Jennifer Carnell

Multidrug-resistant Acinetobacter Infection Mortality Rate and Length of Hospitalization

Acinetobacter infections have increased and gained attention because of the organism’s prolonged environmental survival and propensity to develop antimicrobial drug resistance. The effect of multidrug-resistant (MDR) Acinetobacter infection on clinical outcomes has not been reported. A retrospective, matched cohort investigation was performed at 2 Baltimore hospitals to examine outcomes of patients with MDR Acinetobacter infection compared with patients with susceptible Acinetobacter infections and patients without Acinetobacter infections. Multivariable analysis controlling for severity of illness and underlying disease identified an independent association between patients with MDR Acinetobacter infection (n = 96) and increased hospital and intensive care unit length of stay compared with 91 patients with susceptible Acinetobacter infection (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.2–5.2 and OR 2.1, 95% CI 1.0–4.3] respectively) and 89 uninfected patients (OR 2.5, 95% CI 1.2–5.4 and OR 4.2, 95% CI 1.5–11.6] respectively). Increased hospitalization associated with MDR Acinetobacter infection emphasizes the need for infection control strategies to prevent cross-transmission in healthcare settings.

Cognitive Impairment in Individuals Currently Using Methamphetamine

Although there are increasing reports of methamphetamine use, studies examining the cognitive consequences of methamphetamine have not been performed on a population currently using the drug. To characterize this population, 65 people currently using MA regularly and 65 non-users were given a battery of cognitive tests. The battery included recall, recognition, Digit Symbol, Trail Making A & B, Stroop, Wisconsin Card Sort, backward digit span, and the FAS test of verbal fluency. The methamphetamine users were significantly more impaired on recall tasks, digit symbol, Stroop color words, and Trail Making B, but scores fell within the normal ranges on the other measures.

Ultrasound-guided intercostal nerve block for traumatic pneumothorax requiring tube thoracostomy

A 39-year-old woman presented to our emergency department 3 days after an assault. Initial evaluation demonstrated a right pneumothorax. Given her hemodynamic stability, a series of ultrasound-guided intercostal nerve blocks were performed. The indications, technique, and advantages of this approach are reviewed. A 39-year-old woman with a past medical history of intravenous drug use presented to the emergency department (ED) with chest pain and shortness of breath. She reported being assaulted 3 days prior and leaving against medical advice from another ED yesterday after being diagnosed with a “collapsed lung.”Her vital signs were pulse 118/min, blood pressure 115/72 mm Hg, respirations 24/min, temperature 37.1 degrees, and oxygen saturation 95% while breathing room air. Physical examination revealed decreased breath sounds on the patients right side without crepitus, tracheal deviation, or flail segments. A focused bedside ultrasound demonstrated absent pleural sliding in the anterior, lateral and posterolateral right hemithorax. A portable anteroposterior upright chest radiograph confirmed the diagnosis of large (N50%) pneumothorax. Given the patients hemodynamic stability, the treating emergency physicians performed ultrasoundguided intercostal nerve blocks at the right third through seventh intercostal spaces to decrease pain during and after tube thoracostomy placement. The patient was positioned prone, and the spinous processes of the thoracic vertebrae were identified by palpation. After sterile preparation, a 13-6 MHz high-frequency linear transducer (SonoSite SFAST, Bothell WA) was placed in a longitudinal parasagittal orientation to identify the ribs and pleural line. After subcutaneous infiltration with local anesthetic, a 22-gauge needle attached to a control syringe was advanced using an in-plane technique (Fig. 1). The needle was visualized approaching the inferior margin of the target ribs, and 3 mL of 0.5% bupivicaine with epinephrine was injected into each intercostal space with real-time ultrasound visualization of local anesthetic spread to the adjacent pleura (Fig. 2). 0735-6757/

Ultrasound detection of obstructive pyelonephritis due to urolithiasis in the ED.

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Supracondylar Radial Nerve Block for Treatment of Distal Radius Fractures in the Emergency Department

Identifying acute pyelonephritis (APN) with early obstructive uropathy is clinically important in the emergency department (ED) because obstructive urolithiasis is an independent risk factor for inpatient death, prolonged hospitalization, and failure of outpatient APN therapy. Furthermore, diagnosis of an early obstructive uropathy can be difficult when based solely on clinical findings. Clinicians may assume the cause of the patients symptoms to be APN alone, without considering the concurrent presence of an obstructing stone. A feasible screening test to detect early obstructive uropathy in cases of APN has not been previously identified. Plain film radiographs are insensitive in locating a suspected calcified stone. Computed tomography is readily available in most EDs and clearly defines urologic anatomy, but delivers unnecessary ionizing radiation, can prolong ED length of stay, and is not cost-effective as a screening test for all patients diagnosed with APN. We report a case in which a bedside ultrasound identifying hydronephrosis prompted confirmatory computed tomography imaging and emergency consultation of a patient with APN. In this case, hydronephrosis on bedside ultrasound examination was an indirect marker of a distal ureteral obstruction. By detecting the presence of hydronephrosis in patients with APN, emergency physicians may dramatically increase their ability to identify those patients that need further radiographic investigation and ultimately decrease the rate of outpatient treatment failure. Further surveillance data are needed to determine the statistical characteristics of this novel screening test and if routine renal evaluation of all patients with APN is warranted.

Accuracy of emergency physicians using ultrasound measurement of crown-rump length to estimate gestational age in pregnant females

BACKGROUND Patients with acute distal radius fractures are frequently treated in the emergency department (ED) with closed reduction and splinting. Many of the anesthesia methods frequently employed may either lack efficacy or require additional monitoring and resources. CASE REPORT An 18-year-old woman presented to the ED with a dorsally angulated distal radius fracture (Colles fracture). As an alternative to procedural sedation, an ultrasound-guided block of the radial nerve proximal to its bifurcation into the deep and superficial branches was performed. The resulting anesthesia was adequate to reduce and splint the fracture with minimal discomfort for the patient. CONCLUSION Ultrasound-guided supracondylar block of the radial nerve proximal to the origin of the deep and superficial branches provides safe and efficacious anesthesia for distal radius fracture reduction in the ED.

Constipation in a 7-year-old Boy: Congenital Band Causing a Strangulated Small Bowel and Pulseless Electrical Activity

STUDY OBJECTIVE The objective of this study is to evaluate the accuracy of emergency providers (EPs) of various levels of training in determination of gestational age (GA) in pregnant patients using bedside ultrasound measurement of crown-rump length (CRL). METHODS We conducted a prospective, cross-sectional, observational study of patients in obstetrical care at an urban county hospital. We enrolled a convenience sample of women at 6 to 14 weeks gestation as estimated by last menstrual period. Emergency providers used ultrasound to measure the CRL. Repeat CRL measurements were performed by either an obstetrical ultrasound technician or senior obstetrician and used as the criterion standard for true GA (TGA). RESULTS One hundred five patients were evaluated by 20 providers of various levels of training. The average time required to complete the CRL measurement was 85 seconds. When CRL measurements performed by EPs were compared with the TGAs, the average correlation was 0.935 (0.911-0.959). Using standard accepted variance for CRL measurements at different GAs according to the obstetrics literature (±3 days for 42-70 days and ±5 days for 70-90 days), correlation between EP ultrasound and measured TGA was 0.947 (0.927-0.967). CONCLUSIONS Emergency providers can quickly and accurately determine GA in first-trimester pregnancies using bedside ultrasound to calculate the CRL. Emergency providers should consider using ultrasound to calculate the CRL in patients with first-trimester bleeding or pain because this estimated GA may serve as a valuable data point for the future care of that pregnancy.

Bedside Echocardiography and Passive Leg Raise as a Measure of Volume Responsiveness in the Emergency Department

BACKGROUND Constipation in pediatric patients is a common diagnosis in the emergency department (ED) and may occasionally arise from a significant underlying illness. OBJECTIVE To discuss a rare cause of constipation that led to a strangulated small bowel and cardiac arrest. CASE REPORT A 7-year-old boy presented in pulseless electrical activity. The patient had been seen in the ED 2 days prior with the complaint of abdominal pain, which was diagnosed as constipation. The boy had emigrated from Mexico 18 months earlier. The patient was resuscitated in the ED and taken emergently to the operating room. During surgery he was discovered to have a congenital abdominal adhesive band that led to a strangulated small bowel. He suffered subsequent multi-organ failure, including hypoxic ischemic encephalopathy, and was hospitalized for 5 months. One month after discharge he was improving and being followed by multiple providers. CONCLUSION Congenital adhesive bands, although rare, may be life-threatening anomalies. We present this case to increase awareness of this condition among emergency physicians.

Corrected carotid flow time and passive leg raise as a measure of volume status

The aim of this study was to investigate the value of bedside echocardiography with a passive leg raise as a noninvasive marker of volume responsiveness.

Emergency Department Ultrasound as a Diagnostic and Therapeutic Guide

BACKGROUND The aim of this study was to investigate the value of corrected carotid flow time (FTc) with passive leg raise (PLR) as a non-invasive marker of volume status in end stage renal disease (ESRD) patients. METHODS Prospective observational study of ESRD patients presenting to the Emergency department requiring hemodialysis. The common carotid artery was evaluated in long axis. Flow time measurements pre- and post-dialysis as well as before and after PLR were recorded. RESULTS 54 patients were enrolled, of which, 30 (55%) were male. The mean age was 47.4 years. The mean volume of fluid removed was 3.89 ± 0.91 L. In the pre-dialysis cohort, the mean FTc was 340.16 ms (95% CI, 330.36-349.95). Following PLR, the mean FTc was 341.34 ms (95% CI 331.74-350.94). In the post hemodialysis cohort, the mean FTc was 302.48 ms (95% CI, 293.63-311.32). Following the PLR maneuver, the mean FTc was 340.49 ms (95% CI 331.97-349.02). The mean decrease in corrected carotid flow time was 19.15 ms (95% CI, 22.86-41.17), 32.02 ms (95% CI 4.05-34.25) and 41.17 ms (95% CI, 36.47-54.76) for patients who had <3 L, 3-4 L and >4 L removed, respectively. In patients without CHF, the mean decrease in FTc after hemodialysis was 38.80 ms (95% CI, 30.12-47.49) whereas for CHF patients the mean decrease was 35.60 ms (95% CI, 25.05-46.15). CONCLUSION Corrected flow time in conjunction with passive leg raise seem to correlate with volume status in hemodialysis patients.