Early identification of abdominal aortic aneurysms in some

patients can be difficult and the diagnosis is missed in up to

30% of patients. Ultrasound cannot be used to identify a leak,

but the presence of an aneurysm in an unstable patient is

conclusive. With minimal training emergency physicians can

easily identify the aorta and thus in the early phase of

resuscitation an aneurysm can be confidently excluded. The

purpose of the examination is not to delineate the extent of

the aneurysm, but to identify those patients that will need

emergency surgery. A series of patients presented to the

department in an unstable condition with equivocal abdominal

signs. An ultrasound scan in the resuscitation room by

members of the emergency department revealed an aneurysm,

which was enough to convince the vascular surgeons to

take the patient straight to theatre with good results. In

patients who are stable, computed tomography will continue

to be used to evaluate the extent of the aneurysm and identify a leak

Brenchley, J.

Lalanda, M.

Sloan, J.P.

Venables, H.

Walker, A.

English

PubMed

A Walker

Crossref

Ultrasound by emergency physicians to detect abdominal aortic aneurysms: a UK case series

White Rose Research Online

This is a repository copy of Ultrasound by emergency physicians to detect abdominal aortic aneurysms: a UK case series .White Rose Research Online URL for this paper:http://eprints.whiterose.ac.uk/244/Article:Walker, A., Brenchley, J., Sloan, J.P. et al. (2 more authors) (2004) Ultrasound by emergency physicians to detect abdominal aortic aneurysms: a UK case series. Emergency Medicine Journal, 21 (2). pp. 257-259. ISSN 1472-0213 https://doi.org/10.1136/emj.2002.002121eprints@whiterose.ac.ukhttps://eprints.whiterose.ac.uk/Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version - refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher’s website. Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. CASE REPORTUltrasound by emergency physicians to detect abdominalaortic aneurysms: a UK case seriesA Walker, J Brenchley, J P Sloan, M Lalanda, H Venables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Emerg Med J 2004;21:257–259. doi: 10.1136/emj.2002.002121Early identification of abdominal aortic aneurysms in somepatients can be difficult and the diagnosis is missed in up to30% of patients. Ultrasound cannot be used to identify a leak,but the presence of an aneurysm in an unstable patient isconclusive. With minimal training emergency physicians caneasily identify the aorta and thus in the early phase ofresuscitation an aneurysm can be confidently excluded. Thepurpose of the examination is not to delineate the extent ofthe aneurysm, but to identify those patients that will needemergency surgery. A series of patients presented to thedepartment in an unstable condition with equivocal abdom-inal signs. An ultrasound scan in the resuscitation room bymembers of the emergency department revealed an aneur-ysm, which was enough to convince the vascular surgeons totake the patient straight to theatre with good results. Inpatients who are stable, computed tomography will continueto be used to evaluate the extent of the aneurysm and identifya leak.Abdominal aortic aneurysms (AAA) present an impor-tant diagnostic challenge to emergency physicians.Although not a common condition, they are associatedwith significant mortality and early diagnosis is essential.The diagnosis may be difficult in the emergency situationas patients may present with a non-specific history, and staffneed a high index of suspicion to consider AAA in thedifferential diagnosis.1 Computed tomography is the goldstandard investigation but can lead to a delay in definitivediagnosis and treatment (especially out of normal workinghours), and transfer to scan may be associated with furtherrisks or deterioration. An early ultrasound scan in theresuscitation phase may be the primary investigation ofchoice.Some departments have protocols whereby patients whoare suspected of having a AAA are transferred directly toa vascular surgery centre for definitive diagnosis andtreatment.This may entail inappropriate patients being transferred, ordelays at the presenting hospital if inexperienced medicalstaff require senior backup to make this decision.Ultrasonography is routinely used for screening andmonitoring of aneurysm diameter2 and a limited ultrasoundscan can reliably record the presence of an AAA.If a normal aorta is clearly seen (as in most cases) ananeurysm can be confidently excluded. In the emergencysetting no attempt is made to define the limits or relations ofthe aneurysm.Ultrasound is not accurate in determining the presence of aleak from the aneurysm. In one study in emergencydepartment patients, sonography was accurate in demon-strating presence or absence of aneurysm (98%), but itssensitivity for extraluminal blood was poor (4%).3The combination of an aneurysm on ultrasound and anunstable patient is enough to warrant an emergency vascularsurgery opinion.PRINCIPLES OF EMERGENCY ULTRASOUNDUltrasound use by emergency physicians is a focusedexamination to answer a single clinical question. In theassessment of trauma patients the purpose of the FAST(focused assessment with sonography in trauma) scan is toidentify (rule in) the presence of free intraperitoneal fluid. Inthe context of trauma, this is assumed to be blood. Furthermanagement decisions are made according to the patient’scondition, but ultrasound adds valuable information in theearly stages of assessment.TRAININGAll middle grade and senior emergency physicians at LeedsGeneral Infirmary had previously been trained to useultrasound in the evaluation of blunt abdominal trauma(FAST). This entailed two sessions of both didactic trainingon the principles of ultrasound and the FAST protocol, andpractical experience on normal volunteers and simulatedpatients (peritoneal dialysis patient volunteers). Emergencyphysicians were then required to record scans on 10 normalvolunteers, these were reviewed by expert sonographersbefore accreditation as an emergency physician sonographer.Data from all scanned patients are routinely recorded andsuggest that there is little skill attrition with time. Rotationalmiddle grade staff have been trained in the technique and onreturn to the department months later continue to exhibitadequate sonography skills.Trained emergency physician sonographers underwent afurther session of training by expert sonographers. Thisincluded a review of aortic anatomy, demonstrations ofnormal ultrasound appearances, and review of AAA ultra-sound appearance. Once trained, the emergency AAA scancould be performed in less than five minutes. The appear-ances of the normal aorta scan view are shown in figure 1.CASE SERIESWe present a series of patients who have attended ouremergency department over a six month period and had aprovisional diagnosis of AAA.All patients underwent an ultrasound scan performed byemergency physicians, and after discussion with the vascularsurgeons were immediately transferred to theatre.Case 1A 65 year old man bent down to lift a box and felt painin his left hip. On presentation to hospital, he was. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Abbreviations: AAA, abdominal aortic aneurysms; FAST, focusedassessment with sonography in trauma257www.emjonline.comhaemodynamically stable with a palpable AAA, confirmed onultrasound. Shortly thereafter he became cardiovascularlyunstable and was transferred to theatre for repair of an infra-renal AAA. He made a good recovery and was well six monthslater.Case 2A 72 year old man presented with abdominal and back pain.While in the emergency department he collapsed and theultrasound scan in the resuscitation room demonstrated a7 cm aneurysm. He was transferred to the operating theatrefor repair and was well three months later.Case 3 (fig 2)A 69 year old man collapsed with abdominal pain and wasbrought to the emergency department. An ultrasound scan inthe resuscitation room revealed a large AAA. He wastransferred to operating theatre and is alive and well oneyear later.Case 4A 67 year old man had experienced abdominal and back painovernight, in association with diarrhoea. He was hypotensiveon arrival and a 7 cm AAA was discovered when anemergency physician performed ultrasound in the resuscita-tion room. He was transferred to the operating theatre andsurvived the repair but died three days after operation.Case 5 (fig 3)A 58 year old man had colicky abdominal pain radiating tohis back. He was haemodynamically stable and had anultrasound scan performed as routine and to increase SHOawareness of the investigation. A 6 cm AAA was detected andhe was referred for review by the vascular surgeons. Thirtyminutes later he had a sudden haemodynamic collapse andwas resuscitated and transferred straight to theatre.These cases demonstrate the effectiveness of an emergencyphysician ultrasound scan in appropriate patients.Ultrasound has also been used successfully to exclude anAAA in hypotensive patients seen in the resuscitation room,and has therefore directed further investigations moreappropriately. This is a small case series only looking atpatients with positive scans. There is more work to bedone evaluating the technique as rule out tool in thesecircumstances.DISCUSSIONSome patients have a clear history and obvious clinical signsof an AAA. In these the diagnosis is not difficult. It has beenclearly established that early diagnosis and surgery hassignificant survival benefits in these patients. An emergencyphysician performed ultrasound scan in the resuscitationroom can be completed early while resuscitation is ongoing.Use of ultrasound by emergency physicians to exclude anAAA, is common in other countries.4As increasing numbers of patients are transferred to atertiary centre for surgery after acute presentation. A timelyemergency physician performed ultrasound scan may expe-dite the decision to transfer.Studies have shown that emergency physicians areaccurate in the diagnosis of AAA on ultrasound. One studyfrom Australia included patients in whom the diagnosis ofAAA was suspected.5 Sixty eight scans were performed; 26scans were positive, 40 scans yielded negative findings, and 2scans were indeterminate. Scan interpretations were 100%accurate, compared with standard imaging or radiologyreview of the emergency ultrasound scan. In this study theprimary benefit of ultrasonography was to exclude thediagnosis, but positive scans provided significant benefitsfor patients with AAA and led to improved managementplans.In our department, the use of ultrasound for AAAdiagnosis followed naturally once the machine had beenpurchased by the department and emergency departmentstaff had been trained in the FAST technique. The presence ofan external aortic diameter of greater than 3 cm is consideredFigure 1 Normal anatomy (transverse). A, IVC; B, aorta; C, superiormesenteric artery; D, vertebral body; E, portal vein.Figure 2 Case 2, 7 cm AAA.Figure 3 Case 5, 6 cm AAA.258 Walker, Brenchley, Sloan, et alwww.emjonline.comdiagnostic of an AAA, although increasing size increases therisk of rupture.Initially there were concerns voiced by radiology colleaguesabout the use of ultrasound by non-radiologists. Mostvascular surgeons however, are familiar with the ultrasoundappearances of AAA, and a consensus decision on furthermanagement was reached in the cases presented. In patientswith leaking AAAs, the speed of transfer to definitive care is asignificant prognostic factor, rapid access to a senior vascularsurgical opinion may be expedited by the emergencyphysician ultrasound scan.We have shown that ultrasound skills for specific limitedindications are easily learnt and retained. Support of the localradiology department is invaluable in introducing ultrasoundinto the emergency department. In our department all scanswere initially reviewed by expert sonographers and althoughthere was some disagreement about scan quality, none of theclinical conclusions drawn was invalid. Hard copies of allscans were obtained for inclusion in the patient’s notes andaudit purposes. Ongoing review of a proportion of scans isworthwhile to monitor quality, this could be performed by anexperienced emergency physician sonographer or radiologycolleagues.CONCLUSIONSA limited ultrasound scan is a rapid screening test fordetection of AAA in the resuscitation room. Emergencyphysicians competent in other ultrasound techniques canreliably perform the technique after a short trainingprogrammeAuthors’ affiliations. . . . . . . . . . . . . . . . . . . . .A Walker, J P Sloan, M Lalanda, Department of Emergency Medicine,Leeds General Infirmary, Leeds, UKJ Brenchley, Department of Emergency Medicine, Barnsley DistrictGeneral Hospital, Barnsley, UKH Venables, School of Healthcare Studies, University of Leeds, Leeds, UKCorrespondence to: Dr J Brenchley, Department of EmergencyMedicine, Barnsley District General Hospital, Gawber Road, BarnsleyS75 2EP, UK; jane.brenchley@bdgh-tr.trent.nhs.ukAccepted for publication 7 March 2003REFERENCES1 Miller J, Miller J. Small ruptured abdominal aneurysm diagnosed byemergency physician ultrasound. Am J Emerg Med 1999;17:174–5.2 Shuman WP, Hastrup W, Kohler TR, et al. Suspected leaking abdominal aorticaneurysm: use of sonography in the emergency room. Radiology1988;168:117–19.3 Goldberg BB. Aortosonography. Int Surg 1977;62:294–7.4 Stahmer SA. Accident and emergency medicine. BMJ 1988;316:1071–4.5 Kuhn M, Bonnin RL, Davey MJ, et al. Emergency department ultrasoundscanning for abdominal aortic aneurysm: accessible, accurate, andadvantageous. Ann Emerg Med 2000;36:219–23.Ultrasound to detect abdominal aortic aneurysms 259Bone marrow toxicity after yellow phosphorus ingestionA J Tafur, J A Zapatier, L A Idrovo, J W Oliveros, J C Garces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Emerg Med J 2004;21:259–260. doi: 10/1136/emj.2003.007880Suicidal ingestions of fireworks containing yellow phos-phorus occur often during holidays. A case is reported of a17 year old woman who intentionally ingested an estimatedamount of 5.5 mg of yellow phosphorus, presenting withupper abdominal pain as the only complaint, a physicalexamination was normal. Blood tests showed a considerabledecrease in the granulocyte count; the bone marrow biopsyrevealed a decreased cellular mass with degenerativechanges. Spontaneous remission was observed during thenext 48 hours, with no further complaints.Suicidal ingestions of round, penny sized fireworksknown as diablillos are popular especially during theperiod of Christmas holiday. Each diablillo usuallyweighs 310 mg containing 2.4% of yellow phosphorus (YP),39.4% of silica, and 50% of potassium chlorate.1 Theestimated lethal dose of YP is 1 mg/kg.2 We present acase in which the ingestion of firework containing YPinduced reversible bone marrow toxicity verified on biopsyexamination.CASE REPORTA 17 year old woman, weighing 50 kg, was admitted to theemergency room after the intentional ingestion of threequarters of a diablillo nine hours before arrival (about 5.5 mgof YP). Her vital signs were stable and the patient wasconscious and well oriented. The chief complaint was upperabdominal pain and the rest of the physical examination wasnormal. There was no history of previous relevant illness.Gastric lavage was started with a solution containingpotassium permanganate 1:1000; followed by activatedcharcoal and a mineral cathartic. Blood samples wereobtained, and the analysis reported white blood cell (WBC)count 6.400/ml, red blood cell (RBC) count 3.96106/ml,haemoglobin (Hb)120 g/l, and platelet count 258 000/ml.Granulocyte count was 5900/ml. Hepatic and renal functions,as well as electrolytes were all normal. Intravenous fluids,and folic acid with iron supplementation were prescribed assupport treatment.After 24 hours in hospital, blood tests were repeatedshowing WBC 3.500/ml, RBC 3.736106/ml, Hb 12.2 g/dl,platelet count 226.000/ml, and granulocytes decreased to900/ml. A bone marrow biopsy was undertaken, and thehistopathological analysis reported intense interstitialoedema, haemorrhages, and some necrotic foci. The mor-phology of the three cellular lines was normal, but the totalcellular mass was at 50%. Neoplasic or fibrotic changes werenot found; suggesting the diagnosis of unspecified degen-erative toxic changes in the bone marrow (fig 1).The patient remained stable and no complicationsappeared during her stay in hospital. Spontaneous resolutionof the neutropenia was observed during the next 48 hours.The patient was discharged, and returned one month later forfollow up presenting no further complains.www.emjonline.com

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Ultrasound by emergency physicians to detect abdominal aortic aneurysms: a UK case series

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