Tips and Tricks: Clinical Ultrasound for Small Bowel Obstruction – A Better Diagnostic Tool?
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Small bowel obstruction (SBO) is a common challenge for the emergency physician (EP). It is estimated that approximately 300,000 annual hospitalizations in the United States are due to SBO. These patients comprise approximately 2% of all abdominal pain visits to the emergency department (ED). The history and physical exam are important to aid in the diagnosis of SBO. Abdominal pain, abdominal distension, nausea, vomiting, and past history of intra-abdominal surgeries causing adhesions should raise the EP’s suspicion.
Diagnostic imaging for SBO currently includes plain radiographs to assess for air-fluid levels and dilated loops of bowel, as well as computed tomography (CT) to detect the location of the transition point and potential causes. Magnetic resonance imaging (MRI) is considered by some radiology experts to be the best imaging tool, but requires significant time out of the ED, is not readily available, and has a significantly increased cost.
Tech Updates: Best Apps Part 3: Echo and Critical Care Apps
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Over the past several newsletters, I’ve been covering my picks for the best iOS apps relevant to the emergency sonographer. Whether used for bedside teaching, as a portable reference, or to advance your own ultrasound education, there are a growing number of excellent apps available for your iPhone and iPad.
For this newsletter, I’ll be covering echocardiography and critical care ultrasound apps in the third and final part of this series.
Great Case! Radiation versus Observation: Can Ultrasound Help?
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Chief Complaint: Scalp swelling after fall
1. What anatomy and pathology are shown in the above images?
2. How useful is point-of-care ultrasound in diagnosing such pathology
3. What common mimic must be considered when evaluating for the above pathology?
Case Presentation: A 6-month-old male infant was brought to the ED for evaluation of left parietal scalp swelling. He had fallen approximately 2 feet from a couch onto a hard surface 3 days prior to arrival, but his mother only noticed the swelling on the morning of the ED visit. He had been acting well, without lethargy, vomiting, focal deficits, or seizure-like activity.
On arrival the patient’s vital signs were within normal limits. His anterior fontanelle was soft and flat. Over the left parietal scalp there was a palpable soft, non-tender, fluctuant mass 7-8cm in diameter. Neurological examination was non-focal. The rest of his physical examination was unremarkable.
Point-of-care ultrasound performed by the treating emergency physician over the concerning area revealed a parietal skull fracture. A computed tomography scan of the brain confirmed the skull fracture, with minimal adjacent extra-axial hematoma (but no mass effect). The patient was admitted to the pediatric intensive care unit overnight for observation. He was seen by a neurosurgical consultant the next morning, and was determined to be stable for discharge home with outpatient follow-up.
Ask the Expert: How do you begin to create a Medical School Ultrasound Curriculum?
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An Interview with Richard Hoppmann MD, Director of the Ultrasound Institute, Professor of Medicine and Dean Emeritus, University of South Carolina School of Medicine
When starting or expanding an ultrasound program it is important to identify individuals in your institution with ultrasound experience who are also interested in teaching. A great place to start is within the Emergency Medicine Department which has been the leader in point-of-care ultrasound for two decades. Expertise can also come from radiologists, cardiologists, intensivists, obstetricians/gynecologists, sonographers, and others. A core group of enthusiastic educators is essential for success. It is important to work with course and clerkship directors to determine the most effective approach to introducing ultrasound into the curriculum and meeting course objectives. Ultrasound activities should be coordinated with what the students are being taught in lecture, small groups, and other components of the curriculum.