Dietrich Jehle

Model Curriculum for Physician Training in Emergency Ultrasonography

A model curriculum for the implementation and training of physicians in emergency medicine ultrasonography is described. Widespread use of limited bedside ultrasonography by emergency physicians will improve diagnostic accuracy and efficiency, increase the quality of care, and prove to be a cost-effective technique for the practice of emergency medicine.

The red blood cell distribution width.

The availability of automated blood cell analyzers that provide an index of red blood cell distribution width (RDW) has lead to new approaches to patients with anemia. While the emergency physician is primarily responsible for the detection of patients with anemia, the inclusion of the RDW in the complete blood count has made diagnosing certain anemias easier, especially those that are microcytic. The derivation of the RDW and its clinical application to emergency physicians is discussed and a categorization of anemias based on the mean corpuscular volume (MCV) and RDW is included.

Emergency department ultrasound in the evaluation of blunt abdominal trauma

The main objective of this study was to compare bedside sonographic detection of hemoperitoneum with diagnostic peritoneal lavage/laparotomy in the patient with blunt abdominal trauma. A retrospective review was conducted of all blunt trauma patients that underwent emergency department (bedside) sonography to rule out intraperitoneal hemorrhage at a level I trauma center in 1991 to 1992. Patients were included in the study population only if: (1) the results of the ultrasound examination were interpreted before any other diagnostic studies, and (2) a diagnostic peritoneal lavage (DPL) or laparotomy was performed. The ultrasound examination consisted of a single right inter/subcostal longitudinal view with the patient in the trendelenburg position performed by the emergency physician or surgeon. A real-time sector scanner with a 3.5 MHz probe was used. The presence of an anechoic (black) stripe between the liver and the right kidney (Morrisons pouch) was interpreted as a positive study, and the absence of this finding was interpreted as a negative study. A positive DPL was defined as > or = 10 mL of gross blood or a blood cell count > or = 100,000/mm3 in the returned lavage fluid, and a positive laparotomy as > or = 100 mL of intraperitoneal blood. Forty-four patients met the inclusion criteria for the study. Eleven patients (24%) in this population had either a positive DPL or laparotomy. The sensitivity, specificity, and accuracy of bedside sonography in identifying intraperitoneal hemorrhage was 81.8%, 93.9%, and 90.9%, respectively. The ultrasound study provided an answer in less than 1 minute in most patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency department sonography by emergency physicians

A retrospective study was conducted to examine whether emergency physicians can perform accurate ultrasonography that influences the diagnosis and treatment of selected disorders in the emergency department (ED). The physicians acquired a moderate level of expertise in sonography using a series of practical demonstrations and lectures. Patients with symptoms suggestive of cardiac, gynecologic, biliary tract, and abdominal vascular disease periodically underwent ED sonography. The initial interpretation was used as a diagnostic adjunct to subsequent therapy. The accuracy of positive sonographic findings was assessed by confirmatory testing, formal review, or confirmatory clinical course. Emergency physicians were able to diagnose correctly (1) the presence and approximate size of pericardial effusions, (2) the presence or absence of organized cardiac activity in patient with clinical electrical mechanical dissociation, (3) the presence or absence of intrauterine pregnancy in pregnant patients with lower abdominal/pelvic complaints, (4) the position of intrauterine devices in patients with suspected uterine perforation, (5) the presence of gallstones in patients with suspected biliary tract disease, and (6) the presence and size of abdominal aortic aneurysms in patients with pulsatile masses or unexplained abdominal pain. It was concluded that reliable sonography which influences diagnosis and therapy can be performed by emergency physicians and that sonography should become a standard procedure in EDs.

The influence of demographic factors on seatbelt use by adults injured in motor vehicle crashes

This study determined demographic factors associated with reported seatbelt use among injured adults admitted to a trauma center. A retrospective chart review was conducted including all patients admitted to a trauma center for injuries from motor vehicle crashes (MVC). E-codes (i.e. ICD-9 external cause of injury codes) were used to identify all patients injured in a MVC between January 1995 and December 1997. Age, sex, race, residence zip code (i.e. a proxy for income based on geographic location of residence), position in the vehicle, and seatbelt use were obtained from the trauma registry. Forward logistic regression was used to identify significant predictors of seatbelt use. Complete data was available for 1366 (82%) patients. Seatbelt use was reported for 45% of patients under age of 25 years, 52% of those 25-60 years, and 68% of those over 60 years. Overall, seatbelt use was reported for 45% of men and 63% of women, as well as for 56% of Caucasians (i.e. Whites) and 34% of African Americans. In addition, seatbelt use was reported for 33% of those earning less than

Comparison of normal saline with tap water for wound irrigation

20,000 per year and 55% of those earning over

Ultrasound for the detection of intraperitoneal fluid: the role of Trendelenburg positioning.

20,000. Finally, seatbelt use was reported for 57% of drivers and 43% of passengers. Logistic regression revealed that age, female gender, Caucasian race, natural log of income, and driver were all significant predictors of reported seatbelt use. These results show that seatbelt use was more likely to be reported for older persons, women, Caucasians, individuals with greater incomes, and drivers. Seatbelt use should be encouraged for everyone; however, young people, men, African Americans, individuals with lower incomes, and passengers should be targeted specifically.

Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam.

This study compared irrigation with tap water versus saline for removing bacteria from simple skin lacerations. The study was conducted in an animal model with a randomized, nonblinded crossover design using 10 500-g laboratory rats. Two full-thickness skin lacerations were made on each animal and inoculated with standardized concentrations of Staphylococcus aureus broth. Tissue specimens were removed before and after irrigation with 250 cc of either normal saline from a sterile syringe or water from a faucet. Bacterial counts were determined for each specimen and compared before and after irrigation. There was a mean reduction in bacterial counts of 81.6% with saline and 65.3% with tap water (P = .34). One tap water specimen had markedly aberrant bacterial counts compared with others. Excluding this specimen, the mean reduction for tap water was 80.2%. In this model, reduction in bacterial contamination of simple lacerations was not different comparing tap water with normal saline as an irrigant.

EFFECT OF ALCOHOL CONSUMPTION ON OUTCOME OF PEDESTRIAN VICTIMS

A prospective, observational study was performed to evaluate the role of Trendelenburg positioning in improving the sensitivity of the single-view ultrasound examination. Hemodynamically stable patients undergoing diagnostic peritoneal lavage (DPL) were assigned to one of two groups: supine or 5 degrees of Trendelenburg positioning. Baseline right intercostal oblique images of Morisons pouch were obtained followed by additional images for each 100 cc of lavage fluid instilled into the peritoneal cavity. The initial volume of fluid required to identify an anechoic stripe was recorded for each patient. Patients were excluded if they had (1) a positive DPL for hemoperitoneum (defined as 10 cc of gross blood or >100,000 red blood cells/microL), (2) positive baseline ultrasound study, (3) hemodynamic instability, or (4) lack of documentation (ie, baseline/subsequent hard copy images were not obtained or inadequately demonstrated anechoic stripe). The mean quantity of fluid for visualization of the anechoic stripe was 443.8 cc in the Trendelenburg group (n = 8) and 668.2 cc in the supine group (n = 11). These means were statistically different (P < .05, t test). The median amount of fluid needed for visualization of the anechoic stripe was 400 cc and 700 cc for the Trendelenburg and supine groups, respectively.

A MULTI-STATE SURVEY OF VIDEOTAPING PRACTICES FOR MAJOR TRAUMA RESUSCITATIONS

The multiple-view focused assessment with sonography for trauma (FAST) exam is an integral tool in the assessment of blunt abdominal trauma. A prospective observational study was performed to compute the average minimum volume of detectable intraperitoneal fluid with the pelvic views of the FAST exam. All adult patients from October 1999 to May 2001, who presented to the ED with blunt abdominal trauma and underwent a clinically indicated diagnostic peritoneal lavage (DPL), were candidates for admission to the pelvic ultrasound study. In the supine position, patients were administered lavage fluid in 100 cc increments until the examiner detected the fluid on ultrasound. An independent reviewer also examined the hard-copy ultrasound images for fluid detection. Patients were excluded if they had (1) a positive DPL for hemoperitoneum (defined as 10 cc of gross blood or >100,000 red blood cells/mL), (2) a positive initial ultrasound for free fluid, or (3) lacked sufficient hard-copy ultrasound images. The mean minimal volume of fluid needed for pelvic ultrasound detection by the examiner and reviewer was 157 and 129 cc (n = 7), respectively. The median quantity of fluid for ultrasound detection by both the examiner and reviewer was 100 cc. The pelvic views of the FAST exam identified a significantly smaller quantity of intraperitoneal fluid than previous studies of the right upper quadrant single-view exam.