Geoffrey E. Hayden

Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP.

BACKGROUND Volume status assessment is an important aspect of patient management in the surgical intensive care unit (SICU). Echocardiologist-performed measurement of IVC collapsibility index (IVC-CI) provides useful information about filling pressures, but is limited by its portability, cost, and availability. Intensivist-performed bedside ultrasonography (INBU) examinations have the potential to overcome these impediments. We used INBU to evaluate hemodynamic status of SICU patients, focusing on correlations between IVC-CI and CVP. STUDY DESIGN Prospective evaluation of hemodynamic status was conducted on a convenience sample of SICU patients with a brief (3 to 10 minutes) INBU examination. INBU examinations were performed by noncardiologists after 3 hours of didactics in interpreting and acquiring two-dimensional and M-mode images, and > or =25 proctored examinations. IVC-CI measurements were compared with invasive CVP values. RESULTS Of 124 enrolled patients, 101 had CVP catheters (55 men, mean age 58.3 years, 44.6% intubated). Of these, 18 patients had uninterpretable INBU examinations, leaving 83 patients with both CVP monitoring devices and INBU IVC evaluations. Patients in three IVC-CI ranges (<0.20, 0.20 to 0.60, and >0.60) demonstrated significant decrease in mean CVP as IVC-CI increased (p = 0.023). Although <5% of patients with IVC-CI <0.20 had CVP <7 mmHg, >40% of this group had a CVP >12 mmHg. Conversely, >60% of patients with IVC-CI >0.6 had CVP <7 mmHg. CONCLUSIONS Measurements of IVC-CI by INBU can provide a useful guide to noninvasive volume status assessment in SICU patients. IVC-CI appears to correlate best with CVP in the setting of low (<0.20) and high (>0.60) collapsibility ranges. Additional studies are needed to confirm and expand on findings of this study.

Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED.

BACKGROUND Early identification of sepsis in the emergency department (ED), followed by adequate fluid hydration and appropriate antibiotics, improves patient outcomes. OBJECTIVES We sought to measure the impact of a sepsis workup and treatment protocol (SWAT) that included an electronic health record (EHR)-based triage sepsis alert, direct communication, mobilization of resources, and standardized order sets. METHODS We conducted a retrospective, quasiexperimental study of adult ED patients admitted with suspected sepsis, severe sepsis, or septic shock. We defined a preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with normal systolic blood pressure). We performed extensive data comparisons in the pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory response syndrome criteria, time to intravenous fluids bolus, time to antibiotics, length-of-stay times, and mortality rates. RESULTS There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT group. The mean time to bolus was 31 minutes less in the postimplementation group, 51 vs 82 minutes (95% confidence interval, 15-46; P value < .01). The mean time to antibiotics was 59 minutes less in the postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P value < .01). Segmented regression modeling did not identify secular trends in these outcomes. There was no significant difference in mortality rates. CONCLUSIONS An EHR-based triage sepsis alert and SWAT protocol led to a significant reduction in the time to intravenous fluids and time to antibiotics in ED patients admitted with suspected sepsis, severe sepsis, and septic shock.

Bowel Obstruction and Hernia

Bowel obstruction and abdominal hernia are commonly observed in patients seeking emergency care for abdominal pain. This article discusses bowel obstruction, adynamic ileus, acute colonic pseudo-obstruction, and abdominal hernias, with particular emphasis on the management of patients in the emergency department (ED). Although the diagnostic approach to bowel obstruction often requires imaging, abdominal hernia may be identified in most circumstances by history and physical examination alone. Urgent surgical consultation is indicated when there is a concern for bowel ischemia, strangulation, or complete obstruction. This article reviews an ED-based approach to the patient presenting with symptoms of bowel obstruction or hernia.

Point-of-Care Ultrasound for Pediatric Shock.

Abstract The evaluation of critically ill children in the emergency department is oftentimes challenging. Point-of-care ultrasound is an essential tool in the rapid identification of reversible pathology and provides unique insight into the appropriate treatment approach. In this article, we discuss a straightforward sonographic approach to pediatric patients who present in shock.

Pulmonary embolism in the pediatric emergency department: a case demonstrating the application of point-of-care cardiac ultrasound in a pediatric patient with pulmonary embolism.

Abstract Although pulmonary embolism in children is rare, it is important for the pediatric emergency medicine provider to be aware of its presentation and emergent management. We present a case of bilateral pulmonary embolisms in an adolescent patient to illustrate the benefits from the timely diagnosis of right ventricular dysfunction by point-of-care echocardiography performed by emergency medicine physicians. Ultrasonographic techniques and the emergent management of pulmonary embolism are reviewed.

Republication: Incidental findings on intensivist bedside ultrasonographic examinations: Why should we care?

Introduction: The primary goal of intensivist bedside ultrasonography (INBU) is the assessment of patient hemodynamic and volume status. Inevitably, INBU examinations provide views of various thoracic and abdominal structures. Despite the rapid recent increase in utilization of INBU, there are no published descriptions of incidental findings and/or their significance in this setting. Methods: Echocardiographic and vena cava examinations were performed by noncardiologist intensivists in 124 Surgical Intensive Care Unit (SICU) patients using hand-carried ultrasound. In addition, any findings that were deemed “incidental” were recorded. Information analyzed included patient demographics, time to complete INBU examination, and the nature of each incidental finding. Incidental findings were grouped into cardiac, pulmonary, and abdominal. To determine whether incidental INBU findings may have influenced subsequent diagnostic testing patterns, radiographic, and echocardiographic examinations directly relevant to the INBU findings and performed within 48 h of the INBU examination were reviewed. Results: Fifty-eight out of 124 (46.8%) patients in the study group had at least one incidental finding. There were 86 incidental findings, with 23 patients having more than one incidental finding. Forty-eight of 86 incidental findings (55.8%) were cardiac-related, 30 (34.9%) were pulmonary-related, and 8 (9.30%) were abdominal. There were significantly more diagnostic tests performed within 48 h of INBU in the incidental finding group (1.56/patient) than in the nonincidental group (1.18/patient, P< 0.04). The most common post-INBU diagnostic tests were chest radiogram (62%), formal trans-thoracic echocardiography (21%), and abdominal roentgenogram (14%). Computed tomography, formal abdominal ultrasonography, and trans-esophageal echocardiograms were performed less often. Four of 58 patients (6.9%) had a significant change in clinical management associated with the incidental INBU findings. One patient underwent percutaneous drainage of a pleural effusion; three underwent formal echocardiography, with subsequent change in medical management. Conclusions: Nearly half of all SICU patients who underwent INBU were found to have at least one incidental finding. The presence of an incidental finding may have influenced the subsequent pattern of clinical diagnostic testing. In addition, incidental findings on INBU were associated with a significant change in clinical management in nearly 7% of patients. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice based learning and improvement, Systems based practice. Republished with permission from: Stawicki SP, Shiroff AM, Hayden GE, Panebianco NL, Kirkpatrick JN, Horan AD, Gracias VH, Dean AJ. OPUS 12 Scientist 2008;2(3):11-14.

Ketamine Saves the Day: Priapism in a Pediatric Psychiatric Patient.

Priapism is an adverse effect of medications used to treat psychiatric disorders. Often, this condition is self-limiting but may require urologic intervention involving aspiration and injection to induce detumescence. A case of a 15-year-old patient with priapism secondary to a long-acting stimulant is presented to describe the effectiveness of ketamine treatment for priapism.

Ultrasound-Guided Diagnosis of Femoral Osteomyelitis and Abscess.

Abstract Skin and soft tissue infections are common disease presentations to the pediatric emergency department, and rapid and accurate identification of potentially serious skin and soft tissue infections is critical. In cases of atraumatic musculoskeletal pain with systemic complaints, a bacterial etiology must be ruled out. Point-of-care ultrasonography is increasingly common in the pediatric emergency department and assists in rapid and accurate identification of a variety of disease processes. We present a case of a 14-year-old adolescent boy with atraumatic right knee pain to illustrate the benefits of point-of-care ultrasonography in the timely diagnosis of musculoskeletal and soft tissue pathology. Moreover, we describe the use of ultrasound in procedural guidance of deep-space fluid aspiration, with an eventual diagnosis of femoral osteomyelitis. Ultrasonographic techniques and the emergent work-up and management of osteomyelitis are reviewed.