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The Speed of Sound

The More You Know (or What to Do about Incidental Findings)

Butts, Christine MD

doi: 10.1097/01.EEM.0000574832.85614.04
The Speed of Sound

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If you work in an ED with residents like I do, a lot of ultrasounds are probably being performed every day. Our residents on their ultrasound rotation are often on the hunt for patients who have the patience and curiosity to cooperate with an extended exam, and some try to perform multiple scans on the same patient in their quest to complete their requirements.

Someone with abdominal pain might get an assessment of his gallbladder, kidneys, aorta, and heart. Usually this is all in the name of education, but what happens when something unexpected is found? It's similar to all of the incidental findings popping up on our pan scans, so what do we do with what we find?

A recent study looked at the incidence of positive ultrasound findings in patients presenting to the ED. (BMC Emerg Med. 2018;18[1]:60; http://bit.ly/2Ve8nbU.) The authors wanted to assess for the incidence of theoretically unsuspected pathology. They divided a group of patients into three categories based on their chief complaint: orthopedic, medical, and surgical. All of these patients had extensive ultrasound exams, including cardiac, FAST, and focused abdominal and lung.

The researchers looked for pathology presumably unrelated to their chief complaint (for example, gallstones in a patient presenting with an ankle fracture). They found a large number of unexpected positive findings in more than 400 patients. Almost half of the medical patients, about 45 percent of the surgical patients, and 30 percent of the orthopedic ones had at least one positive finding. The most common finding was cholelithiasis, found in 10 percent of all patients. Other findings included pleural effusion, parenchymal lung pathology, and reduced left ventricular function. Renal cysts were also noted in multiple patients, but these were not considered positive. Very good agreement was present for findings at the bedside and what was found by expert opinion.

What to do with these unexpected findings? Certainly, some of these might be helpful. Finding potential cardiac disease in a patient with an ankle fracture needing operative intervention could prompt a more detailed preoperative clearance. Wouldn't this be found, however, with a more thorough history and physical exam? Our medical patients are frequently sick in many ways.

Would it be surprising that an obese patient with uncontrolled diabetes had cholelithiasis? Perhaps not, but finding this ahead of symptoms might help avoid a delayed diagnosis in the future. If ultrasound is the stethoscope of the 21st century, then we're bound to find things we don't expect, like when the med student hears a murmur in a patient with back pain. I'd argue more information is always better as long as we keep our clinical wits about us.

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Dr. Buttsis the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her on Twitter @EMNSpeedofSound, and read her past columns athttp://bit.ly/EMN-SpeedofSound.

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