Michael E. Abboud

Recognition of Stroke by EMS is Associated with Improvement in Emergency Department Quality Measures

Abstract Objective: Hospital arrival via Emergency Medical Services (EMS) and EMS prenotification are associated with faster evaluation and treatment of stroke. We sought to determine the impact of diagnostic accuracy by prehospital providers on emergency department quality measures. Methods: A retrospective study was performed of patients presenting via EMS between September 2009 and December 2012 with a discharge diagnosis of transient ischemic attack (TIA), ischemic stroke (IS), or intracerebral hemorrhage (ICH). Hospital and EMS databases were used to determine EMS impression, prehospital and in-hospital time intervals, EMS prenotification, NIH stroke scale (NIHSS), symptom duration, and thrombolysis rate. Results: 399 cases were identified: 14.5% TIA, 67.2% IS, and 18.3% ICH. EMS providers correctly recognized 57.6% of cases. Compared to cases missed by EMS, correctly recognized cases had longer median on-scene time (17 vs. 15 min, p = 0.01) but shorter transport times (12 vs. 15 min, p = 0.001). Cases correctly recognized by EMS were associated with shorter door-to-physician time (4 vs. 11 min, p < 0.001) and shorter door-to-CT time (23 vs. 48 min, p < 0.001). These findings were independent of age, NIHSS, symptom duration, and EMS prenotification. Patients with ischemic stroke correctly recognized by EMS were more likely to receive thrombolytic therapy, independent of age, NIHSS, symptom duration both with and without prenotification. Conclusion: Recognition of stroke by EMS providers was independently associated with faster door-to-physician time, faster door-to-CT time, and greater odds of receiving thrombolysis. Quality initiatives to improve EMS recognition of stroke have the potential to improve hospital-based quality of stroke care.

Geographic Modeling to Quantify the Impact of Primary and Comprehensive Stroke Center Destination Policies

Background and Purpose— We evaluated the impact of a primary stroke center (PSC) destination policy in a major metropolitan city and used geographic modeling to evaluate expected changes for a comprehensive stroke center policy. Methods— We identified suspected stroke emergency medical services encounters from 1/1/2004 to 12/31/2013 in Philadelphia, PA. Transport times were compared before and after initiation of a PSC destination policy on 10/3/2011. Geographic modeling estimated the impact of bypassing the closest hospital for the closest PSC and for the closest comprehensive stroke center. Results— There were 2 326 943 emergency medical services runs during the study period, of which 15 099 had a provider diagnosis of stroke. Bypassing the closest hospital for a PSC was common before the official policy and increased steadily over time. Geographic modeling suggested that bypassing the closest hospital in favor of the closest PSC adds a median of 3.1 minutes to transport time. Bypassing to the closest comprehensive stroke center would add a median of 8.3 minutes. Conclusions— Within a large metropolitan area, the time cost of routing patients preferentially to PSCs and comprehensive stroke centers is low.

Accuracy of Emergency Medical Services Dispatcher and Crew Diagnosis of Stroke in Clinical Practice.

Background Accurate recognition of stroke symptoms by Emergency Medical Services (EMS) is necessary for timely care of acute stroke patients. We assessed the accuracy of stroke diagnosis by EMS in clinical practice in a major US city. Methods and results Philadelphia Fire Department data were merged with data from a single comprehensive stroke center to identify patients diagnosed with stroke or TIA from 9/2009 to 10/2012. Sensitivity and positive predictive value (PPV) were calculated. Multivariable logistic regression identified variables associated with correct EMS diagnosis. There were 709 total cases, with 400 having a discharge diagnosis of stroke or TIA. EMS crew sensitivity was 57.5% and PPV was 69.1%. EMS crew identified 80.2% of strokes with National Institutes of Health Stroke Scale (NIHSS) ≥5 and symptom duration <6 h. In a multivariable model, correct EMS crew diagnosis was positively associated with NIHSS (NIHSS 5–9, OR 2.62, 95% CI 1.41–4.89; NIHSS ≥10, OR 4.56, 95% CI 2.29–9.09) and weakness (OR 2.28, 95% CI 1.35–3.85), and negatively associated with symptom duration >270 min (OR 0.41, 95% CI 0.25–0.68). EMS dispatchers identified 90 stroke cases that the EMS crew missed. EMS dispatcher or crew identified stroke with sensitivity of 80% and PPV of 50.9%, and EMS dispatcher or crew identified 90.5% of patients with NIHSS ≥5 and symptom duration <6 h. Conclusion Prehospital diagnosis of stroke has limited sensitivity, resulting in a high proportion of missed stroke cases. Dispatchers identified many strokes that EMS crews did not. Incorporating EMS dispatcher impression into regional protocols may maximize the effectiveness of hospital destination selection and pre-notification.

Ultrasound diagnosis of diverticulitis.

Diverticular disease accounts for approximately 312 000 hospital admissions in the United States annually, and costs nearly 2.6 billion dollars.[1,2] Approximately 20% of Americans with diverticular disease will experience at least one episode of acute diverticulitis, necessitating a visit to their physician’s office or the emergency department (ED) for treatment.[3] As the risk of developing diverticulitis rises with age (nearly 50% of people aged over 60 years have colonic diverticula), the incidence is rising as the elderly population grows.[4] The majority of the patients are treated non-operatively, with a course of oral antibiotics and diet modification. Although computed tomography (CT) imaging is considered the “gold standard” for the diagnosis of acute diverticulitis in the United States, ultrasound is routinely used in Europe, Asia, and Africa as the initial imaging modality of choice in the evaluation of patients with suspected diverticulitis. Recent studies[5,6] have suggested that there is no significant difference in the test performance characteristics of CT as opposed to ultrasound for the diagnosis of diverticulitis. We present two cases in which point-of-care ultrasound was used to diagnose acute uncomplicated diverticulitis in the ED. Case 1 A 30-year-old man with no significant history of medication or surgery presented to the ED because of abdominal pain for several days. He stated that the pain began four days before presentation after breakfast at home, and subsequently deteriorated as a constant, non-radiating pressure. There were no alleviating or aggravating factors. The patient had no history of similar abdominal pain, nor nausea, vomiting, hematemesis, change in bowel habits, fever, anorexia, dysuria, testicular pain, back pain, or rash. On presentation, his temperature was 98.1 °F, heart rate 77 beats per minute, blood pressure 143/92 mmHg, respiratory rate 16 breaths per minute, and oxygen saturation 99% while breathing room air. The patient was alert and oriented and in no acute distress. His sclerae were anicteric. His abdomen was soft with mild tenderness in the left lower quadrant. No rebound or voluntary guarding was noted. There was no costovertebral angle (CVA) tenderness to palpation. In addition, there was no tenderness at McBurney’s point. His genital examination was normal. An emergency physician (EP) performed a point-of-care abdominal ultrasound, paying particular attention to the left lower quadrant of the abdomen. The sigmoid colon was identified in the left lower quadrant of the abdomen, with evidence of bowel wall thickening (Figure 1). In addition, a single diverticulum, visualized as an echo-poor protrusion from the colon wall with surrounding hyperechoic fat stranding, indicative of active inflammation, was noted at the point of maximal tenderness (Figure 2). The EP determined that the patient’s presentation combined with the point-of-care ultrasound images was consistent with a diagnosis of acute diverticulitis. The EP offered the patient the option of further testing with CT imaging versus empiric treatment with oral antibiotics. The patient opted to forego further radiologic testing and was subsequently discharged with a course of oral antibiotics and close primary care follow-up. Figure 1 This figure demonstrates a measurement taken by the EP of the bowel wall that is approximately 1 cm. A measurement of >4–5 mm is indicative of bowel wall thickening. Figure 2 This figure shows a single diverticulum (arrow) with surrounding hyperechoic (bright) fat stranding. Three weeks after his initial ED visit, the patient presented with recurrent abdominal pain to a different ED. He stated that his prior episode of abdominal pain had completely resolved with oral antibiotics. Twelve hours before his second ED visit, however, he developed recurrent left lower quadrant abdominal pain. Relevant bloodwork was as follows: WBC 10.3 K/μL, creatinine of 1.10 mg/dL, blood urea nitrogen 9 mg/dL, ALT 31 U/L, AST 20 U/L, alkaline phosphatase 44 U/L, and lipase 25 U/L. He subsequently underwent CT imaging of the abdomen, which demonstrated both prominent inflamed diverticuli and extensive fat stranding, consistent with acute uncomplicated sigmoid diverticulitis (Figure 3). He was admitted to the hospital and treated with intravenous antibiotics for 24 hours. He was discharged on a 7-day course of oral antibiotics and had no further episodes of diverticulitis. Figure 3 This figure shows the CT findings of acute uncomplicated diverticulitis (arrow) with surrounding fat stranding. Case 2 A 49-year-old man with a history of diverticulitis presented with abdominal pain for one day to the ED. The pain began on the day before his ED presentation; it was described as sharp and localized to the left lower quadrant. He remarked that the pain was worse with movement and bending forward, and alleviated by remaining still. The pain was similar in quality to his one prior episode of uncomplicated diverticulitis. The patient denied fever, nausea, vomiting, diarrhea or constipation. In the ED, the patient’s vital signs were temperature 97.7 °F, heart rate 99 beats per minute, blood pressure 153/92 mmHg, respiratory rate 16 breaths per minute, and oxygen saturation 97% while breathing room air. The patient was awake, alert, and in no acute distress. His heart had a regular rate and rhythm and lungs were clear to auscultation. His abdominal examination was notable for normal bowel sounds and mild tenderness to palpation in the left lower quadrant, without rebound or guarding. He had no CVA or testicular tenderness on examination. The EP performed a point-of-care ultrasound to evaluate the patient’s left lower quadrant abdominal pain, and immediately identified a diverticulum with surrounding echogenic non-compressible fat consistent with an acute inflammatory process (Figure 4). The patient was diagnosed with sigmoid diverticulitis and was treated successfully with a ten-day course of oral antibiotics with a close primary care follow-up. Figure 4 This figure demonstrates a single diverticulum (arrow) with adjacent hyperechoic (bright) fat stranding. DISCUSSION Acute diverticulitis is caused by inflammation of colonic diverticula, which can either occur in a true diverticulum (more frequently noted in right-sided diverticulitis) or in a false or pseudo-diverticulum (generally noted in left-sided diverticulitis).[7] Nearly 20% of patients with diverticula will develop at least one episode of acute diverticulitis, thus rendering diverticulitis a major cause of hospitalization and medical expenditure.[3] As the population ages, the prevalence of diverticulitis will certainly rise, leading to a greater number of urgent care and ED visits for this disease. Computed tomography has long been the diagnostic modality of choice to confirm acute diverticulitis in the United States.[8] Yet given the high cost associated with CT imaging, many countries utilize ultrasound as the first-line imaging study to make this diagnosis.[9] Other obvious drawbacks to CT imaging include radiation exposure and increased length of stay in the ED. As EPs become ever more adept at performing point-of care ultrasound examinations, this imaging modality has developed a reputation as an inexpensive, safe, and radiation-free alternative to CT in the ED. In a few studies ultrasound correctly diagnosed acute diverticulitis in greater than 90% of cases.[10] A recent meta-analysis also noted no significant difference between the sensitivity of ultrasound and CT in the evaluation of patients with suspected acute diverticulitis.[5] The clinician performs an abdominal ultrasound to assess for diverticulitis by gently sweeping through loops of the bowel in the area of localized abdominal pain. A low-frequency curvilinear array transducer is used to visualize bowel as it provides adequate depth. The EP can ask the patient to point to the area of maximal tenderness, which often indicates the highest-yield area for sonographic evaluation. The EP evaluates the symptomatic region with the transducer, looking for evidence of acute diverticulitis: (1) at least one diverticulum; (2) thickening of the bowel wall (typically 4–5 mm or more); and (3) echogenic non-compressible fat surrounding one or more diverticula, suggesting an acute inflammatory process.[11,12] In addition, the clinician may identify a so-called “target sign” or “pseudokidney sign”, which refers to the hypoechoic wall surrounding a hyperechoic center.[13] Although multiple studies have confirmed the high sensitivity and specificity of ultrasound in the evaluation of patients with suspected diverticulitis, there are few reports on point-of-care ultrasound use for this indication. If utilized by providers with appropriate training, point-of-care ultrasound could possibly represent an ideal first-line imaging test for uncomplicated diverticulitis, with CT imaging reserved for ill-appearing patients with unstable vital signs, or for those whose point-of care ultrasound images demonstrate findings concerning complicated diverticulitis, such as an abscess or intra-abdominal free fluid. Further prospective studies are warranted.

Bradycardia caused by intravenous nicardipine in an elderly patient with acute ischemic infarct.

Nicardipine is a dihydropyridine calcium-channel blocker that is frequently used in the acute treatment of hypertension in the emergency department (ED). Reflex sympathetic tachycardia is a well-described side effect of this medication. Two experimental studies and 1 anesthesia case report, however, have previously described nicardipine-induced bradycardia as a very rare side effect. We report the case of an elderly patient with an acute ischemic stroke who developed nicardipine-induced bradycardia in the ED.