29 grifoni s olivotto i cecchini p et al utility of

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29. Grifoni S, Olivotto I, Cecchini P, et al. Utility of an integrated clinical, echocardiographic and venous ultrasonographic approach for triage of patients with suspected pulmonary embolism. Am J Cardiol 1998; 82 : 1230–5. 30. Clark TJ, Sheehan FH, Bolson EL. Characterizing the normal heart using quantitative three-dimensional cardiac ultrasound. Physiol Meas 2006; 27 : 467–508. 31. Jacobs LD, Salgo IS, Goonewardena S, et al. Rapid online quantification of left ventricular volume from real-time three-dimensional echocardio- graphic data. Eur Heart J 2006; 27 : 460–8. 32. Beaulieu Y. Bedside echocardiography in the assessment of the critically ill. Crit Care Med 2007; 35 : S235–49. 90 Diagnostic ultrasound Cardiac ultrasound
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4 First trimester ultrasound Introduction Ectopic pregnancy (EP) is the leading cause of maternal mortality in the United States and is estimated to have a prevalence of 8% in pregnant patients presenting to the emergency department for any complaint [ 1,2 ]. Indeed, the incidence of ectopic pregnancy has been rising since the mid 1980s [ 3 ]. Therefore, any female of child-bearing age who comes to the emergency room with abdominal pain, vaginal bleeding, near-syncope, or syncope has ectopic pregnancy on the differential. This is a “can’t miss” diagnosis. Given the volume of female patients presenting with these com- plaints, an algorithm incorporating first trimester ultrasound can be time- saving for the physician and patient, but it must increase efficiency without compromising safety. The evaluation for ectopic pregnancy differs from other indications for bedside ultrasound. Evaluation of the uterus seeks to confirm an intrauterine pregnancy (IUP), ruling out ectopic gestation by exclusion. Visualization of the actual ectopic pregnancy is not the goal. In contrast, evaluation of the aorta, heart, and other organs typically confirms pathology (aneurysm, asys- tole, hydronephrosis) via direct visualization. There are instances where an extrauterine gestation will be seen on bed- side ultrasound or free fluid will be seen in a hypotensive pregnant female and ectopic pregnancy will be diagnosed or inferred. This will be the excep- tion, however, to how bedside ultrasound is used for this application. Bed- side ultrasonography instead will be used to increase the number of IUP cases that can be definitively diagnosed and discharged in the emergency department without further imaging. One other important subgroup of patients that should be mentioned is those women who are undergoing in-vitro fertilization (IVF) or assisted reproduction and who present to the emergency department with pain or vaginal bleeding. Because the risk of heterotopic pregnancy in these women is higher than in women without assisted reproduction, it is the view of the authors that these patients should always have formal ultrasonography done by gynecology or radiology and should always have a formal gynecology consultation [ 4 –7]. Others have suggested that there are other subgroups of patients (history of ectopic
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