Article, Emergency Medicine

Transcranial sonography in prehospital setting


  1. Jo YH, Kim K, Rhee JE, Kim TY, Lee JH, Kang SB, et al. The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis. Am J Emerg Med 2010;28(7):766-70.

Acute appendicitis: emergency medicine physician and surgeon clinical judgment vs abdominal computed tomographic scan?

To the Editor,

I agree with the authors that the best imaging modalities can never replace the clinical judgment of an experienced surgeon or emergency medicine physician, but it might be “in general” comment. Another study also showed that, even in clinically evident appendicitis, computed tomog- raphy (CT) has the potential to reduce negative appen- dectomies [1]. In that study, the clinically evident appendicitis was defined by emergency medicine physi- cian. Summing up with the results of the study entitled “The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis,” it is not easy to say that CT is not a necessary option in patients with typical findings in history and physical examination [2]. I would not say that CT is a mandatory in all adults with suspected appendicitis. The policy could depend on many factors such as local radiologists and surgeon’s concepts about radiation hazard (balance between radiation hazard and useless operation or delayed diagnosis complicated by abscess without CT), 24/7 availability of ultrasonography by experienced radiologist, individual institutions, and nations.

Kyuseok Kim MD

Department of Emergency Medicine Seoul National University, Bundang Hospital 300 Gumi-dong, Bundang-gu, Sungnam-si Gyeonggi-do, 463-707, South Korea

E-mail address: [email protected] doi:10.1016/j.ajem.2011.06.007


  1. Kim K, Rhee JE, Lee CC, et al. Impact of helical computed tomo- graphy in clinically evident appendicitis. Emerg Med J 2008;25: 482-5.
  2. Jo YH, Kim K, Rhee JE, et al. The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis. Am J Emerg Med 2010;28(7):766-70 [Epub 2010 Mar 25].

Transcranial sonography in prehospital setting?

To the Editor,

Until recently, emergency physicians in the prehospital setting had no tools with which to explore neurologic distress. In France, many emergency medical services are now equipped with hand-held Ultrasound devices for use in the prehospital setting. The transcranial Doppler could contribute to better management of patients with head injury or ischemic stroke [1-3]; and the transcranial sonography (TS) could allow imaging of the brain parenchyma. Several brain disorders can be depicted by TS, such as Intracranial hematomas, brain tumors, neuro- degenerative disorders, and enlargement of the ventricular system [4,5]. We present 2 cases of prehospital TS to illustrate its interest.

A medical team has been dispatched for an 80-year-old man unconscious after a fall and a head injury. On arrival, the patient was conscious but drowsy, with a Glasgow Coma Scale score of 14; blood pressure, heart rate, respiratory rate, and oxygen saturation were normal. Physical examination was normal. Transcranial sonography examination was performed by an emergency physician on the scene (V-Scan; General Electric, France) and showed enlarged cerebral ventricles. Further questioning of the patient’s family revealed the gradual development in recent months of gait disturbance, urinary incontinence, and dementia. A diagnosis of normal pressure hydrocephalus was suspected. Computed tomographic (CT) scan confirmed enlargement of the ventricular system without any other cerebral lesions (Fig. 1A). The patient underwent ventricu- loperitoneal shunting, which led to significant clinical improvement of symptoms.

A medical team has been dispatched for a 49-year-old woman who has been found unconscious at home. On arrival, the patient was conscious but confused, with a Glasgow Coma Scale score of 14. Blood pressure , heart rate, respiratory rate, and oxygen saturation were normal. The patient complained of headache. Physical examination was normal. Transcranial sonography showed a hyperechogenic lesion in Midline shift (Fig. 1B). A diagnosis of subarach- noid hemorrhage was suspected. The patient had been brought in to the hospital with neurosurgery alerted. A CT scan showed small amount of blood in the basal anterior interhemispheric fissure and confirmed subarachnoid hem- orrhage. Computed tomography angiogram showed a small aneurysm of the right anterior communicating artery. The patient underwent surgery for clipping and securing the cerebral aneurysm and left the hospital after 1 month without neurologic sequel.

The TS technique is easy to perform through the acoustic Temporal bone window with phased array transducers (1.75-

? Funding sources: None. ? Conflict of interest: None.

Fig. 1 Corresponding TS and CT scan showing enlargement of the ventricular system (A) and subarachnoid hemorrhage with small amount of blood in the basal anterior interhemispheric fissure (B).

3.5 MHz) and permits exploration of brain parenchyma. We feel that TS is of great interest in exploring neurologic distress in prehospital settings and to guide additional imaging examinations. The limiting factors are the difficulty in visualization due to insufficient quality of the temporal bone window and that this technique requires a great experience in sonography.

Transcranial sonography is a noninvasive, irradiation- free, rapid, portable, relatively inexpensive, and safe imaging technique. Wider use of this technique in emergency medicine will doubtlessly contribute to improved manage- ment of neurologic distress. Further studies are needed to define the indications, feasibility, and training required for these techniques in emergency medicine, particularly in

prehospital settings, but it seems to constitute a promising research tool.

Hichem Chenaitia MD

Department of Emergency Medicine and Intensive Care

Timone University Hospital Marseille, 13005, France

E-mail address: [email protected]

Christian Squarcioni MD

Department of Neurological Intensive Care Timone University Hospital, Marseille, 13005, France

Brun Pierre Marie MD Querellou Emgan MD

Department of Emergency Medicine and Intensive Care Timone University Hospital, Marseille, 13005, France

Petrovic Tomislav MD Prehospital Emergency Medical Unit Avicenne Hospital, Bobigny, 93000, France

WINFOCUS (World Interactive Network Focused On Critical UltraSound) France Group



  1. Petrovic T, Gamand P, Tazarourte K, Catineau J, Lapostolle F. Feasibility of transcranial Doppler ultrasound examination out-of- hospital. Resuscitation 2010;81(1):126-7.
  2. Holscher T, Schlachetzki F, Zimmermann M, Jakob W, Ittner KP, Haslberger J, et al. Transcranial ultrasound from diagnosis to early stroke treatment. 1. Feasibility of prehospital cerebrovascular assess- ment. Cerebrovasc Dis 2008;26(6):659-63.
  3. Maurer M, Shambal S, Berg D, Woydt M, Hofmann E, Georgiadis D, et al. Differentiation between intracerebral hemorrhage and ischemic stroke by transcranial color-coded duplex-sonography. Stroke 1998;29(12):2563-7.
  4. Behnke S, Becker G. sonographic imaging of the brain parenchyma. Eur J Ultrasound 2002;16(1-2):73-80.
  5. Zipper SG, Stolz E. Clinical application of transcranial colour-coded duplex sonography. Eur J Neurol 2002;9(1):1-8.

Drug-induced Visual impairment may be a manifestation of acute angle closure glaucoma

To the Editor,

The patient who was reported as having become “hot, blind, and mad” [1] manifested some of the clinical features of the delirium syndrome, including risk factors such as preexisting dementia in association with sensory deprivation (the latter due to Blurred vision attributable to papillary dilatation) and precipitating factors such as pain (from the scalp laceration) and environmental change (the latter attributable to referral to the emergency department [ED]),

all 4 components being among the ones highlighted in a recent review of this syndrome [2]. The hidden danger is that, in the preoccupation with the management of the cognitive aspects of this syndrome, when the etiological agent is a drug that can cause pupillary dilatation (as may be the case with antihistamines) [1], clinicians may fail to recognize that acute angle closure glaucoma may supervene in those subjects who are predisposed to the latter complication because of having a shallow anterior chamber [3,4]. The same considerations apply to an elderly patient with or without a previous history of dementia who experiences pupillary dilatation because of the administration of nebulized ipratropium bromide for an acute exacerbation of Chronic obstructive airways disease. In this instance, pupillary dilatation occurs when nebulized vapor escapes from an ill-fitting mask, and the condensate diffuses through the cornea to cause mydriasis complicated, in patients with a shallow anterior chamber, by acute angle closure glaucoma [4]. An added twist is the risk of acute Urinary retention (itself a precipitant of Acute delirium) [2] if the elderly patient in question happens to have coexisting benign prostatic hypertrophy [5,6]. Although the latter complication may have a delayed onset, as was the case in 3 patients reported in the literature [6], it is worth noting that some patients who have nebulized bronchodilators pre- scribed for the first time in the ED may, subsequently, be discharged from ED on domiciliary nebulizer therapy, and it is among the so-called recent starters (of nebulized ipratropium bromide) that the risk of Acute urinary retention is highest (adjusted odds ratio, 3.11; 95% confidence interval, 1.21-7.98) [5]. To mitigate the risk of acute angle closure glaucoma, the oblique penlight illumination test has been proposed (with some caveats) to identify patients with a shallow anterior chamber [3]. A high index of suspicion for this disorder should be entertained in older patients, including those among them who are farsighted and those who wear “plus” glasses that magnify objects and those who belong to certain racial groups [3]. As a corollary, for men with a history suggestive of urinary outflow obstruction, “it might be advisable to consider alternatives for inhaled anticholinergic agents” [5], given that “in men with COPD and benign prostatic hyperplasia (BPH) the association (of acute urinary retention) was strongest (adjusted odds ratio 4.67; 95% confidence interval 1.56-14.0)” [5]. Where the patient fits into the “recent starter” category, domiciliary follow-up should include not only evaluation of symptoms of acute angle closure glaucoma but also evaluation of symptoms of urinary outflow obstruction.

Oscar M.P. Jolobe MB, ChB, DPhil

Manchester Medical Society c/o John Rylands University Library Oxford Road

M13 9PP Manchester, UK E-mail address: [email protected]


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