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Rib fractures account for a significant number of emergency department visits each year. A patient’s disposition often depends on the severity of rib fractures, comorbidities, and ability to achieve adequate analgesia. We present a 44-year-old male patient with severe pain secondary to rib fractures. The initial disposition was to admit for pain control. However, upon performing a serratus anterior plane block, patient was functionally appropriate for discharge with proper return precautions. Serratus anterior plane block is within the skillset of the emergency physician and can be used to achieve analgesia for rib fractures without the sedative and respiratory depressive effects associated with opioids.

Purpose – The objective of this study was to determine if exposure to a short-term ultrasound basic biology and anatomy course can promote interest in health careers and other science-related endeavors among DHH students. Design/methodology/approach – This was a single-site, prospective observational study of DHH high school students at a Southern California high school. All participants took a pre-test survey prior to the course. Participants then took part in three teaching sessions which taught basic anatomy using point-of-care ultrasound (POCUS). Following instruction, a post-test survey was performed to determine if students had an increased interest in medicine, science and biology (p = 0.151). Findings – 28 students were enrolled in the study, with an equal distribution of boys and girls. Initially, subjects reported their interest in medicine at an average of 2.8 ± 1.10. The reported interest in science was 3.0 ± 1.13 and for biology was 3.0 ± 1.19. The change in participants' interest was not statistically significant for medicine (p = 0.791), science (p = 0.225) and biology. Practical implications – While our data did not demonstrate a statistically significant difference in students' interest in STEM fields after the training course, there were several students who were interested in more hands-on shadow experience after the course. Regardless, this study demonstrates persistent barriers that exist for a person who is deaf or hard of hearing to engage in the STEM fields. Future studies are needed to determine the level of instructional activities that may impact the careers of these students. Originality/value – Point of care ultrasound has been shown to be an effective teaching modality in medical education. However, to date, no studies have been done to assess the utility of ultrasound in teaching the Deaf and Hard of Hearing (DHH) population.

Background: Over the past few years, both the scope and utility of point-of-care ultrasound (POCUS) have tremendously expanded in the clinical setting. Despite this growth, few studies have evaluated the compliance, documentation, and billing of POCUS in the emergency department (ED). The objective of this study was to evaluate the compliance of billing and documentation of POCUS and determine if a single, individualized e-mail feedback can help improve billing and documentation. Methods: We performed a 6-week prospective review of ED POCUSs performed. Following this review, all emergency physicians were sent an individualized e-mail regarding their ultrasound performance including the total number of ultrasounds, ultrasounds per shift, and breakdown of specific ultrasound types. Following this intervention, we collected data from an additional 6 weeks regarding ultrasound billing performance. Results: A total of 1532 POCUS scans were recorded for data collection. Eight hundred and five scans were enrolled in the preintervention group and 727 scans in the postintervention group. Twelve different types of POCUS scans were recorded. The preintervention group had documented 484/805 scans resulting in a 60.1% (confidence interval [CI] 56.7%–63.5%) documentation ratio. The postintervention group had documented 521/727 resulting in a 71.7% (CI 68.2%–74.9%) documentation ratio. Conclusion: The implementation of timely quality assurance with continuous billing reminders is essential for the maintenance and fiscal sustainability of an emergency medicine ultrasound program. Future studies should further elucidate and quantify the financial impact of modifiable factors within EDs' ultrasound documentation and billing practices.

Introduction: High-altitude pulmonary edema (HAPE) occurs as a result of rapid ascent to altitude faster than the acclimatization processes of the body. Symptoms can begin at an elevation of 2,500 meters above sea level. Our objective in this study was to determine the prevalence and trend of developing B-lines at 2,745 meters above sea level among healthy visitors over four consecutive days. Methods: We performed a prospective case series on healthy volunteers at Mammoth Mountain, CA, USA. Subjects underwent pulmonary ultrasound for B-lines over four consecutive days. Results: We enrolled 21 male and 21 female participants. There was an increase in the sum of B-lines at both lung bases from day 1 to day 3, with a subsequent decrease from day 3 to day 4( P

Linear probe point-of-care ultrasound (LPUS) presents a less invasive alternative for identifying intrauterine pregnancies (IUPs) compared to usual practice (transabdominal (TAUS) or transvaginal (TVUS) ultrasound). TAUS and TVUS can be invasive or produce lower-resolution images than LPUS. The purpose of this study is to determine whether a linear probe alone can identify first-trimester IUPs. A convenience sample of 21 patients were enrolled at the University of California Irvine ED during a 7-month period. The inclusion criteria were English- or Spanish-speaking women (≥18 years) in their first trimester of pregnancy (≤12 weeks pregnant) with a body mass index (BMI) of

Case Presentation: A 65-year-old male presented to the emergency department with symptoms including fever, abnormal urinalysis, and elevated post-void residual. Point-of-care ultrasound was used to rapidly diagnose a bladder diverticulum. The patient was subsequently seen by urology for outpatient bladder repair. Discussion: Bladder diverticula, an out-pouching of the bladder, may occur congenitally or as a result of various bladder conditions and/or surgery. Although bladder diverticula are rare and often asymptomatic, severe complications including frequent recurring urinary tract infections may arise depending on the patient.

Context: As the utility of point-of-care ultrasound (POCUS) continues to expand in the medical field, there is a need for effective educational methods. In Switzerland, medical education follows the European model and lasts 6 years, focusing on preclinical training during the first 2 years. No previous studies have evaluated the optimal time for teaching ultrasound in European medical education. Aims: The aim of this study is to provide ultrasound training to medical students in Switzerland at varying times during their clinical training to determine if the level of training plays a role in their ability to comprehend and to apply basic POCUS skills. Methods: We performed an observational study utilizing a convenience sample of Swiss medical students between July 11, 2016 and August 6, 2016. They were taught a 2-day POCUS course by five American-trained 1st-year medical students. Following this course, students were evaluated with written and clinical examination. Results: 100 Swiss medical students were enrolled in the study. A total of 59 of these students were early clinical students, and 41 students were late clinical students. A two-tailed t-test was performed and demonstrated that the late clinical students performed better than the early clinical students on the written assessment; however, no difference was found in clinical skill. Conclusion: Our data suggest that Swiss medical students can learn and perform POCUS after a 2-day instructional taught by trained 1st-year American medical students. No difference was found between students in early clinical training and late clinical training for the ability to perform POCUS.

Introduction: Point-of-care ultrasound (POCUS) in the emergency department (ED) is being performed with increasing frequency. The objective of this study was to demonstrate how utilization of POCUS can help the emergency physician recognize emphysematous pyelitis (EP) and emphysematous pyelonephritis (EPN). Case Report: A 60-year-old female presented to the ED with normal vital signs and intermittent left-sided flank pain that radiated to her groin. She also had a history of obstructive nephrolithiasis. Within 20 minutes of arrival she became febrile (101.2°Fahrenheit), tachycardic (114 beats per minute), tachypneic (21 breaths per minute), and had a blood pressure of 114/82 millimeters mercury. POCUS was conducted revealing heterogeneous artifact with “dirty shadowing” within the renal pelvis, which was strongly suggestive of air. The emergency physician ordered a computed tomography (CT) to confirm the suspicion for EP and started the patient on broad-spectrum antibiotics. The CT showed a 1.3-centimeter calculus and hydronephrosis with foci of air. The patient received intravenous antibiotics and had an emergent nephrostomy tube placed. Urine cultures tested positive for pan-sensitive Escherichia Coli. Urology was consulted and a repeat CT was obtained to show correct drainage and decreased renal pelvis dilation. Conclusion: Distinctly different forms of treatment are used for EP and EPN, despite both having similar pathophysiology. In EP, air can be seen in the renal pelvis on POCUS, as in this case study, which distinguishes it from EPN. In the case of our patient, the use of POCUS was useful to aid in rapid differentiation between EP and EPN.

Case Presentation: A 77-year-old female presented to the emergency department (ED) with chest pain. Cardiac point-of-care ultrasound (POCUS) was performed and demonstrated a hyperechoic structure on the posterior leaflet of the mitral valve. Admission to cardiology and echocardiogram revealed moderately decreased mobility of the posterior leaflet, mitral annular calcification, and severe mitral regurgitation. Discussion: These findings highlight the role of POCUS in identifying mitral valve pathology in the ED, ultimately leading to appropriate disposition and management. Mitral annular calcification can lead to significant manifestations including mitral stenosis or regurgitation, and advanced cases have been associated with an increased risk of infective endocarditis, thrombosis, and arrhythmia.

Background: Point-of-care ocular ultrasound in the emergency department (ED) is an effective tool for promptly evaluating for several vision-threatening etiologies and can be used to identify more slowly progressing etiologies as well, such as cataract formation within the lens. Case Report: A 62-year-old female presented to the ED with a two-day history of painless vision loss of the left eye as well as reduced vision for the prior 30 days. Conclusion: Point-of-care ultrasound was performed and showed calcification of the lens consistent with cataract.

Introduction: The life- or limb-threatening differential diagnosis for upper extremity swelling can include deep vein thrombosis (DVT), infectious processes, and compartment syndrome. Chronic anatomic abnormalities such as axillary vein stenosis are rarely a consideration in the emergency department. Case Report: We present a 26-year-old female with history of Chiari type 1 malformation who presented with acute left arm swelling. Initial workup, including point-of-care ultrasound, revealed the presence of significant soft tissue swelling without evidence of DVT. Conclusion: Further workup revealed an early, localized rhabdomyolysis secondary to axillary vein stenosis or venous thoracic outlet syndrome, also known as Paget-Schroetter syndrome.

Introduction: Sepsis is a systemic infection that can rapidly progress into multi organ failure and shock if left untreated. Previous studies have demonstrated the utility of point of care ultrasound (POCUS) in the evaluation of patients with sepsis. However, limited data exists on the evaluation of the tricuspid annular plane of systolic excursion (TAPSE) in patients with sepsis. Methods: We prospectively enrolled patients who presented to the emergency department (ED) with concern for severe sepsis or septic shock in a pilot study. In patients that screened positive, the treating physician then performed POCUS to measure the TAPSE value. We compared the intensive care unit (ICU) admission rate, hospital length of stay, and morbidity with their respective TAPSE values. Results: We enrolled 24 patients in the study. Eight patients had TAPSE values less than 16 millimeters (mm), two patients had TAPSE values between 16mm–20mm, and fourteen patients had TAPSE values greater than 20mm. There was no statistically significant association between TAPSE levels and ICU admission (p=0.16), or death (p=0.14). The difference of length of stay (LOS) was not statistically significant in case of hospital LOS (p= 0.72) or ICU LOS. Conclusion: Our pilot data did not demonstrate a correlation between severe sepsis or septic shock and TAPSE values. This may be due to several factors including patient comorbidities, strict definitions of sepsis and septic shock, as well as the absence of septic cardiomyopathy (SCM) in patients with sepsis and septic shock. Future large-scale studies are needed to determine if TAPSE can be beneficial in the ED evaluation of patients with concern for SCM.

Background: Establishing a definitive airway is often an initial step in the management of critically ill patients in the emergency department (ED). Currently, there is no universally accepted gold standard for airway confirmation. Recent literature has shown that point-of-care ultrasound (POCUS) may be helpful in confirming the correct endotracheal tube (ETT) placement. Objective: The objective of this study is to evaluate the accuracy of a comprehensive three-window POCUS assessment to confirm correct ETT placement. Methods: This was a prospective, single-center, observational study using a convenience sample of patients in the ED and Medical Intensive Care Unit. After presumed successful ETT intubation, three sonographic windows were obtained, which included the trachea, bilateral lung sliding, and diaphragm movement. Results: We enrolled a total of 140 patients. There were no esophageal intubations. The three-window POCUS method correctly identified 132 of 137 ETTs placed in the trachea with 96.4% sensitivity (95% confidence interval [CI] 91.7%–98.8%) and 33.3% specificity (95% CI 0.8%–90.6%). Only one of the three mainstem intubations was identified using POCUS. Ultrasound assessment was completed on average 25 min quicker than the usual confirmatory plain film radiography (95% CI 6.2–43.9 min, P = 0.005). Conclusions: The three-window POCUS assessment is a rapid and potentially reliable method to identify ETT intubation, but may not be reliable at confirming mainstem intubation.

Introduction: Sudden cardiac death is a rare cause of death in young athletes. Current screening techniques include history and physical exam (H and P), with or without an electrocardiogram (ECG). Adding point of care cardiac ultrasound has demonstrated benefits, but there is limited data about implementing this technology. We evaluated the feasibility of adding ultrasound to preparticipation screening for collegiate athletes. Methods: We prospectively enrolled 42 collegiate athletes randomly selected from several sports. All athletes were screened using a 14-point H and P based on 2014 American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, ECG, and cardiac ultrasound. Results: We screened 11 female and 31 male athletes. On ultrasound, male athletes demonstrated significantly larger interventricular septal wall thickness (p = 0.002), posterior wall thickness (p

A 58-year-old male with no past medical history presented to the emergency department with sudden onset left lower extremity weakness and central chest pain with radiation to his back. Electrocardiogram revealed an acute inferior and posterior ST-segment elevation myocardial infarction (STEMI). Point-of-care ultrasound (POCUS) demonstrated right ventricular akinesis consistent with infarction, and an intimal defect consistent with an aortic dissection. We determined that cardiothoracic surgery was indicated rather than left-heart catheterization and anticoagulation. Using POCUS we were able to immediately diagnose a dissection of the aortic arch and considerably alter treatment in a patient presenting with STEMI.

A 95-year-old female with a history of dementia and atrial fibrillation (not on anticoagulation) presented to the emergency department (ED) by ambulance from her skilled nursing facility due to hypoxia. Point-of-care ultrasound was performed, and showed evidence of a large mobile thrombus in the right ventricle on apical four-chamber view. Further evidence of associated right heart strain was seen on the corresponding parasternal short-axis view. These ultrasound findings in combination with the patient’s clinical presentation are diagnostic of acute pulmonary embolism with right heart strain. Point-of-care transthoracic cardiac ultrasound in the ED is an effective tool to promptly diagnose acute pulmonary embolism with right heart strain and thrombus in transit and guide further treatment.

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

Introduction: Retinal detachment is an ocular emergency that commonly presents to the emergency department (ED). Ophthalmologists are able to accurately make this diagnosis with a dilated fundoscopic exam, scleral depression or ophthalmic ultrasound when a view to the retina is obstructed. Emergency physicians (EPs) are not trained to examine the peripheral retina, and thus ophthalmic ultrasound can be used to aid in diagnosis. We assessed the accuracy of ocular point-ofcare ultrasound (POCUS) in diagnosing retinal detachment. Methods: We retrospectively reviewed charts of ED patients with suspected retinal detachment who underwent ocular POCUS between July 2012 and May 2015. Charts were reviewed for patients presenting to the ED with ocular complaints and clinical concern for retinal detachment. We compared ocular POCUS performed by EPs against the criterion reference of the consulting ophthalmologist’s diagnosis. Results: We enrolled a total of 109 patients. Of the 34 patients diagnosed with retinal detachment by the ophthalmologists, 31 were correctly identified as having retinal detachment by the EP using ocular POCUS. Of the 75 patients who did not have retinal detachment, 72 were ruled out by ocular POCUS by the EP. This resulted in a POCUS sensitivity of 91% (95% CI [76-98]) and specificity of 96% (95% CI [89-99]). Conclusion: This retrospective study suggests that ocular POCUS performed by EPs can aid in the diagnosis of retinal detachment in ED.

Isolated angioedema of the uvula, or Quincke’s disease, is a rare condition that can cause respiratory compromise. Although typically self-limiting, episodes of angioedema may require prompt therapy to prevent obstruction of the proximal airway. In this case report we review the appropriate steps for initial evaluation of patients with suspected angioedema, primary etiologies, and appropriate initial therapy.

History of present illness: A 46-year-old female was sent to the emergency department from clinic with an oxygen saturation of 86%. She endorsed fevers with cough and generalized weakness for one week. She had been evaluated by her primary care provider on day two of illness and was started empirically on Oseltamivir without improvement of her symptoms. The patient arrived febrile, tachycardic, tachypneic, and hypoxic on room air with left-sided crackles on exam. Significant findings: Point-of-care ultrasound of the left lower lobe demonstrates lung hepatization, a classic finding for pneumonia. In addition, a shred sign is present with both air bronchograms and focal B-lines—all suggestive of poorly aerated, consolidated lung.1 The patient was started on antibiotics and admitted to the hospital with a diagnosis of community-acquired pneumonia. Discussion: With a systematic approach, a skilled clinician can distinguish patterns on point-of-care ultrasound to evaluate for underlying pathology of the lung. Such findings include focal B-lines, an artifact that results from altered fluid-air compositions in the alveoli.2,3 Studies show, that when referenced with the gold standard of computed tomography, ultrasound is more sensitive than chest X-ray in diagnosing pneumonia. Nazerian et al.4 conducted a 190-patient study in which ultrasound had a higher sensitivity—81% compared to a dismal 65% by chest X-ray. Similarly, Cortellaro et al.5 concluded bedside ultrasound (96% sensitivity) is a reliable and superior tool for timely diagnosis of pneumonia compared to chest X-ray (69% sensitivity). Bourcier et al.6 drew conclusions on the effectiveness of ultrasound over chest X-ray on two groups of patients. In the group who exhibited symptoms for less than 24 hours, ultrasound outperformed chest X-ray, where the PPV of ultrasound was 76% and chest X-ray 23%. For those who exhibited symptoms for more than 24 hours, ultrasound demonstrated a PPV of 93% while chest X-ray only 77%. Thus, the use of point-of-care ultrasound in the diagnosis of pneumonia can improve sensitivity while minimizing radiation.

Laceration injuries comprise over 8% of all emergency department (ED) visits annually. 1 Given that laceration injuries represent a significant volume of ED visits, emergency physicians (EP) should be comfortable treating these types of injuries. We present the case of a 34-year-old male who presented to the ED as a trauma activation who suffered multiple injuries including complex full-thickness lacerations to his face. While there are scenarios in which consulting a specialist is necessary, knowledge and application of basic wound closure principles allows for many complex lacerations to be repaired by EPs. We provide a helpful systematic approach to evaluating and treating complex facial lacerations in the ED.

History of present illness: A 59-year-old woman presented to the emergency department (ED) with right eye pain. She had a history of cataract surgery in the right eye three months prior. The patient was seen at an outside ED eight days prior and reportedly had normal vision, normal eye pressures, with a large corneal ulcer and hypopyon in the anterior chamber. She was given subconjunctival injections of antibiotics and discharged with antibiotic drops. She was seen by a retina specialist the next day and had no evidence of endophthalmitis. On her second ED presentation, she had worsening right eye pain. Workup included normal intraocular pressures bilaterally and visual acuity with only light-perception in the affected eye. An ultrasound of her right eye was performed and is shown in figures 1 and 2. Significant findings: The patient’s ultrasound revealed an attached retina and a complex network of hyperechoic, mobile, membranous material in the posterior segment. Discussion: Endophthalmitis is a bacterial or fungal infection inside the vitreous and/or aqueous humors. The classic presentation is painful vision loss in a patient with recent ophthalmologic surgical intervention, an immunocompromised patient, or a septic patient. The specific bacteria or fungus causing the infection will vary depending on the reason for infection (post-surgical vs sepsis). Ultrasound findings typically include low amplitude mobile echoes, vitreous membranes, and thickening of the retina and choroid.1 Treatment for endophthalmitis includes direct, intraocular antibiotic injections by an ophthalmologist; hence, disposition for these patients would include admission for ophthalmology consultation. If there is a blood source of infection rather than a direct ocular inoculation, IV antibiotics should be initiated. Patients should also receive tetanus vaccination if tetanus status is outdated. In this case, the patient was diagnosed with endophthalmitis of the right eye. Ophthalmology performed a tap of the posterior segment, which was sent for cultures, and gave intravitreal injections of antibiotics.

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A 61-year-old female was brought in by ambulance after being the restrained driver of a head-on motor vehicle collision at 40MPH. There was positive airbag deployment and intrusion from the other vehicle. During workup, the patient complained of midline chest pain, and left chest wall pain. The patient was not in acute respiratory distress, and had the following vital signs: temperature 37°C, heart rate 84, blood pressure of 150/64, respiratory rate 18, and oxygen saturation of 97% on two liters of oxygen. On physical exam, breath sounds were heard bilaterally, with no acute cardiopulmonary issues identified. A bruise was identified on the lower abdomen, which was thought to be a potential seatbelt sign. A focused assessment with sonography for trauma was negative, and an ultrasound of additional chest and mediastinal structures was performed for the chest tenderness.

CASE A 63-year-old female with insulin-dependent type II diabetes mellitus and end-stage renal disease presented to the emergency department with spontaneous blistering to the tips of her left index and middle fingers. The blisters had gradually become tense and mildly painful over the preceding 10 days. She denied burn injury, trauma, fever, or new medications. On physical exam, the patient was noted to have a tense, nontender bullae on the pad of the left middle finger, and a collapsed, hemorrhagic bullae on the left index finger. There were no signs of inflammation or infection. A radiograph of the left hand, complete blood count, and basic metabolic panel were unremarkable. The diagnosis of bullosis diabeticorum was made, and supported by a consulting endocrinologist.