Patients presenting to the Emergency Department (ED) with a peritonsillar abscess often pose a diagnostic dilemma, as clinical impression is often unreliable. Once correctly diagnosed, literature demonstrates that emergency physician (EPs) drain abscesses with a 50% success rate. Bedside ultrasonography (US) has been described in both the diagnosis and drainage of a petitonsillar abscess. Furthermore, US gives the EPs the ability to identify other conditions, which may not be visible on physical exam alone. The impact on ED length of stay has been inadequately studied. We performed a retrospective chart review of all patients over 21 years of age who presented to the ED at an academic level 1 trauma center between 1/2011-2/2014 with billing code: “peritonsillar abscess”. The ED arrival/discharge times were obtained from electronic records and length of stay was determined. In patients that had bedside US, the use of CT scan/ENT consultations and presence of any return visits within 30 days were recorded. Out of a sample of 75 initial charts, 7 had documented bedside US performed and are described. 4 patients were diagnosed with a peritonsillar abscess. These patients had US guided abscess drainage performed by an EP. Out of these, 3 received intravenous (IV) antibiotics in the ED and 2 were given a steroid injection. All were discharged on oral antibiotics. Additionally, one patient was diagnosed with pharyngitis, one with tonsillitis, and another with peritonsillar cellulitis. The patient with pharyngitis was seen 2 days prior and diagnosed with the same. The remaining patients had no prior visits. CT scans and ENT consultations were not obtained in any patients. There were no return visits within the subsequent 30 days. The average ED length of stay for these 7 cases was 160 min. (range: 52 to 270 min.) As a reference point, the ED length of stay for all other cases of suspected PTA during same time frame was 293 min. (range 34 to 780 min.). The use of bedside US in 7 cases of suspected peritonsillar abscess was associated with an ED length of stay of 160 min. Whereas, it was 293 min. for cases that bedside US was not performed.

Abdominal aortic aneurysms (AAA) rank as the 10th leading cause of death in the elderly. Varied presentation of these patients often makes the diagnosis difficult. The most common location for an AAA is the infrarenal or distal aorta, which can be difficult to visualize using bedside ultrasound. Our objective was to identify if a patient’s self-reported weight, sex, or age influenced our ability to visualize the distal aorta on bedside abdominal aortic ultrasound scans. Aortic scans completed in the emergency department (ED) from September 2010 to September 2013 under the supervision of credentialed emergency physicians who had an accompanying completed ultrasound quality assurance worksheet were retrospectively evaluated. The Chief of Emergency and Critical Care Ultrasound reviewed all worksheets for quality control. Patients 21 years and older were included. Scans missing age, sex, or self-reported weight were excluded. Scans were completed using a Zonare (Zone Ultra, Mountain View, CA) or Sonosite (M-Turbo, Bothell, WA) device. Seven hundred eleven aortic ultrasound worksheets were evaluated during the study period. One hundred eighty-five were excluded because of incomplete worksheets. Twenty-six additional scans were excluded because age, sex, and/or weight were unknown. Five hundred aortic scans were included. The average weight was 76.6 ± 20.1 kg. Two hundred sixty-four males and 236 females were included. The distal aorta was visualized in 393 patients (78.6%). The medial aorta was visualized in 417 patients (83.4%). The proximal aorta was visualized in 454 patients (90.8%). The average male weight for whom the distal aorta was visualized and not visualized was 81.0 kg and 84.9 kg respectively. The average female weight for whom the distal aorta was visualized and not visualized was 69.7 kg and 74.1 kg respectively. Weight significantly predicted visualization for the proximal aorta (unadjusted P=.0098, adjusted P=.0095) and moderately for visualization of the distal aorta (unadjusted P=.071, adjusted P=.019). Neither age nor sex was significantly associated with visualization of the aorta (all P>.20) (Table). Visualization of the distal aorta was associated with weight but less robustly than the proximal aorta. The approximate 5 kg weight difference identified was similar enough clinically that we recommend patients should continue to receive potentially life-saving aortic scans regardless of their weight or body habitus.TableMeans & standard deviations or Ns & percentages with P valuesAorta LocationPredictorVisualization YesVisualization NoUnadjusted P value for differenceAdjusted P value for differenceProximalAge (years)Mean (SD)66.9 (18.4)68.0 (19.4).72.35ProximalWeight (kg)Mean (SD)75.8 (19.5)84.0 (21.8).0098.0095ProximalSex (male)N (%)237 (52.2)27 (58.7).40.79MedialAge (years)Mean (SD)66.7 (18.4)68.9 (18.9).31.20MedialWeight (kg)Mean (SD)76.1 (19.0)79.0 (23.6).22.16MedialSex (male)N (%)218 (52.3)46 (55.4).60.84DistalAge (years)Mean (SD)66.4 (18.7)69.4 (17.6).13.052DistalWeight (kg)Mean (SD)75.7 (19.1)79.7 (22.2).071.019DistalSex (male)N (%)209 (52.2)55 (51.4).74.40P value based on logistic regression model. Adjusted P value for other predictor (Age, weight, sex). Open table in a new tab

A 40-year-old woman with no previous medical problems presented to the Emergency Department (ED) 2 h after ingesting an unknown amount of Fioricet® (butalbital/acetaminophen/caffeine), oxycodone, and fentanyl patches about 90 min prior to emergency medical service (EMS) dispatch. The patient’s husband reported they had had a fight, and he went down to the basement; when he came back upstairs, he found the patient unconscious with an empty pill bottle. A call to the patient’s pharmacy by ED staff revealed that the patient had her prescription for butalbital/acetaminophen/caffeine tablets refilled 5 days earlier and that she had convinced the pharmacist to override the refill amount to dispense 540 tablets; according to the pharmacist, the patient stated she was going on a trip to Italy and needed a 6-month supply. EMS personnel removed a fentanyl patch (unknown strength) from her skin. The source of the fentanyl and the strength and formulation of the oxycodone were not recorded. Prehospital treatment included naloxone 4 mg IV without any noticeable clinical response, insertion of a nasal trumpet, and initiation of bag-valve-mask ventilation. A fingerstick glucose was 137 mg/dL. On arrival to the ED, the patient was unconscious with the following vital signs: blood pressure, 98/54 mmHg; pulse, 72 beats/min; respiratory rate, 14 breaths/min; and pulse oximetry, 100 % on a non-rebreather mask. Auscultation of her chest revealed clear but bilaterally diminished breath sounds and a regular cardiac rhythm without murmurs, rubs, or gallops. The patient’s ventilation improved with jaw thrust, but, due to increased secretions, she was intubated within 10 min of ED arrival using etomidate and succinylcholine. On further examination, she had palpable distal pulses, and her abdomen was soft and non-tender. The patient’s pupils were 1–2 mm in diameter and sluggishly reactive to light. The patient was noted to be shivering prior to being fully exposed, and her skin was warm and dry, revealing no signs of traumatic injuries. An ECG revealed a normal sinus rhythm at 86 beats per minute with a prolonged QTc interval (504 ms). An orogastric tube and Foley catheter were both inserted, with a large volume (700 cc) of dark-colored urine quickly filling the Foley bag. Activated charcoal 50 g was administered via orogastric tube. Due to the reported large ingestion of acetaminophen and some initial uncertainty about the time of ingestion, an IV N-acetylcysteine (NAC) infusion was started according to the 21-h protocol, prior to obtaining serum acetaminophen level results. About 90 min after arrival (3 h after ingestion), the patient began having massive diuresis, producing 5,800 cc of urine over 1 h. Due to concerns about the patient’s reported fentanyl patch ingestion and the lack of knowledge regarding possible extendedThis project was not funded.