Tania D. Strout

Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy

INTRODUCTION Cricothyrotomy is a difficult, infrequently performed lifesaving procedure. OBJECTIVES The objectives of the study were to develop a standardized ultrasound technique to sonographically identify the cricothyroid membrane (CM) and to evaluate the ability of emergencyphysicians (EPs) to apply the technique in a cohort of Emergency Department (ED) patients. METHODS Four cadaveric models were used to develop a technique to accurately identify the CM. Two EPs then sonographically imaged 50 living subjects. Time to visualization of the CM and relevant landmarks, as well as perception of landmark palpation difficulty, were recorded. RESULTS Fifty subjects were enrolled, and relevant structures were identified in all participants. The mean time to visualization of the CM was 24.32 +/- 20.18 seconds (95% confidence interval, 18.59-30.05 seconds). Although a significant relationship between palpation difficulty and body mass index was noted, body mass index did not impact physician ability to identify the CM. CONCLUSIONS Emergency physicians were able to develop and implement a reliable sonographic technique for the identification of anatomy relevant to performing an emergent cricothyrotomy.

Effect of Bedside Ultrasonography on the Certainty of Physician Clinical Decisionmaking for Septic Patients in the Emergency Department

STUDY OBJECTIVE Sepsis protocols promote aggressive patient management, including invasive procedures. After the provision of point-of-care ultrasonographic markers of volume status and cardiac function, we seek to evaluate changes in emergency physician clinical decisionmaking and physician assessments about the clinical utility of the point-of-care ultrasonographic data when caring for adult sepsis patients. METHODS For this prospective before-and-after study, patients with suspected sepsis received point-of-care ultrasonography to determine cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility. Physician reports of treatment plans, presumed causes of observed vital sign abnormalities, and degree of certainty were compared before and after knowledge of point-of-care ultrasonographic findings. The clinical utility of point-of-care ultrasonographic data was also evaluated. RESULTS Seventy-four adult sepsis patients were enrolled: 27 (37%) sepsis, 30 (40%) severe sepsis, 16 (22%) septic shock, and 1 (1%) systemic inflammatory response syndrome. After receipt of point-of-care ultrasonographic data, physicians altered the presumed primary cause of vital sign abnormalities in 12 cases (17% [95% confidence interval {CI} 8% to 25%]) and procedural intervention plans in 20 cases (27% [95% CI 17% to 37%]). Overall treatment plans were changed in 39 cases (53% [95% CI 41% to 64%]). Certainty increased in 47 (71%) cases and decreased in 19 (29%). Measured on a 100-mm visual analog scale, the mean clinical utility score was 65 mm (SD 29; 95% CI 58 to 72), with usefulness reported in all cases. CONCLUSION Emergency physicians found point-of-care ultrasonographic data about cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility to be clinically useful in treating adult patients with sepsis. Increased certainty followed acquisition of point-of-care ultrasonographic data in most instances. Point-of-care ultrasonography appears to be a useful modality in evaluating and treating adult sepsis patients.

Tamsulosin for Ureteral Stones in the Emergency Department: A Randomized, Controlled Trial

STUDY OBJECTIVE The alpha-adrenergic antagonist tamsulosin hydrochloride has become an increasingly common adjunct in the treatment of ureteral calculi; however, its efficacy in a general emergency department (ED) population has not been investigated. METHODS We conducted a randomized, controlled trial of adult ED patients with distal ureteral calculi diagnosed by computed tomography scan. Patients were randomized to receive either a 10-day course of ibuprofen and oxycodone plus tamsulosin or ibuprofen and oxycodone alone. The primary outcome measure was successful spontaneous ureteral stone expulsion at 14 days. Secondary outcomes included time to stone passage, self-reported pain scores, number of colicky pain episodes, unscheduled return ED/primary care visits, number of days of missed work/usual function, amount of analgesic used, and adverse events. RESULTS Eighty subjects were enrolled in the study, with 77 completing the trial. Mean stone size was 3.6 mm (95% confidence interval [CI] 3.4 to 3.9). Successful spontaneous stone expulsion at 14 days was similar between the groups, with 27 (77.1%) subjects in the tamsulosin group and 24 (64.9%) subjects in the standard therapy group reporting spontaneous stone passage, a difference of 12% (95% CI -8.4% to 32.8%). At 2-, 5-, and 14-day follow-up, there were no clinically important (or statistically significant) differences between the groups for any secondary outcome measure. No adverse events were reported in either group. CONCLUSION In this cohort of adult ED patients with distal ureteral calculi, treatment with tamsulosin did not substantially improve any of the studied outcome measures compared with treatment with ibuprofen and oxycodone alone.

Measuring the Youth Bullying Experience: A Systematic Review of the Psychometric Properties of Available Instruments.

BACKGROUND Bullying is a significant problem in schools and measuring this concept remains problematic. The purposes of this study were to (1) identify the published self-report measures developed to assess youth bullying; (2) evaluate their psychometric properties and instrument characteristics; and (3) evaluate the quality of identified psychometric papers evaluating youth bullying measures. METHODS A systematic review of the literature was conducted using 4 electronic databases. Data extraction and appraisal of identified instruments were completed using a standardized method and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Thirty-one articles describing 27 self-report instruments were evaluated in our analysis. Quality assessments ranged from 18% to 91%, with 6 papers reaching or exceeding a quality score of 75%. Limited evidence supporting the reliability, validity, and responsiveness of existing youth bullying measures was identified. CONCLUSIONS Evidence supporting the psychometric soundness of the instruments identified was limited. Many measures were in early development and additional evaluation is necessary to validate their psychometric properties. A pool of instruments possesses acceptable initial psychometric dependability for selected assessment purposes. These findings have significant implications for assessing youth bullying and designing and evaluating school-based interventions.

Spontaneous Peripartum Coronary Artery Dissection Presentation and Outcome

Objective: The objective of this study was to determine whether spontaneous peripartum coronary artery dissection (SPCAD) is a cause of acute myocardial infarction in women. Methods: Patients with SPCAD reported in the recent literature were analyzed to elucidate the clinically relevant characteristics of this condition. Results: Forty-seven cases of SPCAD are described. Patient characteristics include the following: mean age, 33.5 ± 5.2 years; gravity, 2.7 (95% confidence interval, 1.8–3.5); mean gestational age if prepartum, 32.5 ± 4.2 weeks (range, 23–36 weeks); and mean onset if postpartum, 22.9 ± 26.1 days (range, 3–90 days). Only 17 patients (36%) reported a cardiac risk factor, with the most frequent being smoking. All presented with characteristic ischemic pain; 25% of patients were hemodynamically unstable; and 81% of initial electrocardiograms demonstrated ST-elevation myocardial infarctions. The left coronary artery system was involved 81% of the time. Thirty percent of patients were managed conservatively or with thrombolytic therapy, whereas 34% received emergent percutaneous cardiac intervention and 36% required bypass surgery. There were no maternal deaths. Long-term follow-up revealed good cardiac function in the majority of patients, although 3 women required heart transplantation. Conclusions: SPCAD can occur weeks before or after delivery and should be considered in women presenting during the peripartum period with acute chest pain.

Development and Implementation of an Inductive Model for Evidence-Based Practice: A Grassroots Approach for Building Evidence-Based Practice Capacity in Staff Nurses

Evidence-based practice (EBP) is an essential component of the development of nursing science and has importance for todays clinical nurses. It benefits patients, organizations, and the nursing discipline, as well as having personal and professional benefits for individual clinicians. As interest in EBP has grown, so has the need for educational programs designed to develop the scholarly skills of the nursing workforce. The Clinical Scholar Model is one grassroots approach to developing a cadre of clinical nurses who have the EBP and research skills necessary in todays demanding health care delivery environments.

Repeatability of the Manchester Triage System for children

Objective The authors aimed to assess the repeatability of the Manchester Triage System (MTS) in children. Methods All emergency department nurses (n=43) from a general teaching hospital and a university childrens hospital in The Netherlands triaged 20 written case scenarios using the Manchester Triage system. Second, at two emergency departments (EDs), real-life simultaneous triage of patients (<16 years) was performed by ED nurses and two research nurses. The written case scenarios and the patients included in the real-life simultaneous triage study were representative of children attending the ED, in age, problem and urgency level. The authors assessed inter-rater agreement using quadratic weighted kappa values. Results The weighted kappa between the nurses, triaging the case scenarios, was 0.83 (95% CI 0.74 to 0.91). In total, 88% (N=198) of the eligible ED patients were triaged simultaneously, with a weighted κ of 0.65 (95% CI 0.56 to 0.72). Conclusions The MTS showed good to very good repeatability in paediatric emergency care.

Youth bullying: A review of the science and call to action

Recognized as a critical public health problem, youth bullying is reportedly experienced by approximately 20% of todays youths. In the last decade, attention to bullying has increased and the scientific knowledge base relevant for practitioners who treat youths, research their issues, and create policy has expanded. The purpose of this review is to highlight key developments related to the health effects of bullying, interventions aimed at curbing bullying behaviors, the measurement of bullying, and nursings disciplinary response to this phenomenon. A call to action for nurses involved in caring for youths across settings and roles is offered and strategic actions for nursing professionals are provided.

Intussusception in traditional pediatric, nontraditional pediatric, and adult patients

STUDY OBJECTIVES We sought to determine the rate of intussusception in 3 age groups (traditional pediatric-age [T], nontraditional pediatric-age [N], and adult-age [A]) and to compare group characteristics. METHODS We conducted a retrospective records review for patients discharged with diagnosis of intussusception between October 1999 and June 2008. RESULTS Ninety-five cases of intussusception were diagnosed as follows: 61 T (64%), 12 N (13%), and 22 A (23%). Bloody stool was more common in T patients (P = .016). Air contrast enema (36%) and ultrasound (33%) were the most common diagnostic tests in T, whereas computed tomography was most common in N (83%) and A (68%) patients. Bowel resection occurred more often in older (T) patients (P = .001). The most frequent causative pathologic conditions were adenitis (T), Peutz-Jeghers polyp (N), and carcinoma (A) and prior gastric bypass in 10 A patients. CONCLUSIONS The incidence of intussusception is substantially higher in nontraditional age groups than previously reported. Symptoms, management strategies, and causative pathologic conditions varied with age. All adults with intussusception require definitive diagnostic testing to determine the cause, given the concerning list of possibilities we observed.

Red Blood Cell Transfusion: Experience in a Rural Aeromedical Transport Service

INTRODUCTION The administration of blood products to critically ill patients can be life-saving, but is not without risk. During helicopter transport, confined work space, communication challenges, distractions of multi-tasking, and patient clinical challenges increase the potential for error. This paper describes the in-flight red blood cell transfusion practice of a rural aeromedical transport service (AMTS) with respect to whether (1) transfusion following an established protocol can be safely and effectively performed, and (2) patients who receive transfusions demonstrate evidence of improvement in condition. METHODS A two-year retrospective review of the in-flight transfusion experience of a single-system AMTS servicing a rural state was conducted. Data elements recorded contemporaneously for each transfusion were analyzed, and included hematocrit and hemodynamic status before and after transfusion. Compliance with an established transfusion protocol was determined through structured review by a multidisciplinary quality review committee. RESULTS During the study, 2,566 missions were flown with 45 subjects (1.7%) receiving in-flight transfusion. Seventeen (38%) of these transports were scene-to-facility and 28 (62%) were inter-facility. Mean bedside and in-flight times were 22 minutes (range 3-109 minutes) and 24 minutes (range 8-76 minutes), respectively. The most common conditions requiring transfusion were trauma (71%), cardiovascular (13%) and gastrointestinal (11%). An average of 2.4 liters (L) of crystalloid was administered pre-transfusion. The mean transfusion was 1.4 units of packed red blood cells. The percentages of subjects with pre- and post-transfusion systolic blood pressures of <90 mmHg were 71% and 29%, respectively. The pre- and post-transfusion mean arterial pressures were 62 mmHg and 82 mmHg, respectively. The pre- and post- transfusion mean hematocrit levels were 17.8% and 30.4%, respectively. At the receiving institution, 9% of subjects died in the Emergency Department, 18% received additional transfusion within 30 minutes of arrival, 36% went directly to the operating room, and 36% were directly admitted to intensive care. Thirty-one percent of subjects died prior to hospital discharge. There were no protocol violations or reported high-risk provider blood exposure incidents or transfusion complications. All transfusions were categorized as appropriate. CONCLUSIONS In this rural AMTS, transfusion was an infrequent, likely life-saving, and potentially high-risk emergent therapy. Strict compliance with an established transfusion protocol resulted in appropriate and effective decisions, and transfusion proved to be a safe in-flight procedure for both patients and providers.