Showing papers in "American Journal of Emergency Medicine in 2012"

Role of inferior vena cava diameter in assessment of volume status: a meta-analysis.

Abstract: Background and Objective Hypovolemic shock is an important cause of death in the emergency department (ED). We sought to conduct a meta-analysis to quantify existing evidence on sonographic measurement of inferior vena cava (IVC) diameter in assessing of volume status adult ED patients. Methods A search of 5 major databases of biomedical publication, EMBASE, Ovid Medline, evidence-based medicine (EBM) Reviews, Scopus, and Web of Knowledge, was performed in first week of March 2011. Studies meeting the following criteria were included: (1) prospectively conducted, (2) measured IVC diameter using ultrasonography, (3) inpatients under spontaneous ventilation, and (4) reported IVC diameter measurement with volume status or shock. Article search, study quality assessment, and data extraction were done independently and in duplicate. Mean difference in IVC diameter was calculated using RevMan version 5.5 (Cochrane collaboration). Results A total of 5 studies qualified for study eligibility from 4 different countries, 3 being case-control and 2 before-and-after design, studying 86 cases and 189 controls. Maximal IVC diameter was significantly lower in hypovolemic status compared with euvolemic status; mean difference (95% confidence interval) was 6.3 mm (6.0-6.5 mm). None of the studies blinded interpreters for volume status of participants. Conclusion Moderate level of evidence suggests that the IVC diameter is consistently low in hypovolemic status when compared with euvolemic. Further blinded studies are needed before it could be used in the ED with confidence.

Renal infarction in the ED: 10-year experience and review of the literature

Abstract: Objective We aimed to describe clinical and radiologic features of acute renal infarction (RI). Methods Clinical, computed tomography (CT), and laboratory findings were retrospectively reviewed for patients diagnosed from 1999 to 2009 with CT proof of acute RI. Possible etiology of infarction was recorded. All available published series of RI were reviewed. Results Thirty-eight patients with acute RI met inclusion criteria; 127 cases of RI from 7 previous series were pooled for analysis. The most common symptoms were abdominal pain, flank pain, nausea, and vomiting. Leukocytosis (>10 × 109/L) and elevated lactate dehydrogenase levels (>620 IU/L) were the most prominent laboratory findings. Computed tomography features included wedge-shaped hypodensities in the renal parenchyma in 35 (92%) and global renal ischemia in 3 (8%) patients; 13 patients (34%) had concomitant splenic infarction. The most common etiology was atrial fibrillation. Computed tomography determined the specific cause for RI in 5 patients (13%) and a possible etiology in 17 (45%). Exact correlation with previous series was limited by methodological diversity. Conclusion Renal infarction should be considered in the differential diagnosis of a patient presented to the emergency department with abdominal or flank pain. Laboratory workup should include lactate dehydrogenase levels. After ruling out stone disease, contrast-enhanced CT examination is essential for the diagnosis.

The impact of emergency medical services on the ED care of severe sepsis.

Abstract: Objective The identification and treatment of critical illness is often initiated by emergency medical services (EMS) providers. We hypothesized that emergency department (ED) patients with severe sepsis who received EMS care had more rapid recognition and treatment compared to non-EMS patients. Methods This was a prospective observational study of ED patients with severe sepsis treated with early goal-directed therapy (EGDT).We included adults with suspected infection, evidence of systemic inflammation, and either hypotension after a fluid bolus or elevated lactate. Prehospital and ED clinical variables and outcomes data were collected. The primary outcome was time to initiation of antibiotics in the ED. Results There were 311 patients, with 160 (51.4%) transported by EMS. Emergency medical services–transported patients had more organ failure (Sequential Organ Failure Assessment score, 7.0 vs 6.1; P = .02), shorter time to first antibiotics (111 vs 146 minutes, P = .001), and shorter time from triage to EGDT initiation (119 vs 160 minutes, P = .005) compared to non–EMS-transported patients. Among EMS patients, if the EMS provider indicated a written impression of sepsis, there was a shorter time to antibiotics (70 vs 122 minutes, P = .003) and a shorter time to EGDT initiation (69 vs 131 minutes, P = .001) compared to those without an impression of sepsis. Conclusions In this prospective cohort, EMS provided initial care for half of the patients with severe sepsis requiring EGDT. Patients presented by EMS had more organ failure and a shorter time to both antibiotic and EGDT initiation in the ED.

D-dimer is a significant prognostic factor in patients with suspected infection and sepsis.

Abstract: Purpose The aim of the study was to determine whether C-reactive protein (CRP), procalcitonin (PCT), and d-dimer (DD) are markers of mortality in patients admitted to the emergency department (ED) with suspected infection and sepsis. Basic Procedures We conducted a prospective cohort in a university hospital in Medellin, Colombia. Patients were admitted between August 1, 2007, and January 30, 2009. Clinical and demographic data and Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment scores as well as blood samples for CRP, PCT, and DD were collected within the first 24 hours of admission. Survival was determined on day 28 to establish its association with the proposed biomarkers using logistic regression and receiver operating characteristic curves. Main Findings We analyzed 684 patients. The median Acute Physiology and Chronic Health Evaluation II and Sepsis Organ Failure Assessment scores were 10 (interquartile range [IQR], 6-15) and 2 (IQR, 1-4), respectively. The median CRP was 9.6 mg/dL (IQR, 3.5-20.4 mg/dL); PCT, 0.36 ng/mL (IQR, 0.1-3.7 ng/mL); and DD, 1612 ng/mL (IQR, 986-2801 ng/mL). The median DD in survivors was 1475 ng/mL (IQR, 955-2627 ng/mL) vs 2489 ng/mL (IQR, 1698-4573 ng/mL) in nonsurvivors ( P =.0001). The discriminatory ability showed area under the curve–receiver operating characteristic for DD, 0.68; CRP, 0.55; and PCT, 0.59. After multivariate analysis, the only biomarker with a linear relation with mortality was DD, with an odds ratio of 2.07 (95% confidence interval, 0.93-4.62) for values more than 1180 and less than 2409 ng/mL and an odds ratio of 3.03 (95% confidence interval, 1.38-6.62) for values more than 2409 ng/mL. Principal Conclusions Our results suggest that high levels of DD are associated with 28-day mortality in patients with infection or sepsis identified in the emergency department.

Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters

Abstract: Study Objectives Obtaining intravenous (IV) access in the emergency department (ED) can be especially challenging, and physicians often resort to placement of central venous catheters (CVCs). Use of ultrasound-guided peripheral IV catheters (USGPIVs) can prevent many “unnecessary” CVCs, but the true impact of USGPIVs has never been quantified. This study set out to determine the reduction in CVCs by USGPIV placement. Methods This was a prospective, observational study conducted in 2 urban EDs. Patients who were to undergo placement of a CVC due to inability to establish IV access by other methods were enrolled. Ultrasound-trained physicians then attempted USGPIV placement. Patients were followed up for up to 7 days to assess for CVC placement and related complications. Results One hundred patients were enrolled and underwent USGPIV placement. Ultrasound-guided peripheral IV catheters were initially successfully placed in all patients but failed in 12 patients (12.0%; 95 confidence interval [CI], 7.0%-19.8%) before ED disposition, resulting in 4 central lines, 7 repeated USGPIVs, and 1 patient requiring no further intervention. Through the inpatient follow-up period, another 11 patients underwent CVC placement, resulting in a total of 15 CVCs (15.0%; 95 CI, 9.3%-23.3%) placed. Of the 15 patients who did receive a CVC, 1 patient developed a catheter-related infection, resulting in a 6.7% (95 CI, 1.2%-29.8%) complication rate. Conclusion Ultrasound prevented the need for CVC placement in 85% of patients with difficult IV access. This suggests that USGPIVs have the potential to reduce morbidity in this patient population.

Cardiotoxicity associated with the synthetic cannabinoid, K9, with laboratory confirmation.

Abstract: Synthetic cannabinoids have been popular recreational drugs of abuse for their psychoactive properties. Five of the many synthetic cannabinoids have been recently banned in the United States because of their unknown and potentially harmful adverse effects. Little is known about these substances. They are thought to have natural cannabinoid-like effects but have different chemical structures. Adverse effects related to synthetic cannabinoids are not well known. We provide clinical effects and patient outcome following K9 use. In addition, we briefly review synthetic cannabinoids. We present a 17-year-old adolescent boy with chest pain, tachycardia, and then bradycardia associated with smoking K9. Two synthetic cannabinoids, JWH-018 and JWH-073, were confirmed on laboratory analysis. In addition to the limited current data, we demonstrate harmful adverse effects related to toxicity of 2 synthetic cannabinoids. Further studies are needed.

The effect of bedside ultrasound on diagnosis and management of soft tissue infections in a pediatric ED

Abstract: Background: Presentation of skin and soft tissue infections (SSTIs) to the pediatric emergency department (PED) has increased. Physical examination alone can be inadequate in differentiating cellulitis from an abscess. The purposes of this study were to determine the effect of bedside ultrasound (US) in improving diagnostic accuracy for SSTIs in the PED and to evaluate its effect on the management of patients with SSTIs. Methods: We conducted a prospective study of a convenience sample of children who presented to an inner-city PED with signs and symptoms of SSTI. The treating physician's pretest opinions regarding the need for incision and drainage and procedural sedation were collected. A bedside US was performed by trained PED physicians to evaluate for cellulitis vs abscess. The treating physician was made aware of the US findings, and the effect on management was recorded. Results: Sixty-five patients were enrolled, of whom 47 had US-proven abscess and 18 had cellulitis. The sensitivity of US for detection of abscess was 97.5% (95% confidence interval [CI], 90.1%-99.5%), and the specificity was 69.2% (95% CI, 57.8-72.4%). In comparison, the sensitivity for physical examination alone for detection of abscess was 78.7% (95% CI, 71.4%-84.4%), and the specificity was 66.7% (95% CI, 47.6-81.6%). Ultrasound disagreed with clinical examination and changed management in 9 (13.8%) of 65 patients. Conclusions: Emergency department bedside US improves accuracy in diagnosis of SSTIs. Bedside US changes management in a small but significant number of patients with SSTIs.

ED visits for drug-related poisoning in the United States, 2007

Abstract: Background Fatal drug-related poisoning has been well described. However, death data only show the tip of the iceberg of drug-related poisoning as a public health problem. Using the 2007 Nationwide Emergency Department Sample, this study described the characteristics of emergency department visits for drug-related poisoning in the United States. Methods Any ED visit that had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 960-979 was defined as a drug-related poisoning case. Intentionality of poisoning was determined by E-codes. Weighted estimates of ED visits were calculated by patient and hospital characteristics, intentionality of poisoning, and selected drug classes. Population rates by sex, age, urban/rural classification, median household income in patient's zip code, and hospital region were calculated. Results An estimated 699 123 (95% confidence interval, 666 529-731 717) ED visits for drug-related poisoning occurred in 2007. Children 0 to 5 years old had the highest rate for unintentional poisoning (male, 237 per 100 000; female, 218 per 100 000). The rate of drug-related poisoning in rural areas (684 per 100 000) was 3 times higher than the rates in other areas. Psychotropic agents and analgesics were responsible for 43.7% of all drug-related poisoning. Women 18 to 20 years old had the highest ED visit rate for suicidal poisoning (245 per 100 000). The estimated ED charges were $1 394 051 262, and 41.1% were paid by Medicaid and Medicare. Conclusion Antidepressants and analgesics were responsible for nearly 44% of ED visits for drug-related poisoning in the United States. Interventions and future research should target prescription opioids, rural areas, children 0 to 5 years old for unintentional drug-related poisoning, and female ages 12 to 24 years for suicidal drug-related poisoning.

Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation

Abstract: Purpose: Ultrasound (US) is a useful tool for peripheral vein cannulation in patients with difficult venous access. However, few data about the survival of US-guided peripheral catheters in acute care setting exist. Some studies showed that the survival rate of standard-length catheters (SC) is poor especially in obese patients. The use of longer than normal catheters could provide a solution to low survival rate. The aim of the present study was to compare US-guided peripheral SCs vs US-guided peripheral long catheters inserted with Seldinger technique (LC) in acute hospitalized patients with difficult venous access. Methods: This was a prospective, randomized controlled trial. A total of 100 consecutively admitted subjects in an urban High Dependency Unit were randomized to obtain US-guided intravenous access using either SC or LC after 3 failed blind attempts. Primary outcome was catheter failure rate. Results: Success rate was 86% in the SC groups and 84% in the LC group (P = .77). Time requested to positioning venous access resulted to be shorter for SC as opposed to LC (9.5 vs 16.8 minutes, respectively; P = .001). Catheter failure was observed in 45% of patients in the SC group and in 14% of patients in the LC group (relative risk, 3.2; P b .001). Conclusions: Both SC and LC US-guided cannulations have a high success rate in patients with difficult venous access. Notwithstanding a higher time to cannulation, LC US-guided procedure is associated with a lower risk of catheter failure compared with SC US-guided procedure.

Cardiac troponin: a critical review of the case for point-of-care testing in the ED

Abstract: The measurement of cardiac troponin concentrations in the blood is a key element in the evaluation of patients with suspected acute coronary syndromes, according to current guidelines, and contribu ...

Diagnostic accuracy of heart-type fatty acid-binding protein for the early diagnosis of acute myocardial infarction.

Abstract: Objective The aim of this study was to evaluate the diagnostic efficacy of multiple tests—heart-type fatty acid–binding protein (H-FABP), cardiac troponin I (cTnI), creatine kinase-MB, and myoglobin—for the early detection of acute myocardial infarction among patients who present to the emergency department with chest pain. Methods A total of 1128 patients provided a total of 2924 venous blood samples. Patients with chest pain were nonselected and treated according to hospital guidelines. Additional cardiac biomarkers were assayed simultaneously at serial time points using the Cardiac Array (Randox Laboratories Ltd, Crumlin, United Kingdom). Results Heart-type fatty acid–binding protein had the greatest sensitivity at 0 to 3 hours (64.3%) and 3 to 6 hours (85.3%) after chest pain onset. The combination of cTnI measurement with H-FABP increased sensitivity to 71.4% at 3 to 6 hours and 88.2% at 3 to 6 hours. Receiver operating characteristic curves demonstrated that H-FABP had the greatest diagnostic ability with area under the curve at 0 to 3 hours of 0.841 and 3 to 6 hours of 0.894. The specificity was also high for the combination of H-FABP with cTnI at these time points. Heart-type fatty acid–binding protein had the highest negative predictive values of all the individual markers: 0 to 3 hours (93%) and 3 to 6 hours (97%). Again, the combined measurement of cTnI with H-FABP increased the negative predictive values to 94% at 0 to 3 hours, 98% at 3 to 6 hours, and 99% at 6 to 12 hours. Conclusion Testing both H-FABP and cTnI using the Cardiac Array proved to be both a reliable diagnostic tool for the early diagnosis of myocardial infarction/acute coronary syndrome and also a valuable rule-out test for patients presenting at 3 to 6 hours after chest pain onset.

Cardiopulmonary resuscitation for cardiac arrest: the importance of uninterrupted chest compressions in cardiac arrest resuscitation.

Abstract: Over the last decade, the importance of delivering high-quality cardiopulmonary resuscitation (CPR) for cardiac arrest patients has become increasingly emphasized. Many experts are in agreement concerning the appropriate compression rate, depth, and amount of chest recoil necessary for high-quality CPR. In addition to these factors, there is a growing body of evidence supporting continuous or uninterrupted chest compressions as an equally important aspect of high-quality CPR. An innovative resuscitation protocol, called cardiocerebral resuscitation, emphasizes uninterrupted chest compressions and has been associated with superior rates of survival when compared with traditional CPR with standard advanced life support. Interruptions in chest compressions during CPR can negatively impact outcome in cardiac arrest; these interruptions occur for a range of reasons, including pulse determinations, cardiac rhythm analysis, electrical defibrillation, airway management, and vascular access. In addition to comparing cardiocerebral resuscitation to CPR, this review article also discusses possibilities to reduce interruptions in chest compressions without sacrificing the benefit of these interventions.

The ultrasound-guided superficial cervical plexus block for anesthesia and analgesia in emergency care settings

Abstract: The ultrasound-guided superficial cervical plexus (SCP) block may be useful for providers in emergency care settings who care for patients with injuries to the ear, neck, and clavicular region, including clavicle fractures and acromioclavicular dislocations. The SCP originates from the anterior rami of the C1-C4 spinal nerves and gives rise to 4 terminal branches—greater auricular, lesser occipital, transverse cervical, and suprascapular nerves—that provide sensory innervation to the skin and superficial structures of the anterolateral neck and sections of the ear and shoulder. Here we describe an ultrasound-guided technique for blockade of the SCP that is potentially well suited to emergency care settings. We present the first case description of its successful use to manage pain for a patient with an acute clavicle fracture. This case is presented to highlight one of several potential applications of this promising new technique in the emergency department. © 2012 Published by Elsevier Inc.

Should we fear “flu fear” itself? Effects of H1N1 influenza fear on ED use

Abstract: Background Surges in patient volumes compromise emergency departments' (EDs') ability to deliver care, as shown by the recent H1N1 influenza (flu) epidemic. Media reports are important in informing the public about health threats, but the effects of media-induced anxiety on ED volumes are unclear. Objective The aim of this study is to examine the effect of widespread public concern about flu on ED use. Methods We reviewed ED data from an integrated health system operating 18 hospital EDs. We compared ED visits during three 1-week periods: ( a ) a period of heightened public concern regarding flu before the disease was present ("Fear Week"), ( b ) a subsequent period of active disease ("Flu Week"), and ( c ) a week before widespread concern ("Control Week"). Fear Week was identified from an analysis of statewide Google electronic searches for "swine flu" and from media announcements about flu. Flu Week was identified from statewide epidemiological data. Results Data were reviewed from 22 608 visits during the study periods. Fear Week (n = 7712) and Flu Week (n = 7687) were compared to Control Week (n = 7209). Fear Week showed a 7.0% increase in visits (95% confidence interval, 6-8). Pediatric visits increased by 19.7%, whereas adult visits increased by 1%. Flu Week showed an increase over Control Week of 6.6% (95% confidence interval, 6-7). Pediatric visits increased by 10.6%, whereas adult visits increased by 4.8%. Conclusion At a time of heightened public concern regarding flu but little disease prevalence, EDs experienced substantial increases in patient volumes. These increases were significant and comparable to the increases experienced during the subsequent epidemic of actual disease.

The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity☆

Abstract: Introduction Ultrasound-guided peripheral intravenous catheters (USGPIVs) have been observed to have poor durability. The current study sets out to determine whether vessel characteristics (depth, diameter, and location) predict USGPIV longevity. Methods A secondary analysis was performed on a prospectively gathered database of patients who underwent USGPIV placement in an urban, tertiary care emergency department. All patients in the database had a 20-gauge, 48-mm-long catheter placed under ultrasound guidance. The time and reason for USGPIV removal were extracted by retrospective chart review. A Kaplan-Meier survival analysis was performed. Results After 48 hours from USGPIV placement, 32% (48/151) had failed prematurely, 24% (36/151) had been removed for routine reasons, and 44% (67/151) remained in working condition yielding a survival probability of 0.63 (95% confidence interval [CI], 0.53-0.70). Survival probability was perfect (1.00) when placed in shallow vessels ( P P = .0002. The impact of vessel depth and location was significant after 3 hours and 18 hours, respectively. Vessel diameter did not affect USGPIV longevity. Conclusion Cannulation of deep and proximal vessels is associated with poor USGPIV survival. Careful selection of target vessels may help improve success of USGPIV placement and durability.

Killip classification in patients with acute coronary syndrome: insight from a multicenter registry.

Abstract: The purpose of this study was to assess the prognostic value of the Killip classification at the presentation in patients with acute coronary syndrome (ACS). In 2007 and over 5 months, 6704 consecutive patients with ACS were enrolled in the Gulf Registry of Acute Coronary Events. Patients were categorized according to Killip classification at presentation (Classes I, II, III, and IV). Patients' characteristics and in-hospital outcomes were analyzed. High Killip classes were defined in 22% of patients. In comparison to Killip Class I, patients with higher Killip class had greater prevalence of cardiovascular risk factors, presented late, were less likely to have angina, and were less likely to receive antiplatelet, statins, and β-blockers. Classes II, III, and IV were associated with higher adjusted odds of death in ST-elevation myocardial infarction (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.25-3.69; OR 6.1, 95% CI 3.41-10.86; and OR 28, 95% CI 15.24-54.70, respectively) and non-ST-elevation acute coronary syndrome (adjusted OR 2.4, 95% CI 1.24-4.82; OR 3.2,95% 1.49-7.02; and OR 9.8, 95% CI 3.79-25.57, respectively). In conclusion, across ACS, patients with higher Killip class had worse clinical profile and were less likely to be treated with evidence-based therapy. High Killip class was independent predictors of mortality in ST-elevation myocardial infarction and non-ST-elevation acute coronary syndrome. Physician in the emergency department should be aware of the importance of clinical examination in the risk stratification in patients presenting with ACS.

Hospital burden of unintentional carbon monoxide poisoning in the United States, 2007

Abstract: Background Unintentional, non–fire-related (UNFR) carbon monoxide (CO) poisoning is a leading cause of poisoning in the United States, but the overall hospital burden is unknown. This study presents patient characteristics and the most recent comprehensive national estimates of UNFR CO–related emergency department (ED) visits and hospitalizations. Methods Data from the 2007 Nationwide Inpatient and Emergency Department Sample of the Hospitalization Cost and Utilization Project were analyzed. The Council of State and Territorial Epidemiologists' CO poisoning case definition was used to classify confirmed, probable, and suspected cases. Results In 2007, more than 230 000 ED visits (772 visits/million) and more than 22 000 hospitalizations (75 stays/million) were related to UNFR CO poisoning. Of these, 21 304 ED visits (71 visits/million) and 2302 hospitalizations (8 stays/million) were confirmed cases of UNFR CO poisoning. Among the confirmed cases, the highest ED visit rates were among persons aged 0 to 17 years (76 visits/million) and 18 to 44 years (87 visits/million); the highest hospitalization rate was among persons aged 85 years or older (18 stays/million). Women visited EDs more frequently than men, but men were more likely to be hospitalized. Patients residing in a nonmetropolitan area and in the northeast and midwest regions of the country had higher ED visit and hospitalization rates. Carbon monoxide exposures occurred mostly (>60%) at home. The hospitalization cost for confirmed CO poisonings was more than $26 million. Conclusion Unintentional, non–fire-related CO poisonings pose significant economic and health burden; continuous monitoring and surveillance of CO poisoning are needed to guide prevention efforts. Public health programs should emphasize CO alarm use at home as the main prevention strategy.

High rates of quinolone resistance among urinary tract infections in the ED

Abstract: Objectives The objectives of this study are to examine antibiotic resistance rates and to determine appropriate empiric oral antibiotic for patients with urinary tract infections (UTIs) evaluated and discharged from the ED. Methods A retrospective, single-institution chart review study from August 2008 to March 2009 was conducted. Adult patients seen in the ED with UTI were identified for study inclusion from review of microbiology records. Hospitalized or asymptomatic bacteriuria cases were excluded. Health care-associated (HA)–UTI was defined as UTI with indwelling urinary catheters, health care exposure, or urologic procedures within 3 months. Prevalence of causative bacteria, antibiotic resistance rates, and risk factors for quinolone resistance were determined. Results There were 337 eligible patients with 83% women. The most common uropathogens among 357 bacterial isolates were Escherichia coli (71%) and Klebsiella spp. (9%). Overall levofloxacin resistance rate was 17%. Resistance rates for HA-UTIs were significantly greater than those for community-associated–UTI: levofloxacin, 38% vs 10%; trimethoprim-sulfamethoxazole, 26% vs 17%; amoxicillin, 53% vs 45%; and amoxicillin-clavulanate, 16% vs 6%. Nitrofurantoin resistance rates were similar (9%). Independent risk factors for levofloxacin resistance were long-term medical conditions (adjusted odds ratio [aOR], 4.23; P = .001), HA-UTI (aOR, 2.56; P = .006), and prior quinolone use within 1 week (aOR, 14.90; P = .02) and within 1 to 4 weeks (aOR, 4.62; P = .04). Conclusions We report high rates of quinolone resistance in ED patients with UTIs at our institution. For patients with risk factors for quinolone resistance, empiric therapy with cephalosporins or nitrofurantoin may be preferred. Urine culture and susceptibility testing should be performed to guide definitive therapy for HA-UTIs.

Initial accuracy of bedside ultrasound performed by emergency physicians for multiple indications after a short training period

Abstract: Purposes Emergency physician–performed ultrasonography holds promise as a rapid and accurate method to diagnose multiple diseases in the emergency department (ED). Our objective was to assess the initial diagnostic accuracy (first 55 explorations) of emergency physician–performed ultrasonography for multiple categories of ultrasound use after a short training period. Basic Procedures This was a prospective observational study conducted at an urban ED from June 2010 to March 2011 in patients with suspected cholecystitis, hydronephrosis, deep vein thrombosis, and different cardiovascular problems. Five physicians had a 10-hour training session before enrolling patients. The test characteristics of bedside ultrasonography were determined with the final radiologist/cardiologist interpretation. Main Findings A total of 275 ultrasonographic examinations were performed (78 abdominal explorations, 80 renal explorations, 76 2-point compression ultrasonographic examinations in patients with suspected deep vein thrombosis, and 41 echocardiograms in patients with different acute cardiovascular problems). Radiologists/cardiologists detected 28 cases of cholecystitis, 26 cases of deep vein thrombosis, 49 cases of hydronephrosis, and 15 cases of significant cardiovascular alterations. The overall diagnostic accuracy of ED ultrasonograms yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 92.6% (95% confidence interval [CI], 90%-99%), 89% (95% CI, 84%-94%), 86.2 % (95% CI, 82%-93%), and 94.2% (95% CI, 92%-99%), respectively. Nineteen (6.9%) false-positive results and 6 false-negative results (2.1%) were obtained. Principal Conclusions Emergency physicians in our institution attained reasonably high initial accuracy in the performance of ultrasonography for a variety of clinical problems after a 10-hour training period.

Pulseless electrical activity in cardiac arrest: electrocardiographic presentations and management considerations based on the electrocardiogram.

Abstract: Pulseless electrical activity (PEA), a cardiac arrest rhythm scenario with an associated poor prognosis, is defined as cardiac electrical activity without a palpable pulse. Considering both outpatient and inpatient cardiac arrest presentations, PEA as a rhythm group has been increasing over the past 10 to 20 years with a corresponding decrease in the "shockable" rhythms, such as pulseless ventricular tachycardia and ventricular fibrillation. This review focuses on electrocardiographic findings encountered in PEA cardiac arrest presentations with an emphasis on recognition of patients with a potential opportunity for successful resuscitation.

Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period

Abstract: Objective The study aims to define extent of lawsuits filed against emergency physicians (EPs) over point-of-care emergency ultrasound (US) during the last 20 years. Methods We performed a nationwide search of the WESTLAW legal database for filed lawsuits involving EPs and US. WESTLAW covers all state and federal lawsuits dating back to 1939. Using an electronic search feature, all states were searched using emergency and US as key words. The database automatically accounts for different variants on US such as sonography. An attorney who is also boarded in and practices emergency medicine, as well as an emergency US expert, reviewed returned cases. Descriptive statistics were used to evaluate the data. Results Using the search criteria and excluding obvious radiology suits, 659 cases were returned and reviewed. There were no cases of EPs being sued for performance or interpretation of point-of-care US. There was one case alleging EP failure to perform point-of-care US and diagnose an ectopic before it ruptured. This case was won by the defense. There were no cases against EPs for common causes of radiology and obstetric litigation including sexual assault during endovaginal US. Cases of missed testicular torsion on US were frequent in the emergency setting but none linked EP US. Conclusions Only one case filed against EPs over the last 2 decades was identified, it was over failure to perform US. Most frequent litigations against radiologists and obstetricians are unlikely to be duplicated in the emergency department, and future litigations may also come from EP failure to perform point-of-care US.

External validation of the Glasgow-Blatchford Bleeding Score and the Rockall Score in the US setting

Abstract: Background The Glasgow-Blatchford Bleeding Score (GBS) and Rockall Score (RS) are clinical decision rules that risk stratify emergency department (ED) patients with upper gastrointestinal bleeding (UGIB). We evaluated GBS and RS to determine the extent to which either score identifies patients with UGIB who could be safely discharged from the ED. Methods We reviewed and extracted data from the electronic medical records of consecutive adult patients who presented with signs or symptoms of UGIB (hematemesis and/or melena) to an academic ED from April 1, 2004, to April 1, 2009. The primary outcome was need for intervention (blood transfusion and/or endoscopic/surgical intervention) or death within 30 days. Results We identified 171 patients with the following characteristics: mean age of 69.9 years (SD, 17.0 years ), 52% women, 20% with a history of liver disease, and 22% with history of gastrointestinal bleeding. Ninety (52.6%, 95% confidence interval, 44.9-60.3) patients had the primary outcome. GBS outperformed pre-endoscopy RS [area under the receiver operating characteristic curve (AUC) = 0.79 vs 0.62; P = .0001; absolute difference, 0.17]. The prognostic accuracy of GBS and post-endoscopy RS was similarly high (AUC, 0.79 vs 0.72; P = .26; absolute difference, 0.07). The specificity of GBS and RS was suboptimal at all potential decision thresholds. Conclusions Although GBS outperformed pre-endoscopy RS, the prognostic accuracy of GBS and post-endoscopy RS was similarly high. The specificity of GBS and RS was insufficient to recommend use of either score in clinical practice.

Practice variation in neuroimaging to evaluate dizziness in the ED

Abstract: Background The appropriate role of neuroimaging to evaluate emergency department (ED) patients with dizziness is not established by guidelines or evidence. Methods We identified all adults with a triage complaint of dizziness who were evaluated at 20 EDs of a large Northern California integrated health care program in 2008. Using comprehensive medical records, we captured all head computed tomographies (CTs) or brain magnetic resonance images (MRIs) completed at presentation or within 2 days and all stroke diagnoses within 1 week. We assessed variation in neuroimaging use by site using a random-effects logistic model to account for differences in patient- (demographic and vascular risk factors) and site-level factors (volume, % patients with dizziness, and % patients with dizziness admitted) and linear regression to assess the relationship between neuroimaging rates and stroke diagnosis rates by site. Results Of 378 992 patients seen in 2008, 20 795 (5.5%) had at least one ED visit for dizziness. Overall, 5585 patients (26.9%) had a head CT and 652 (3.1%) had a brain MRI. Between 21.8% and 32.8% of ED patients with dizziness at each site had a head CT ( P P Conclusion The use of neuroimaging for ED patients with dizziness varies substantially without an associated improvement in stroke diagnosis, which is identified only rarely.

Bedside renal ultrasound in the evaluation of suspected ureterolithiasis.

Abstract: Objective To determine whether ultrasound changes emergency physicians' estimated likelihood of acute ureterolithiasis in patients with flank pain. Methods This prospective, observational study enrolled patients awaiting computed tomographic (CT) scan for presumed renal colic. Using a visual analogue scale, treating physicians estimated the likelihood of acute ureterolithiasis based first on clinical findings and urinalysis, then after ultrasound, and finally after CT. A 20% change in estimated likelihood was considered clinically significant. Test characteristics of ultrasound for any ureteral stone and for those greater than or equal to 5 mm in size were determined. Results One hundred seven patients were enrolled. Sensitivity, specificity, and negative predictive value of ultrasound for stones observed on CT were 76.3% (95% confidence interval [CI], 59.4%-88.0%), 78.3% (95% CI, 66.4%-86.9%), and 85.7% (95% CI, 74.1%-92.9%) respectively, and for stones >5 mm 90.0% (95% CI, 54.1%-99.5%), 63.9% (95% CI, 53.4%-73.2%), and 98.4% (95% CI, 90.3%-99.9%), respectively. Ultrasound significantly impacted the estimated likelihood of disease in 33 of 107 cases (30.8%, 95% CI, 22.5%-40.6%). Computed tomography further significantly changed physicians' impression of disease in 55 of 107 cases (51.4%, 95% CI, 41.6%-61.1%). Conclusions Bedside renal ultrasound had only a limited impact on the physicians' clinical impression of patients with possible ureterolithiasis. The sensitivity of sonographic hydronephrosis was modest for detecting any ureteral stone, but much better for detecting a large stone. Further study is needed to define the precise role ultrasound should play in evaluating patients with suspected ureterolithiasis.

Sex disparity in resuscitation efforts and outcomes in out-of-hospital cardiac arrest

Abstract: Objectives The aim of this study was to investigate the association between sex, cardiopulmonary resuscitation efforts, and outcomes of out-of-hospital cardiac arrests in Korea. Methods We used a nationwide, out-of-hospital cardiac arrest cohort database in 2008. We extracted cases involving patients older than 20 years with symptoms of presumed cardiac etiology. Potential predictors were collected using the Utstein style. The primary outcome was the resuscitation effort: basic life support and application of an automatic external defibrillator by emergency medical service providers, and advanced cardiac life support by emergency department physicians. Secondary outcomes were survival to admission and survival to discharge. Univariate and multivariate logistic regression models were applied by sex to calculate odds ratios and 95% confidence intervals adjusting for potential predictors. Results The total number of eligible patients was 13 922. Of these, 5158 patients (37.0%) were female. Females were also less likely than males to receive basic life support (70.8% vs 77.5%, P P P P = .43) and 3.1% (vs 1.8%, P Conclusions Females were less likely than males to receive resuscitation. Female sex was associated with a higher rate of survival at admission rate, whereas it was not associated with survival at discharge.

Acute aortic dissection in the ED: risk factors and predictors for missed diagnosis

Abstract: Objective This study aims to explore the risk factors and predictors involved in the missed diagnosis of acute aortic dissection (AAD) among patients in the emergency medicine department (EMD). Methods This is a single-center retrospective chart review conducted over a 10-year period (January 1998 to December 2008). Records with a diagnosis of "dissection of aorta" ( International Classification of Diseases, Ninth Revision code 441.0) from the hospital discharge database and hospital death register were selected. Acute aortic dissection was defined as missed if diagnostic imaging to diagnose AAD or cardiothoracic surgeon consult was not elicited while in the EMD. We compared the history, clinical findings, and investigations between patients who had the diagnosis of AAD missed in the EMD and those who did not. Results A total of 68 patients were included in the analysis during the study period, of which 38.2% had a missed diagnosis. There was 63.2% of type A AAD by Stanford classification. Neither age, sex, nor a history of hypertension were significant risk factors for missed diagnosis of AAD. The likelihood of missed diagnosis was significantly higher in the absence of a pulse deficit (odds ratio, 35.76; 95% confidence interval, 3.70-345.34) and absence of widened mediastinum on chest radiography (odds ratio, 33.16; 95% confidence interval, 5.74-191.49). Conclusion Well-known risk factors for AAD such as age, male sex, and hypertension were not risk factors for missed diagnosis for AAD presenting in the EMD. The absence of pulse deficit or widened mediastinum does not exclude the diagnosis of AAD.

The impact of overcrowding on the bacterial contamination of blood cultures in the ED

Abstract: Objectives This study aims to determine the risk factors associated with the bacterial contamination of blood cultures among adults visiting the emergency department (ED). Methods Clinical variables and medical records of adults with bacterial growth of blood cultures in the ED as well as the degree of ED crowding, between August 2007 and July 2008, were prospectively collected. Results Of the 11 491 adults who underwent blood culture sampling, the medical records of 558 (4.86%) eligible patients with bacterial growth in their blood cultures were analyzed. Most patients (366, or 3.19%) had true bacteremia, whereas 192 (1.67%) were regarded as contaminated. In multivariate analyses, ED overcrowding (scoring was based on a National Emergency Department Overcrowding Study [NEDOCS] score ≥100 points) was independently associated with blood culture contamination (odds ratio [OR], 1.58; P = .04). In contrast, other medical comorbidities, such as liver cirrhosis (OR, 0.31; P = .02), thrombocytopenia ( 3 ; OR, 0.28; P = .002), or high serum levels of C-reactive protein (>100 mg/L; OR, 0.24; P γ = 0.99, P Conclusions Emergency department overcrowding may have an adverse impact on the quality of clinical care, including increasing the risk of blood culture contamination.

A systematic review of nicardipine vs labetalol for the management of hypertensive crises.

Abstract: Hypertensive emergencies are acute elevations in blood pressure (BP) that occur in the presence of progressive end-organ damage. Hypertensive urgencies, defined as elevated BP without acute end-organ damage, can often be treated with oral agents, whereas hypertensive emergencies are best treated with intravenous titratable agents. However, a lack of head-to-head studies has made it difficult to establish which intravenous drug is most effective in treating hypertensive crises. This systematic review presents a synthesis of published studies that compare the antihypertensive agents nicardipine and labetalol in patients experiencing acute hypertensive crises. A MEDLINE search was conducted using the term "labetalol AND nicardipine AND hypertension." Conference abstracts were searched manually. Ultimately, 10 studies were included, encompassing patients with hypertensive crises across an array of indications and practice environments (stroke, the emergency department, critical care, surgery, pediatrics, and pregnancy). The results of this systematic review show comparable efficacy and safety for nicardipine and labetalol, although nicardipine appears to provide more predictable and consistent BP control than labetalol.

Ketamine sedation is not associated with clinically meaningful elevation of intraocular pressure

Abstract: Background Ketamine is widely used for procedural sedation, but there is limited knowledge on whether ketamine use is associated with elevated intraocular pressure (IOP). Objective The aim of this study was to examine whether there are clinically important elevations of IOP associated with ketamine use during pediatric procedural sedation. Methods We prospectively enrolled children without ocular abnormalities undergoing procedural sedation that included ketamine for nonperiorbital injuries. We measured IOP for each eye before and at 1, 3, 5, 15, and 30 minutes after initial intravenous ketamine administration. We performed Bland-Altman plots to determine if IOP measurements in both eyes were in agreement. Linear regression was used to model the mean IOP of both eyes as a function of time, dose, and age, with a robust sandwich estimator to account for repeated measures. Results Among 25 participants, median (interquartile range) age was 11 (9-12) years, and 18 (72%) were male. Median ketamine dose was 1.88 mg/kg (interquartile range, 1.43-2.03 mg/kg; range 0.96-4 mg/kg). Bland-Altman plots demonstrated a mean difference of IOP between eyes near zero at all time points. The largest predicted difference from baseline IOP occurred at 15 minutes, with an estimated change of 1.09 mm Hg (95% confidence interval, −0.37 to 2.55). The association between ketamine dose and mean IOP was not statistically significant or clinically meaningful (P = .90; estimated slope, 0.119 [95% confidence interval, −1.71 to 1.95]). There were no clinically meaningful levels of increased measured average IOP reached at any time point. Conclusions At dosages of 4 mg/kg or less, there are not clinically meaningful associations of ketamine with elevation of IOP.

Impact of inappropriate empirical antibiotic therapy on outcome of bacteremic adults visiting the ED

Abstract: Objectives To investigate the clinical impact of inappropriate empirical antibiotics on patient outcome and determine the risk factors for mortality in bacteremic adults who visited the emergency department (ED). Methods Bacteremic adults visiting the ED from January 2007 to June 2008 were identified retrospectively. Demographic characteristics, clinical conditions, bacteremic pathogens, antimicrobial agents, and outcomes were determined from chart records. Results The total of 454 eligible bacteremic adults were included in the analysis; excluded from the study were another 261 patients with contaminated blood cultures and 64 patients with ED stays of less than 24 hours. Among the included individuals, the mean age was 64.6 years, with a small predominance of males (230 patients, 50.7%). Of a total 494 bacteremic isolates, Escherichia coli (206, 41.7%) and Klebsiella species (81, 16.4%) were the most frequently encountered microorganisms. A lower 28-day mortality rate was demonstrated in bacteremic patients treated with appropriate antibiotics than that in those with inappropriate antibiotics or that in those with no antibiotic therapy, as judged by Kaplan-Meier survival curves ( P = .01). Moreover, the differences among these three groups achieved higher significance ( P = .002) in critically ill patients (Pittsburgh bacteremia scores of ≥4 points). In multivariate analyses, inappropriate antibiotic therapy in the ED was associated independently with mortality at 28 days (odds ratio, 2.26; 95% confidence interval, 1.01-5.13; P = .04). Conclusions For bacteremic adults visiting the ED, their outcomes were favorable following appropriate antibiotics, compared to treatment with inappropriate antibiotics or no antibiotics.