A prospective, multicenter evaluation of point-of-care ultrasound for appendicitis in the emergency department.

OBJECTIVE: The main objective of this study was to evaluate the accuracy of point-of-care ultrasound (POCUS) for the diagnosis of appendicitis in a general emergency department (ED) population as performed by emergency physicians with variable ultrasound experience. METHODS: We performed a prospective, multicenter, observational study examining a convenience sample of adult patients with potential appendicitis presenting to the ED between July 2014 and February 2020. Each emergency physician-performed POCUS was interpreted at the bedside and retrospectively by an expert reviewer. Test characteristics were calculated for POCUS and blinded expert interpretation compared to surgical pathology in patients undergoing appendectomy and advanced imaging in patients managed nonoperatively. RESULTS: A total of 256 subjects were included in the primary analysis with an overall appendicitis prevalence of 28.1%. For the diagnosis of appendicitis, POCUS demonstrated an overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 0.85 (95% confidence interval [CI] = 0.74 to 0.92), 0.63 (95% CI = 0.56 to 0.70), 2.29 (95% CI = 1.85 to 2.84), and 0.24 (95% CI = 0.14 to 0.42), respectively. Expert review yielded a lower sensitivity (0.74 [95% CI = 0.62 to 0.83]) with a similar specificity (0.63 [95% CI = 0.56 to 0.70]). CONCLUSION: POCUS is moderately accurate for acute appendicitis as performed by emergency physicians with a wide range of ultrasound expertise, but lacks adequate sensitivity and specificity to function as a definitive test in an undifferentiated ED population. Further study is warranted to elucidate the optimal role of integrated POCUS in the general approach to suspected appendicitis.

Point-of-care Ultrasound in the Diagnosis of Calciphylaxis.

CASE PRESENTATION: A 63-year-old male with a past medical history of end stage renal disease presented to the emergency department with painful, lower-extremity necrotic ulcerations. Ultrasound and computed tomography imaging showed concerns for calcium deposits. Biopsy confirmed the diagnosis of calciphylaxis, a rare lethal disease. DISCUSSION: Emergency physicians should keep this disease on their differential due to the high mortality rate.

Young patients with chest pain: 1-year outcomes.

OBJECTIVE: Prior studies found that young adult chest pain patients without known cardiac disease with either no cardiac risk factors or a normal electrocardiogram (ECG) are at low risk (<1%) for acute coronary syndromes (ACS) and 30-day cardiovascular events. Longer-term event rates in this subset of patients are unknown. We hypothesized that patients younger than 40 years without past cardiac history and a normal ECG are at less than 1% risk for 1-year adverse cardiovascular events. METHODS: We conducted a prospective cohort study in an urban university emergency department evaluating patients younger than 40 years who received an ECG for evaluation of potential ACS. Cocaine users, cancer patients, and patients with a history of myocardial infarction or revascularization were excluded. Structured data collection at presentation included demographics, chest pain description, history, laboratory results, and ECG data. Hospital course was followed. Follow-up was obtained by telephone, record review, and social security death index search. Our main outcome was 1-year adverse cardiovascular events (death; acute myocardial infarction [AMI]; or revascularization-percutaneous coronary intervention [PCI] or coronary artery bypass graft). Descriptive statistics and 95% confidence intervals were used. RESULTS: Of 3846 chest pain patients, 609 met criteria. Of those, 35.5% were admitted. Patients had a mean age of 34.8 years (SD, 3.8 years). They were most often female (57.6%) and black (69.5%). There were 7 patients (1.1%; 95% CI, 0.5%-2.4%) with adverse cardiovascular events over the year. Of the subset of 560 patients with a normal/nonspecific ECG, there were 2 deaths (0.4%), 3 AMI (0.5%), and 2 PCIs (0.4%) by 1 year for a composite adverse cardiovascular event rate of 6 (1.1%; 95% CI, 0.4%-2.3%). Of the subset of 269 patients with no cardiac risk factors and a normal/nonspecific ECG, there were no deaths, 1 AMI, and 1 PCI for a composite adverse cardiovascular event rate at 1 year of 0.3% (0.01%-2.1%). The addition of an initial cardiac marker to this group resulted in a cohort that was event-free at 1 year (95% CI, 0%-1.4%). CONCLUSIONS: Patients younger than 40 years without a cardiac history who present to the ED with symptoms consistent with ACS but have either no risk factors or a normal or nonspecific ECG have a very low rate of adverse events during the subsequent year.

Relation between thrombolysis in myocardial infarction risk score and one-year outcomes for patients presenting at the emergency department with potential acute coronary syndrome.

The Thrombolysis in Myocardial Infarction (TIMI) score, derived from unstable angina/non-ST-segment elevation acute myocardial infarction patient population, predicts 14-day cardiovascular events. It has been validated in emergency department (ED) patients with potential acute coronary syndrome with respect to 30-day outcomes. Our objective was to determine whether the initial TIMI score could risk stratify ED patients with potential acute coronary syndrome with respect to the 1-year outcomes. This was a prospective cohort study of patients presenting to the ED with chest pain who underwent electrocardiography. Patients with ST-segment elevation myocardial infarction (acute myocardial infarction) were excluded. Follow-up was conducted by telephone and record review >1 year after the index visit. The main outcome was the 1-year mortality, nonfatal acute myocardial infarction, or revascularization stratified by the TIMI score. Of 2,819 patients, 253 (9%) met the composite outcome. The overall incidence of the composite 1-year outcome of death (n = 119), acute myocardial infarction (n = 96), and revascularization (n = 90) according to TIMI score was TIMI 0 (n = 1,162), 4%; TIMI 1 (n = 901), 8%; TIMI 2 (n = 495), 13%; TIMI 3 (n = 193), 23%; TIMI 4 (n = 60), 28%; and TIMI 5 to 7 (n = 8), 88% (p <0.001). In conclusion, in addition to risk stratifying ED patients with chest pain at the initial ED evaluation, the TIMI score can also predict the 1-year cardiovascular events in this patient population.

Coronary computerized tomography angiography for rapid discharge of low-risk patients with cocaine-associated chest pain.

BACKGROUND: Most patients presenting to emergency departments (EDs) with cocaine-associated chest pain are admitted for at least 12 hours and receive a "rule out acute coronary syndrome" protocol, often with noninvasive testing prior to discharge. In patients without cocaine use, coronary computerized tomography angiography (CTA) has been shown to be useful for identifying a group of patients at low risk for cardiac events who can be safely discharged. It is unclear whether a coronary CTA strategy would be efficacious in cocaine-associated chest pain, as coronary vasospasm may account for some of the ischemia. We studied whether a negative coronary CTA in patients with cocaine-associated chest pain could identify a subset safe for discharge. METHODS: We prospectively evaluated the safety of coronary CTA for low-risk patients who presented to the ED with cocaineassociated chest pain (self-reported or positive urine test). Consecutive patients received either immediate coronary CTA in the ED (without serial markers) or underwent coronary CTA after a brief observation period with serial cardiac marker measurements. Patients with negative coronary CTA (maximal stenosis less than 50%) were discharged. The main outcome was 30-day cardiovascular death or myocardial infarction. RESULTS: A total of 59 patients with cocaine-associated chest pain were evaluated. Patients had a mean age of 45.6 +/- 6.6 yrs and were 86% black, 66% male. Seventy-nine percent had a normal or nonspecific ECG and 85% had a TIMI score <2. Twenty patients received coronary CTA immediately in the ED, 18 of whom were discharged following CTA (90%). Thirty-nine received coronary CTA after a brief observation period, with 37 discharged home following CTA (95%). Six patients had coronary stenosis >or=50%. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% CI, 0-6.1%) and no patient sustained a nonfatal myocardial infarction (0%; 95% CI, 0-6.1%). CONCLUSIONS: Although cocaine-associated myocardial ischemia can result from coronary vasoconstriction, patients with cocaine associated chest pain, a non-ischemic ECG, and a TIMI risk score <2 may be safely discharged from the ED after a negative coronary CTA with a low risk of 30-day adverse events.

One-year outcomes following coronary computerized tomographic angiography for evaluation of emergency department patients with potential acute coronary syndrome.

OBJECTIVES: Coronary computerized tomographic angiography (CTA) has high correlation with cardiac catheterization and has been shown to be safe and cost-effective when used for rapid evaluation of low-risk chest pain patients from the emergency department (ED). The long-term outcome of patients discharged from the ED with negative coronary CTA has not been well studied. METHODS: The authors prospectively evaluated consecutive low- to intermediate-risk patients who received coronary CTA in the ED for evaluation of a potential acute coronary syndrome (ACS). Patients with cocaine use, known cancer, and significant comorbidity reducing life expectancy and those found to have significant disease (stenosis > or = 50% or ejection fraction < 30%) were excluded. Demographics, medical and cardiac history, labs, and electrocardiogram (ECG) results were collected. Patients were followed by telephone contact and record review for 1 year. The main outcome was 1-year cardiovascular death or nonfatal acute myocardial infarction (AMI). RESULTS: Of 588 patients who received coronary CTA in the ED, 481 met study criteria. They had a mean (+/-SD) age of 46.1 (+/-8.8) years, 63% were black or African American, and 60% were female. There were 53 patients (11%) rehospitalized and 51 patients (11%) who received further diagnostic testing (stress or catheterization) over the subsequent year. There was one death (0.2%; 95% confidence interval [CI] = 0.01% to 1.15%) with unclear etiology, no AMI (0%; 95% CI = 0 to 0.76%), and no revascularization procedures (0%; 95% CI = 0 to 0.76%) during this time period. CONCLUSIONS: Low- to intermediate-risk patients with a Thrombosis In Myocardial Infarction (TIMI) score of 0 to 2 who present to the ED with potential ACS and have a negative coronary CTA have a very low likelihood of cardiovascular events over the ensuing year.