At the conclusion of the simulation, learners will be able to: 1) demonstrate ability to efficiently review patient records to optimize patient care and identify relevant details to current presentation, 2) rapidly assess a patient when there is a change in clinical status, 3) recognize the need to start resuscitative fluids for undifferentiated hypotension, 4) identify anaphylaxis, 5) demonstrate the medical management of anaphylaxis, 6) utilize the I-PASS framework to communicate with the inpatient team during the transition of care.
On the initial ED visit, an abdominal ultrasound (US) was ordered which showed the classic intussusception finding of a target sign (yellow arrow), or concentric rings of telescoped bowel, on the transverse view of the left lower quadrant (LLQ).
Point-Of-Care Ultrasound Use for Detection of Multiple Metallic Foreign Body Ingestion in the Pediatric Emergency Department: A Case ReportDOI: https://doi.org/10.21980/J83D2D
Bedside POCUS was performed on the patient’s abdomen using the curvilinear probe. The left upper quadrant POCUS image demonstrates multiple hyperechoic spherical objects with shadowing and reverberation artifacts concerning multiple foreign body ingestions. Though the patient and mother initially denied knowledge of foreign body ingestion, on repeated questioning after POCUS findings, the patient admitted to his mother that he ate the spherical magnets he received for his birthday about one week ago. The patient swallowed these over the course of two days. The presence of multiple radiopaque foreign bodies was confirmed with an abdominal X-ray.
Bedside ultrasound was performed and showed thickened bowel wall (orange marker), fat enhancement (green marker), and phlegmonous structure with central echogenicity (yellow marker). Imaging of the abdomen and pelvis with CT showed marked wall thickening and inflammatory change involving a 7.0cm segment of the distal/terminal ileum suspicious for severe ileitis with phlegmon and microabscess on the coronal image (yellow arrow). Additonally, the transverse images show a small rim-enhancing focus within this region of inflammation measuring up to 1.4cm which could represent microabscess (yellow arrow). Diagnosis of diverticulitis by ultrasound is made by identifying the following findings: colon wall thicker than 5mm, fat enhancement, evidence of abscess, visualized diverticuli, air artifacts suggesting diverticuli, and tenderness with compression of the probe.6 Diagnosis of diverticulitis by CT is made by identifying the following findings: colonic wall thickening, pericolic fat stranding, abscess formation and enhancement of the colonic wall. Often, these signs are associated with an identifiable inflamed diverticulum.7
The mushroom displayed here is large and lacks any gills. Small puffball mushrooms can resemble young immature button top Amanita type mushrooms. Opening the Amanita mushroom should reveal apparent gills and quickly differentiate the two- -the puffball mushroom should have a white interior without gills.
By the end of this simulation, learners will be able to: 1) manage a hypotensive patient with syncope and hematemesis, 2) pharmacologically manage an acute UGIB addressing the various causes, 3) recognize worsening clinical status and intervene by performing difficult airway management, 4) place a gastroesophageal balloon tamponade device.
The CT imaging of the abdomen and pelvis demonstrated multiple loops of dilated small bowel with a whirl sign (red arrow) within the mid abdomen and a transition point (green arrow), suspicious for closed loop bowel obstruction and internal hernia.
By the end of this didactic activity, learners will be able to: 1) identify causes of upper gastrointestinal bleeding; 2) recall test-taking buzzwords for infectious causes of diarrhea; 2) acknowledge the correct hepatitis B titers that correspond with various clinical scenarios; 3) describe the management for alkali caustic ingestions; 4) determine the components of Maddrey Discriminant Function Score, Charcot’s triad, Ranson’s Criteria for Pancreatitis, and Glasgow-Blatchford Score; 5) diagnose specific gastrointestinal diseases from a clinical description; 6) choose the correct gastrointestinal diagnosis based on clinical image findings; 7) demonstrate teamwork in solving problems.
Point of Care Ultrasound as a Diagnostic Tool to Detect Small Bowel Obstruction in the Emergency Department: A Case ReportDOI: https://doi.org/10.21980/J8XD1G
The ultrasound findings suggestive of small bowel obstruction (SBO) are typically visualized in video; however, certain still images can also demonstrate SBO including greater than three dilated loops of small bowel (>2.5 cm), thickened-walled bowel (>3 mm), visualization of plicae circulares, and extraluminal fluid caused by inflammatory changes along the bowel wall, which are all highly suggestive of SBO.3 In this patient’s case, we were able to visualize several dilated loops of small bowel (red arrow) with oscillating intraluminal contents known as “Whirl Sign.” Additionally, we were able to visualize extraluminal fluid, demonstrated as an anechoic triangular-shaped collection. The characteristic shape of this triangular shaped collection of fluid is known as a “Tanga Sign,” given its name due to way it looks similar to the lower half of a bikini (blue arrow). Tanga sign can occur when the loops of dilated bowel appear prominent in contrast to the inflammatory extraluminal fluid in an SBO. These ultrasound findings were highly concerning for SBO which was later confirmed on CT imaging of the abdomen, which demonstrated SBO with a transition point in the left lower quadrant.
A Case Report on Detecting Porcelain Gallbladder form Wall-Echo-Shadow Sign on Point-of-Care UltrasoundDOI: https://doi.org/10.21980/J8164G
Point-of-care ultrasound (POCUS) was performed by the emergency physician. Gallbladder ultrasound (US) should be performed using a curvilinear probe. If the patient’s body habitus does not allow for the use of a curvilinear probe, a phased array probe may be used. To find the gallbladder with ultrasonography, two approaches are commonly used. Many physicians prefer the “subcostal sweep” in which the probe is placed on the xiphoid process in a sagittal plane and swept along the inferior costal margin until the gallbladder is visualized. If this does not adequately locate the gallbladder, the “X minus 7” approach may be used. In this approach, the probe is placed on the xiphoid (X) process in a transverse view and moved 7 centimeters (minus 7) to the patient’s right. This technique is useful for patients with a larger body habitus. If the gallbladder is still not visualized, placing the patient in left lateral decubitus position or asking them to take a deep breath and hold may help the ultrasonographer locate the gallbladder. The US revealed mild hepatic biliary duct dilation with cholelithiasis and sludge, but no additional evidence to suggest cholecystitis. The US image showed a dilated common bile duct at 0.94 cm and calcifications. Visualization of the gallbladder wall is essential in differentiating between a positive wall-echo-shadow (WES) sign and a porcelain gallbladder. While a hypoechoic gallbladder wall is indicative of a WES sign, a hyperechoic wall layer will indicate a calcified gallbladder wall, suggesting a porcelain gallbladder. In image 1, the hyperechoic gallbladder wall can be visualized (white arrow), suggesting the presence of porcelain gallbladder and distinguishing it from a positive WES sign.