Prospective, multicentre observational study of point-of-care ultrasound practice in emergency departments across Australia and New Zealand: The POCUS-ED Registry.

OBJECTIVES: The present study aimed to describe the characteristics, performance, accuracy and significance of point-of-care ultrasound (POCUS) use in the ED, by utilising an expanded version of the ACEM-mandated special skills placement (SSP) logbook, to develop a novel clinical quality registry. METHODS: A prospective, observational study was performed across EDs in Australia and New Zealand over a 12-month period. Trainees undertaking ACEM-approved ultrasound (US) SSPs recorded all US scan interpretations and follow-up imaging reports in an online database. RESULTS: In total, 2647 USs were recorded by 26 special skills trainees across 10 EDs in Australia or New Zealand; of these 2356 scans (89%) were clinically indicated. Overall, 2493 scans (94%) were used for diagnostic assessment, of which 1147 (43%) had abnormal findings. Basic echocardiography, extended Focused Assessment with Sonography in Trauma and right upper quadrant scans were the most commonly used modalities. There were 134 US-guided procedures logged in the registry. Approximately 36% of scans were reported to alter the original provisional diagnosis, whereas in another 37% of cases, POCUS was thought to confirm the original clinical suspicion. The majority of scans (76.5%) entered into the registry were physically reviewed by the SSP supervisor. CONCLUSIONS: This multicentred registry provides a detailed description of the current utilisation of POCUS within special skills US placements across EDs in Australia and New Zealand. This data should inform clinical leaders in emergency US to improve both POCUS education and governance around this important tool.

Derivation and validation of a clinical prediction rule for uncomplicated ureteral stone--the STONE score: retrospective and prospective observational cohort studies.

OBJECTIVE: To derive and validate an objective clinical prediction rule for the presence of uncomplicated ureteral stones in patients eligible for computed tomography (CT). We hypothesized that patients with a high probability of ureteral stones would have a low probability of acutely important alternative findings. DESIGN: Retrospective observational derivation cohort; prospective observational validation cohort. SETTING: Urban tertiary care emergency department and suburban freestanding community emergency department. PARTICIPANTS: Adults undergoing non-contrast CT for suspected uncomplicated kidney stone. The derivation cohort comprised a random selection of patients undergoing CT between April 2005 and November 2010 (1040 patients); the validation cohort included consecutive prospectively enrolled patients from May 2011 to January 2013 (491 patients). MAIN OUTCOME MEASURES: In the derivation phase a priori factors potentially related to symptomatic ureteral stone were derived from the medical record blinded to the dictated CT report, which was separately categorized by diagnosis. Multivariate logistic regression was used to determine the top five factors associated with ureteral stone and these were assigned integer points to create a scoring system that was stratified into low, moderate, and high probability of ureteral stone. In the prospective phase this score was observationally derived blinded to CT results and compared with the prevalence of ureteral stone and important alternative causes of symptoms. RESULTS: The derivation sample included 1040 records, with five factors found to be most predictive of ureteral stone: male sex, short duration of pain, non-black race, presence of nausea or vomiting, and microscopic hematuria, yielding a score of 0-13 (the STONE score). Prospective validation was performed on 491 participants. In the derivation and validation cohorts ureteral stone was present in, respectively, 8.3% and 9.2% of the low probability (score 0-5) group, 51.6% and 51.3% of the moderate probability (score 6-9) group, and 89.6% and 88.6% of the high probability (score 10-13) group. In the high score group, acutely important alternative findings were present in 0.3% of the derivation cohort and 1.6% of the validation cohort. CONCLUSIONS: The STONE score reliably predicts the presence of uncomplicated ureteral stone and lower likelihood of acutely important alternative findings. Incorporation in future investigations may help to limit exposure to radiation and over-utilization of imaging. TRIAL REGISTRATION: www.clinicaltrials.gov NCT01352676.

ED echo of reverse Tako-tsubo cardiomyopathy: a rare and misleading finding.

Tako-tsubo transient cardiomyopathy (TCM) is a syndrome of specific myocardial wall motion abnormalities that appear in response to extreme physiological or emotional stress. The patients have normal coronary arteries and usually present as new-onset heart failure or acute coronary syndrome. We report on a 48-year-old woman with post-community cardiac arrest presenting as an acute myocardial infarction. An emergency physician­performed echocardiogram showed significant wall motion abnormalities, suggesting myocardial infarction. Cardiac catheterization revealed patent epicoronary circulation, and ventriculography demonstrated a rare and only recently described variant of TCM:"reverse" TCM. The patient subsequently died from a subarachnoid hemorrhage.

Cholinergic crisis after rodenticide poisoning.

Rodenticides have historically been common agents in attempted suicides. As most rodenticides in the United States (U.S.) are superwarfarins, these ingestions are generally managed conservatively with close monitoring for coagulopathy, and if necessary, correction of any resulting coagulopathy. However, alternate forms of rodenticides are imported illegally into the U.S. and may be ingested either accidentally or in suicide attempts. We present an unusual case of poisoning by the illegally imported rodenticide, "Tres Pasitos." The main ingredient of this rat poison is aldicarb, a potent carbamate pesticide that causes fulminant cholinergic crisis. This case is relevant and timely because carbamates and organophosphates are still used as insecticides and emergency physicians (EP) working in rural areas may have to evaluate and manage patients with these poisonings. As international travel and immigration have increased, so has the possibility of encountering patients who have ingested toxic substances from other countries. In addition, there has been increased concern about the possibility of acts of terrorism using chemical substances that cause cholinergic toxidromes.1,2 EPs must be able to recognize and manage these poisonings. This report describes the mechanism of action, clinical manifestations, laboratory evaluation and management of this type of poisoning. The pertinent medical literature on poisoning with aldicarb and similar substances is reviewed.

Subdural empyema complicating sinusitis.

Acute sinusitis is a common childhood illness most often involving the ethmoid and maxillary sinuses. Diagnosis is usually based on a history of an upper respiratory tract infection lasting longer than 7 days with a prominent nasal component. Treatment involves 10-14 days of antibiotics. Intracranial complications of pediatric sinusitis are rare, but potentially life-threatening. These include cavernous sinus thrombosis, orbital and intracranial extension, and meningitis. Children with these complications may experience significant morbidity from their infection. In such cases, delay in diagnosis and treatment may lead to irreparable brain damage or death. We report a case of sinusitis causing a subdural empyema in an otherwise healthy immunocompetent adolescent boy.

An unusual cause of dyspnea.

Dyspnea is an alarming symptom for both the patient and the emergency physician. There are many causes of dyspnea, some of which are life-threatening, especially in the elderly patient. In addition to the usual cardiac and pulmonary causes such as congestive heart failure, asthma exacerbation, COPD, pneumonia, and pulmonary embolism, there are less common causes of dyspnea, which if not diagnosed and managed expeditiously may have dire consequences for both the patient and physician. We present a case of an elderly patient with a life-threatening unusual cause of acute shortness of breath, a diaphragmatic hernia with sepsis.

Two teenagers with syncope.

We report the cases of 2 teenagers with syncope and headaches who were subsequently found, on head computed tomography examinations, to have central nervous system etiologies (arteriovenous malformation and arachnoid cyst) of their syncope. These cases highlight the importance of a focused history and physical examination when evaluating patients who present with syncope.