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Introduction: Diagnosing deep venous thromboses and venous thromboemboli (DVT/VTE) in pregnant patients presents a unique challenge for emergency physicians. The risk of DVT/VTE increases during pregnancy, and the potential consequences of misdiagnoses are severe. Point-of-care ultrasonography (POCUS) is frequently a first-line diagnostic imaging modality. However, recent studies have shown a high incidence of thromboses proximal to the common femoral vein during pregnancy, and these would not be visualized using compressive ultrasonography, which traditionally can only visualize thromboses distal to the femoral vein.Case Report: A 38-year-old female, 25-weeks primiparous, presented to the emergency department with a three-day history of left lower extremity swelling. Point-of-care three-point compression testing was used to evaluate for a DVT; however, no thrombus was visualized. Given high clinical suspicion, color and spectral Doppler testing were performed and demonstrated turbulent flow and reduced respiratory variation in the common femoral vein. This prompted further additional testing for a proximal DVT using magnetic resonance venography, which revealed an occlusive left external iliac thrombus. The patient was subsequently started on daily subcutaneous enoxaparin and discharged home with close follow-up.Conclusion: Emergency physicians play a critical role in evaluations for the presence of DVT/VTE, particularly in pregnant patients. We endorse the use of POCUS with three-point compression testing, as well as color and spectral Doppler imaging, to help identify proximal DVTs in this patient population. This case report can aid physicians in the diagnosis of this pathological condition that if left untreated can have severe consequences.

In patients presenting with severe dyspnea, several diagnostic challenges arise in distinguishing the diagnosis of pneumothorax versus several other pulmonary etiologies like bullous lung disease, pneumonia, interstitial lung disease, and acute respiratory distress syndrome. Distinguishing between large pulmonary bullae and pneumothorax is of the utmost importance, as the acute management is very different. While multiple imaging modalities are available, plain radiographs may be inadequate to make the diagnosis and other advanced imaging may be difficult to obtain. Ultrasound has a very high specificity for pneumothorax. We present a case where a large pulmonary bleb mimics the lung point and therefore inaccurately suggests pneumothorax. [West J Emerg Med. 2015;16(3):447–449.]

Introduction: As the prevalence of patients with left ventricular assist devices (LVAD) presenting to the emergency department (ED) increases, clinicians must be aware of LVAD-associated infections.Case Report: A well-appearing, 41-year-old male with history of heart failure status post prior-LVAD placement presented to the ED for swelling of his chest. What appeared initially as a superficial infection was further assessed with point-of-care ultrasound and found to represent a chest wall abscess involving the driveline, ultimately resulting in sternal osteomyelitis and bacteremia.Conclusion: Point-of-care ultrasound should be considered an important tool in the initial assessment of potential LVAD-associated infection.

Introduction: Uterine rupture is a rare but potentially fatal complication of pregnancy. The incidence of uterine rupture is estimated to be between 0.3 and 11 per 10,000. Additionally, uterine sacculation is a sac or outpouching of the uterus that can lead to uterine rupture in pregnancy. Here we describe a case of a patient who was found to have a uterine sacculation on point-of-care ultrasound in the emergency department (ED) that was complicated by uterine rupture.Case Report: A 32-year-old female at approximately 18 weeks gestation presented to the ED with three days of abdominal discomfort. The patient’s medical history was significant for prior uterine fibroids requiring recent myomectomy. On arrival the patient was tachycardic, and her abdominal exam revealed distention with mild tenderness to palpation in all quadrants. A point-of-care transabdominal obstetric ultrasound was performed to evaluate the fetal heart rate, which was 157 beats per minute; it also revealed a defect in the uterine wall compatible with a uterine sacculation. The patient underwent magnetic resonance imaging, which revealed a sac-like structure in the fundal portion of the uterus containing a portion of gestational sac and pregnancy contents. Subsequently, she became hypotensive and tachycardic and was taken emergently to the operating room for concern for uterine rupture. Intraoperatively, uterine rupture was confirmed. The patient underwent surgical repair with evacuation of fetal tissue and recovered in the surgical intensive care unit.Conclusion: Point-of-care ultrasound is a useful and readily available procedure to identify uterine sacculation. Early identification can help escalate the urgency of the patient complaint and may lead to a need for further maternal-fetal evaluation. Emergency physicians should keep a high index of suspicion when evaluating the pregnant patient with a history of uterine surgery.

Introduction: Ruptured ectopic pregnancy is one of the leading causes of maternal death. Point-of-care ultrasound (POCUS) has been shown to be highly sensitive for excluding ectopic pregnancy.Ectopic pregnancy after a hysterectomy is a rare but life-threatening occurrence. We present a case where POCUS helped to diagnose a post-hysterectomy ectopic pregnancy.Case report: A 36-year-old female with a prior surgical history of hysterectomy without oophorectomy presented to the emergency department with lower abdominal pain. A POCUS revealed free fluid in the right upper quadrant with an unremarkable gallbladder. Subsequently, the pelvic POCUS noted free fluid as well as a heterogeneous structure in the right adnexa. The clinician ordered a serum beta human chorionic gonadotropin level, which was 173.2 international units per milliliter (lU/mL) (negative: < 5m IU/ml). Transvaginal ultrasound revealed a right adnexal echogenic structure with surrounding vascularity and moderate, complex free fluid suggestive of hemorrhage. Given the concern for possible ectopic pregnancy, obstetrics took the patient to the operating room where a right tubal ectopic pregnancy was confirmed.Conclusion: A ruptured ectopic pregnancy is a life-threatening condition that requires rapid diagnosis. Ectopic pregnancy post hysterectomy is an uncommon occurrence infrequently considered in the differential diagnosis of lower abdominal pain, leading to considerable delays in diagnosis. Although uncommon, emergency clinicians must consider this diagnosis in female patients with lower abdominal pain.

Introduction: Coronavirus disease 2019 (COVID-19) may predispose patients to increased risk of venous thromboembolism (VTE) due to various pathophysiological mechanisms, including but not limited to endothelial injury, inflammation, cytokine-mediated microvascular damage, and reactive thrombocytosis. A high risk of vessel thrombosis correlates with disease severity, making early identification and treatment of prime consideration.Although identification of a deep venous thrombosis (DVT) or pulmonary embolism warrants immediate treatment with anticoagulation, trying to predict which COVID-19 patients may be at increased risk for developing these pathologies is challenging.Case Reports: We present two cases of patients with COVID-19 who had ultrasonographic findings of turbulent blood flow within the deep venous system, without clear evidence of acute proximal DVT, who were subsequently found to have significant VTE.   Conclusion: Point-of-care lower extremity ultrasound has become one of the core applications used by emergency physicians. Typically we perform compression ultrasound for DVT evaluation. This novel finding of turbulent blood flow, or “smoke,” within the deep venous system, may serve as a marker of increased risk of clot development and could be an indication to consider early anticoagulation.

Introduction: Retrobulbar hemorrhage (RBH) is a rare complication of facial trauma that can lead to dangerous orbital compartment pressures and must be rapidly recognized to prevent permanent vision loss. Point-of-care ultrasound (POCUS) offers a rapid modality for evaluating a wide variety of ocular pathologies, and prior case reports demonstrate the ability of clinicians to recognize RBH using ultrasound. This study aimed to assess the ability of clinicians at various stages of training to identify a RBH using POCUS in a cadaveric model. Clinicians also were assessed for self-reported comfort using ultrasound for ocular pathology before and after the study.Methods: Participants included 17 physicians who evaluated 10 eyes (from five cadavers) that were independently randomized to have either a modeled RBH or no hemorrhage. Participants’ final diagnosis of each eye was recorded (RBH present or not), and participants also completed pre- and post-activity surveys.Results: The overall sensitivity and specificity to correctly diagnose retrobulbar fluid was 87% and 88%, respectively. Sensitivity and specificity were higher after excluding clinicians in their early phase of training. Additionally, self-reported comfort level with ocular ultrasound was significantly improved by this activity.Conclusion: Emergency physicians at a variety of training levels can correctly identify a cadaveric model of retrobulbar hemorrhage. Use of this cadaveric model can improve exposure of clinicians to the appearance of a rare but vision-threatening ocular pathology such as RBH.

Gastric outlet obstruction (GOO) is a rare condition occurring as a consequence of numerous processesthat prevent gastric emptying. Presenting symptoms of GOO are non-specific and include nausea, vomiting, epigastric discomfort and decreased appetite. The diagnosis of GOO is often challenging. Emergency physicians must have a heightened awareness of GOO to ensure proper diagnosis and rapid treatment. Although the gold standard for diagnoses of GOO is endoscopy, many patients are identified by computerized tomography imaging. Point-of-care ultrasound (POCUS) is a rapid and non-invasive technique for evaluating patients in the emergency department. Previous literature has validated the use of ultrasound in diagnosing various intra-abdominal pathologies including bowel obstructions and appendicitis; however, there is limited research on evaluating gastric disease.1 We report three cases of GOO diagnosed with the “black-and-white cookie” sign on POCUS.

Introduction: Diagnosing deep venous thromboses and venous thromboemboli (DVT/VTE) in pregnant patients presents a unique challenge for emergency physicians. The risk of DVT/VTE increases during pregnancy, and the potential consequences of misdiagnoses are severe. Point-of-care ultrasonography (POCUS) is frequently a first-line diagnostic imaging modality. However, recent studies have shown a high incidence of thromboses proximal to the common femoral vein during pregnancy, and these would not be visualized using compressive ultrasonography, which traditionally can only visualize thromboses distal to the femoral vein. Case Report: A 38-year-old female, 25-weeks primiparous, presented to the emergency department with a three-day history of left lower extremity swelling. Point-of-care three-point compression testing was used to evaluate for a DVT; however, no thrombus was visualized. Given high clinical suspicion, color and spectral Doppler testing were performed and demonstrated turbulent flow and reduced respiratory variation in the common femoral vein. This prompted further additional testing for a proximal DVT using magnetic resonance venography, which revealed an occlusive left external iliac thrombus. The patient was subsequently started on daily subcutaneous enoxaparin and discharged home with close follow-up. Conclusion: Emergency physicians play a critical role in evaluations for the presence of DVT/VTE, particularly in pregnant patients. We endorse the use of POCUS with three-point compression testing, as well as color and spectral Doppler imaging, to help identify proximal DVTs in this patient population. This case report can aid physicians in the diagnosis of this pathological condition that if left untreated can have severe consequences. [ABSTRACT FROM AUTHOR]

Prosthetic hip dislocation is a common but unfortunate complication in patients who have undergone total hip arthroplasty. Successful closed reduction in the emergency department leads to a reduced length of stay and rate of hospitalization.1,2 The use of regional anesthesia by femoral nerve block represents a novel approach for controlling pain in patients with hip pathologies.3 Ultrasound-guided approaches have been used with great success for controlling pain in patients with hip fractures.4,5 Here we report the case of a 90-year-old male who presented with a dislocated hip prosthesis, which was subsequently corrected with closed reduction following delivery of regional anesthesia to the femoral nerve under ultrasound guidance. To our knowledge, this represents the first reported use of an ultrasound-guided femoral nerve block to facilitate closed reduction of a dislocated prosthetic hip, and highlights a novel approach that avoids the use of procedural sedation in an elderly patient.

We present a case of a 12-year-old female with a history of congenital solitary kidney presenting to an academic pediatric emergency department (ED) in acute abdominal pain. Using ultrasound as the initial diagnostic modality, the patient was found to have Herlyn-Werner-Wunderlich syndrome (HWWS), an abnormal development of the Müllerian system during embryogenesis resulting in obstructed hemivagina with resulting hematometrocolpos. The patient presented with undifferentiated abdominopelvic pain, and in the course of the ED workup was diagnosed witha disorder in frequently encountered by emergency physicians. We present a case of markedly abnormal point-of-care ultrasound findings prompting additional studies, ultimately leading to a diagnosis of HWWS during the initial ED visit.

Choledochal cysts are rare but serious bile duct abnormalities found in young children, usually during the first year of life.1 They require urgent surgical intervention due to the risk of developing cholangiocarcinoma.2 Clinicians should consider this diagnosis and perform a point-of-care ultrasound (POCUS) when a child presents to the emergency department (ED) with findings of jaundice, abdominal pain, and the presence of an abdominal mass. We present the case of a six-year-old child presenting only with abdominal pain upon arrival to our ED and was ultimately diagnosed by POCUS to have a choledochal cyst.

Vaginal bleeding in early pregnancy is a common emergency department complaint. Point-of-care ultrasound is a useful tool to evaluate for intrauterine ectopic pregnancy. Emergency physicians performing these studies need to be cognizant of artifacts produced by ultrasound technology, as they can lead to misdiagnosis. We present two cases where mirror-image artifacts initially led to a concern for heterotopic pregnancies but were excluded on further imaging. [West J Emerg Med. 2014;15(6):-0]

Ketamine associated urinary dysfunction has become increasingly more common worldwide. Point-of-care ultrasound (POCUS) is an established modality for diagnosing hydronephrosis in the emergency department. We describe a case of a young male ketamine abuser with severe urinary urgency and frequency in which POCUS performed by the emergency physician demonstrated bilateral hydronephrosis and a focally thickened irregular shaped bladder. Emergency physicians should consider using POCUS evaluate for hydronephrosis and bladder changes in ketamine abusers with lower urinary tract symptoms. The mainstay of treatment is discontinuing ketamine abuse. [West J Emerg Med. 2014;15(4):382–384.]

Lower abdominal pain in females of reproductive age continues to be a diagnostic dilemma for the emergency physician (EP). Point-of-care ultrasound (US) allows for rapid, accurate, and safe evaluation of abdominal and pelvic pain in both the pregnant and non-pregnant patient. We present 3 cases of females presenting with right lower quadrant and adnexal tenderness where transvaginal ultrasonography revealed acute appendicitis. The discussion focuses on the use of EP-performed transvaginal US in gynecologic and intra-abdominal pathology and discusses the use of a staged approach to evaluation using US and computed tomography, as indicated. [West J Emerg Med. 2013;14(5):415-418.]

Background: Chest injury can result in life-threatening complications like tension pneumothorax, in which rapid deterioration can occur without decompression. Traditionally, the second intercostal space (ICS) along the mid-clavicular line is taught as the site for decompression. However, this has been questioned due to high rates of treatment failure. The fifth ICS on the mid-axillary line (MAL) is hypothesized to have a shorter distance from skin to pleura based on recent studies.Objective: The purpose of this study was to use point-of-care ultrasound (POCUS) to compare chest wall thickness at these two locations. The primary objective was to evaluate the distance from skin to pleura line at the second ICS along the mid-clavicular line and the fifth ICS along the MAL. Secondarily, we aimed to evaluate inter-rater reliability of the two assessments.Methods: This was a single-center, observational, pilot study. POCUS was performed using a linear transducer. Measurements of skin to pleura line were obtained at the right second ICS and fifth ICS. These measurements were then repeated by a blinded second ultrasonographer. Intraclass correlations (ICCs) for each measurement site were calculated to determine the inter-rater reliability.Results: Ninety-three percent of volunteers had a smaller chest wall distance at the fifth ICS-MAL. The median distance at the second and fifth ICS was 2.28 cm and 1.80 cm. The ICC for second ICS was 0.75 (95% CI 0.54-0.87), and 0.90 for the fifth ICS (95% CI 0.81-0.95), both indicating good reliability.Conclusions: The data support that patients have a smaller chest wall distance at the fifth ICS vs. the second ICS. We support performing needle decompression at the fifth ICS and believe POCUS can be used to determine the optimal location for decompression. [ABSTRACT FROM AUTHOR]

Synthesis of inducible heat shock protein 70 (HSP70) is impaired in aged animals following acute stresses including exercise. In this study we determined whether aging affects expression of this cytoprotective protein following chronic exercise participation. Male Fischer 344 rats, final ages 6 and 24 months, exercised identically for 10 weeks on a treadmill (15[degrees] incline, 15 m/min for up to 60 miuutes, 5 days/week). In 6-month-old animals, exercise increased HSPT0 in heart (44%), liver (216%), and skeletal muscle (126%) (p < .05 vs sedentary). In 24-month-old animals, exercise increased HSP70 in muscle (69%), but not in heart or liver. In heart, antioxidant enzyme activities and HSP70 messenger RNA were measured and found to be unaffected by exercise at both ages. Our results indicate an age-related decrease in HSP70 production in heart and liver following chronic exercise. Furthermore, the aged heart does not increase its antioxidant enzyme defenses to compensate for the HSP70 deficit.