Ultrasound Case of the Month

Case: Submitted by Dr. Daniel Coleman

This patient was a 44 year-old male with a past medical history significant for HIV, hepatitis C, diabetes, hypertension, and asthma, who presented with chest pressure, shortness of breath, and nausea. His symptoms developed over the previous 2 days, and were associated with intermittent diaphoresis, palpitations, and mild edema of the lower extremities. Pain was significantly worse when lying down.  The patient also endorsed symptoms of an upper respiratory infection with subjective fever approximately 1 week prior to presentation.

Diagnosis

Moderate pericardial effusion secondary to pericarditis without tamponade physiology

Discussion 

The image above demonstrates a small to moderate-sized circumferential pericardial effusion.  The effusion is seen by the anterior anechoic strip between the epi and pericardium. Effusions typically collect posteriorly/inferiorly, but will become circumferential as they get larger. Effusions around the anterior aspect of the heart may be differentiated from epicardial fat by their anechoic nature, whereas fat substance may be punctuated with mixed echogenicity. (1)

Ultrasound is a great tool for the evaluation of pericardial effusions, not only to detect the presence of said effusion, but to assess for the presence of tamponade as well, which may be caused by effusions as small as 50 mL. (2) There are several ways to evaluate for tamponade on ultrasound:

Right atrial collapse: While brief collapse of the RA wall during systole can be a normal variant, collapse lasting more than 1/3 of systole is almost 100% sensitive and specific for tamponade.  This phenomenon is best observed and measured using M mode (Figure 1), but may be difficult to discern in a tachycardic patient. (1)

Figure 1: On left, visualization of right atrial collapse.  On right, M mode allows temporal  measurement of collapse. (2)

Figure 1: On left, visualization of right atrial collapse.  On right, M mode allows temporal  measurement of collapse. (2)

Right ventricular collapse: If intrapericardial pressure exceeds the lowest RV pressure, it may collapse the RV free wall during diastole. This is best visualized in the parasternal long and short views (Figure 2). This finding is highly specific, but less sensitive than RA collapse, as a thickened RV wall of any etiology may not collapse under tamponade pressures. (1)

Figure 2: Right ventricle collapse during diastole. (2)

Figure 2: Right ventricle collapse during diastole. (2)

Swinging heart: On EKG, electrical alternans occurs during tamponade when the heart swings back and forth within the large effusion.  Ultrasound allows direct visualization of this phenomenon, (3) as see here.

IVC dilation: Tamponade physiology inhibits the ability of the heart to fill, resulting in back pressure and plethora of the ICV (Figure 3) with decreased respiratory variation has a sensitivity of 92%. (1)

Figure 3: Plethora of IVC during tamponade. (2)

Figure 3: Plethora of IVC during tamponade. (2)

Faculty Reviewer: Dr. Kristen Dwyer

Additional resources: Ultrasound podcast: Pericardial Tamponade

References:

1.      Goodman A, Perera P, Mailhot T, Mandavia D.  The role of bedside ultrasound in the diagnosis of pericardial effusion and cardiac tamponade.  J Emerg Trauma Shock.  2012; 5(1): 72-75.

2.      Perez-Casares A, Cesar S, Brunet-Garcia L, Sanchez-de-Toledo J.  Echocardiographic Evaluation of Pericardial Effusion and Cardiac Tamponade.  Front Pediatr.  2017; 5: 79.

3.      Mokta J, Mokta K, Panda P et al.  A swinging heart.  

AEM Early Access 07: Patterns and Costs of Patients Visiting Multiple EDs

Welcome to the seventh episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

            A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

            A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

Discussing: (click on title for full text, open access through November 30, 2017)

Patients Visiting Multiple Emergency Departments: Patterns, Costs and Risk Factors

Todd W. Lyons MD, MPH, Karen L. Olson PhD,Nathan P. Palmer PhD, Reed Horwitz, Kenneth D. Mandl MD, MPH, Andrew M. Fine MD, MPH

LISTEN NOW: INTERVIEW WITH LEAD AUTHOR DR. TODD LYONS, MD MPH

Dr Todd Lyons

Dr. Todd Lyons, MD MPH

Clinical Instructor, Harvard Medical School

Staff Physician, Boston Children's Hospital

 

Article Summary

Objective: The authors of this study investigated the prevalence and impact of ED care fragmentation by characterizing the population of patients seeking care at multiple EDs and quantifying costs associated with this patient population.

 

Methods: This is a retrospective cohort study of insured patients who had one or more ED visit between 2010 and 2016. Outcomes investigated included number of EDs visited by each patient, the costs associated with this subset of patients, and factors associated with visiting multiple EDs.

 

Results: The study included 53,015,427 patients belonging to a single for-profit payer. Of this group, 8,651,716 patients had at least 1 ED visit and accounted for 16,390,676 ED visits resulting in  $26,102,831,740 in ED costs.

  • 20.5% of patients visited more than one ED but accounted for 41.4% of visits and 39.2% of costs

  • A small proportion (0.4%) of patients visited 5 or more EDs but accounted for 2.8% of ED visits and costs

  • Factors most strongly associated with visiting multiple EDs included age, living in the South, total years of enrollment and higher visit complexity

  • Diagnoses most strongly associated with visiting multiple EDs included alcohol and drug diagnoses and mental health disorders

 

Conclusion: A minority of patients seek care at multiple EDs but account for a significant cost burden. Characterization of this population suggests they represent higher complexity visits and are more likely to suffer from comorbid substance abuse and mental health conditions. The authors recommend further work to evaluate the impact of ED care fragmentation of care utilization and outcomes and recommend improving access to patient records to mitigate its effects.

SUGGESTIONS FOR FURTHER READING:

1.  Bourgeois FC, Olson KL, Mandl KD. Patients treated at multiple acute health care facilities: Quantifying information fragmentation. Arch Intern Med. 2010;170(22):1989-1995. 


2.  Cook LJ, Knight S, Junkins EP, Mann NC, Dean JM, Olson LM. Repeat Patients to the Emergency Department in a Statewide Database. Acad Emerg Med. 2004;11(3):256-263. 


3.  Fertel, Baruch S., Hart, Kimberly W., Lindsell, Christopher J., Ryan, Richard J., Lyons MS. Patients Who Use Multiple EDs: Quantifying the Degree of Overlap Between ED Populations. West J Emerg Med. 2015;49(2):229. 

AEM Education and Training 02: A Global Health Milestones Tool

Welcome to the second episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to an AEM E&T Article or Article in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find this podcast series on iTunes here.

           A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

           A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

Discussing open access article (with link to full text):

Development of a Global Health Milestones Tool for Learners in Emergency Medicine: A Pilot Project. Katherine Douglass, Gabriel Jacquet, et al. AEM Education and Training 2017;1:269-279.

Milestones have been a hot topic in medical education, particularly with the implementation of a milestones-based assessment tool across all residencies in emergency medicine. This week we discuss the creation of milestones for emergency medicine learners involved in global medicine.

LISTEN NOW: LEAD AUTHOR INTERVIEW WITH DR. KATHERINE DOUGLASS, MD, MPH

Douglass.jpg

 

Katherine Douglass MD MPH

Associate Professor of Emergency Medicine and Global Health

Director, Global Health Fellowship

The George Washington University

 

ARTICLE SUMMARY:

OBJECTIVE: Recognizing the vast array of global medicine opportunities available for emergency medicine learners (including students, residents and fellows) and the inherent challenge of assessing these learners, this paper outlines the process of the creation of a milestones-based “standardized assessment tool.”

 

METHODS: A working group involving over a dozen stakeholders used an iterative process to develop milestones for learners based on learning domains created by the Consortium of Universities for Global Health’s Education Committee.

 

RESULTS:  A standardized milestones assessment tool was created, with five levels of competency across eleven different domains. For example, in the “Sociocultural and Political Awareness Domain,” a Level 1 learner “demonstrate[s] understanding of general concepts [of] cultural proficiency…” while a Level 5 learner “creates of strengthens multidisciplinary partnerships across organizations…”

 

CONCLUSIONS: The authors developed a standardized framework for assessing learners in global emergency medicine. Their next steps include disseminating this tool to assess its effectiveness.

 

FURTHER READING:

Battat R, Seidman G, Chadi N et al., Global Health Competencies and Approaches in Medical Education: A Literature Review. BMC Med Educ 2010;10:94.

Identifying Interpersonal Global Health Competencies for 21st Century Health Professionals. Annals of Global Health, 81(2):239-247.