Image to Fit the Clinical Picture: Point-of-care Ultrasound Assessment of Ebstein’s Anomaly in Peru

Ebstein’s anomaly is a congenital heart defect that when left untreated can lead to unique physical exam and ultrasound findings. This case describes a patient who presented with dyspnea and was found to have cyanosis, clubbing, and dilation of right-sided chambers on point-of-care ultrasound. The series of images highlights findings in late-stage Ebstein’s anomaly and serves as a springboard for the discussion of the pathophysiology, diagnosis, and treatment of this rare congenital heart disease

Ultrasound-guided Posterior Tibial Nerve Block for Frostbite of the Plantar Surfaces

Introduction: Frostbite is a painful condition that requires rapid identification and wound care to optimize outcomes. The Posterior Tibial Nerve (PTN) block, however, has yet to be described in the literature for pain control of frostbite injuries on the plantar surfaces.Case Series: In this case series we discuss three patients who presented with bilateral frostbite on the plantar surfaces. Ultrasound-guided PTN blocks were performed on these patients and pain control was achieved in under 10 minutes, facilitating burn care. No patient experienced adverse effects. All patients had been scheduled for future debridement that was either not performed or performed using intravenous (IV) medications due to pain control issues.Conclusion: The ultrasound-guided PTN block facilitated proper wound debridement that was previously intolerable with oral and IV pain medications. This case series highlights the efficacy, safety, and accessibility of this block for frostbite pain control in the emergency department.   Additionally, it emphasizes the potential role of ultrasound-guided PTN blocks as part of a multi-modal pain control strategy in other clinical settings

Image to Fit the Clinical Picture: Point-of-care Ultrasound Assessment of Ebstein’s Anomaly in Peru

Ebstein’s anomaly is a congenital heart defect that when left untreated can lead to unique physical exam and ultrasound findings. This case describes a patient who presented with dyspnea and was found to have cyanosis, clubbing, and dilation of right-sided chambers on point-of-care ultrasound. The series of images highlights findings in late-stage Ebstein’s anomaly and serves as a springboard for the discussion of the pathophysiology, diagnosis, and treatment of this rare congenital heart disease

Point-of-care Ultrasound Diagnosis of Pulmonary Hydatid Cyst Disease Causing Shock: A Case Report

Introduction: Point-of-care ultrasound (POCUS) is accepted as an important tool for evaluatingpatients presenting to the emergency department (ED) with dyspnea1 and undifferentiated shock.2Identifying the etiology and type of shock is time-critical since treatments vary based on thisinformation. Clinicians typically rely on the history, exam, and diagnostics tests to identify theetiology of shock. In resource-limited settings where there is reduced access to timely laboratory anddiagnostic studies. The use of POCUS enables rapid classification and directed treatment of shock.Additionally, POCUS can aid in the diagnosis of rarer tropical diseases that can be important causesof shock in resource-limited settings.Case Report: We discuss a case of a pediatric patient who presented to an ED in Cusco, Peru, withacute dyspnea and shock. Point-of-care ultrasound was used to expedite the diagnosis of a rupturedpulmonary hydatid cyst, guide proper management of septic and anaphylactic shock, and expeditedefinitive surgical intervention.Conclusion: In resource-limited settings where there is reduced access to timely laboratory anddiagnostic studies, the use of POCUS enables rapid classification and directed treatment of shock

Erector Spinae Plane Block Performed in the Emergency Department for Abdominal Pain: A Case Series

Introduction: Ultrasound-guided nerve blocks are fast becoming a core part of opioid- sparing, multimodal, acute pain management in the emergency department (ED) setting. The ultrasound-guided erector spinae plane block (ESPB) has been shown to be effective in treating a variety of musculoskeletal and neuropathic painful conditions in the ED. Case Series: Here we report the effective use of the ESPB for pain control in four patients who presented with acute abdominal pain related to biliary obstruction in a resource-limited setting. Conclusion: The ESPB may be helpful in treating abdominal pain related to biliary obstruction, which is a novel indication for this well-established technique. This application is particularly relevant in resource-limited settings with significant delay in definitive surgical management. Further research is needed prior to widespread adoption

A Novel Technique to Reduce Reliance on Opioids for Analgesia from Acute Appendicitis: The Ultrasound-guided Erector Spinae Plane Block

Single injection, ultrasound-guided nerve blocks have drastically changed the multimodal approach to pain management of the acutely injured patient in the emergency department (ED). Ultrasound-guided femoral nerve blocks in the ED have become standard aspects of multiple, hospital system pain management protocols, with early evidence demonstrating improved patient outcomes. Developing a multimodal pain management strategy can improve analgesia while reducing reliance on opioids in this era of opioid addiction.1 The single injection, ultrasound-guided erector spinae plane (ESP) block is a technique safely used for pain control for rib fractures that can be easily performed at the bedside and integrated into optimal emergency care. A more inferiorly located ultrasound-guided ESP block has been recently described in the anesthesia literature for perioperative pain control for various abdominal surgeries but has not yet been described for patients with acute appendicitis. Here we describe a single injection, lower ESP block performed by emergency physicians that successfully alleviated pain from acute appendicitis in an ED patient awaiting definitive surgical treatment. Along with allowing clinicians to actively manage pain without reliance on opioids, this novel ED technique may improve patient care outcomes

Role of Tele-ultrasound for Teaching Ultrasound-guided Nerve Blocks in the Emergency Department: A Case Series from Peru

Introduction: Ultrasound-guided nerve blocks (UGNB) represent a procedural skill set that can be used to treat acute pain by physicians in the emergency department (ED). However, limited access to education and training represents a barrier to widespread adoption of this core skill set. The implementation of UGNBs within the ED can aid in resource allocation, particularly in limited-resource settings.Case Series: In this case series we discuss our experience using tele-ultrasound to train emergency physicians on the use of UGNBs within our international point-of-care ultrasound fellowship in Peru. We highlight the potential role UGNBs serve in management of acute pain when working in resource-limited, public safety-net hospitals in Peru.Conclusion: Tele-ultrasound may represent a strategy for teaching procedures such as UGNBs via remote guidance and supervision

Point-of-care Ultrasound Diagnosis of Tetralogy of Fallot Causing Cyanosis: A Case Report

Introduction: Tetralogy of Fallot (TOF) is a congenital heart defect with characteristic features leading to unique physical exam and ultrasound findings. In settings where there is limited prenatal screening, TOF can present with cyanosis at any time from the neonatal period to adulthood depending on the degree of obstruction of the right ventricular outflow tract.Case Report: This case describes a pediatric patient who presented with undifferentiated dyspnea and cyanosis, for whom point-of-care ultrasound (POCUS) supported the diagnosis of TOF. We highlight the important role POCUS can play in a setting with limited access to formal echocardiography or consultative pediatric cardiology services.Conclusion: This report highlights the utility of POCUS as an inflection point in the diagnostic and management pathway of this patient, which is particularly important when working in a limited-resource or rural setting

A Novel Multimodal Approach to Point-of-Care Ultrasound Education in Low-Resource Settings

Point-of-care ultrasound (POCUS) enables physicians to make critical diagnosis and treatment decisions at the bedside. However, access to and expertise with this technology remain limited in Peru. Establishing longitudinal POCUS educational curriculums in remote, low-resource settings can be challenging due to geographical distances, encumbering the ability to provide ongoing hands-on support. Previously described educational interventions have focused on training individual users on clinical applications of POCUS, rather than training physicians how to teach POCUS, thereby limiting scalability and sustainable impact. We therefore describe our experiences establishing the first ultrasound fellowship curriculum in Peru, which incorporates tele-ultrasonography to circumvent traditional geographical barriers