Jonathan H. Valente

Non-Invasive Pulse CO-oximetry Screening in the Emergency Department Identifies Occult Carbon Monoxide Toxicity

As carbon monoxide (CO) toxicity may present with non-specific signs and symptoms and without history of exposure, screening for CO toxicity may identify occult cases. The objective of this study was to determine whether non-invasive screening for CO exposure could be performed in all patients presenting to a high-volume urban emergency department (ED) and would identify patients with unsuspected CO toxicity. A study of adult patients, who presented to the ED for any complaint, prospectively screened for carboxyhemoglobin concentration by a pulse CO-oximeter (SpCO). ED triage staff recorded SpCO on the patients chart at triage. Data, including SpCO and vital signs, were recorded in a database by two trained research assistants. When available, carboxyhemoglobin concentration obtained by venous blood was also included in the data set. There were 14,438 patients who presented to the ED and were entered in the study. Data from 10,856 (75%) patients receiving screening for SpCO were analyzed. Patients were 44 +/- 19 years old and 51% female; 32% of the patients smoked. The mean SpCO was 5.17% +/- 3.78% among smokers and 2.90% +/- 2.76% among non-smokers. During the study period, 11 patients with presenting signs and symptoms not consistent with CO toxicity were identified through SpCO screening. Screening for CO toxicity using a non-invasive pulse CO-oximeter can be conducted even in a busy tertiary center ED and identify patients with occult CO toxicity.

Point-of-care ultrasonography by pediatric emergency medicine physicians

Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.

Effect of Bedside Ultrasound on Management of Pediatric Soft-Tissue Infection

BACKGROUND Superficial soft-tissue infections (SSTI) are frequently managed in the emergency department (ED). Soft-tissue bedside ultrasound (BUS) for SSTI has not been specifically studied in the pediatric ED setting. OBJECTIVE To evaluate the effect of a soft-tissue BUS evaluation on the clinical diagnosis and management of pediatric superficial soft-tissue infection. METHODS We conducted a prospective observational study in two urban academic pediatric EDs. Eligible patients were aged < 18 years presenting with suspected SSTI. Before BUS, treating physicians were asked to assess the likelihood of subcutaneous fluid collection and whether further treatment would require medical management or invasive management. A trained emergency physician then performed a BUS of the lesion(s). A post-test questionnaire assessed whether the physician changed the initial management plan based on the results of the BUS. RESULTS BUS changed management in 11/50 cases. After initial clinical assessment, 20 patients were designated to receive invasive management, whereas the remaining 30 patients were designated to receive medical management. Management changed in 6/20 in the invasive group. In the medical group, 5/30 patients changed management. BUS had a sensitivity of 90% (95% confidence interval [CI] 77-100%) and specificity of 83% (05% CI 70-97%), whereas clinical suspicion had a sensitivity of 75% (95% CI 56-94%) and specificity of 80% (95% CI 66-94%) in detecting fluid collections requiring drainage. CONCLUSIONS BUS evaluation of pediatric SSTI may be a useful clinical adjunct for the emergency physician. It changed management in 22% of cases by detecting subclinical abscesses or avoiding unnecessary invasive procedures.

Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients with suspected acute nontraumatic thoracic aortic dissection. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients with suspected acute nontraumatic thoracic Volume 65, no. 1 : January 2015

Point-of-Care Ultrasonography by Pediatric Emergency Physicians

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Aluminum foreign bodies: do they show up on x-ray?

The objective of this study is to evaluate the utility of radiographs in the detection of aluminum foreign bodies (FB). Aluminum can tabs were placed at the upper esophagus/posterior pharyngeal area in ten randomly selected cadavers. Anterior–posterior (AP) and lateral (LAT) radiographies were performed before and after placement. Twenty sets of randomly ordered radiographs were assessed by two blinded radiologists for the presence of radio-opaque FB. For any positive reading on an AP or a LAT radiograph, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for radiologist A were 80, 90, 89, and 82%, respectively, and for radiologist B were 90, 100, 100, and 91%, respectively. These values were also calculated using only AP and LAT views. Aluminum FB can often be visualized on radiographs. The sensitivity of this method, however, is not adequate to completely rule out their presence. Additional testing in these cases is warranted. Conversely, a high PPV suggests that therapy based on this finding alone is a logical choice.

Time to first antibiotics for pneumonia is not associated with in-hospital mortality.

BACKGROUND Time to first antibiotic (TTFA) is postulated to impact pneumonia mortality. The Joint Commission/Centers for Medicare and Medicaid Services national quality standards previously indicated that TTFA should be <6 h (modified from <4 h when the study was initiated, now eliminated as a time measure entirely). OBJECTIVE The purpose of this article was to determine whether TTFA is associated with inpatient mortality. METHODS The records of 444 consecutive patients admitted with pneumonia at a single institution were retrospectively reviewed for a correlation between TTFA and inpatient complications, including death. Statistical significance was set at p < 0.01 due to multiple comparisons. RESULTS Patients whose TTFA was <4 h had more complications (27% vs. 3%; p < 0.01) including death, intensive care unit admission, and intubation. These patients were judged sicker on arrival (median Emergency Severity Index 2 vs. 3; p < 0.001) and were more likely to be triaged to a critical care bed (36% vs. 5%; p < 0.001). Shortness of breath was the only presenting factor that was more frequent in the TTFA <4-h group (61% vs. 16%; p < 0.01). CONCLUSIONS Shorter TTFA is not associated with improved inpatient mortality. TTFA should not be considered to be a marker of quality of care but rather a reflection of patient disease severity.

Handoffs: Transitions of care for children in the emergency department

Transitions of care (ToCs), also referred to as handoffs or sign-outs, occur when the responsibility for a patient’s care transfers from 1 health care provider to another. Transitions are common in the acute care setting and have been noted to be vulnerable events with opportunities for error. Health care is taking ideas from other high-risk industries, such as aerospace and nuclear power, to create models of structured transition processes. Although little literature currently exists to establish 1 model as superior, multiorganizational consensus groups agree that standardization is warranted and that additional work is needed to establish characteristics of ToCs that are associated with clinical or practice outcomes. The rationale for structuring ToCs, specifically those related to the care of children in the emergency setting, and a description of identified strategies are presented, along with resources for educating health care providers on ToCs. Recommendations for development, education, and implementation of transition models are included.

Clinical Policy: Critical Issues in the Evaluation of Adult Patients With Suspected Transient Ischemic Attack in the Emergency Department

This clinical policy from the American College of Emergency Physicians addresses key issues for adults presenting to the emergency department with suspected transient ischemic attack. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients with suspected transient ischemic attack, are there clinical decision rules that can identify patients at very low short-term risk for stroke who can be safely discharged from the emergency department? (2) In adult patients with suspected transient ischemic attack, what imaging can be safely delayed from the initial emergency department workup? (3) In adult patients with suspected transient ischemic attack, is carotid ultrasonography as accurate as neck computed tomography angiography or magnetic resonance angiography in identifying severe carotid stenosis? (4) In adult patients with suspected transient ischemic attack, can a rapid emergency department-based diagnostic protocol safely identify patients at short-term risk for stroke? Evidence was graded and recommendations were made based on the strength of the available data.