jamjoom RS. Point-of-Care Ultrasound detecting testicular rupture in pediatric emergency. J Am Coll Emerg Physicians Open 2020; 1:1530-1532. [PMID: 33392561 PMCID: PMC7771765 DOI: 10.1002/emp2.12199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/15/2020] [Accepted: 07/02/2020] [Indexed: 11/21/2022] Open
Abstract
Acute scrotal pain is a true emergency that needs to be identified, diagnosed, and managed quickly to avoid any testicular tissue loss. In pediatric emergency, testicular torsion has been the most worrisome diagnosis that needs to be included or excluded as fast as possible. Point-of-care ultrasound (POCUS) has been reported to be a game changer. However, because testicular rupture is an extremely rare entity in the pediatric age group, there are limited reports about POCUS use in diagnosing the condition. We describe a case of a 4-year-old boy who presented with acute scrotal pain secondary to trauma 2 days previous, where POCUS was able to identify and diagnose testicular rupture in a timely fashion that facilitated management and intervention.
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Affiliation(s)
- Enas Raml
- Department of Pediatric SurgeryKing Abdulaziz University HospitalJeddahSaudi Arabia
| | - Roaa S. Jamjoom
- Faculty of MedicineKing Abdulaziz UniversityJeddahSaudi Arabia
- Emergency Medicine DepartmentKing Abdulaziz University HospitalJeddahSaudi Arabia
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Using Point-of-Care Ultrasound to Characterize Acute Inguinal Swelling of Young Children in the Pediatric Emergency Department. Pediatr Emerg Care 2020; 36:304-307. [PMID: 32011551 DOI: 10.1097/pec.0000000000002014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute inguinal swelling in young children is frequently assumed to be an inguinal hernia, often prompting a bedside reduction attempt. We report 3 cases of inguinal swelling where the use of point-of-care ultrasound changed the patients' management by identifying an alternate diagnosis, thus avoiding unnecessary and painful procedures as well as their associated sedation risks.
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Friedman N, Pancer Z, Savic R, Tseng F, Lee MS, Mclean L, Bagli DJ, Tessaro MO. Accuracy of point-of-care ultrasound by pediatric emergency physicians for testicular torsion. J Pediatr Urol 2019; 15:608.e1-608.e6. [PMID: 31455581 DOI: 10.1016/j.jpurol.2019.07.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Acute scrotum is a common presentation to the pediatric emergency department, and ultrasound is frequently used to narrow the differential diagnosis. Point-of-care ultrasound (POCUS) is increasingly used by urologists and emergency physicians and could potentially be used to detect pediatric testicular torsion. OBJECTIVES This study aimed to determine the accuracy of POCUS by pediatric emergency physicians in diagnosing testicular torsion and the agreement between point-of-care ultrasound and final diagnosis for other causes of acute scrotum. STUDY DESIGN A chart review of patients presenting to the study emergency department who received POCUS by a pediatric emergency physician, as well as radiology department ultrasound and/or surgery, was performed. Charts were reviewed for POCUS diagnoses, final diagnoses, and imaging time metrics. RESULTS A total of 120 patients met study criteria, with 12 cases of testicular torsion. The diagnostic accuracy of POCUS for testicular torsion is described in the summary table. For all causes of acute scrotum, point-of-care ultrasound agreed with final diagnosis in 70% (95% confidence interval [CI] 62-78%) of cases, and more experienced point-of-care ultrasound users displayed higher agreement with final diagnosis. Point-of-care ultrasound results were generated a median of 73 min (Q1 = 51, Q3 = 112) before radiology department ultrasound results. DISCUSSION Scrotal POCUS performed by pediatric emergency physicians appears to be an accurate tool to detect testicular torsion in children with acute scrotum and saves time compared with radiology ultrasound. The study results may not be generalizable to hospitals without a multidisciplinary POCUS system for quality assurance and image sharing. Future work on POCUS for acute scrotum should investigate its impact on patient outcomes, cost-effectiveness, and family satisfaction. CONCLUSION Point-of-care ultrasound by pediatric emergency physicians is accurate for detecting testicular torsion in children with acute scrotum and could expedite diagnosis of this time-sensitive condition.
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Affiliation(s)
- N Friedman
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada.
| | - Z Pancer
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - R Savic
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - F Tseng
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - M S Lee
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - L Mclean
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - D J Bagli
- Division of Urology, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - M O Tessaro
- Emergency Point-of-Care Ultrasound Program, Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
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Sorensen B, Hunskaar S. Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. Ultrasound J 2019; 11:31. [PMID: 31749019 PMCID: PMC6868077 DOI: 10.1186/s13089-019-0145-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services. METHODS Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound. RESULTS On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies. CONCLUSION Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.
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Affiliation(s)
- Bjarte Sorensen
- Hjelmeland General Practice Surgery, Prestagarden 13, 4130, Hjelmeland, Norway.
| | - Steinar Hunskaar
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Bergen, Norway
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Ultrasound-Guided Manual Testicular Detorsion in the Emergency Department. J Emerg Med 2019; 58:85-92. [PMID: 31653532 DOI: 10.1016/j.jemermed.2019.09.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Scrotal ultrasound helps in the rapid diagnosis of complete testicular torsion and assessment of alternative causes of acute scrotal pain. Early detection of torsion of the testis and reperfusion, either manually or surgically, is paramount to preserving testicular viability. Manual detorsion also offers immediate symptom relief by alleviating ischemia. Bedside ultrasound performed by a trained emergency physician (EP) can significantly reduce the time to diagnosis and reperfusion by means of performing an ultrasound-guided manual detorsion in the emergency department (ED). CASE REPORT We report two cases of ultrasound-guided manual detorsion of testis that were performed successfully by EPs in the ED. After manual detorsion, both patients underwent nonemergent orchidopexy and recovered well after surgery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Manual testicular detorsion is a simple, safe, and effective maneuver that can be performed in the ED by EPs. Bedside ultrasound is helpful in confirming the diagnosis of complete torsion of the testicle (no blood flow) and successful reperfusion after manual detorsion. We recommend EPs be trained to perform scrotal ultrasound and manual detorsion of a torted testicle. We strongly emphasize that manual detorsion of the testes is not a substitute for definitive surgical management and should only be used as a temporary measure for reperfusion to allow more time to organize the logistics of surgery, which can be critical in remote settings.
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Jakubowski J, Moskovitz J, Leonard NJ. Imaging Modalities in Genitourinary Emergencies. Emerg Med Clin North Am 2019; 37:785-809. [PMID: 31563208 DOI: 10.1016/j.emc.2019.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Emergency physicians rely on a multitude of different imaging modalities in the diagnosis of genitourinary emergencies. There are many considerations to be taken into account when deciding which imaging modality should be used first, as oftentimes several diagnostic tools can be used for the same pathologic condition. These factors include radiation exposure, sensitivity, specificity, age of patient, availability of resources, cost, and timeliness of completion. In this review, the strengths and weaknesses of different imaging tools in the evaluation of genitourinary emergencies are discussed.
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Affiliation(s)
- Julian Jakubowski
- Department of Emergency Medicine, Emergency Medicine Residency Marietta Memorial Hospital, 401 Matthew Street, Marietta, OH 45750, USA; The Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA.
| | - Joshua Moskovitz
- Department of Emergency Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, Building 6 Room 1B25, Bronx, NY 10461, USA; Hofstra School of Health and Human Services, Hempstead, NY, USA
| | - Nicole J Leonard
- Department of Emergency Medicine, Jacobi Montefiore Emergency Medicine Residency, 1400 Pelham Parkway South, Building 6, Bronx, NY 10461, USA
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Chan EP, Wang PZT, Myslik F, Chen H, Dave S. Identifying systems delays in assessment, diagnosis, and operative management for testicular torsion in a single-payer health-care system. J Pediatr Urol 2019; 15:251.e1-251.e7. [PMID: 31005635 DOI: 10.1016/j.jpurol.2019.03.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/21/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Testicular torsion (TT) is a common pediatric urologic emergency. Management of TT is time sensitive and often confirmed on scrotal Doppler ultrasound (DUS). Acquiring DUS, however, can result in delays in the management of TT, affecting testicular salvage rates. OBJECTIVE The objective of this study is to identify delays in the assessment and diagnosis for patients presenting with TT to a Canadian academic hospital using patient flow analysis. STUDY DESIGN A retrospective review was performed for patients presenting to the emergency department (ED) who received a scrotal DUS to rule out possible TT between 2012 and 2017. The primary outcome measured cycle-time measurements (median time) between points along the clinical flow pathway for a patient with suspected TT. The secondary outcome assessed diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of standard scrotal DUS components (Doppler flow, arterial waveform, heterogeneous echotexture). RESULTS A total of 609 patients presented with an acute scrotum warranting a scrotal DUS to rule out TT; of which, 46 underwent scrotal exploration. Testicular salvage rate was 82.6% in the series (38 testes salvaged, 8 required orchiectomy). Median time from symptom onset to ED presentation for patients with possible TT was 4 h. After triage, a median of 79.8 min was required for ED physician assessment and an additional 48 min for scrotal DUS to be performed. Absence of Doppler flow on scrotal DUS had a 97.4% PPV for diagnosing TT confirmed during scrotal exploration. DISCUSSION Almost 4 h of in-ED time is required from triage to surgical intervention for potential TT at the institution. One area of delay is the time needed to conduct a scrotal DUS (48-128 min; Fig. 1). This represents an area of opportunity for patient flow optimization through the use of standardized clinical pathways and diagnostic adjuncts, such as point-of-care ultrasound. This study is limited in its retrospective nature and does not include patients with overt signs of TT who underwent surgical detorsion without need for scrotal DUS. CONCLUSION Patient flow delays to surgical intervention for patients with TT represent a preventable cause of orchiectomy in young men. This study identifies intervention points in patient-care flow pathways where delays to surgical intervention can be potentially reduced by up to 2 h. The findings support the need for further studies into the optimization of patient flow and management protocols to reduce delays in the diagnosis and management of TT.
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Affiliation(s)
- E P Chan
- Department of Surgery, Division of Urology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - P Z T Wang
- Department of Surgery, Division of Urology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Surgery, Division of Paediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - F Myslik
- Department of Medicine, Division of Emergency Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - H Chen
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - S Dave
- Department of Surgery, Division of Urology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Surgery, Division of Paediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
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Ota K, Fukui K, Oba K, Shimoda A, Oka M, Ota K, Sakaue M, Takasu A. The role of ultrasound imaging in adult patients with testicular torsion: a systematic review and meta-analysis. J Med Ultrason (2001) 2019; 46:325-334. [DOI: 10.1007/s10396-019-00937-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
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Holliday TL, Robinson KS, Dorinzi N, Vucelik AW, Setzer EL, Williams DL, Sharon MJ, Minardi JJ. Testicular Rupture: A Tough Nut to Crack. Clin Pract Cases Emerg Med 2018; 1:221-224. [PMID: 29849294 PMCID: PMC5965175 DOI: 10.5811/cpcem.2017.3.33348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/08/2017] [Accepted: 03/29/2017] [Indexed: 01/17/2023] Open
Abstract
Blunt scrotal injury represents a diagnostic dilemma for emergency physicians (EP). Consequently, point-of-care ultrasound (POCUS) has emerged as a tool for early investigation of the acute scrotum in the emergency department. We describe a case where an EP used scrotal POCUS to immediately visualize the loss of testicular contour and underlying heterogeneous parenchyma to rapidly make the diagnosis of testicular rupture in a young male presenting with scrotal trauma. The use of POCUS in this case expedited therapy, likely improving the patient’s outcome. To our knowledge, this is the first detailed description of testicular rupture diagnosed with POCUS by an EP
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Affiliation(s)
- Tyler L Holliday
- West Virginia University, School of Medicine, Morgantown, West Virginia
| | - Kristine S Robinson
- West Virginia University, Department of Emergency Medicine, Morgantown, West Virginia
| | - Nicole Dorinzi
- West Virginia University, Department of Emergency Medicine, Morgantown, West Virginia
| | - Andrew W Vucelik
- West Virginia University, Department of Emergency Medicine, Morgantown, West Virginia
| | - Erin L Setzer
- West Virginia University, Department of Emergency Medicine, Morgantown, West Virginia
| | - Debra L Williams
- West Virginia University, Department of Emergency Medicine, Morgantown, West Virginia
| | - Melinda J Sharon
- West Virginia University, Department of Emergency Medicine, Morgantown, West Virginia
| | - Joseph J Minardi
- West Virginia University, Department of Emergency Medicine, Morgantown, West Virginia
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Abstract
Pediatric emergency medicine physicians may be able to use point-of-care ultrasound (POCUS) as a tool to evaluate abdominal wall masses. We present a case of a 2-month-old infant with a lower abdominal mass identified as a hernia sac by POCUS. It was initially thought to represent a Spigelian-type abdominal wall hernia but subsequently determined to be an unusual presentation of an inguinal hernia with testicular entrapment. We review each of these diagnoses in addition to relevant POCUS findings.
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Indra S, Kannikeswaran N, Arora R. A Case of Testicular Rupture Diagnosed by Point-of-Care-Ultrasound. Pediatr Emerg Care 2017; 33:516-518. [PMID: 28665898 DOI: 10.1097/pec.0000000000001192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Point-of-care ultrasound is an expanding diagnostic tool in the pediatric emergency department. We describe a case of testicular rupture diagnosed by ultrasound at the bedside, which led to prompt surgical intervention and repair.
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Affiliation(s)
- Sean Indra
- From the Children's Hospital of Michigan, Detroit Medical Center, Detroit, MI
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Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
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Marin JR, Lewiss RE. Point-of-care ultrasonography by pediatric emergency physicians. Policy statement. Ann Emerg Med 2016; 65:472-8. [PMID: 25805037 DOI: 10.1016/j.annemergmed.2015.01.028] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Indexed: 01/10/2023]
Abstract
Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.
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Henneberry RJ, Hanson A, Healey A, Hebert G, Ip U, Mensour M, Mikhail P, Miller S, Socransky S, Woo M. Use of point of care sonography by emergency physicians. CAN J EMERG MED 2015; 14:106-12. [DOI: 10.2310/8000.caepps] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
The use of ultrasonography in medical practice has evolved dramatically over the last few decades and will continue to improve as technological advances are incorporated into daily medical practice. Although ultrasound machine size and equipment have evolved, the basic principles and fundamental functions have remained essentially the same. This article reviews the general ultrasound apparatus design, the most common probe types available, and the system controls used to manipulate the images obtained. Becoming familiar with the machine and the controls used for image generation optimizes the scans being performed and enhances the use of ultrasound in patient care.
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Affiliation(s)
- J Luis Enriquez
- Department of Emergency Medicine, Maricopa Medical Center, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA.
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24
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Abstract
A 35-day-old female infant presents to the pediatric emergency department with increased crying and persistent fullness in the right groin. On examination, the infant was noted to have increased fullness and a nonreducible mass in the right mons pubis. Point-of-care ultrasound was used to help diagnose an incarcerated ovary, allowing for expedited care while waiting for confirmatory imaging. The infant underwent surgery with salvage of the ovary.
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Altinkilic B, Pilatz A, Weidner W. Detection of Normal Intratesticular Perfusion Using Color Coded Duplex Sonography Obviates Need for Scrotal Exploration in Patients with Suspected Testicular Torsion. J Urol 2013; 189:1853-8. [DOI: 10.1016/j.juro.2012.11.166] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Bora Altinkilic
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, Giessen, Germany
| | - Adrian Pilatz
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, Giessen, Germany
| | - Wolfgang Weidner
- Department of Urology, Pediatric Urology and Andrology, Justus Liebig University Giessen, Giessen, Germany
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27
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Evans CS, Harris NS. Ultrasound and Ski Resort Clinics: Mapping Out the Potential Benefits. Wilderness Environ Med 2012; 23:239-47. [PMID: 22704080 DOI: 10.1016/j.wem.2012.03.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 03/21/2012] [Accepted: 03/22/2012] [Indexed: 01/10/2023]
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Holliman CJ, Mulligan TM, Suter RE, Cameron P, Wallis L, Anderson PD, Clem K. The efficacy and value of emergency medicine: a supportive literature review. Int J Emerg Med 2011; 4:44. [PMID: 21781295 PMCID: PMC3158547 DOI: 10.1186/1865-1380-4-44] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 07/22/2011] [Indexed: 11/10/2022] Open
Abstract
Study objectives The goal of this study was to identify publications in the medical literature that support the efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. In this study we use the term "value" to refer both to the "efficacy of clinical care" in terms of achieving desired patient outcomes, as well as "efficiency" in terms of effective and/or cost-effective utilization of healthcare resources in delivering emergency care. A comprehensive listing of publications describing the efficacy or value of EM has not been previously published. It is anticipated that the accumulated reference list generated by this study will serve to help promote awareness of the value of EM as a medical specialty, and acceptance and development of the specialty of EM in countries where EM is new or not yet fully established. Methods The January 1995 to October 2010 issues of selected journals, including the EM journals with the highest article impact factors, were reviewed to identify articles of studies or commentaries that evaluated efficacy, effectiveness, and/or value related to EM as a specialty or to clinical care delivered by EM practitioners. Articles were included if they found a positive or beneficial effect of EM or of EM physician-provided medical care. Additional articles that had been published prior to 1995 or in other non-EM journals already known to the authors were also included. Results A total of 282 articles were identified, and each was categorized into one of the following topics: efficacy of EM for critical care and procedures (31 articles), efficacy of EM for efficiency or cost of care (30 articles), efficacy of EM for public health or preventive medicine (34 articles), efficacy of EM for radiology (11 articles), efficacy of EM for trauma or airway management (27 articles), efficacy of EM for using ultrasound (56 articles), efficacy of EM faculty (34 articles), efficacy of EM residencies (24 articles), and overviews and editorials of EM efficacy and value (35 articles). Conclusion There is extensive medical literature that supports the efficacy and value for both EM as a medical specialty and for emergency patient care delivered by trained EM physicians.
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Affiliation(s)
- C James Holliman
- The Center for Disaster and Humanitarian Assistance Medicine, Uniformed Services University of the Health Sciences, and George Washington University School of Medicine and Health Sciences, Bethesda, MD, USA.
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31
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Adhikari S, Blaivas M. WITHDRAWN: Point-of-care emergency ultrasound evaluation of acute scrotal pain in the ED. Am J Emerg Med 2011:S0735-6757(11)00052-0. [PMID: 21450431 DOI: 10.1016/j.ajem.2011.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 01/15/2011] [Accepted: 01/16/2011] [Indexed: 11/24/2022] Open
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Srikar Adhikari
- Department of Emergency Medicine, University of Arizona Health Sciences Center, Tucson, AZ
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33
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Fry E, Counselman FL. A right scrotal abscess and foreign body ingestion in a schizophrenic patient. J Emerg Med 2010; 38:587-592. [PMID: 18155384 DOI: 10.1016/j.jemermed.2007.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 02/01/2007] [Accepted: 03/22/2007] [Indexed: 05/25/2023]
Abstract
A 38-year-old man with a history of schizophrenia presented with pain and swelling of his testicles, with the right side worse than the left. Physical examination was remarkable for a very firm, large, right-sided scrotal mass. Testicular ultrasound was suspicious for neoplasm or abscess. On the pelvic computed tomography (CT) scan, which was obtained as part of a metastatic cancer work-up, two metallic foreign bodies were identified in the pelvis. On further questioning, the patient admitted to ingesting the nails 2 days prior, in a suicide attempt. We review the evaluation of unilateral scrotal pain and swelling, and incidental foreign body ingestion.
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Affiliation(s)
- Emily Fry
- Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Yagil Y, Naroditsky I, Milhem J, Leiba R, Leiderman M, Badaan S, Gaitini D. Role of Doppler ultrasonography in the triage of acute scrotum in the emergency department. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2010; 29:11-21. [PMID: 20040771 DOI: 10.7863/jum.2010.29.1.11] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE The purpose of this study was to examine the triage role of scrotal Doppler ultrasonography (DUS) as the primary preoperative diagnostic tool in patients presenting to the emergency department (ED) with acute scrotum. METHODS Patients who presented to the ED with acute scrotum and underwent scrotal DUS in the ultrasound unit over a 3-year period (2004-2007) were included in the study. Patient characteristics, DUS findings, and clinical management were retrospectively collected and reviewed. Doppler ultrasonographic diagnoses were compared with histopathologic findings for patients who underwent exploration and with final diagnoses at the time of discharge for patients undergoing medical treatment. RESULTS A total of 620 consecutive patients with 669 DUS examinations were included. The most common scrotal DUS diagnoses were epididymitis, hydrocele, varicocele, and orchitis. Scrotal trauma was present in 77 cases. Hospitalization followed the initial ED evaluation for 155 patients; 68 underwent surgery. Testicular torsion was ultrasonographically suspected in 20 patients and confirmed in 18. Scrotal malignancy was incidentally diagnosed in 13 patients and testicular hematoma in 8. Doppler ultrasonography for the diagnosis of testicular torsion had 94% sensitivity, 96% specificity, 95.5% accuracy, an 89.4% positive predictive value (PPV), and a 98% negative predictive value (NPV). Doppler ultrasonography for the diagnosis of testicular malignancy had 92% sensitivity, 95% specificity, 94% accuracy, a 78.5% PPV, and a 98% NPV. CONCLUSIONS Scrotal DUS is a highly sensitive preoperative diagnostic tool, thereby validating its routine use in the initial triage of patients with acute scrotum presenting to the ED.
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Affiliation(s)
- Yael Yagil
- Department of Medical Imaging, Rambam Health Care Campus, PO Box 9602, Ha'Aliya St 8, 31096 Haifa, Israel
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Akhtar S, Theodoro D, Gaspari R, Tayal V, Sierzenski P, Lamantia J, Stahmer S, Raio C. Resident training in emergency ultrasound: consensus recommendations from the 2008 Council of Emergency Medicine Residency Directors Conference. Acad Emerg Med 2009; 16 Suppl 2:S32-6. [PMID: 20053207 DOI: 10.1111/j.1553-2712.2009.00589.x] [Citation(s) in RCA: 143] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Over the past 25 years, research performed by emergency physicians (EPs) demonstrates that bedside ultrasound (US) can improve the care of emergency department (ED) patients. At the request of the Council of Emergency Medicine Residency Directors (CORD), leaders in the field of emergency medicine (EM) US met to delineate in consensus fashion the model "US curriculum" for EM residency training programs. The goal of this article is to provide a framework for providing US education to EM residents. These guidelines should serve as a foundation for the growth of resident education in EM US. The intent of these guidelines is to provide minimum education standards for all EM residency programs to refer to when establishing an EUS training program. The document focuses on US curriculum, US education, and competency assessment. The use of US in the management of critically ill patients will improve patient care and thus should be viewed as a required skill set for all future graduating EM residents. The authors consider EUS skills critical to the development of an emergency physician, and a minimum skill set should be mandatory for all graduating EM residents. The US education provided to EM residents should be structured to allow residents to incorporate US into daily clinical practice. Image acquisition and interpretation alone are insufficient. The ability to integrate findings with patient care and apply them in a busy clinical environment should be stressed.
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Affiliation(s)
- Saadia Akhtar
- Department of Emergency Medicine, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY, USA.
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Emergency ultrasound guidelines. Ann Emerg Med 2009; 53:550-70. [PMID: 19303521 DOI: 10.1016/j.annemergmed.2008.12.013] [Citation(s) in RCA: 403] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 12/10/2008] [Accepted: 12/10/2008] [Indexed: 02/06/2023]
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Abstract
PURPOSE OF REVIEW Emergency bedside ultrasound has been used by emergency and critical care physicians for over two decades. Its use has grown rapidly in emergency medicine and the range of diagnostic and procedural applications has continued to expand; only recently, however, has this tool been embraced by pediatric emergency and critical care physicians. As this technology develops and becomes more available pediatricians should understand its uses and limitations. RECENT FINDINGS Use of emergency bedside ultrasound for victims of trauma and for procedural applications such as central venous access are well established in adults. Recent published studies suggest that utilizing bedside ultrasound for these purposes may be beneficial in pediatric emergency medicine. Other reports portend future pediatric applications such as assessment of volume status and dehydration, fracture identification and reduction, and aiding in the performance of lumbar punctures. SUMMARY In a review of the literature, it is clear that emergency bedside ultrasound has a role in pediatric emergency and critical care medicine. Much more research is needed, however, to determine which sonographic assessments are of the greatest value. Collaborative efforts will likely be needed to establish definitive applications.
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Abstract
Bedside emergency ultrasound has been used by emergency physicians for >20 years for a variety of conditions. In adult centers, emergency ultrasound is routinely used in the management of victims of blunt abdominal trauma, in patients with abdominal aortic aneurysm and biliary disease, and in women with first-trimester pregnancy complications. Although its use has grown dramatically in the last decade in adult emergency departments, only recently has this tool been embraced by pediatric emergency physicians. As the modality advances and becomes more available, it will be important for primary care pediatricians to understand its uses and limitations and to ensure that pediatric emergency physicians have access to the proper training, equipment, and experience. This article is meant to review the current literature relating to emergency ultrasound in pediatric emergency medicine, as well as to describe potential pediatric applications.
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Affiliation(s)
- Jason A Levy
- Division of Emergency Medicine, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA.
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Tsai MH, Lien R, Chao HC, Huang HR, Chu SM. Orchitis as a rare complication of meningococcemia in a young infant. Eur J Pediatr 2007; 166:613-4. [PMID: 17387516 DOI: 10.1007/s00431-006-0388-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Accepted: 11/23/2006] [Indexed: 12/01/2022]
Affiliation(s)
- Ming-Horng Tsai
- Department of Pediatrics, Division of Neonatology, Chang Gung Children's Hospital, Fushing Street 5-7, Gueishan Shiang, Taoyuan, Taiwan, Republic of China
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Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: The evolution of a new imaging paradigm. Crit Care Med 2007; 35:S126-30. [PMID: 17446770 DOI: 10.1097/01.ccm.0000260623.38982.83] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The tradition of clinical ultrasound in the hands of physicians who provide critical care to the most acutely ill patients stretches back into the 1980s and is rich with experiences from surgical, emergency medicine, and other practices. Now, as critical care ultrasound explodes around the world, it is important to realize the path its development has taken and learn from trials and tribulations of early practitioners in the field. The development and battles for the right to use ultrasound at the patient's bedside for >20 yrs is described in relation to its emergency medicine and surgical origins. Approaches to education, scanning, documentation, and organization at the national and regional levels are described.
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Affiliation(s)
- John L Kendall
- Emergency Ultrasound, Denver Health Medical Center, Denver, CO, USA.
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42
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Hegenbarth MA. Bedside ultrasound in the pediatric emergency department: Basic skill or passing fancy? CLINICAL PEDIATRIC EMERGENCY MEDICINE 2004. [DOI: 10.1016/j.cpem.2004.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Acute scrotal pain makes up approximately 0.5% of all complaints presenting to an emergency department. Some of the most com-mon diagnoses for this complaint are testicular torsion and epididymitis. Misdiagnosing testicular torsion can lead to organ loss,cosmetic deformity, and compromised fertility. Modem ultrasound examination of the scrotum is the test of choice for acute scrotal pathology and yields high accuracy compared with surgical exploration. A key component of the testicular examination is use of power and spectral Doppler ultrasonography. Examination of the acute scrotum should not be undertaken unless Doppler capability is available because the evaluation of blood flow is such an important part of diagnosis of testicular torsion, orchitis, epididymitis,trauma, and hemorrhage into a mass.
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Affiliation(s)
- Michael Blaivas
- Section of Emergency Ultrasound, Department of Emergency Medicine, Medical College of Georgia, 1120 15th Street, AF-2039, Augusta, GA 30912-4007, USA.
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Abstract
For longer than 40 years, ultrasound (US) has been a widely used imaging tool in medical practice, which has proved helpful for the diagnosis and staging of diseases. Although three-dimensional ultrasound (3D) US has been available for more than 10 years, it was only through the development of the most recent computer technologies and its adaptation to ultrasound systems, that 3D US has become able to achieve the high level of sensitivity and performance necessary to be considered seriously in clinical practice. 3D US is rapidly turning into a technology with an ever-increasing range of applications in numerous fields because, among other reasons, it helps overcome some of the key limitations related to two-dimensional imaging. 3D US can be used in ultrasonography for small parts, among other medical areas. The assessment of the testicle, parotid, thyroid and parathyroid glands is properly achieved. The multiplanar presentation and niche mode are quite useful to determine the extension--inside or outside the organs-, of nodules, cysts or tumors. The volume measurement is better assessed with 3D US and given this, we can perform studies that follow growth in order to decide medical or surgical treatment. The VOCAL makes it possible to obtain a proper after-treatment follow-up of focal disorders in these small organs. Neovascularization is clearly viewed with 3D US and probably can suggest malignant origin of a neoplasm. 3D US offers a more comprehensive image of anatomical structures and pathological conditions and also permits to observe the exact spatial relationships. We are aware more studies are needed to demonstrate specificity and sensibility of 3D US in particular clinical conditions, not only in small parts but also is some other non-Ob/Gyn applications.
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Affiliation(s)
- Leandro J Fernandez
- Laboratorio de Ecografia Avanzada, Instituto Medico La Floresta, Caracas, Venezuela.
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45
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Abstract
PURPOSE This article reviews the acute, nontraumatic scrotal conditions of testicular torsion, torsion of an epididymal or testicular appendage, and epididymitis in order to assist the nurse practitioner (NP) with arriving at a diagnosis. Primary and emergency care management are presented. DATA SOURCES Selected published literature in refereed journals and the authors' clinical experiences. CONCLUSIONS Signs and symptoms of testicular pathologies can overlap, making diagnosis problematic. However, key features can raise the NP's index of suspicion for a particular diagnosis and can assist in selecting the most appropriate management strategy. IMPLICATIONS FOR PRACTICE Although these conditions are rarely fatal, they may carry a risk of morbidity in the form of testicular necrosis, infarction, or atrophy with concomitant infertility. Any patient with scrotal or testicular pain should be presumed to have testicular torsion until proven otherwise, as this condition carries a high degree of morbidity. The information gained through a thorough history and physical examination can assist in arriving at the proper diagnosis.
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Affiliation(s)
- Frank L Cole
- Division Head of Emergency Care, School of Nursing, University of Texas Health Science Center, Houston, USA.
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46
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Blaivas M, Theodoro D, Sierzenski PR. Elevated intracranial pressure detected by bedside emergency ultrasonography of the optic nerve sheath. Acad Emerg Med 2003; 10:376-81. [PMID: 12670853 DOI: 10.1111/j.1553-2712.2003.tb01352.x] [Citation(s) in RCA: 157] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED Patients with altered level of consciousness may be suffering from elevated intracranial pressure (EICP) from a variety of causes. A rapid, portable, and noninvasive means of detecting EICP is desirable when conventional imaging methods are unavailable. OBJECTIVES The hypothesis of this study was that ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) could accurately predict the presence of EICP. METHODS The authors performed a prospective, blinded observational study on emergency department (ED) patients with a suspicion of EICP due to possible focal intracranial pathology. The study was conducted at a large community ED with an emergency medicine residency program and took place over a six-month period. Patients suspected of having EICP by an ED attending were enrolled when study physicians were available. Unstable patients were excluded. ONSD was measured 3 mm behind the globe using a 10-MHz linear probe on the closed eyelids of supine patients, bilaterally. Based on prior literature, an ONSD above 5 mm on ultrasound was considered abnormal. Computed tomography (CT) findings defined as indicative of EICP were the presence of mass effect with a midline shift 3 mm or more, a collapsed third ventricle, hydrocephalus, the effacement of sulci with evidence of significant edema, and abnormal mesencephalic cisterns. For each patient, the average of the two ONSD measurements was calculated and his or her head CT scans were evaluated for signs of EICP. Student's t-test was used to compare ONSDs in the normal and EICP groups. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS Thirty-five patients were enrolled; 14 had CT results consistent with EICP. All cases of CT-determined EICP were correctly predicted by ONSD over 5 mm on US. One patient with ONSD of 5.7 mm in one eye and 3.7 mm in the other on US had a mass abutting the ipsilateral optic nerve; no shift was seen on CT. He was placed in the EICP category on his data collection sheet. The mean ONSD for the 14 patients with CT evidence of EICP was 6.27 mm (95% CI = 5.6 to 6.89); the mean ONSD for the others was 4.42 mm (95% CI = 4.15 to 4.72). The difference of 1.85 mm (95% CI = 1.23 to 2.39 mm) yielded a p = 0.001. The sensitivity and specificity for ONSD, when compared with CT results, were 100% and 95%, respectively. The positive and negative predictive values were 93% and 100%, respectively. CONCLUSIONS Despite small numbers and selection bias, this study suggests that bedside ED US may be useful in the diagnosis of EICP.
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Affiliation(s)
- Michael Blaivas
- Department of Emergency Medicine, Medical College of Georgia, 1120 15th Street, AF-2056, Augusta, GA 30912-4007, USA.
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47
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Blaivas M. Color doppler in the diagnosis of ectopic pregnancy in the emergency department: is there anything beyond a mass and fluid? J Emerg Med 2002; 22:379-84. [PMID: 12113849 DOI: 10.1016/s0736-4679(02)00431-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pregnant patients with first trimester complications are a common presentation in many Emergency Departments (EDs). The burden of disproving the existence of an ectopic pregnancy falls on the Emergency Physician (EP). This may be a difficult task depending on the availability of specialty backup and radiologic services. For more than a decade EPs have documented use of bedside ultrasonography for ruling out cases of ectopic pregnancy. Now, with the entry of newer technology into many emergency ultrasound programs, color Doppler is available to an increasing number of EPs. Color Doppler is used as an adjunct to diagnosing ectopic pregnancy by both radiology and gynecology practitioners and can at times provide critical information regarding early pregnancy. Presented are three cases of ectopic pregnancy diagnosed on the basis of abnormal color Doppler findings, and a discussion of the technique.
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Affiliation(s)
- Michael Blaivas
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York 11030, USA
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