In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 (PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision.
The double-line sign (DLS) is a wedge-shaped hypoechoic area in Morison's pouch bounded on both sides by echogenic lines. It represents a false-positive finding for free intraperitoneal fluid when performing focused assessment with sonography in trauma examinations. The purpose of this study was to determine the prevalence of DLS. Secondarily, the study will further investigate the relationship between the presence of a DLS and body mass index (BMI). This was a prospective study that enrolled patients over a 7-month period. Inclusion criteria were patients ≥ 18 years of age presenting to the Emergency Department (ED) requiring a FAST examination as part of the patient's standard medical care. Each examination was performed by one of six experienced ultrasonographers. Presence or absence of the DLS was established in real time and gender, height, weight, and BMI were recorded for each patient. The overall prevalence rate of DLS and the corresponding 95 % confidence interval were calculated, as well as the prevalence rates broken down by BMI characterized as underweight, normal weight, overweight, and obese; and age category (18-29, 30-64, and 65+). The Chi-square test and a Fisher's exact test for BMI category were used to compare the prevalence rates of positive DLS among the different demographic groups. 100 patients were enrolled in the study; the overall prevalence was 27 %. There was no statistical significance among the different demographic groups or BMI. The DLS is a prevalent finding. We believe this sign has become more apparent due to improved imaging technology and resolution.
images in clinical medicineT h e n e w e ng l a n d j o u r na l o f m e dic i n e n engl j med 365;2 nejm.org july 14, 2011 e4 A 71-year-old man presented to the emergency department with rapidly progressive tongue swelling during the previous 5 hours. Physical examination revealed a swollen tongue and no hypotension, rash, bronchospasm, urticaria, or flushing. There was no personal or family history of similar episodes, and the patient had no recent exposure to known food allergens, new medications, or insect stings. His usual outpatient medications included aspirin, simvastatin, diltiazem, and enalapril. A provisional diagnosis of angioedema associated with the use of an angiotensin-converting-enzyme (ACE) inhibitor was made. Inhibition of ACE may prompt a decrease in the production of angiotensin II and an increase in the bradykinin level, resulting in the regional vasodilatation and increased vascular permeability that are characteristic of angioedema. The onset of angioedema can occur even after long-term use of ACE inhibitors. In this patient, no improvement was noted after the parenteral administration of diphenhydramine, methylprednisolone, and epinephrine. With the patient awake, a nasotracheal intubation was performed to prevent impending respiratory compromise. Treatment with enalapril was discontinued. The edema resolved, the tongue returned to normal size, and the patient was extubated the next day. There has been no return of symptoms after discontinuation of the ACE inhibitor.
Confirmation of central venous catheter placement by dynamic sonographic visualization of a saline flush with exclusion of pneumothorax is an accurate, safe, and more efficient method than confirmation by chest radiography. It allows the central line to be used immediately, expediting patient care.
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.
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