Can Emergency Physicians Diagnose Cirrhosis by Ultrasound: A Prospective Single-Arm Educational Intervention.

Background and purpose Liver cirrhosis is common, and timely diagnosis of decompensated cirrhosis may impact acute care and resuscitation. Point-of-care ultrasound is a core competency of US emergency medicine training and is increasingly available in many acute care settings, including those where usual diagnostic modalities of cirrhosis may not be available. Only a few works of literature exist that evaluate the ultrasound diagnosis of cirrhosis and decompensated cirrhosis by emergency physicians (EPs). We aim to evaluate whether EPs can diagnose cirrhosis by ultrasound after a brief educational intervention and determine the accuracy of EP-interpreted ultrasound compared to the radiology-interpreted ultrasound as a gold standard. Methods This single-center prospective single-arm educational intervention evaluated the accuracy of EPs diagnosing cirrhosis and decompensated cirrhosis on ultrasound before and after a short educational intervention. Responses were paired across the three assessments, and paired sample t-tests were performed. Sensitivity, specificity, and likelihood ratios were calculated using attending radiology-interpreted ultrasounds as the gold standard. Results EPs scored a mean of 16% higher on a delayed knowledge assessment one month after the educational intervention than on the pre-intervention assessment. EP-interpreted ultrasound revealed a sensitivity of 0.90, specificity of 0.71, positive likelihood ratio of 3.08, and negative likelihood ratio of 0.14 compared to radiology-interpreted ultrasound. The sensitivity of our cohort was 0.98 for decompensated cirrhosis. Conclusions After a brief educational intervention, EPs can significantly increase their sensitivity and specificity in diagnosing cirrhosis using ultrasound. EPs were particularly sensitive in their diagnosis of decompensated cirrhosis.

A Rare Cause of Headache and an Unorthodox Transfer: A Case Report.

INTRODUCTION: Emergency department (ED) crowding and hospital diversion times are increasing nationwide, with negative effects on patient safety and an association with increased mortality. Crowding in referral centers makes transfer of complex or critical patients by rural emergency physicians (EP) more complicated and difficult. We present a case requiring an unorthodox transfer method to navigate extensive hospital diversion and obtain life-saving neurosurgical care. CASE REPORT: We present the case of a previously healthy 21-year-old male with two hours of headache and rapid neurologic decompensation en route to and at the ED. Computed tomography revealed obstructive hydrocephalus recognized by the EP, who medically managed the increased intracranial pressure (ICP) and began the transfer process for neurosurgical evaluation and management. After refusal by six referral centers in multiple states, all of which were on diversion, the EP initiated an unorthodox transfer procedure to the institution at which he trained, ultimately transferring the patient by air. Bilateral external ventricular drains were placed in the receiving ED, and the patient ultimately underwent neurosurgical resection of an obstructive colloid cyst. CONCLUSION: First, our case illustrates the difficulties faced by rural EPs when attempting to transfer critical patients when large referral centers are refusing transfers and the need for improvements in facilitating timely transfers of critically ill, time-sensitive patients. Second, EPs should be aware of colloid cysts as a rare but potentially catastrophic cause of rapid neurologic decline due to increased ICP, and the ED management thereof, which we review.

Optic nerve sheath diameter correlates to intracranial pressure in spontaneous CSF leak patients.

BACKGROUND: Spontaneous cerebrospinal fluid (sCSF) leaks develop from pressure erosion due to idiopathic intracranial hypertension, treatment of which is paramount to preventing recurrence. Direct measurements of intracranial pressure (ICP) for monitoring response to treatment via lumbar drain (LD) or ventriculostomy are invasive and have risks. The objectives of this study are to determine whether ultrasonographic measurements of optic nerve sheath diameter (ONSD) correlate with LD ICP in patients with sCSF leaks undergoing treatment, and whether ONSDs are larger in patients with sCSF leaks than controls. METHODS: Subjects with sCSF leaks and controls were prospectively recruited. ONSD, sex, and body mass index (BMI) were analyzed. For sCSF leak subjects, ultrasonography was performed at the time of LD opening and each pressure check postoperatively, including the acetazolamide response. In control patients, measurements were obtained at the time of surgery. Pearson's correlation between ONSD and ICP was performed. RESULTS: Subjects with sCSF leaks (n = 9, age 52.4 ± 9.5, all female) and controls (n = 8, age 60.1 ± 14.8, two females) had significantly different BMIs, 38.4 ± 8.1 vs. 29.2 ± 4.8, t(15) = 2.793, p = 0.014. ONSD was strongly correlated with ICP measurements (r = 0.583, p = 0.002). However, percentage change in ONSD and ICP measurements were more strongly correlated (r = 0.733, p < 0.001). Patients with sCSF leaks had significantly higher ONSDs than controls, 0.63 cm ± 0.044 vs. 0.56 cm ± 0.074, t(15) = 2.329, p = 0.034. CONCLUSION: ONSD significantly correlated with ICP in sCSF leak patients and was wider in sCSF leak subjects than controls. Ultrasonography has utility in monitoring the ICP response to acetazolamide.

Evaluation of a novel handheld point-of-care ultrasound device in an African emergency department.

BACKGROUND: Many point-of-care ultrasound devices are now "pocket-sized" or handheld, allowing easy transport during travel and facilitating use in crowded spaces or in austere low-resource settings. Concerns remain about their durability, image quality, and clinical utility in those environments. METHOD: Five emergency physicians with training in point-of-care ultrasound employed the Butterfly iQ, a novel handheld ultrasound device, in routine clinical care in a busy, high-acuity African emergency department over a period of 10 weeks. We retrospectively evaluated the performance of the Butterfly iQ from the perspectives of both the clinicians using the device and expert ultrasound faculty reviewing the images. RESULTS: We found advantages of the Butterfly iQ in a high-acuity African emergency department include its use of a single probe for multiple functions, small size, ease of transport, relatively low cost, and good image quality in most functions. Disadvantages include large probe footprint, lower, though still adequate, cardiac imaging quality, frequent overheating, and reliance on internet-based cloud storage, but these were surmountable. We also report a wide variety of patient presentations, pathology, and procedures to which the device was used. CONCLUSION: We conclude the Butterfly iQ is an effective, though imperfect, point-of-care ultrasound device in a low-resource emergency setting. We will continue to employ the device in clinical emergency care and teaching in this setting.

Clinical ultrasonography in patients who inject drugs (the CUPID protocol): an illustrated case series.

In 2017, there were ≈47,600 opioid overdose-related deaths in the United States. US emergency department (ED) visits for suspected opioid overdose increased by 30% between July 2016 and September 2017.2 The current US opioid epidemic makes it critical for emergency physicians to be aware of common and uncommon infectious and non-infectious complications of injection drug use. Point-of-care ultrasound has become a widely available, non-invasive diagnostic tool in EDs across the United States and worldwide. The increasing population of injection drug use patients is at risk for serious morbidity and mortality from an array of disease states amenable to ultrasound-based diagnosis. We propose a protocol for clinical ultrasonography in patients who inject drugs (the CUPID protocol), a focused, 3-system point-of-care ultrasound approach emphasizing cardiovascular, thoracic, and musculoskeletal imaging. The protocol is a screening tool, designed to detect high risk infectious and noninfectious complications of injection drug use.

COVID-19: A review of therapeutics under investigation.

The COVID-19 outbreak has disrupted global health care networks and caused thousands of deaths and an international economic downturn. Multiple drugs are being used on patients with COVID-19 based on theoretical and in vitro therapeutic targets. Several of these therapies have been studied, but many have limited evidence behind their use, and clinical trials to evaluate their efficacy are either ongoing or have not yet begun. This review summarizes the existing evidence for medications currently under investigation for treatment of COVID-19, including remdesivir, chloroquine/hydroxychlorquine, convalescent plasma, lopinavir/ritonavir, IL-6 inhibitors, corticosteroids, and angiotensin-converting enzyme inhibitors.

An adapted emergency department triage algorithm for the COVID-19 pandemic.

The novel coronavirus disease 2019 (COVID-19) pandemic, with its public health implications, high case fatality rate, and strain on hospital resources, will continue to challenge clinicians and researchers alike for months to come. Accurate triage of patients during the pandemic will assign patients to the appropriate level of care, provide the best care for the maximum number of patients, rationally limit personal protective equipment (PPE) usage, and mitigate nosocomial exposures. The authors describe an adapted COVID-19 pandemic triage algorithm for emergency departments (EDs) guided by the best available evidence and responses to prior pandemics, with recommendations for clinician PPE use for each level of encounter in the setting of an ongoing PPE shortage. Our algorithm adheres to Centers for Disease Control and Prevention guidelines and supports discharge of patients with mild symptoms coupled with explicit and strict return precautions and infection control education.

Bowel Perforation in the Emergency Department Related to Bevacizumab Therapy and Recurrent Ovarian Cancer.

CASE PRESENTATION: We describe the presentation to the emergency department of a patient with recurrent ovarian cancer treated with bevacizumab with the complication of bowel perforation. DISCUSSION: We review the frequency and outcomes of bevacizumab-related bowel perforation. We also report the patient's imaging findings, including the radiologic presentation of free intraperitoneal air and portal venous gas, both indicative of bowel perforation and the need for emergent surgical evaluation. Our case also illustrates the potentially catastrophic side effects of bevacizumab and other targeted oncologic therapies of which emergecny physicians may not be aware.

Coronavirus disease 2019: International public health considerations.

On December 31, 2019, the Chinese government announced an outbreak of a novel coronavirus, recently named COVID-19. During the following weeks the international medical community has witnessed with unprecedented coverage the public health response both domestically by the Chinese government, and on an international scale as cases have spread to dozens of countries. While much regarding the virus and the Chinese public health response is still unknown, national and public health institutions globally are preparing for a pandemic. As cases and spread of the virus grow, emergency and other front-line providers may become more anxious about the possibility of encountering a potential case. This review describes the tenets of a public health response to an infectious outbreak by using recent historical examples and also by characterizing what is known about the ongoing response to the COVID-19 outbreak. The intent of the review is to empower the practitioner to monitor and evaluate the local, national and global public health response to an emerging infectious disease.

Point-of-care ultrasound in resource-limited settings: the PURLS fellowship.

BACKGROUND: The role of point-of-care ultrasonography (POCUS) is rapidly expanding in both resource-rich and resource-limited settings (RLS). One limitation to this rapid expansion has been the lack of educators adequately trained to teach this user-dependent skill. This is particularly true in RLS, where disease presentations, infrastructure limitations, and approach to medical education present unique challenges to the direct application of resource-rich emergency department POCUS curricula. OBJECTIVES: We describe the point-of-care ultrasound in resource-limited settings (PURLS) fellowship, a novel curriculum designed to provide advanced training and expertise in clinical care and POCUS application and education in RLS. CONCLUSION: Our curriculum design is one approach to create context-specific POCUS education for use in RLS, thereby improving patient care.