Gavin Budhram

Single-operator ultrasound-guided intravenous line placement by emergency nurses reduces the need for physician intervention in patients with difficult-to-establish intravenous access.

BACKGROUND Emergency physicians (EPs) have become facile with ultrasound-guided intravenous line (USIV) placement in patients for whom access is difficult to achieve, though the procedure can distract the EP from other patient care activities. OBJECTIVES We hypothesize that adequately trained Emergency Nurses (ENs) can effectively perform single-operator USIV placement with less physician intervention than is required with blind techniques. METHODS This was a prospective multicenter pilot study. Interested ENs received a 2-h tutorial from an experienced EP. Patients were eligible for inclusion if they had either two failed blind peripheral intravenous (i.v.) attempts, or if they reported or had a known history of difficult i.v. placement. Consenting patients were assigned to have either EN USIV placement or standard of care (SOC). RESULTS Fifty patients were enrolled, of which 29 were assigned to USIV and 21 to SOC. There were no significant differences in age, race, gender, or reason for inclusion. Physicians were called to assist in 11/21 (52.4%) of SOC cases and 7/29 (24.1%) of USIV cases (p = 0.04). Mean time to i.v. placement (USIV 27.6 vs. SOC 26.4 minutes, p = 0.88) and the number of skin punctures (USIV 2.0 vs. SOC 2.1, p = 0.70) were not significantly different. Patient satisfaction was higher in the USIV group, though the difference did not reach statistical significance (USIV 86.2% vs. SOC 63.2%, p = 0.06). Patient perception of pain on a 10-point scale was also similar (USIV 4.9 vs. SOC 5.5, p = 0.50). CONCLUSIONS ENs performing single-operator USIV placement in patients with difficult-to-establish i.v. access reduces the need for EP intervention.

Bedside Ultrasound Aids Identification and Removal of Cutaneous Foreign Bodies: A Case Series

BACKGROUND Soft tissue injury with a retained foreign body (FB) is a common emergency department (ED) complaint. Detection and precise localization of these foreign bodies is often difficult with traditional plain radiographic imaging or computed tomography (CT). CASE REPORT We present three cases in which bedside ultrasound was used to identify and guide management of retained soft tissue foreign bodies. Comparison of ultrasound vs. plain radiography and CT, as well as techniques for FB identification and removal, are discussed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Bedside ultrasound is an invaluable tool in the localization of foreign bodies in relation to other anatomic structures, and aids in the decision to remove them in the ED.

Young Patients with Suspected Uncomplicated Renal Colic are Unlikely to Have Dangerous Alternative Diagnoses or Need Emergent Intervention

Introduction In the United States there is debate regarding the appropriate first test for new-onset renal colic, with non-contrast helical computed tomography (CT) receiving the highest ratings from both Agency for Healthcare Research and Quality and the American Urological Association. This is based not only on its accuracy for the diagnosis of renal colic, but also its ability to diagnose other surgical emergencies, which have been thought to occur in 10–15% of patients with suspected renal colic, based on previous studies. In younger patients, it may be reasonable to attempt to avoid immediate CT if concern for dangerous alternative diagnosis is low, based on the risks of radiation from CTs, and particularly in light of evidence that patients with renal colic have a very high likelihood of having multiple CTs in their lifetimes. The objective is to determine the proportion of patients with a dangerous alternative diagnosis in adult patients age 50 and under presenting with uncomplicated (non-infected) suspected renal colic, and also to determine what proportion of these patients undergo emergent urologic intervention. Methods Retrospective chart review of 12 months of patients age 18–50 presenting with “flank pain,” excluding patients with end stage renal disease, urinary tract infection, pregnancy and trauma. Dangerous alternative diagnosis was determined by CT. Results Two hundred and ninety-one patients met inclusion criteria. One hundred and fifteen patients had renal protocol CTs, and zero alternative emergent or urgent diagnoses were identified (one-sided 95% CI [0–2.7%]). Of the 291 encounters, there were 7 urologic procedures performed upon first admission (2.4%, 95% CI [1.0–4.9%]). The prevalence of kidney stone by final diagnosis was 58.8%. Conclusion This small sample suggests that in younger patients with uncomplicated renal colic, the benefit of immediate CT for suspected renal colic should be questioned. Further studies are needed to determine which patients benefit from immediate CT for suspected renal colic, and which patients could undergo alternate imaging such as ultrasound.

Validity of STONE scores in younger patients presenting with suspected uncomplicated renal colic.

OBJECTIVES Recent studies have cast doubt on the routine need for emergent computed tomographic (CT) scan in patients with suspected renal colic. A clinical prediction rule, the STONE score, was recently published with the goal of helping clinicians predict obstructive kidney stones in noninfected flank pain patients before CT scan. We sought to examine the validity of this score in younger, noninfected flank pain patients. METHODS A secondary analysis of a retrospective cohort study was performed to determine the validity of STONE scores for predicting the outcome of obstructive kidney stone in patients age 18 to 50 years presenting with flank pain suggestive of uncomplicated ureterolithiasis. Validity was measured by calculation of the area under the curve of the receiver operating characteristic curve. Sensitivity, specificity, negative predictive value, positive predictive value, and ±likelihood ratios were calculated for various cutoff values. RESULTS Of 134 patients who met inclusion criteria, 56.7% were female, average age was 37 years, and 52% had an obstructing kidney stone by CT scan. The receiver operating characteristic curve for the STONE score had an area under the curve of 0.87 (95% confidence interval, 0.80-0.93) and indicated that a cutoff of greater than or equal to 8 would have a sensitivity of 78.6%, specificity of 84.4%, negative predictive value of 78.3%, positive predictive value of 84.6%, and +likelihood ratio of 4.9. CONCLUSIONS This analysis suggests that the STONE score is valid in younger populations. It can aid in determining pretest probability and help inform conversations about the likelihood of the diagnosis of renal colic before imaging, which may be useful for decision making.

Bedside Ultrasound in the Diagnosis of Complex Hand Infections: A Case Series

BACKGROUND The red, swollen, infected hand can be a diagnostically challenging presentation in the emergency department (ED). Hand infections are a relatively uncommon ED complaint, and diagnoses may range from simple cellulitis to deep space abscess, and even to suppurative flexor tenosynovitis. The accurate differentiation of these clinical entities is of paramount importance to healing and recovery of function. CASE SERIES In this case series, we review 4 patients with similar presenting complaints of a red, swollen hand, but with much different diagnoses and eventual treatment strategies. We describe how ultrasound was used to assist in making the diagnosis and initiating the most appropriate therapy. Finally, we review techniques for sonographic evaluation of the hand and provide imaging tips to improve visualization and accurate diagnosis. Why should an emergency physician be aware of this? Bedside ultrasound may allow for a more rapid and accurate diagnosis of various hand infections when diagnosis by physical examination is unclear.

Implementation of a Successful Incentive-Based Ultrasound Credentialing Program for Emergency Physicians

Introducion: With the rapid expansion of emergency ultrasound, resident education in ultrasound has become more clearly developed and broadly integrated. However, there still exists a lack of guidance in the training of physicians already in practice to become competent in this valuable skill. We sought to employ a step-wise, goal-directed, incentive-based credentialing program to educate emergency physicians in the use of emergency ultrasound. Successful completion of this program was the primary outcome. Methods: The goal was for the physicians to gain competency in 8 basic ultrasound examinations types: aorta, focused assessment with sonography in trauma, cardiac, renal, biliary, transabdominal pelvic, transvaginal pelvic, and deep venous thrombosis. We separated the 2.5 year training program into 4 distinct blocks, with each block focusing on 2 of the ultrasound examination types. Each block consisted of didactic and hands-on sessions with the goal of the physician completing 25 technically-adequate studies of each examination type. There was a financial incentive associated with completion of these requirements. Results: A total of 31 physicians participated in the training program. Only one physician, who retired prior to the end of the 2.5 year period, did not successfully complete the program. All have applied for and received hospital privileging in emergency ultrasound and incorporated it into their daily practice. Conclusion: We found that a step-wise, incentive-based ultrasound training program with a combination of didactics and ample hands-on teaching was successful in the training of physicians already in practice.

Diagnosis of Ascending Aortic Dissection Using Emergency Department Bedside Echocardiogram

A 36-year-old white male with history of hypertension and schizophrenia presented to the emergency department (ED) with several hours of severe throat pain and shortness of breath that began abruptly while climbing stairs. Examination revealed a severely agitated, pale, diaphoretic patient who was vomiting. The patient’s pulse was noted to be 100 beats ⁄ min, with blood pressure 70 ⁄ 35 mmHg. Examination of the oropharynx and neck was unremarkable. Examination of the chest revealed only occasional rales and tachycardia. A chest radiograph revealed cardiomegaly and pulmonary edema. An ED bedside echocardiogram was performed by an emergency physician. Significant aortic root dilatation was seen on a parasternal long axis view (Figure 1). An intimal flap extending around the aortic arch was visualized on a suprasternal view (Figure 2). Surgery was immediately consulted and the patient was taken to the operating room. In this case, early ultrasound diagnosis (videos available as online Data Supplements at http://www.blackwell-synergy. com/doi/suppl/10.1111/j.1553-2712.2008.00106.x) led to prompt operative intervention, and the patient was ultimately discharged from the hospital several weeks later.

Left ventricular thrombus development during ventricular fibrillation and resolution during resuscitation in a swine model of sudden cardiac arrest.

BACKGROUND Intracardiac thrombus is a well-known complication of low-flow cardiac states including acute myocardial infarction and atrial fibrillation. Little is known, however, about the formation of intracardiac (left ventricular [LV]) thrombus during the extreme low-flow state of cardiac arrest. OBJECTIVE Using a swine model of sudden cardiac arrest, we examined the sonographic development of LV thrombus over time after induction of ventricular fibrillation (VF) and resolution of thrombus with cardiopulmonary resuscitation (CPR). METHODS This observational study was IACUC approved. Forty-five Yorkshire swine were sedated, intubated, and instrumented under general anesthesia before VF was electrically induced. Sonographic data was collected immediately after VF induction and at 2-min intervals thereafter. Following 12min of untreated VF, resuscitation was initiated with closed chest compressions using an oxygen-powered mechanical resuscitation device. Observations were continued during attempted resuscitation. At the end of the experiment, the animals were euthanized while still at a surgical depth of anesthesia. The data was analyzed descriptively. RESULTS Sonographic evidence of LV thrombus was observed in 43/45 animals (95.6% [95%CI: 85.2%, 98.8%]). Thrombus was detected within 6min in 39/45 (86.7% [95%CI: 73.8%, 93.8%]) animals that developed thrombus. Thrombus resolved within 2min after initiation of chest compressions in 31/43 (72.1% [95%CI: 57.3%, 83.3%]) animals. CONCLUSION Similar to other low-flow cardiac states, LV thrombus develops early in the natural history of VF arrest and resolves quickly once forward flow is re-established by chest compressions. Institutional protocol number: 154600-8.

Diagnosis of Pulmonary Embolism Using Emergency Department Bedside Echocardiogram

A previously healthy 88-year-old female presented to the emergency department (ED) with a 4-day history of progressive shortness of breath, dyspnea on exertion, nonproductive cough, weakness, fatigue, and episodic fever. She had experienced mild, left-sided chest discomfort early in the course of her illness, which had resolved prior to presentation. Initial examination revealed a comfortable-appearing, pleasant, elderly woman. Her vital signs were notable for heart rate of 108 beats ⁄ min and oxygen saturation on room air of 84%. She was placed on 4 L of supplemental oxygen via nasal cannula, with improved oxygen saturation to 98%. The physical examination was remarkable only for mild tachycardia and bilateral, Figure 3. Late apical four-chamber view showing right atrial and ventricular dilatation and septal deviation. RA = right atrium; RV = right ventricle.

Impending paradoxical embolus: A bedside diagnosis in the Emergency Department

Impending paradoxical embolus (IPE) is a rare disease process where a thrombus is visualized crossing from the right heart to the left heart, typically through a patent foramen ovale (PFO). It can present to the EDwith symptoms of cerebral vascular accident (CVA) or pulmonary embolus (PE). Mortality has been estimated at 18–20%mainly due to embolic CVA. Transthoracic echocardiography (TTE) or transesophageal echocardiography (TTE) have been the mainstay of diagnosis for the last three decades.We present a case of IPE diagnosed using focused cardiac ultrasonography (FOCUS) at the bedside in the emergency department which guided medical decisions for the duration of the patients hospital admission. A 92 year-old female nursing home patient presented to the EDwith back pain and “feeling horrible all day”. She was noted to be hypoxic at her nursing home with a pulse oximetry near 80% and thus was sent to the ED for evaluation. Her past medical history included coronary artery disease status post bypass grafting, paroxysmal atrial fibrillation, not anticoagulated, CVA, and congestive heart failure with an ejection fraction of 20% on digoxin. On arrival the patient was comfortable, with the following vital signs of: pulse 105, blood pressure 100/60, respiratory rate 30, oxygen saturation 98% on four liters oxygen by nasal cannula, and temperature 98.0 °F. A bedside ultrasound evaluation of her aorta was normal, but because of her hypoxia focused cardiac ultrasonography was also performed. On this evaluation, the patient was found to have a large, linear thrombi in the left and right atria (Fig. 1A-C, Supplemental videos 1 and 2). Ultrasound of the right lower extremity also revealed thrombus in the left popliteal vein (Fig. 1D). Heparin was started empirically for suspected impending paradoxical embolus, and a subsequent computed tomography (CT) angiogram of the chest found pulmonary emboli involving all of her lobar pulmonary arteries (Fig. 2). Formal echocardiography confirmed bi-atrial thrombi as well as a thrombus in transit through a PFO, but the patient was deemed to be too high risk for thrombolytic or surgical treatment options. Unfortunately, eight days after admission the patient developed slurred speech, rightward eye deviation, and left-sided weakness. A CT demonstrated an acute ischemic infarct in the right globus pallidus and external capsule, presumed to result from the IPE despite having a supratherapeutic International Normalized Ratio (INR) of 3.9. ☆ No grants or other financial support were received by either author for this case