Introduction: Osteomyelitis can occur at various osseous locations and commonly presents in the emergency department (ED). The incidence of osteomyelitis is 21.8 cases per 100,000 persons annually.1 Hematogenous osteomyelitis typically occurs in the vertebrae; however, it may seldomly occur in the manubrium. Hematogenous osteomyelitis can be seen in patients with complicated thoracic surgery, radiation, fracture, diabetes, immunosuppression, steroid therapy, and malnutrition.2 Because signs and symptoms of osteomyelitis may be nonspecific, clinicians must have high suspicion based on history and physical. Workup should include identifying the source, imaging, and surgical cultures.

Case Report: A 60-year-old male with hypertension and diabetes presented with atraumatic right shoulder and chest pain. The patient presented twice to the ED for clavicle pain five days prior. Computed tomography (CT) of the chest detected osseous infection of the manubrium and upper sternum, right clavicle, and mediastinal phlegmon. A CT of the abdomen and pelvis revealed osteomyelitis and discitis of the 12th thoracic and first lumbar vertebral body with gas at the psoas muscle, as well as sigmoid diverticulitis with colovesicular fistula. The patient was started on broad spectrum antibiotics and 1,500 milliliters of lactated Ringer’s in the ED. After evaluation by cardiothoracic surgery, the patient was taken to the operating room for neck exploration, incision/drainage, manubriectomy, and right sternoclavicular joint resection. Surgical, blood, urine, and respiratory cultures grew Klebsiella pneumoniae. After a 34-day hospital course, the patient was discharged on two weeks of oral levofloxacin and follow-up appointments with cardiothoracic surgery and infectious disease. The patient had good prognosis and recovery.

Conclusion: Hematogenous osteomyelitis to the manubrium is rare and may present with only chest pain. It is important to consider other sources that seed in the manubrium and imaging to evaluate multisite infection. Treatment should include intravenous antibiotics and/or surgical intervention for debridement with washout or manubriectomy.

Introduction: Thoracic ultrasound is frequently used in the emergency department (ED) to determine the etiology of dyspnea, yet its use is not widespread in the prehospital setting. We sought to investigate the feasibility and diagnostic performance of paramedic acquisition and assessment of thoracic ultrasound images in the prehospital environment, specifically for the detection of B-lines in congestive heart failure (CHF).

Methods: This was a prospective observational study of a convenience sample of adult patients with a chief complaint of dyspnea. Paramedics participated in a didactic and hands-on session instructing them how to use a portable ultrasound device. Paramedics assessed patients for the presence of B-lines. Sensitivity and specificity for the presence of bilateral B-lines and any B-lines were calculated based on discharge diagnosis. Clips archived to the ultrasound units were reviewed and paramedic interpretations were compared to expert sonologist interpretations.

Results: A total of 63 paramedics completed both didactic and hands-on training, and 22 performed ultrasounds in the field. There were 65 patients with B-line findings recorded and a discharge diagnosis for analysis. The presence of bilateral B-lines for diagnosis of CHF yielded a sensitivity of 80.0% (95% confidence interval [CI], 51.4-94.7%) and specificity of 72.0% (95% CI, 57.3-83.3), while presence of any B-lines was 93.3% sensitive (95% CI, 66.0-99.7%), and 50% specific (95% CI, 35.7-64.2%) for CHF. Paramedics archived 117 ultrasound clips of which 63% were determined to be adequate for interpretation. Comparison of paramedic and expert sonologist interpretation of images showed good inter-rater agreement for detection of any B-lines (k = 0.60; 95% CI, 0.36-0.84).

Conclusion: This observational pilot study suggests that prehospital lung ultrasound for B-lines may aid in identifying or excluding CHF as a cause of dyspnea. The presence of bilateral B-lines as determined by paramedics is reasonably sensitive and specific for the diagnosis of CHF and pulmonary edema, while the absence of B lines is likely to exclude significant decompensated heart failure. The study was limited by being a convenience sample and highlighted some of the difficulties related to prehospital research. Larger funded trials will be needed to provide more definitive data.