82

Determining the Change in Intraocular Pressure During

Bedside Orbital Ultrasonography
Berg CK, Zaia B, Doniger S, Williams S/Stanford University, Palo Alto, CA
Study Objectives: Bedside ultrasound (US) of the orbit is a valuable tool for the
evaluation of traumatic orbital injuries. Conventionally, any maneuver that may
increase intraocular pressure (intraocular pressure) has been contraindicated in the
setting of globe rupture. Some authors have cautioned against the use of US in these
scenarios because of a theoretical concern that an US examination may cause or
exacerbate the extrusion of intraocular contents. This study set out to investigate
whether orbital US affects intraocular pressure.
Methods: A convenience sample of healthy adult volunteers was enrolled. The
baseline intraocular pressure for each patient was obtained by using a transpalpebral
tonometer. Orbital US was then performed on each subject. A second intraocular
pressure was obtained during the US examination. A third intraocular pressure
measurement was obtained following the US examination. In order to validate
transpalpebral measurement, a subset of subjects also underwent traditional
transcorneal applanation tonometry before and after US examination. The intraocular
pressure measures were then compared.
Results: The study included 40 subjects. Intraocular pressure values during US
examination were slightly greater than baseline (average 1.8mmHg, p0.017).
Post-US examination intraocular pressure values were not signicantly different than
baseline (average -0.15mmHg, p0.421). In the subset of 10 subjects, intraocular
pressure values were not signicantly different between transpalpebral and
transcorneal tonometry (average 0.03mmHg, p0.068).
Conclusion: Bedside orbital US causes a small and transient increase in
intraocular pressure. However, this change in pressure is considerably less than the
mean diurnal variation in healthy subjects (5.9mmHg), and is unlikely to be clinically
signicant.
83
Time Correlation of Optic Nerve Sheath Diameter to
Increasing Intracranial Pressure in a Cadaveric Model
Lyon M, Ganapathy P, Burbacher T, Yadegar J/Georgia Health Sciences
University, Augusta, GA; UtopiaCompression Corporation, Los Angeles, CA
Study Objectives: Ultrasound (US) evaluation of the optic nerve sheath width
(diameter) has been shown to correlate with intracranial pressure. Normal optic
nerve sheath diameter as measured 3 mm distal to the posterior globe is less than
5 mm. As intracranial pressure increases, the optic nerve sheath dilates. However,
the speed at which the optic nerve sheath dilation occurs is unknown. Our
objective was to determine the speed and the extent of dilation of the optic nerve
sheath using a cadaveric model with increasing intracranial pressure.
Methods: This was a prospective observational cadaveric trial comparing 2D
US measurements of the optic nerve sheath to invasive intracranial monitoring of
the intracranial space. Using an intracranial monitoring device, 5 ml of saline was
instilled in the intracranial space while simultaneous measurements of the optic
nerve sheath diameter were made using a SonoSite Micromaxx US system and a
L38 (10 - 5 MHz) linear transducer. Measurements of the intracranial pressure
were noted as changes from the baseline intracranial pressure. US measurements
of the optic nerve sheath were taken in a single plane 3 mm distal to the posterior
globe. US measurements were made every 5 minutes after uid instillation until
no further changes in the optic nerve sheath were detected. Three measurements
of the optic nerve sheath were averaged for each measurement trial.
Results: The intracranial pressure increased immediately after uid instillation
into the intracranial space. However, as the uid redistributed within the intracranial
space, the pressure would decrease and would reach a steady-state baseline within the
rst 5 minutes. The optic nerve sheath diameter changed immediately with
instillation of uid into the intracranial space. There was little change in the optic
nerve sheath diameter as the uid redistributed within the intracranial space.
However, the amount of change in the optic nerve sheath diameter was not
proportional to the amount of uid instilled into the intracranial space or to the
intracranial space measurements. Figure 1 demonstrates the change in optic nerve
sheath diameter and intracranial pressure values for 1 hour duration of the
experiment. Although the change in optic nerve sheath dilation is simultaneous with
intracranial pressure increase, the behavior of optic nerve sheath dilation (varies from
4.2 mm to 5.3 mm) is less dynamic than change in intracranial pressure levels (4 cm/
H2O to 34 cm/ H2O).
Conclusion: The change in the optic nerve sheath diameter is simultaneous
with the increase in the intracranial pressure. However, the optic nerve
sheath dilation is less dynamic compared to change in the intracranial pressure
level.
84
Point-of-Care Ocular Sonography to Detect Optic Disc
Swelling
Lenaghan P, Teismann N, Green A, Nolan R, Wang R, Stein J/University of
California San Francisco, San Francisco, CA
Study Objective: Emergency physicians frequently evaluate patients who are
at risk for increased intracranial pressure. Evaluation modalities for this condition
include direct ophthalmoscopy and neuroimaging. However, emergency
physicians use direct ophthalmoscopy with inadequate frequency and accuracy in
patients with neurologic complaints, leaving CT and lubar puncture as primary
diagnostic modalities. Emergency physician-performed ultrasound has been
described as an additional tool to assess for increased intracranial pressure. Efforts
have been made to correlate optic nerve sheath diameter with intracranial
pressure measurement, but sonographic assessment of optic disc swelling
visualized as a hyperechoic outpouching of the optic disc into the vitreous is a
more promising technique.
We sought to compare emergency physician-performed sonographic assessment
of optic disc swelling to a gold standard of Optical Coherence Tomography (OCT)
measurement of optic disc height (ODH) and assessment of clinical optic disc
swelling as determined by a neuro-ophthalmologist.
Methods: We performed a prospective study on a convenience sample of
patients presenting to neuro-ophthalmology clinic for idiopathic intracranial
hypertension or other condition associated with optic disc swelling. We
compared emergency physician-performed ultrasound assessment of optic disc
swelling with actual ODH based on OCT and clinical assessment of optic disc
swelling by a neuro-ophthalmologist. Two emergency physicians experienced in
ocular sonography performed the bedside ultrasound. We sought to determine
the degree of optic disc swelling by measuring the ODH in each eye. We dened
ODH as the anterior-posterior distance between the disc apex and surface of the
posterior globe using a high-frequency (10-12 MHz) transducer. A neuro-
ophthalmologist blinded to the ultrasound results interpreted OCT
measurements and clinical assessment of disc swelling. The ultrasound, OCT,
and clinical evaluation were all performed during the same neurology
appointment. We assessed the correlation between ultrasound measurement and
OCT measurement with spearmans correlation coefcient. We assessed the
receiver operating characteristic curve for the diagnosis of optic disc swelling
based on ODH as assessed by ultrasound.
Results: Eighteen eye measurements were made by ultrasound that also had OCT
measurements, and an additional 2 measurements were done that also had assessment
of disc swelling by the neuro-ophthalmologist. There was excellent correlation
between ODH based on OCT and height obtained by bedside ultrasound, with a
correlation coefcient of 0.84 (p 0.019). We found that the area under the
receiver operating characteristic curve was 0.92 (95% CI 0.8 to 1), suggesting the
potential for an excellent screening test for optic disc swelling.
Conclusion: Based on our initial study, ODH as measured on bedside ultrasound
seems to correlate well with gold standard assessment by OCT. Measurement of
ODH by emergency physician-performed ultrasound also served as an excellent test
to assess for optic disc swelling compared to neuro-ophthalmologist assessment.
Although optic disc swelling has a broad differential diagnosis, bilateral swelling seen
in the emergency department should mandate further evaluation to rule out increased
intracranial pressure. In the future, this tool may prove to be more reliable than
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Volume ,, xo. s : October :c:: Annals of Emergency Medicine S205
emergency physician assessment of papilledema for the diagnosis of increased
intracranial pressure. More studies are needed to prove correlation and to assess
emergency physician ability to diagnose papilledema especially in subjects with mild
disease.
85
Optic Nerve Ultrasound in the Hypertensive Patient
Roque PJ, Barth L, Drachman D, Wu T, LoVecchio F/Maricopa
Medical Center, Phoenix, AZ
Study Objective: Patients routinely present to the emergency department
(ED) with hypertension and a variety of associated symptoms, with the most
common being headache. It is difcult to determine if a patients headache is
secondary to elevated intracranial pressure (intracranial pressure) from a
hypertensive crisis. Recent attention has turned towards the use of bedside
ultrasound (US) to evaluate optic nerve sheath diameters as a marker of increased
intracranial pressure. At this time, the exact relationship between blood pressure
(BP), optic nerve sheath diameter, and intracranial pressure is unclear. We sought
to determine whether dilation of the optic nerve sheath diameter (optic nerve
sheath diameter) on bedside US correlates with patient BP and patient
symptomatology. Data was collected to determine the BP cutoff point where
abnormal changes in the optic nerve sheath diameter occur in both symptomatic
and asymptomatic patients. The relationship between BP, optic nerve sheath
diameter, and specic symptomatology was also evaluated.
Methods: Maricopa Medical Center is a 449-bed tertiary referral teaching
hospital with an ED volume of 70,000 patients annually. This was a single-
blinded, prospective, observational trial. One hundred fty patients presenting to
the ED were enrolled as a convenience sample. There were 3 arms to the study
with 50 patients in each arm: (1) optic nerve sheath diameter in normotensive,
asymptommatic patients, (2) optic nerve sheath diameter in hypertensive,
asymptommatic patients, and (3) optic nerve sheath diameter in hypertensive,
symptomatic patients. Hypertension was dened as systolic BP 140mmHg or a
diastolic BP 90mmHg. Patients were classied as being symptomatic if they
presented with 1 or more of the following symptoms: headache, nausea/vomiting,
visual changes, chest pain, shortness of breath, abdominal pain, vertigo, dizziness
and extremity pain or weakness. Ocular US was conducted using a 10-13 MHz
linear probe to obtain axial cross-sectional imaging of the optic nerve.
Measurements were repeated following hypertension treatment. All statistical
analyses were performed using the statistical program SPSS version 15 (SPSS,
Chicago, IL). Statistical signicance was dened as a p value 0.05.
Results: There was a signicant correlation between systolic BP and optic
nerve sheath diameter in all hypertensive patients (p0.0005). Diastolic BP did
not reach statistical signicance when compared with optic nerve sheath diameter
(p0.331). Post-treatment ocular ultrasound measurements resulted in an overall
average decrease in optic nerve sheath diameter of 0.067 cm (p0.073). The
average BP cutoff point for abnormal optic nerve sheath diameter measurements
was 170/95 mmHg. Although blurry vision was the symptom with the highest
mean optic nerve sheath diameter at 0.50cm, the overall correlation between
optic nerve sheath diameter and presenting symptom was not statistically
signicant (0.288).
Conclusion: There is a growing body of evidence suggesting that millimetric
increases in the sonographic optic nerve sheath diameter are related to increased
intracranial pressure with the abnormal cutoff point set at 5.0mm. To our
knowledge there are no studies examining the correlation between BP and the
optic nerve sheath diameter size measured by bedside ultrasound. Our study
shows a strong relationship between optic nerve sheath diameter and systolic BP
in the hypertensive patient. The obvious decrease in optic nerve sheath diameter
after BP treatment further supports the correlation between BP and optic nerve
sheath diameter, despite statistical insignicance (p0.073). Optic nerve
ultrasound may therefore help with clinical decision in deciding which
hypertensive patient needs urgent blood pressure treatment in the emergency
department.
86
Radiation Exposure Among Highest CT Scan Utilizers
Runde DP, Godbout B, Shah K, Newman DH, Lee J, Wiener D/St.
Lukes Roosevelt Hospital Center, New York, NY; Mt. Sinai School of Medicine,
New York, NY
Study Objective: The risk of cancer from CT scan radiation is a rising concern in
the medical eld. Our objective was to determine how many patients received more
than 10 CT scans in the ED over the course of 7 years and to quantify their radiation
exposure and cancer risk.
Methods: An electronic chart review was performed at our inner city,
academic institution with an annual census of 110,000 patients. All patients who
underwent a CT scan performed during ED management between the dates of
January 2001 and December 2007 were identied. Specic, pre-determined data
elements (eg, subject demographics, type of CT scan) were extracted by 2
researchers blinded to hypothesis, using a pre-formatted data form. After
identifying patients with more than 10 CTs performed during the study period,
radiation exposure was calculated based on accepted and reported radiation doses
for the respective anatomic CTs, and lifetime attributable cancer risk was
calculated based on BEIR VII projections (7th report of the Biological Effects of
Ionizing Radiation).
Results: Over the 7-year study period, 24,393 patients received 34,671 CT
scans. 25 (0.1%) patients received more than 10 CTs, 272 (1%) received 5-10
CTs and 4239 (17%) received 2 CTs. Among those with more than 10 CTs, the
mean, median, and range for number of CTs were 13.8, 13, and 11-23. The
mean age of these patients was 53.3 years, with a range of 26-84 years. Mean
radiation exposure was 93.8 mSv (range 24-240). The average lifetime
attributable cancer risk above baseline in this group is 0.9% with a range from
0.2% to 2.4%.
Conclusion: Among those undergoing CT in our ED, although high exposure
patients (10 scans) constituted a very small minority, attributable cancer risk
increases (up to 2.4%) for these patients may have important public health
implications.
87
Computed Tomography Utilization Rates after Placement
of a Scanner in an Emergency Department
Runde DP, Godbout B, Kirschner J, Shah K, Newman DH, Lee J, Wiener D/St.
Lukes Roosevelt Hospital Center, New York, NY; Indiana University Emergency
Medicine Residency, Indianopolis, IN; Mt. Sinai School of Medicine, New York,
NY
Study Objective: The convenience of a computed tomography (CT) scanner in
the emergency department (ED) may impact CT utilization rates by emergency
physicians. Our primary aim was to determine the rate of CT utilization before and
after placement of an ED CT scanner. Our secondary aims were to determine the rate
of CT utilization by anatomic region and during a 5-month period when the ED
scanner was not available.
Methods: We performed an electronic chart review at our inner city, academic
emergency department with an annual census of 70,000 patients. We identied all
patients over the age of 21 who had a CT scan performed during ED management
from January 2008 to October 2010. Specic, pre-determined data elements (eg,
subject demographics, type of CT scan) were extracted on standardized data forms by
trained abstractors. We analyzed our data with standard descriptive statistics and a
Pearsons chi-squared analysis.
Results: We found a CT utilization rate of 114 per 1000 patient visits before and
139 per 1000 patient visits after placement of a CT scanner in the ED (p0.0001).
CT rates increased in the following anatomic regions: head CTs by 14 per 1000 visits
(p0.0001); neck CTs by 3 per 1000 visits (p0.0001); abdomen/pelvis CTs by 4
per 1000 visits (p0.0015); other CTs by 2 per 1000 visits (p0.0001). Increased
rates of chest CT and facial bone CT approached signicance with p-values of 0.05
and 0.05 respectively. During the 5-month downtime, CT utilization remained
unchanged at a rate of 141 per 1000 visits (p0.38).
Conclusion: We found that the overall CT utilization rate increased after
placement of a CT scanner in the emergency department. Additionally, we found a
signicant increase in almost all subtypes of CT scans, with the most pronounced
increase in head CT scans. Interestingly, during a 5-month period of scanner
downtime, the utilization rates remained unchanged from rates occurring after
placement of the CT scanner in the emergency department.
88
Comparison of Emergency Department Patients Who
Received One versus Multiple Head CT Scans Over a One-
Year Period at an Urban Academic Hospital
Gratton M, McGeeney CM, Hackman J, Bonham A/Truman Medical Center/
University of Missouri Kansas City, School of Medicine, Kansas City, MO
Study Objectives: Computed tomographic (CT) head scanning is 1 of the
most common radiographic studies used in emergency departments (ED). There
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