Jason T. Nomura

A Randomized Controlled Trial of Ultrasound-Assisted Lumbar Puncture

Evidence showing the systematic utility of ultrasound imaging during lumbar puncture (LP) in the emergency department is lacking. Our hypothesis was that ultrasound‐assisted LP would increase the success rate and ease of performing LP with a greater benefit in obese patients.

Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest

BACKGROUND Point-of-care ultrasound has been suggested to improve outcomes from advanced cardiac life support (ACLS), but no large studies have explored how it should be incorporated into ACLS. Our aim was to determine whether cardiac activity on ultrasound during ACLS is associated with improved survival. METHODS We conducted a non-randomized, prospective, protocol-driven observational study at 20 hospitals across United States and Canada. Patients presenting with out-of-hospital arrest or in-ED arrest with pulseless electrical activity or asystole were included. An ultrasound was performed at the beginning and end of ACLS. The primary outcome was survival to hospital admission. Secondary outcomes included survival to hospital discharge and return of spontaneous circulation. FINDINGS 793 patients were enrolled, 208 (26.2%) survived the initial resuscitation, 114 (14.4%) survived to hospital admission, and 13 (1.6%) survived to hospital discharge. Cardiac activity on US was the variable most associated with survival at all time points. On multivariate regression modeling, cardiac activity was associated with increased survival to hospital admission (OR 3.6, 2.2-5.9) and hospital discharge (OR 5.7, 1.5-21.9). No cardiac activity on US was associated with non-survival, but 0.6% (95% CI 0.3-2.3) survived to discharge. Ultrasound identified findings that responded to non-ACLS interventions. Patients with pericardial effusion and pericardiocentesis demonstrated higher survival rates (15.4%) compared to all others (1.3%). CONCLUSION Cardiac activity on ultrasound was the variable most associated with survival following cardiac arrest. Ultrasound during cardiac arrest identifies interventions outside of the standard ACLS algorithm.

Ultrasound Diagnosis of Penile Fracture

BACKGROUND Rupture of the corpus cavernosum, penile fracture, is an uncommon occurrence. Diagnosis is straightforward when classical historical and physical examination findings are present. However, atypical presentations can make the diagnosis difficult. OBJECTIVES Review the literature supporting use of ultrasound for the diagnosis of penile fracture. Review of the ultrasonographic findings in patients with penile fracture. CASE REPORT A 32-year-old man presented with penile ecchymosis after sex but lacking several historical and physical examination elements for a diagnosis of penile fracture. Ultrasound performed by the treating physician revealed rupture of the tunica albuginea and presence of a hematoma, leading to a diagnosis of penile fracture. CONCLUSION Ultrasound is a simple, efficient, and non-invasive imaging method to assist in the diagnosis of penile fracture.

Ultrasound-Guidance Can Reduce Adverse Events During Femoral Central Venous Cannulation

BACKGROUND Ultrasound-guidance for internal jugular central venous cannulation (CVC) has become the recommended best practice and has been shown to improve placement success and reduce complications. There is a dearth of studies that evaluate emergency point-of-care ultrasound guidance of femoral CVC. OBJECTIVE Our aim was to determine if point-of-care ultrasound guidance for femoral CVC decreases adverse events and increases the likelihood of successful placement when compared with the landmark technique. METHODS We conducted an Institutional Review Board-approved, prospective, observational study of consecutive patients who required CVC. Physicians who performed CVC completed a standardized, web-based data sheet for a national CVC registry. We evaluated single-institution data regarding CVC site, ultrasound usage, CVC indication, and mechanical complications (e.g., pneumothorax, arterial puncture, failed access, catheter misdirection, and hematoma). The study period was between January 2006 and June 2010. Analysis using Pearsons χ(2) and Agresti-Coull binomial confidence intervals was performed; significance was defined as p < 0.05. RESULTS We evaluated data for 143 patients who had femoral CVC in our institution. Sixty CVCs (42%) were performed under ultrasound guidance, 83 (58%) via landmark technique (p = 0.0159); 3.3% of femoral central venous lines placed by ultrasound guidance had recorded adverse events compared with 9.6% for the landmark technique (p = 0.145). There was no statistically significant difference in complications between ultrasound-guidance and landmark techniques. Our data showed a trend toward decreased rates of arterial puncture and reduced cannulation attempts resulting in improved placement success. CONCLUSIONS Our experience shows that ultrasound guidance for femoral CVC might decrease complications and improve placement success, although we cannot recommend this approach without additional data. We recommend a larger study to further evaluate this technique.

Delayed cardiac dysrhythmias after fingolimod administration

A 51-year-old woman with relapsing-remitting multiple sclerosis was initiated on fingolimod. She developed a Mobitz Type I (Wenckebach)second-degree atrioventricular (AV) heart block during the initial 6-hour monitoring. She was transferred to the emergency department for further monitoring, where she went into a junctional tachycardia then went back into a Mobitz Type I AV block. The patient was symptomatic with a heart rate nadir of 38 beats per minute and treated with atropine. Junctional tachycardia has not been previously reported with fingolimod use. Patients may require extended cardiac monitoring after fingolimod administration.

Goal-directed Focused Ultrasound Milestones Revised: A Multiorganizational Consensus

In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 (PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision.

ULTRASOUND DIAGNOSIS OF ACUTE THROMBOSIS OF AN ABDOMINAL AORTIC ANEURYSM: A CASE REPORT

BACKGROUND Point-of-care ultrasound is an effective and reliable method to diagnosis the presence of an abdominal aortic aneurysm. However, there has been limited literature regarding ultrasound diagnosis of acute aortic thrombosis. OBJECTIVE Discuss a patient case with acute aortic thrombosis diagnosed by point-of-care emergency ultrasound. Review common etiologies and treatment options in this rare diagnosis. CASE REPORT A patient with a known abdominal aortic aneurysm presented with mottled lower extremities. Point-of-care ultrasound was utilized by her physicians to diagnose acute thrombosis of her abdominal aorta. With conservative treatment the patient survived to hospital discharge. CONCLUSION Aortic thrombosis is a rare and devastating problem that can be diagnosed with point-of-care ultrasound.

A retrospective study of pulseless electrical activity, bedside ultrasound identifies interventions during resuscitation associated with improved survival to hospital admission. A REASON Study

OBJECTIVE Our objective was to determine whether organized or disorganized cardiac activity is associated with increased survival in patients who present in pulseless electrical activity (PEA) treated with either 1) standard advanced cardiac life support (ACLS) medications or 2) other interventions. METHODS This was a secondary analysis of a prospective, multi-center observational study utilizing ultrasound in out-of-hospital or inemergency department PEA arrest. Bedside ultrasound was performed as ACLS protocol started and during pulse checks. Only cases with visible cardiac activity on ultrasound were included in the present analysis. Cardiac activity was categorized as disorganized (agonal twitching) or organized (contractions with changes in ventricular dimensions). Patients were categorized as receiving either standard bolus ACLS medications or alternative medications during the resuscitation (continuous adrenergic agents, thrombolytics, others). The primary outcome was survival to hospital admission. The secondary outcome was return of spontaneous circulation (ROSC). Multivariate modeling was performed to assess association between survival to hospital admission in patients with intravenous adrenergic agents and cardiac activity. RESULTS In our cohort of 225 patients in PEA cardiac arrest with cardiac activity on ultrasound, the overall survival rate was higher in patients with organized cardiac activity than with disorganized cardiac activity. PEA cardiac arrest patients with organized cardiac activity treated with standard ACLS interventions demonstrated improved survival to hospital admission compared to those with disorganized activity (37.7% (95%CI 24.8-50.2%) versus 17.9% (95%CI 10.9-28%). PEA cardiac arrest patients with organized cardiac activity who received continuous adrenergic agents during the resuscitation and prior to ROSC demonstrated higher survival to hospital admission 45.5% (95%CI 26.9-65.4%) and ROSC 90.9% (95%CI 71.0-98.7%) compared to those with disorganized cardiac activity who received continuous adrenergic agents during the resuscitation 0% (95%CI 0-23.0%) and 47.1% (95%CI 26-69%). Regression analysis demonstrates an association between increased survival in patients receiving intravenous adrenergic agents and organized cardiac activity. CONCLUSION Survival in patients following PEA arrest is higher in patients with organized cardiac activity. The initiation of continuous adrenergic agents during PEA was associated with improved survival to hospital admission in patients with organized cardiac activity on bedside ultrasound, but this improvement was not seen in patients in PEA with disorganized cardiac activity. Bedside ultrasound may identify a subset of patients that respond differently to ACLS interventions.

Survey of Individual and Institutional Risk Associated with the Use of Social Media

Introduction Residents and faculty in emergency medicine (EM) residency programs might be unaware of the professional and legal risks associated with the use of social media (SM). The objective of this study was to identify and characterize the types and reported incidence of unprofessional SM behavior by EM residents, faculty, and nurses and the concomitant personal and institutional risks. Methods This multi-site study used an 18-question survey tool that was distributed electronically to the leaders of multiple EM residency programs, members of the Council of Emergency Medicine Residency Directors (CORD), and the residents of 14 EM programs during the study period May to June 2013. Results We received 1,314 responses: 772 from residents and 542 from faculty. Both groups reported encountering high-risk-to-professionalism events (HRTPE) related to SM use by residents and non-resident providers (NRPs), i.e., faculty members and nurses. Residents reported posting of one of the following by a resident peer or nursing colleague: identifiable patient information (26%); or a radiograph, clinical picture or other image (52%). Residents reported posting of images of intoxicated colleagues (84%), inappropriate photographs (66%), and inappropriate posts (73%). Program directors (PDs) reported posting one of the following by NRPs and residents respectively: identifiable patient information (46% and 45%); a radiograph, clinical picture or other image (63% and 58%). PDs reported that NRPs and residents posted images of intoxicated colleagues (64% and 57%), inappropriate photographs (63% and 57%), or inappropriate posts (76% and 67%). The directors also reported that they were aware of or issued reprimands or terminations at least once a year (30% NRPs and 22% residents). Residents were more likely to post photos of their resident peers or nursing colleagues in an intoxicated state than were NRPs (p=0.0004). NRPs were more likely to post inappropriate content (p=0.04) and identifiable patient information (p=0.0004) than were residents. Conclusion EM residents and faculty members cause and encounter HRTPE frequently while using SM; these events present significant risks to the individuals responsible and their associated institution. Awareness of these risks should prompt responsible SM use and consideration of CORD’s Social Media Task Force recommendations.

Importance of the Emergency Medicine Application Components: The Medical Student Perception.

BACKGROUND The National Resident Matching Program (NRMP) application has several elements. With limited time and resources, students must prioritize the key application elements on which to focus. It is unclear if medical students applying to emergency medicine (EM) prioritize the same items as program directors. OBJECTIVE We sought to determine medical student perception of the importance of each factor of the NRMP application to an EM residency. METHODS This was a cross-sectional study approved by the Institutional Review Board at an academic tertiary care Level I trauma center. A pilot-tested and validated survey tool was given to all medical students rotating in EM during an 18-month period. The students ranked each application item on a 5-point scale (1 = not important and 5 = very important) with verbal anchors. RESULTS Of 136 medical students, 85.3% responded. Excluded were 31% who were not planning to apply to EM, leaving 80 responses for analysis. Items ranked higher were EM rotation grade, interview, clinical rotation grades, and letters of recommendation. Less emphasis was placed on Alpha Omega Alpha (AOA) honor society status, publication in medical literature, and personal statement. Items most agreed upon and believed to be most important by the students were EM rotation grade, interviews, and clinical rotation grades. CONCLUSIONS This is similar to previously reported rankings by program directors. Although medical students agreed on the importance of most aspects of the NRMP application, areas of discordance included emphasis on extracurricular activities and AOA. This can have implications for medical student mentoring and advising.