Jahan Fahimi

Computed Tomography Use Among Children Presenting to Emergency Departments With Abdominal Pain

OBJECTIVE: To evaluate trends in and factors associated with computed tomography (CT) use among children presenting to the emergency department (ED) with abdominal pain. METHODS: This study was a cross-sectional, secondary analysis of the National Hospital Ambulatory Medical Care Survey data from 1998 to 2008. We identified ED patients aged <19 years with abdominal pain and collected patient demographic and hospital characteristics, and outcomes related to imaging, hospital admission, and diagnosis of appendicitis. Trend analysis was performed over the study period for the outcomes of interest, and a multivariate regression model was used to identify factors associated with CT use. RESULTS: Of all pediatric ED visits, 6.0% were for abdominal pain. We noted a rise in the proportion of these patients with CT use, from 0.9% in 1998 to 15.4% in 2008 (P < .001), with no change in ultrasound/radiograph use, diagnosis of appendicitis, or hospital admission. Older and male patients were more likely to have a CT scan, whereas black children were one-half as likely to undergo a CT scan compared with white children (odds ratio: 0.50 [95% confidence interval: 0.31–0.81]). Admitted children had much higher odds of undergoing a CT scan (odds ratio: 4.11 [95% confidence interval: 2.66–6.35]). There was a plateau in CT use in 2006 to 2008. CONCLUSIONS: There was a dramatic increase in the utilization of CT imaging in the ED evaluation of pediatric patients with abdominal pain. Some groups of children may have a differential likelihood of receiving CT scans.

Increasing Critical Care Admissions From U.S. Emergency Departments, 2001–2009

Objectives:Little is known about how recent system-wide increases in demand for critical care have affected U.S. emergency departments (EDs). This study describes changes in the amount of critical care provided in U.S. EDs between 2001 and 2009. Design:Analysis of data from the National Hospital Ambulatory Medical Care Survey for the years 2001–2009. Setting:National multistage probability sample of U.S. ED data. U.S. ED capacity was estimated using the National Emergency Department Inventory-United States. Patients:ED patients admitted a critical care unit. Interventions:None. Measurements:Annual hours of ED-based critical care and annual number critical care ED visits. Clinical characteristics, demographics, insurance status, setting, geographic region, and ED length of stay for critically ill ED patients. Main Results:Annual critical care unit admissions from U.S. EDs increased by 79% from 1.2 to 2.2 million. The proportion of all ED visits resulting in critical care unit admission increased from 0.9% to 1.6% (ptrend < 0.001). Between 2001 and 2009, the median ED length of stay for critically ill patients increased from 185 to 245 minutes (+ 60 min; ptrend < 0.02). For the aggregated years 2001–2009, ED length of stay for critical care visits was longer among black patients (12.6% longer) and Hispanic patients (14.8% longer) than among white patients, and one third of all critical care ED visits had an ED length of stay greater than 6 hrs. Between 2001 and 2009, total annual hours of critical care at U.S. EDs increased by 217% from 3.2 to 10.1 million (ptrend < 0.001). The average daily amount of critical care provided in U.S. EDs tripled from 1.8 to 5.6 hours per ED per day. Conclusions:The amount of critical care provided in U.S. EDs has increased substantially over the past decade, driven by increasing numbers of critical care ED visits and lengthening ED length of stay. Increased critical care burden will further stress an already overcapacity U.S. emergency care system.

Factors Associated with Ambulance Use Among Patients with Low-Acuity Conditions

Abstract Background. The use of ambulances for low-acuity medical complaints depletes emergency medical services (EMS) resources that could be used for higher-acuity conditions and contributes to emergency department (ED) overcrowding and ambulance diversion. Objective. We sought to understand the characteristics of patients who use ambulances for low-acuity conditions. We hypothesized that patients who arrive to the ED by ambulance for low-acuity conditions are more likely to be members of vulnerable populations. Methods. A secondary analysis was performed on the National Hospital Ambulatory Medical Care Survey (NHAMCS). We included only patients aged 18 years or older who were triaged to the “nonurgent” category upon presentation to the ED. To compare patients who arrived by ambulance with those who arrived by all other modes, multivariate logistic regression was performed using a generalized linear model, and adjusted relative risks (ARRs) were calculated. Results. A total of 16,109 records from 1997 to 2008 (excluding 2001–2002) were included in the analysis. Significantly higher rates of ambulance use for low-acuity conditions were associated with: 1) older age (ARR 1.30, 95% confidence interval [CI]: 1.18–1.43; per 10 years); 2) Medicare or Medicaid insurance (ARR 1.81, 95% CI: 1.36–2.41, and ARR 1.46, 95% CI: 1.12–1.91, respectively); 3) homelessness (ARR 3.30, 95% CI: 1.61–6.78); 4) arrival between 11 pm and 6:59 am (ARR 1.80, 95% CI: 1.43–2.27); and 5) certain chief complaint categories: psychiatric (ARR 1.78, 95% CI: 1.03–3.07), toxicologic/poisoning (ARR 3.26, 95% CI: 1.85–5.76), and neurologic/psychological (ARR 1.71, 95% CI: 1.34–2.18). Patients who arrived by ambulance were more likely than nonambulance patients to receive laboratory diagnostic tests (ARR 3.50, 95% CI: 2.80–4.39), radiographic imaging (ARR 2.26, 95% CI: 1.91–2.68), and admission to the hospital (ARR 3.99, 95% CI: 3.03–5.27). Conclusion. Our study builds on a body of work highlighting the factors associated with ambulance transport to EDs, confirms that certain vulnerable populations disproportionately use ambulances, and may inform interventions aimed at increasing access to nonambulance transportation and urgent care for these patients.

Emergency Department Ultrasonographic Probe Contamination and Experimental Model of Probe Disinfection

STUDY OBJECTIVE We evaluate the frequency of emergency department (ED) ultrasonographic probe contamination and the bacterial species involved and evaluate probe cleaning and disinfection methods. METHODS This was a 3-part observational cross-sectional study. Surveillance cultures were taken of linear and curvilinear probes on 3 ultrasonographic machines between patient encounters. Cultures of uncovered probes were taken immediately after scanning of skin and soft tissue infections. After experimental probe contamination with methicillin-resistant Staphylococcus aureus (MRSA), we assessed 3-step disinfection by sequential cleaning with a dry towel, saline solution-moistened towel, and quaternary ammonia germicidal wipe and 1-step disinfection by germicidal wipe alone. Cultures were obtained by applying the probe to a blood agar plate. RESULTS In part 1, of 164 surveillance cultures obtained from 6 probes on 29 sampling days during 11 months, 111 (67%; 95% confidence interval [CI] 60% to 74%) grew normal skin flora or environmental flora, 52 had no growth (32%; 95% CI 25% to 39%), and 2 (1.2%; 95% CI 0.3% to 4.3%) grew a clinically important pathogen. In part 2, 14 of 20 (70%; 95% CI 48% to 85%) cultures taken after skin and soft tissue infection scanning produced heavy growth of a clinically important pathogen, including 13 S aureus (5 MRSA). In part 3, cleaning with a dry and moist towel reduced but did not eliminate MRSA. The germicidal wipe step resulted in no growth in 15 of 15 (100%; 95% CI 80% to 100%) cultures in 3-step disinfection and in 9 of 10 (90%; 95% CI 60% to 98%) when used alone. CONCLUSION Skin and environmental flora are commonly present on ultrasonographic probes between patient encounters in our ED; however, clinically important pathogens are uncommon. S aureus (including MRSA) frequently contaminates uncovered probes during skin and soft tissue infection scanning, but in an experimental model, MRSA appears to be reliably removed by a quaternary ammonia germicidal wipe if the probe is partially cleaned first.

The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED☆ , ☆☆ , ★,★★

OBJECTIVES The objective of this study is to describe the clinical use and safety profile of low-dose ketamine (LDK) (0.1-0.3 mg/kg) for pain management in the emergency department (ED). METHODS This was a retrospective case series of consecutive patients given LDK for pain at a single urban ED between 2012 and 2013. Using a standardized data abstraction form, 2 physicians reviewed patient records to determine demographics, indication, dose, route, disposition, and occurrence of adverse events. Adverse events were categorized as minor (emesis, psychomimetic or dysphoric reaction, and transient hypoxia) and serious (apnea, laryngospasm, hypertensive emergency, and cardiac arrest). Additional parameters measured were heart rate and systolic blood pressure. RESULTS Five hundred thirty patients received LDK in the ED over a 2-year period. Indications for LDK were diverse. Median patient age was 41 years, 55% were women, and 63% were discharged. Route of administration was intravenous in 93% and intramuscular in 7%. Most patients (92%) received a dose of 10 to 15 mg. Comorbid diseases included hypertension (26%), psychiatric disorder (12%), obstructive airway disease (11%), and coronary artery disease (4%). There was no significant change in heart rate or systolic blood pressure. Thirty patients (6%) met our criteria for adverse events. Eighteen patients (3.5%) experienced psychomimetic or dysphoric reactions. Seven patients (1.5%) developed transient hypoxia. Five patients (1%) had emesis. There were no cases of serious adverse events. Agreement between abstractors was almost perfect. CONCLUSION Use of LDK as an analgesic in a diverse ED patient population appears to be safe and feasible for the treatment of many types of pain.

Point-of-Care Multi-Organ Ultrasound Improves Diagnostic Accuracy in Adults Presenting to the Emergency Department with Acute Dyspnea

Introduction Determining the etiology of acute dyspnea in emregency department (ED) patients is often difficult. Point-of-care ultrasound (POCUS) holds promise for improving immediate diagnostic accuracy (after history and physical), thus improving use of focused therapies. We evaluate the impact of a three-part POCUS exam, or “triple scan” (TS) – composed of abbreviated echocardiography, lung ultrasound and inferior vena cava (IVC) collapsibility assessment – on the treating physician’s immediate diagnostic impression. Methods A convenience sample of adults presenting to our urban academic ED with acute dyspnea (Emergency Severity Index 1, 2) were prospectively enrolled when investigator sonographers were available. The method for performing components of the TS has been previously described in detail. Treating physicians rated the most likely diagnosis after history and physical but before other studies (except electrocardiogram) returned. An investigator then performed TS and disclosed the results, after which most likely diagnosis was reassessed. Final diagnosis (criterion standard) was based on medical record review by expert emergency medicine faculty blinded to TS result. We compared accuracy of pre-TS and post-TS impression (primary outcome) with McNemar’s test. Test characteristics for treating physician impression were also calculated by dichotomizing acute decompensated heart failure (ADHF), chronic obstructive pulmonary disease (COPD) and pneumonia as present or absent. Results 57 patients were enrolled with the leading final diagnoses being ADHF (26%), COPD/asthma (30%), and pneumonia (28%). Overall accuracy of the treating physician’s impression increased from 53% before TS to 77% after TS (p=0.003). The post-TS impression was 100% sensitive and 84% specific for ADHF. Conclusion In this small study, POCUS evaluation of the heart, lungs and IVC improved the treating physician’s immediate overall diagnostic accuracy for ADHF, COPD/asthma and pneumonia and was particularly useful to immediately exclude ADHF as the cause of acute dyspnea.

National Trends in Ambulance Use by Patients With Stroke, 1997-2008

tion, the differential diagnosis may also include a number of other conditions such as lichen sclerosus, psoriasis, discoid lupus, graft-vs-host disease, and secondary syphilis. The intention of our article was to provide a clear and concise introduction to lichenoid drug eruption, rather than dwell on the subtleties of the differential diagnosis. We agree that in cases in which the clinical diagnosis “was so clinically clear that no other diagnosis was considered,” there is little point in subjecting a patient to a skin biopsy. We would go 1 step further to recommend that a biopsy not be performed unless the results could alter clinical management. However, when considering inflammatory dermatoses (including lichenoid drug eruption) with overlapping clinical patterns and divergent treatment approaches, the skin biopsy is of tremendous importance in reaching an accurate diagnosis, especially when performed by a dermatologist. With respect to our patient, we would have recommended discontinuation of lisinopril with every differential diagnosis. However, our definitive diagnosis allowed us to (1) more accurately counsel the patient regarding the expected time course and resolution of her eruption, (2) advise her of potential associated symptoms, (3) recommend alternative antihypertensives that are not likely to induce her particular eruption, and (4) have a treatment plan in place in the event that her eruption failed to resolve or worsened. In general, a biopsy early in the clinical course of an eruption—and prior to any physicianor patient-initiated treatment—provides the most definitive, accurate, and cost-effective result. Finally, although our patient’s history was relatively straightforward and lent itself well to the teaching purposes of the article, most cases are not so clear-cut. Lichenoid drug eruptions have an extremely variable latency period (from weeks to years) and can be induced by numerous medications. It is frequently much more difficult to determine whether the eruption is drug-induced than it was in this case. In addition, the discontinuation of a potential culprit medication may have much more serious implications for the patient. As discussed in the article, histological features are often helpful in differentiating idiopathic lichen planus from lichenoid drug eruption.

Evaluation of a Cornstarch-Based Ultrasound Gel Alternative for Low-Resource Settings

BACKGROUND Ultrasound is an ideal imaging modality for low-resource settings given its portability, ease of use, and wide range of applications. Commercially available ultrasound gels may be unavailable or cost prohibitive in low-resource settings. OBJECTIVE Our aim was to investigate the quality of images obtained with an alternative ultrasound gel made from cornstarch and water in comparison with commercially available gel. METHODS The cornstarch gel was made by heating water and cornstarch. The gel was used to obtain standard ultrasound images of the gallbladder, kidneys, bladder, heart, and neck vessels by the study investigators. Commercial gel was used as the control. Twenty-four ultrasound clips were shown to four blinded radiologists and two ultrasound-fellowship-trained emergency department physicians. They rated the images on adequacy (yes/no) and graded the images detail, resolution, and quality using a continuous 0-10 scale. RESULTS A total of 144 video clips were shown to reviewers and 129 data-collection sheets were returned. There was no statistical difference in the proportion of images deemed to be of adequate quality: cornstarch-based gel = 0.97 (95% confidence interval [CI] 0.92-1.00) vs. commercially available gel = 0.85 (95% CI 0.75-0.94) (p = 0.053). The cornstarch gel was superior to commercial gel on all three image parameters: detail (p = 0.002), resolution (p = 0.018), and quality (p = 0.013). CONCLUSIONS In this study, a gel made from cornstarch and water was an acceptable coupling medium and provided equally adequate images as compared with commercial ultrasound gel. This inexpensive gel made from ubiquitous materials can be an acceptable alternative to commercial gel in low-resource settings.

Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis

Study objective: Tamsulosin is recommended for patients receiving a diagnosis of a ureteral stone less than 10 mm who do not require immediate urologic intervention. Because of conflicting results from recent meta‐analyses and large randomized controlled trials, the efficacy of tamsulosin is unclear. We perform a systematic review and meta‐analysis to investigate the effect of tamsulosin on stone passage in patients receiving a diagnosis of ureteral stone. Methods: MEDLINE, EMBASE, and CENTRAL databases were searched without language restriction through November 2015 for studies assessing the efficacy of tamsulosin and using a double‐blind, randomized, controlled trial design. Meta‐analysis was conducted with a random‐effects model and subgroup analyses were conducted to determine sources of heterogeneity. Results: Eight randomized controlled trials (N=1,384) contained sufficient information for inclusion. The pooled risk of stone passage in the tamsulosin arm was 85% versus 66% in the placebo arm, but substantial heterogeneity existed across trials (I2=80.2%; P<.001). After stratifying of studies by stone size, the meta‐analysis of the large stone subgroup (5 to 10 mm; N=514) indicated a benefit of tamsulosin (risk difference=22%; 95% confidence interval 12% to 33%; number needed to treat=5). The meta‐analysis of the small stone subgroup (<4 to 5 mm; N=533) indicated no benefit (risk difference=–0.3%; 95% confidence interval –4% to 3%). Neither meta‐analysis for the occurrence of dizziness or hypotension showed a significant effect. Conclusion: Tamsulosin significantly improves stone passage in patients with larger stones, whereas the effect of tamsulosin is diminished in those with smaller stones, who are likely to pass their stone regardless of treatment.

The role of adjunctive antibiotics in the treatment of skin and soft tissue abscesses: a systematic review and meta-analysis.

OBJECTIVE To perform a review and meta-analysis on the effect of antibiotics on treatment of skin and soft tissue abscesses (SSTAs) after incision and drainage. METHODS We searched MEDLINE, EMBASE, Web of Knowledge, and Google Scholar databases to identify randomized controlled trials (RCTs) and observational studies. For RCTs, we included studies comparing any antibiotic (treatment) to placebo (control). For observational studies, treatment was the use of appropriate antibiotics effective against bacterial isolate, and control was the use of inappropriate (ineffective) or no antibiotics. Outcome was treatment success during follow-up. Two investigators reviewed records, assessed quality (according to Cochrane and Newcastle-Ottawa tools), and extracted treatment success rates. Primary analysis was the effect of treatment among RCTs. Secondary analyses included the effect of treatment in 1) observational studies of confirmed methicillin-resistant Staphylococcus aureus (MRSA) infection (MRSA-only) and 2) all studies after 1998 (MRSA-era). We used random effects modelling, except when no heterogeneity was present when we used fixed effects. RESULTS We screened 1,968 records. Twelve were included (five RCTs, seven observational studies), representing 1,969 subjects. Seven enrolled from emergency departments, two from surgical clinics, and three from ambulatory clinics. Three enrolled children only. Pooled relative risk (RR) of treatment success among RCTs was 1.03 (95% confidence interval [CI] 0.97-1.08). Pooled RR in the secondary analyses was 1.05 (95% CI 0.96-1.15) in MRSA-only and 0.99 (95% CI 0.98-1.01) in MRSA-era. CONCLUSION Despite limitations in pooling available data, there is no clear evidence to support antibiotic use in treating uncomplicated SSTAs.