Kevin M. Ban

The use of point-of-care bedside lung ultrasound significantly reduces the number of radiographs and computed tomography scans in critically ill patients.

BACKGROUND: Chest radiography has been reported to have low diagnostic accuracy in critically ill intensive care unit (ICU) patients, and chest computed tomography (CT) scans require patients to be transported out of the ICU, putting them at risk of adverse events. In this study we assessed the efficacy of routine bedside lung ultrasound (LUS) in the evaluation of pleural effusions (PE) in the ICU. METHODS: Three hundred seventy-six patients admitted to the ICU for major trauma (46.3%), medical pathology (41.5%), and postsurgical complications (12.2%) (May 2008 to April 2009) were included in this study. Patients were placed into either the control group (group C) or the study group (group S), on the basis of the introduction of routine LUS performed by a single group of intensivists in 1 tertiary care ICU. To reduce provider bias, the physicians conducting the LUS were not aware of the study. Collected data included patient demographics, clinical course, and number of chest radiographs and CT scans performed. As a secondary goal, we assessed the reliability of Baliks formula in PE estimation. RESULTS: No significant differences were found between the 2 groups with regard to their demographics and ICU clinical course. Group S had a significant reduction in the total number of chest radiographs obtained (−26%; P < 0.001) and CT scans (−47%; P < 0.001) in comparison with the comparison group C. A 6-month follow-up analysis of the ICU LUS protocol revealed a time-dependent decrease in the number of radiological examinations requested for patients with PE. Lastly, PE volume estimation using the LUS and Baliks formula correlates well with the effective volume drained (r = 0.65; P < 0.0001). CONCLUSIONS: Routine use of LUS in the ICU setting can be associated with a reduction of the number of chest radiographs and CT scans performed.

Vacuum-assisted closure device enhances recovery of critically ill patients following emergency surgical procedures

IntroductionCritically ill surgical patients frequently develop intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) with subsequent high mortality. We compared two temporary abdominal closure systems (Bogota bag and vacuum-assisted closure (VAC) device) in intra-abdominal pressure (IAP) control.MethodsThis prospective study with a historical control included 66 patients admitted to a medical and surgical intensive care unit (ICU) of a tertiary care referral center (Careggi Hospital, Florence, Italy) from January 2006 to April 2009. The control group included patients consecutively treated with the Bogota bag (Jan 2006-Oct 2007), whereas the prospective group was comprised of patients treated with a VAC. All patients underwent abdominal decompressive surgery. Groups were compared based upon their IAP, SOFA score, serial arterial lactates, the duration of having their abdomen open, the need for mechanical ventilation (MV) along with length of ICU and hospital stay and mortality. Data were collected from the time of abdominal decompression until the end of pressure monitoring.ResultsThe Bogota and VAC groups were similar with regards to demography, admission diagnosis, severity of illness, and IAH grading. The VAC system was more effective in controlling IAP (P < 0.01) and normalizing serum lactates (P < 0.001) as compared to the Bogota bag during the first 24 hours after surgical decompression. There was no significant difference between the SOFA scores. When compared to the Bogota, the VAC group had a faster abdominal closure time (4.4 vs 6.6 days, P = 0.025), shorter duration of MV (7.1 vs 9.9 days, P = 0.039), decreased ICU length of stay (LOS) (13.3 vs 19.2 days, P = 0.024) and hospital LOS (28.5 vs 34.9 days; P = 0.019). Mortality rate did not differ significantly between the two groups.ConclusionsPatients with abdominal compartment syndrome who were treated with VAC decompression had a faster abdominal closure rate and earlier discharge from the ICU as compared to similar patients treated with the Bogota bag.

Difficult airway management

Airway management is unequivocally the most important responsibility of the emergency physician. No matter how prepared for the task, no matter what technologies are utilized, there will be cases that are difficult.The most important part of success in the management of a difficult airway is preparation. When the patient is encountered, it is too late to check whether appropriate equipment is available, whether a rescue plan has been in place, and what alternative strategies are available for an immediate response.The following article will review the principles of airway management with an emphasis upon preparation, strategies for preventing or avoiding difficulties, and recommended technical details that hopefully will encourage the reader to be more prepared and technically skillful in practice.

Procedure lab used to improve confidence in the performance of rarely performed procedures.

Objectives The objective of this study is to assess the efficacy of an animal procedure lab in improving the level of comfort in performing important emergency medicine procedures. The procedures included central venous line, chest tube, cricothyrotomy, pericardiocentesis, venous cutdown, and thoracotomy. Methods The students were physicians participating in the Tuscan Emergency Medicine Initiative as part of a certificate program in emergency medicine. They attended a 1-h lecture discussing the procedures to be performed. Participants filled out a questionnaire before and after the lab, which asked how many times they had performed each procedure, how comfortable they felt, on a five-point scale, performing each procedure, and whether they felt comfortable performing it by themselves, with assistance or whether they would not feel comfortable performing the procedure. Differences in rated numerical values for each procedure before and after the lab were analyzed using a two-tailed t-test. Alpha was set at 0.95. Results In all, there were 20 participants with a wide range of experience. A statistical improvement was observed in comfort level and willingness to perform the procedures independently (P<0.01). The only non-significant change was in willingness to perform central lines. Conclusions The use of an animal lab improves the comfort level of practitioners in performing procedures. Although procedures are best learned on patients with supervision, this is not always feasible. This lab is a useful adjunct to teaching in emergency medicine and allows participants exposure to critical procedures.

Ability of Emergency Ultrasonography to Detect Pediatric Skull Fractures: A Prospective, Observational Study

BACKGROUND Blunt head trauma is a common reason for medical evaluation in the pediatric Emergency Department (ED). The diagnostic work-up for skull fracture, as well as for traumatic brain injury, often involves computed tomography (CT) scanning, which may require sedation and exposes children to often-unnecessary ionizing radiation. OBJECTIVES Our objective was to determine if bedside ED ultrasound is an accurate diagnostic tool for identifying skull fractures when compared to head CT. METHODS We present a prospective study of bedside ultrasound for diagnosing skull fractures in head-injured pediatric patients. A consecutive series of children presenting with head trauma requiring CT scan was enrolled. Cranial bedside ultrasound imaging was performed by an emergency physician and compared to the results of the CT scan. The primary outcome was to identify the sensitivity, specificity, and predictive values of ultrasound for skull fractures when compared to head CT. RESULTS Bedside emergency ultrasound performs with 100% sensitivity (95% confidence interval [CI] 88.2-100%) and 95% specificity (95% CI 75.0-99.9%) when compared to CT scan for the diagnosis of skull fractures. Positive and negative predictive values were 97.2% (95% CI 84.6-99.9%) and 100% (95% CI 80.2-100%), respectively. CONCLUSIONS Compared to CT scan, bedside ultrasound may accurately diagnose pediatric skull fractures. Considering the simplicity of this examination, the minimal experience needed for an Emergency Physician to provide an accurate diagnosis and the lack of ionizing radiation, Emergency Physicians should consider this modality in the evaluation of pediatric head trauma. We believe this may be a useful tool to incorporate in minor head injury prediction rules, and warrants further investigation.

Assessing the sustainability of hand hygiene adherence prior to patient contact in the emergency department: A 1-year postintervention evaluation

BACKGROUND Health care-associated infection is one of the most important patient safety problems in the world. While many methods exist to prevent health care-associated infection, most experts believe that improving hand hygiene is paramount. We previously published the results of a successful before-and-after hand hygiene interventional study performed in the pediatric emergency department of the Meyer Hospital in Florence, Italy. The goal of the current study is to assess the longer term sustainability of the previously described intervention. METHODS Direct observation was used to assess hand hygiene compliance for both doctors and nurses in the emergency department using the same methods and observers as previously employed. RESULTS In addition to the 420 preintervention and 463 immediately postintervention observations previously reported, we observed another 456 clinician-patient interactions approximately 1 year after the intervention. Among all health care workers, there was no significant difference between hand hygiene compliance immediately postintervention (44.9%) compared with 1 year after the intervention (45.2%). Adherence among nurses, however, increased from 40.7% to 49.8% (P = .03), whereas adherence among doctors decreased from 50.5% to 36.5% (P = .008). CONCLUSION The overall effects of the intervention were sustained over a 1-year period, although a marked difference was observed between nurses and doctors.

Cervical Spine Injuries in Children, Part I: Mechanism of Injury, Clinical Presentation, and Imaging

BACKGROUND Cervical spine injuries are difficult to diagnose in children. They tend to occur in different locations than in adults, and they are more difficult to identify based on history or physical examination. As a result, children are often subjected to radiographic examinations to rule out cervical spine injury. OBJECTIVES This two-part series will review the classic cervical spine injuries encountered in children based on age and presentation. Part I will discuss the mechanisms of injury, clinical presentations, and the use of different imaging modalities, including X-ray studies and computed tomography (CT). Part II discusses management of these injuries and special considerations, including the role of magnetic resonance imaging, as well as injuries unique to children. DISCUSSION Although X-ray studies have relatively low risks associated with their use, they do not identify all injuries. In contrast, CT has higher sensitivity but has greater radiation, and its use is more appropriate in children over 8 years of age. CONCLUSION With knowledge of cervical spine anatomy and the characteristic injuries seen at different stages of development, emergency physicians can make informed decisions about the appropriate modalities for diagnosis of pediatric cervical spine injuries.

Cervical Spine Injuries in Children, Part II: Management and Special Considerations

BACKGROUND The diagnosis and management of cervical spine injury is more complex in children than in adults. OBJECTIVES Part I of this series stressed the importance of tailoring the evaluation of cervical spine injuries based on age, mechanism of injury, and physical examination findings. Part II will discuss the role of magnetic resonance imaging (MRI) as well as the management of pediatric cervical spine injuries in the emergency department. DISCUSSION Children have several common variations in their anatomy, such as pseudosubluxation of C2-C3, widening of the atlantodens interval, and ossification centers, that can appear concerning on imaging but are normal. Physicians should be alert for signs or symptoms of atlantorotary subluxation and spinal cord injury without radiologic abnormality when treating children with spinal cord injury, as these conditions have significant morbidity. MRI can identify injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal X-ray study or CT scan. CONCLUSION With knowledge of these variations in pediatric anatomy, emergency physicians can appropriately identify injuries to the cervical spine and determine when further imaging is needed.

Selected Urologic Problems

Urinary tract infection (UTI) describes an inflammatory response of urothelium to microorganisms in the urinary tract, resulting in clinical symptoms including dysuria, frequency, urgency, hematuria, and suprapubic or costovertebral angle discomfort selfreported by the patient or elicited on physical examination. This term does not differentiate between upper and lower tract infections. Traditionally the emphasis has been on distinguishing lower tract from upper tract infections. Although this distinction may seem sensible from an anatomic perspective, it often does not provide additional information for making important management and disposition decisions. Bacteriuria is the presence of bacteria in the urine but is not considered to represent a UTI in the absence of clinical manifestations. Bacteriuria accompanied by symptoms should be treated, whereas bacteriuria in the absence of symptoms should be treated only in select patients (e.g., pregnant women, immunosuppressed patients). It is more useful to designate UTIs as being either uncomplicated or complicated, rather than as lower or upper tract infections. An uncomplicated infection is one involving a structurally and functionally normal urinary tract. The causative pathogen generally can be eradicated with a short course of standard antibiotics. This type of infection usually occurs in nonpregnant, sexually active, young women who have no evidence of an obstructive process. Complicated infection is that associated with underlying neurologic, structural, or medical problems, all of which may reduce the efficacy of standard antimicrobial therapy. These types of infections often require a prolonged course of antibiotic therapy and a more in-depth approach to testing and anatomic evaluation. Urethritis refers to the inflammation of the urethra secondary to either an infection or trauma. Frequently, urethritis may be a manifestation of a sexually transmitted disease (STD), such as gonococcal urethritis in Neisseria gonorrhoeae infection, but may occur in other clinical scenarios as well. Cystitis generally refers to inflammation of the bladder resulting in increased urinary frequency, urgency, dysuria, and suprapubic pain. Cystitis can be separated into bacterial and nonbacterial (e.g., radiation) etiologic categories. Acute pyelonephritis is a UTI of the renal parenchyma and collecting system manifesting with the clinical syndrome of fever, chills, and flank pain. Management and disposition of patients with acute pyelonephritis depend on whether the infection is simple or complicated. Epidemiology

Learner perception of oral and written examinations in an international medical training program

BackgroundThere are an increasing number of training programs in emergency medicine involving different countries or cultures. Many examination types, both oral and written, have been validated as useful assessment tools around the world; but learner perception of their use in the setting of cross-cultural training programs has not been described.AimsThe goal of this study was to evaluate learner perception of four common examination methods in an international educational curriculum in emergency medicine.MethodsTwenty-four physicians in a cross-cultural training program were surveyed to determine learner perception of four different examination methods: structured oral case simulations, multiple-choice tests, semi-structured oral examinations, and essay tests. We also describe techniques used and barriers faced.ResultsThere was a 100% response rate. Learners reported that all testing methods were useful in measuring knowledge and clinical ability and should be used for accreditation and future training programs. They rated oral examinations as significantly more useful than written in measuring clinical abilities (p < 0.01). Compared to the other three types of examinations, learners ranked oral case simulations as the most useful examination method for assessing learners’ fund of knowledge and clinical ability (p < 0.01).ConclusionsPhysician learners in a cross-cultural, international training program perceive all four written and oral examination methods as useful, but rate structured oral case simulations as the most useful method for assessing fund of knowledge and clinical ability.