Objectives Ultrasound measurement of the optic nerve sheath diameter (ONSD) is a rapid, non-invasive means to indirectly assess intracranial pressure. Previous research has demonstrated the ability of emergency physicians to measure ONSD accurately with bedside ultrasound when compared to CT scan or MRI, however the reliability of this measurement between two or more operators has been called into question (Hassen et al. in J Emerg Med 48:450–457, 2015; Shirodkar et al. in Ind J Crit Care Med 19:466–470, 2015). Given the need for accurate and precise measurement to use this as a screening exam, we sought to determine the inter-rater reliability between ONSD measurements obtained in real time by fellowship-trained emergency ultrasound physicians. Methods Three ultrasound fellowship-trained emergency physicians measured bilateral ONSD of 10 healthy volunteers using a high-frequency linear transducer. The physicians were blinded to the other scanners’ measurements, and no instructions were given other than to obtain the ONSD. Each sonographer measured the ONSD in real time and it was recorded by a research coordinator. All measurements were recorded in millimeters. Intraclass correlation coefficients (ICCs) were calculated to estimate the inter-rater reliability. Results A total of 60 measurements of ONSD were obtained. The average measurement was 4.3 mm (3.83–4.77). Very little variation was found between the three physicians, with a calculated ICC of 0.82 (95% confidence interval 0.63–0.92). Conclusions ONSD measurement obtained by ultrasound fellowship-trained emergency medicine physicians is a reliable measurement with a high degree of correlation between scanners.

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This case illustrates the diagnostic approach to evaluating an elderly person with altered mental status. It is important to maintain a broad differential of possible etiologies contributing to a decreased level of alertness. In this case, the patient suffers from hypercarbia due to hypoventilation. This patient is at increased risk of hypoventilation due to his history of chronic obstructive pulmonary disease and the administration of narcotic pain medication. Airway management is a top priority during the resuscitation of a patient suffering from hypercarbia. Methods of airway management include ensuring a patent airway, the administration of oxygen, initiating noninvasive positive pressure ventilation, and, if these measures fail, endotracheal intubation.