Kristin Carmody

Right Ventricular Dilatation on Bedside Echocardiography Performed by Emergency Physicians Aids in the Diagnosis of Pulmonary Embolism

STUDY OBJECTIVE The objective of this study was to determine the diagnostic performance of right ventricular dilatation identified by emergency physicians on bedside echocardiography in patients with a suspected or confirmed pulmonary embolism. The secondary objective included an exploratory analysis of the predictive value of a subgroup of findings associated with advanced right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, McConnells sign). METHODS This was a prospective observational study using a convenience sample of patients with suspected (moderate to high pretest probability) or confirmed pulmonary embolism. Participants had bedside echocardiography evaluating for right ventricular dilatation (defined as right ventricular to left ventricular ratio greater than 1:1) and right ventricular dysfunction (right ventricular hypokinesis, paradoxical septal motion, or McConnells sign). The patients medical records were reviewed for the final reading on all imaging, disposition, hospital length of stay, 30-day inhospital mortality, and discharge diagnosis. RESULTS Thirty of 146 patients had a pulmonary embolism. Right ventricular dilatation on echocardiography had a sensitivity of 50% (95% confidence interval [CI] 32% to 68%), a specificity of 98% (95% CI 95% to 100%), a positive predictive value of 88% (95% CI 66% to 100%), and a negative predictive value of 88% (95% CI 83% to 94%). Positive and negative likelihood ratios were determined to be 29 (95% CI 6.1% to 64%) and 0.51 (95% CI 0.4% to 0.7%), respectively. Ten of 11 patients with right ventricular hypokinesis had a pulmonary embolism. All 6 patients with McConnells sign and all 8 patients with paradoxical septal motion had a diagnosis of pulmonary embolism. There was a 96% observed agreement between coinvestigators and principal investigator interpretation of images obtained and recorded. CONCLUSION Right ventricular dilatation and right ventricular dysfunction identified on emergency physician performed echocardiography were found to be highly specific for pulmonary embolism but had poor sensitivity. Bedside echocardiography is a useful tool that can be incorporated into the algorithm of patients with a moderate to high pretest probability of pulmonary embolism.

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.

Optic Neuritis Diagnosed by Bedside Emergency Physician−Performed Ultrasound: A Case Report

BACKGROUND Optic neuritis is an inflammatory demyelinating condition of the optic nerve that causes subacute visual loss. It is often the result of an underlying systemic condition, such as multiple sclerosis. Due to the possible long-term morbidity associated with this condition, it is essential that the emergency physician recognizes the diagnosis and expedites treatment. OBJECTIVE This case report describes optic neuritis diagnosed at the bedside by emergency physician-performed ultrasound. CASE REPORT This is a case report of a young man presenting with unilateral painful vision loss. Optic neuritis must be considered in the differential diagnosis of any young patient who presents with visual complaints without any other neurologic findings. This report is unique because there are very few cases describing the findings of optic neuritis on emergency physician-performed bedside ultrasound in the literature. CONCLUSIONS This article presents the case, describes diagnostic modalities, especially the use of ultrasound in its diagnosis, and the course of treatment for this particular condition.

Revival of the use of ultrasound in screening for appendicitis in young adult men.

Our primary aim was to evaluate the use of ultrasound (US) as an initial screening test for diagnosing appendicitis in young adult men. Secondary exploratory analyses included the effects of using US for initial screening in these patients, compared with the use of CT, on radiation exposure, length of stay (LOS), and cost of imaging.

Point-of-care ultrasound and undergraduate medical education: the perils of learning a new way to see

Editor – Thank you to Dr Feilchenfeld et al. for their detailed review of the integration of point-of-care ultrasound (POCUS) into undergraduate medical education (UME). Their review of the existing literature, using the theoretical underpinnings of Foucauldian discourse analysis, has highlighted some weaknesses in the methods, outcomes and conclusions of POCUS UME studies to date. The authors conclude that there is incomplete evidence that POCUS training is beneficial and question its educational necessity in the context of the potential for intensive cost and resource expenditures.

SonoGames: Effect of an Innovative Competitive Game on the Education, Perception, and Use of Point-of-Care Ultrasound: Impact of SonoGames on Ultrasound Education

Gamification is a powerful tool in medical education. SonoGames is a competitive games‐based event designed to educate and inspire emergency medicine (EM) residents about point‐of‐care ultrasound. We sought to describe: (1) the perceived effectiveness of a competitive event on both immediate learning and long‐term education; and (2) the resultant attitudes of participants and program directors regarding ultrasound training.

Point of Care Echocardiography in an Acute Thoracic Dissection with Tamponade in a Young Man with Chest Pain, Tachycardia, and Fever

BACKGROUND Although thoracic aortic dissections are uncommon in young patients, they must be considered in the differential diagnosis in the presence of chest pain and abnormal vital signs. Although computed tomography angiography is the test of choice for thoracic dissection in the emergency department, point of care (POC) transthoracic echocardiography has a high specificity in the diagnosis of this disease. It is especially helpful in patients with proximal ascending dissections in the presence of a pericardial effusion. CASE REPORT This case report illustrates a young patient presenting with chest pain, persistent tachycardia, and fever with a presumed upper respiratory infection who had an ascending thoracic dissection with tamponade discovered on POC echocardiography. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POC echocardiography should be an important part of the algorithm in young patients presenting with chest pain and abnormal vital signs that do not improve with supportive measures. Definitive care in patients who present with a thoracic aortic dissection in the presence of cardiac tamponade diagnosed on POC echocardiography should not be delayed in order to wait for other imaging methods to be performed. POC echocardiography may expedite care and treatment in young patients presenting with this deadly disease.

The man with a persistently runny nose

Cerebrospinal fluid (CSF) rhinorrhea is rarely seen in the emergency department (ED) and most often occurs after a traumatic event. Spontaneous CSF leaks are much less common and are often the result of benign intracranial hypertension. If not recognized early on, CSF infections are the most serious consequence of this condition and therefore its early diagnosis and treatment are essential. This case report describes a patient who presented to the ED with a CSF leak not caused by a traumatic event. The patient presented with persistent unilateral rhinorrhea and headache that had previously been misdiagnosed. It describes the importance of early diagnosis and treatment of this serious condition. This is a case report of an uncommon but potentially dangerous disease that carries high morbidity if not diagnosed and treated early. This disease must be considered in the differential diagnosis of any patient who presents with persistent atraumatic unilateral rhinorrhea. Although CSF leaks have been portrayed in the literature, this case report is unique because it describes a rare manifestation of this condition and its diagnosis by emergency physicians. This article presents the case, discusses the incidence, potential causes, predisposing factors, diagnostic modalities and the course of treatment for this particular diagnosis.

Ultrasound vs. Computed Tomography for Severity of Hydronephrosis and Its Importance in Renal Colic

Introduction Supporting an “ultrasound-first” approach to evaluating renal colic in the emergency department (ED) remains important for improving patient care and decreasing healthcare costs. Our primary objective was to compare emergency physician (EP) ultrasound to computed tomography (CT) detection of hydronephrosis severity in patients with suspected renal colic. We calculated test characteristics of hydronephrosis on EP-performed ultrasound for detecting ureteral stones or ureteral stone size >5mm. We then analyzed the association of hydronephrosis on EP-performed ultrasound, stone size >5mm, and proximal stone location with 30-day events. Methods This was a prospective observational study of ED patients with suspected renal colic undergoing CT. Subjects had an EP-performed ultrasound evaluating for the severity of hydronephrosis. A chart review and follow-up phone call was performed. Results We enrolled 302 subjects who had an EP-performed ultrasound. CT and EP ultrasound results were comparable in detecting severity of hydronephrosis (x2=51.7, p<0.001). Hydronephrosis on EP-performed ultrasound was predictive of a ureteral stone on CT (PPV 88%; LR+ 2.91), but lack of hydronephrosis did not rule it out (NPV 65%). Lack of hydronephrosis on EP-performed ultrasound makes larger stone size >5mm less likely (NPV 89%; LR− 0.39). Larger stone size > 5mm was associated with 30-day events (OR 2.30, p=0.03). Conclusion Using an ultrasound-first approach to detect hydronephrosis may help physicians identify patients with renal colic. The lack of hydronephrosis on ultrasound makes the presence of a larger ureteral stone less likely. Stone size >5mm may be a useful predictor of 30-day events.

377 Right Ventricular Strain on Bedside Echocardiography: Does It Help in the Diagnosis of a Pulmonary Embolism?

Study Objectives: Treatment of deep venous thrombosis accounts for 600,000 hospitalizations per year. Despite literature advocating an outpatient treatment protocol for these patients, many hospitals continue to admit these patients in order to observe, arrange follow-up and educate patients prior to discharge. The diversity of cases that are being handled in an emergency department (ED) observation unit continues to grow as hospitals look to provide quality patient care, yet minimize cost. To date, no studies have described the treatment of deep venous thrombosis in an ED observation unit. Our primary objective was to evaluate the feasibility of a structured ED observation unity deep venous thrombosis treatment protocol. Methods: We performed a prospective observational trial of patients placed in the ED observation unity deep venous thrombosis treatment protocol from April 1 st 2010 to March 1st, 2011. The study was performed at William Beaumont Hospital, a tertiary care facility with an annual ED census of 118,000 patients. During this pilot, patients with an uncomplicated acute deep venous thrombosis were placed in the ED observation unity at the discretion of the treating emergency physician. To pilot the treatment of deep venous thrombosis in an ED observation unity, we developed a structured treatment algorithm focusing on 4 key facets of deep venous thrombosis management. First, we initiated treatment with low-molecular weight heparin and warfarin. This included a monitored self-administration of the second dose of low-molecular weight heparin in the ED observation unity. Second, we created an in-depth educational component including a video presentation and pamphlet describing deep venous thrombosis, low-molecular weight heparin and warfarin as well as potential risks and complications. Third, we observed the patient for a minimum of 12 hours for any signs of bleeding complications or pulmonary embolus. Fourth, we arranged follow-up with our anticoagulation monitoring service. Our primary outcome measures were admission, death, bleeding complications or pulmonary embolus on the index visit and at 30 days. Our secondary outcome measure was the cost difference between ED observation unit and admitted patients during the same period. Data was analyzed using descriptive statistics; confidence intervals were reported using a modified Wald method. Results: During the pilot study period 28 patients were treated with the ED observation unity deep venous thrombosis protocol. 7 (25%) of the patients were female with an average age of 56.6 ϩ/Ϫ 15.3. Within the pilot group there were 0 (C.I. 0.00% to 10.5%) deaths, bleeding complications or …