Intercostal pulmonary hernia is a rare condition that may present to the emergency department spontaneously, following blunt trauma or as a complication of thoracic surgery. With the evolution of minimally invasive thoracic surgery pulmonary hernia may become more common. In this case of postoperative chest pain, incisional swelling, and shortness of breath, we present the ultrasound characteristics of a postoperative intercostal pulmonary hernia and its resemblance to subcutaneous emphysema.
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Introduction: The extent of hypoxic-ischemic injury (HII) after cardiac arrest (CA) remains an important knowledge deficit with lack of objective clinical data that is measurable repeatedly. There is a need to better understand an individual patient’s level of HII. Optic nerve sheath diameter (ONSD) has not been explored after CA as a possible bedside modality to measure the extent of HII over time, at the bedside, during targeted temperature management (TTM). Objective: We sought to characterize the temporal trajectories of point-of-care ultrasound obtained ONSD during the post- return of spontaneous circulation (ROSC) phase, in patients with and without TTM. Methods: Adult CA patients at an urban academic ED were included from 2017-2021. ONSD was measured by emergency ultrasound fellowship trained faculty at 1, 6, 24, 48, and 72 hours after ROSC using an ocular preset on a 15MHz linear probe. ONSD measurements at these time points were compared with patient demographic information and intervention of TTM . Results: A total of 78 participants had ONSD measurements. The mean age was 62 (+/-15) and 46% were female. Of the 65% of the cases with TTM, a sex disparity was noted with 73% of males receiving TTM versus 56% of females. There was a trend toward a decrease in mean ONSD by 0.015cm for TTM patients during the early time points of 1 to 6 hours compared to an increase in 0.006cm in those without TTM. Similar trend was noted between 1 to 24 hours, with a decrease in ONSD by 0.025cm in those with TTM relative to an average increase of 0.008 cm in those without TTM. However, neither delta ONSD was statistically significant between the two cohorts. When further assessing if delay in cooling had an impact on ONSD change, we found that the ONSD change between 24 to 48 hours was significantly increased in those in whom TTM was not initiated within 14 hours (beta=0.036; p=0.016). Conclusion: This pilot study revealed ONSD changes during TTM. There is potential for monitoring brain injury through ONSD trajectories to evaluate responders vs non-responders to TTM. Additional research is needed to evaluate ONSD changes during the rewarming time frame and may further distinguish patients with worse HII. Correlation to survival outcomes can be possible with a larger sample size.
Introduction: Hypoxic-ischemic injury from cardiac arrest may cause cerebral edema, leading to increased intracranial pressure (ICP) and brain tissue damage. Optic nerve sheath diameter (ONSD) is associated with elevated ICP. Limited clinical studies have reported ONSD changes in the early post-resuscitation time frame. We sought to evaluate the utility of bedside ocular ultrasound measurements in the assessment of post-cardiac arrest brain injury. Methods: We studied adult out-of-hospital cardiac arrests treated at an urban academic ED and achieving return of spontaneous circulation (ROSC) between May 2018 to May 2019. We included witnessed and unwitnessed arrest as well as shockable and non-shockable rhythms. After ROSC, trained emergency physicians performed bedside ultrasonographic assessment of bilateral ONSD at 1, 6, 24, 48, and 72 hours using an ocular preset on a 15MHz linear probe. ONSD measurements at these time frames were compared between groups stratified by rhythm type and neurological outcome. Cerebral performance category (CPC) was measured at 72 hours and at discharge. Results: Out of 48 eligible patients, 15 were excluded from the study due to lack of consent or available ultrasound images. We included 33 patients, of which 11 were female and 22 were male, with a median age of 57 (IQR 20). There were 19 with an initial rhythm of asystole or pulseless electrical activity (PEA), 9 with ventricular fibrillation arrests, and 5 with an unclear rhythm. At 1 hour, patients with CPC 1-2 had smaller ONSD compared to patients with CPC 3-5 (5.5mm vs 6.1mm, p=0.03). At 72 hour, patients with CPC score of 1-2 had an average reduction in ONSD of 1.6mm verses 0.29mm increase in patients with CPC 3-5. Despite small sample size, a trend towards higher ONSD were seen in patients with non-shockable vs shockable rhythm. Females were also consistently found to have smaller ONSD measurements in all time periods compared to males. Conclusions: This is the first study in the USA to perform analysis using ONSD measurements in cardiac arrest patients. Preliminary analysis of this on-going pilot revealed a greater improvement in ONSD diameters in patients with a favorable neurological outcome. OSND may have utility in prognostication of the post-arrest state.
Introduction: Neurologically guided resuscitation after out-of-hospital cardiac arrest (OHCA) to improve survival has been limited due to knowledge gaps in cerebral edema changes. Point-of-care ultrasound (POCUS) for the assessment of optic nerve sheath diameter (ONSD) is an established modality to characterize the extent of cerebral edema. We aimed to describe ONSD differences by sex, rhythm type, neurological outcome using cerebral performance category (CPC), and overall survival status. Methods: We studied adult OHCA treated at an urban academic ED with return of spontaneous circulation (ROSC) from May 2018 to May 2020. After ROSC, trained emergency physicians obtained bilateral ONSD measurements at 1, 6, 24, 48, and 72 hours, in the transverse, oblique, and sagittal planes for each eye. All the ONSD measurements were averaged for each time point and comparisons were made between each predictor’s categories. To compare the mean at each time point between groups, t-test or ANOVA was used. The trend comparison was done using generalized estimating equations. Statistical analysis was performed using SAS 9.4 under the significance level of 0.05. Results: Out of 62 eligible patients, 35 (56%) were male and 27 (44%) were female, 33 (59%) had a shockable rhythm and 23 (41%) had non-shockable rhythm. At 72 hr, 6 (10%) had a CPC of 1-2 and 57 (90%) had CPC of 3-5. Overall, there were 37 (61%) survivors and 24 (39%) non-survivors. There was a notable sex difference in the mean ONSD across all time points between males and females (p = 0.031), with males showing higher ONSD, and between shockable and non-shockable (p= 0.035), with the shockable group having relatively lower ONSD. There is a statistically significant difference of mean ONSD between CPC 1-2 and CPC 3-5 groups at 6hr, 48hr, and at 72hr, with higher means in the CPC 3-5 group. Across all times, the trend line was statistically significant between non-survivors and survivors (p= 0.015), with non-survivors having higher ONSD. Conclusion: Males, patients with non-shockable rhythm, CPC 3-5 at 72 hr, and non-survivors had higher ONSD. Understanding cerebral edema dynamics during resuscitation will allow for future work to potentially tailor interventions to individual patient cerebral injury patterns.
Study Objectives: To evaluate the cost effectiveness and difference in length of stay between early discharge and hospital observation for ED patients diagnosed with lowrisk pulmonary embolism.Methods: Length of stay, encounter costs, and 30-day composite costs were calculated for a prospective cohort of consecutive patients diagnosed with low-risk pulmonary embolism (PESI score <86) at five centers enrolled in the Low-risk PE (LoPE) study. Patients were observed in either the emergency department (EDO) or in the hospital under observation status (HO) and underwent both formal echocardiography and deep venous thrombosis ultrasound. Patients were initiated on FDA-approved therapeutic anticoagulation, were seen by a physician specializing in thrombosis, and had outpatient follow-up scheduled prior to discharge. Patients were also followed for a composite clinical outcome of 90-day all-cause mortality, recurrent PE or DVT, and major bleeding as previously described.
Objective: There are numerous psychosocial and ethical complexities in the medical and psychological care of an adolescent with cancer and a concurrent pregnancy. The article aims to discuss specific ethical dilemmas in a case, proposed frameworks for managing these complexities, and a summary of how the psychologist navigated these difficulties. It is notable that many states in the United States allow minors to legally consent for care related to their pregnancy but not their own psychological or oncological care. Methods: This article discusses a unique and complex case encountered by a pediatric psychologist specializing in psycho-oncology, including a discussion of the numerous challenges faced. Relevant cultural considerations are also discussed. Results: The case is further complicated when the patient experiences a spontaneous abortion and disagreements arise between the parents and the psychologist about how to acknowledge the loss. In addition, there is a lack of legal and ethical clarity related to an adolescent's ability to consent to therapy addressing a pregnancy-related loss. Specific ethical issues that arose in this case pertain to beneficence, nonmaleficence, and respect for rights and dignity for both the patient and for her parents. Considerations for resolving ethical dilemmas are presented, including the use of an ethical framework. Conclusions: There is limited research and discussion in the literature about how to manage psychological goals of care disagreements. It would be beneficial to have additional research, case reports, and clearer laws and ethical guidelines related to the parameters of adolescent pregnancy consent. Implications for Impact StatementThis article discusses complex legal and ethical ambiguities that arise when providing psychological care to a pregnant teenager receiving cancer treatment. The case demonstrates the importance of a pediatric psychologist being able to evaluate and attempt to resolve complex ethical dilemmas, particularly in the context of a family's culture and values.
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