J Emerg Med
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Cardiac tamponade is associated with high mortality, and making the diagnosis is a core skill of emergency physicians. Proper diagnosis relies on specific clinical and echocardiographic findings. It is not known whether expert sonographers consistently recognize echocardiographic signs of tamponade. ⋯ There was poor agreement among expert emergency medicine sonographers in identifying echocardiographic signs of cardiac tamponade from a single cine loop or clip without clinical context. Further investigation is warranted to understand differences in recognition of clinical tamponade.
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Case Reports
Epstein-Barr in a Patient Presenting with Right Upper Quadrant Pain: A Case Report from the Emergency Department.
Right upper quadrant abdominal pain and elevated cholestasis blood tests are usually associated with bacterial calculous cholecystitis. However, viral infections, such as Epstein-Barr virus (EBV) can also manifest with a similar clinical picture and is an important differential diagnosis. ⋯ This case report discusses a young woman presenting to the emergency department with acute right upper quadrant abdominal pain. The initial assessment revealed a positive Murphy's sign, elevated white blood count, and a cholestatic pattern on liver function tests, leading one to suspect bacterial calculous cholecystitis and initiating antibiotic therapy. However, clinical examination also revealed tonsillar exudates and differential white blood cell count revealed monocytosis and lymphocytosis rather than a high neutrophil count. The patient tested positive for EBV. Furthermore, ultrasound and magnetic resonance imaging revealed gallbladder wall edema with no gallstones, leading one to conclude that the clinical manifestation and laboratory results were due to an EBV infection. Antibiotic therapy was ceased and the patient did not require surgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Calculous bacterial cholecystitis usually entails antibiotic therapy and cholecystectomy. It is important to be aware of the differential diagnosis of EBV, as it usually does not require either of these and resolves spontaneously.
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Case Reports
Invasive Fungus Balls Diagnosed by Point-of-Care Ultrasound in the Emergency Department.
Genitourinary tract fungus balls are a rare complication of urinary tract infections (UTI). They arise from dense aggregations of hyphae that combine with surrounding urothelial cells and debris. Symptoms can progress to urosepsis and systemic dissemination. Unfortunately, fungus balls may remain unrecognized. Even with computed tomography (CT) and magnetic resonance imaging, fungus balls can be mistaken for malignancies, urinary calculi, or blood clots. ⋯ A 54-year-old man with past medical history of type 2 diabetes mellitus presented to the Emergency Department (ED) reporting urinary retention for one week. He had undergone Foley catheter insertion three separate times for this symptom over the past five weeks. The emergency physicians expected that point-of-care ultrasound (POCUS) would show a distended, anechoic bladder. Instead, there were multiple discrete, gravitationally-dependent, circular echogenic masses without posterior acoustic shadowing, floating freely within a mosaic-like background of mixed echogenicity urine. These findings, together with the CT scan subsequently ordered, raised concern for fungus balls. Instead of being discharged with antibiotics for UTI, the patient was admitted for antifungal coverage, with contingency plans for bladder irrigation and antifungal instillation as needed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This is the first known case report in which emergency physicians used POCUS to diagnose invasive fungus balls in the ED. POCUS findings led to further CT imaging and specialist consultation that otherwise would not have occurred. Rather than discharge with antibiotics, goal-directed management and appropriate disposition mitigated the risk of systemic decompensation in an immunocompromised patient.
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Case Reports
Incidental Diagnosis of Left Pneumothorax Using a New Variant of the Lung Point Sign During Cardiac Ultrasound.
Pneumothorax is a common issue in the intensive care unit and emergency department, often diagnosed using lung ultrasound. The absence of lung sliding and the presence of the lung point sign are characteristic findings for pneumothorax. We describe a case of left pneumothorax diagnosed incidentally while performing a cardiac ultrasound through a new variant of the lung point sign. ⋯ A 60-year-old patient with a medical history of diabetes, stroke, and right colon cancer underwent urgent surgical treatment for intestinal sub-occlusion. In the intensive care unit, the patient required mechanical ventilation due to shock unresponsive to fluid administration, and hemodynamic monitoring was performed using echocardiography. During systole in an apical four-chamber view, the abrupt vanishing of the heart was observed. When evaluating the tricuspid annular plane systolic excursion (TAPSE) using M-mode, the interposition of the stratosphere sign during mid-systole prevented the visualization of the TAPSE peak. Lung ultrasound revealed the absence of lung sliding and the presence of the lung point sign on the left side of the thorax, confirming the diagnosis of pneumothorax. A chest x-ray study further confirmed the diagnosis, and urgent drainage was performed. The patient showed improvement in hemodynamic and respiratory conditions and was successfully weaned from mechanical ventilation, and eventually discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: By incorporating the lung ultrasound findings, including this new variant of the lung point sign, into their diagnostic approach to pneumothorax, emergency physicians can promptly initiate appropriate intervention, such as chest tube insertion, leading to improved patient outcomes.
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Intracerebral hemorrhage (ICH) is a potential complication from traumatic brain injury, with a 30-day mortality rate of 35-52%. Rapid diagnosis allows for earlier treatment, which impacts patient outcomes. A trauma activation (TA) is called when injury severity meets institutional criteria. The patient is immediately roomed, and a multispecialty team is present. A trauma evaluation (TE) occurs when injuries are identified after standard triage processes. ⋯ Diagnosis and treatment times were significantly faster in TA patients than in TE patients. Given the similarities in injury severity between groups, the increased time to treatment may be detrimental for patients. Trauma activations are a resource-heavy process, but TE delays care. These data suggest that an intermediary process may be beneficial.