Ultrasound-Guided Radial Artery Puncture by Nurses in Emergency Department: A Randomized Controlled Study.

INTRODUCTION: Radial artery puncture has been performed by palpation as a standard method in many emergency departments and intensive care units. Nurses play an important role in the care of patients in various settings. Ultrasonography can be performed and interpreted not only by physicians but also by nurses. This study aimed to evaluate whether emergency nurses would be more successful in radial artery puncture procedure by using ultrasonography instead of palpation. METHODS: This single-center, prospective, randomized controlled study was conducted in the emergency department. The patients included in the study were randomized into 2 groups as ultrasonography and palpation groups. Data were recorded on the number of interventions, the duration of the procedure in seconds, total time in seconds, whether the puncture was successfully placed, whether there were complications, the types of complications (hematoma, bleeding, and infection), or whether it was necessary to switch to an alternative technique. RESULTS: A total of 72 patients, 36 patients in the ultrasonography group and 36 patients in the palpation group, participated in the study. The success rate at the first attempt was statistically significantly higher in the ultrasonography group. Although hematoma formation among the complications occurred in the entire palpation group, it was observed in 72.2% of the ultrasonography group. Puncture time and total time were statistically significantly lower in the ultrasonography group. DISCUSSION: Our study shows that emergency nurses can use bedside ultrasonography for radial artery puncture successfully.

Factors Relating to Decision Delay in the Emergency Department: Effects of Diagnostic Tests and Consultations.

Purpose: The purpose of this study is to investigate the factors increasing waiting time (WT) and length of stay (LOS) in patients, which may cause delays in decision-making in the emergency departments (ED). Patients and Methods: Patients who arrived at a training hospital in the central region of Izmir City, Turkey, during the first quarter of 2020 were retrospectively analyzed. WT and LOS were the outcome variables of the study, and gender, age, arrival type, triage level determined based on the clinical acuity, diagnosis encoded based on International Classification of Diseases-10 (ICD-10), the existence of diagnostic tests or consultation status were the identified factors. The significance of the differences in WT and LOS values based on each level of these factors was analyzed using independent sample t-tests and ANOVA. Results: While patients for which no diagnostic testing or consultation was requested had a significantly higher WT in EDs, their LOS values were substantially lower than those for which at least one diagnostic test or consultation was ordered (p≤0.001). Besides, elderly and red zone patients and those who arrived by ambulance had significantly lower WT and higher LOS values than other levels for all groups of patients for which laboratory-type or imaging-type diagnostic test or consultation was requested (p≤0.001 for each comparison). Conclusion: Besides ordering diagnostic tests or consultation in EDs, different factors may extend patients' WT and LOS values and cause significant decision-making delays. Understanding the patient characteristics associated with longer waiting times and LOS values and, thus, delayed decisions will enable practitioners to improve operations management in EDs.

Comparison of tricuspid and mitral annular plane systolic excursion in determination of acute blood loss in healthy volunteers.

Ultrasound is used more and more in determining acute blood loss. This study is to compare tricuspid annular plane systolic excursion (TAPSE) and mitral annular plane systolic excursion (MAPSE) measurement to determine volume loss pre and post blood donation in healthy volunteers. The systolic, diastolic and mean arterial blood pressures and pulses of the donors were measured in the standing and supine position by the attending physician, then, inferior vena cava (IVC), TAPSE and MAPSE measurements were made pre and post blood donation. Statistically significant differences were found in systolic blood pressure and pulse rate values that obtained in the standing position, and in the systolic blood pressure, diastolic blood pressure, mean arterial pressure and pulse values that obtained in the supine position (p < 0.05). The difference between IVC expiration (IVCexp) pre and post blood donation was 4.76 ± 2.94 mm, and the difference in IVC inspiration (IVCins) was 2.73 ± 2.91 mm. In addition, the MAPSE and TAPSE differences were 2.16 ± 1.4 mm and 2.98 ± 2.13 mm, respectively. Statistically significant differences were found between IVCins-exp, TAPSE and MAPSE values. TAPSE and MAPSE can be helpful in the early diagnosis of acute blood loss.

Verification of Endotracheal Tube Position by Emergency Nurses Using Ultrasound: A Repeated Measures Cadaver Study.

INTRODUCTION: Endotracheal intubation is a lifesaving procedure frequently performed in emergency departments. It is associated with some potential risks. Rapid and reliable confirmation of endotracheal tube placement during intubation is critical. Nurses play an important role in the care of patients in various settings. Ultrasound can be performed and interpreted not only by physicians but also by nurses. The aim of this study was to evaluate how well nurses without previous ultrasound experience can determine both esophageal and tracheal localization of endotracheal tubes in cadavers after a short ultrasound training. METHODS: This was a repeated measures study with an educational intervention and no control/contemporaneous comparison group. The study was performed to evaluate the ability of emergency nurses to confirm correct endotracheal tube placement and identify esophageal intubations. A total of 7 emergency nurses were given theoretical education and hands-on training about ultrasound. They diagnosed tracheal or esophageal intubation using ultrasound. RESULTS: Four cadavers were used 8 times each for the study. A total of 32 intubation procedures were evaluated with ultrasound by each nurse. In the analysis based on 224 responses, sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and overall accuracy of ultrasound applied by nurses to detect tracheal intubation were 95.61% (90.06%-98.56%), 97.27% (92.24%-99.43%), 35.06 (11.48-107.10), 0.05 (0.02-0.11), and 96.43% (93.08%-98.45%), respectively. The mean time to evaluate the tube location by ultrasound was 6.57 seconds. DISCUSSION: The results support that ultrasound can be performed by nurses for the confirmation for esophageal and tracheal intubations quickly and accurately.

The role of tricuspite annular plane systolic excursion as a marker of hypovolemia in healthy blood donor volunteers.

AIM: The aim of this study is to compare the diameter of the inferior vena cava with tricuspid annular plane systolic excursion (TAPSE) measurement in order to determine the volume loss before and after blood donation in healthy volunteers. METHODS: This Institutional Review Board-approved single center, prospective, cross-sectional study included 60 healthy blood donors donating in a tertiary care hospital's blood bank. After obtaining written consent, systolic, diastolic, and mean arterial blood pressures along with pulse rate of the donors were measured in sitting and supine positions by the attending physician, then, inferior vena cava (IVC) and TAPSE measurements were made before and after blood donation. RESULTS: Statistically significant differences was found between standing systolic blood pressure and pulse rate, lying systolic blood pressure and pulse rate, IVC and TAPSE values before and after blood donation (p < 0.05). There was no difference between the other variables before and after blood donation. CONCLUSION: Our study revealed that, low IVC and TAPSE values correlated in determining blood loss after blood donation. TAPSE may be useful to predict blood loss in early stages of hypovolemic shock.

Simple Manual Pressure with Ultrasound-Guided Femoral Nerve Block: A randomized single blind study.

PURPOSE: The aim of this study was to investigate the effect of compression on the Visual Analog Scale (VAS) score following the application of 3-in-1 femoral nerve block (FNB), used for pain palliation in patients with hip fractures. METHODS: This was a randomized controlled trial study on application of pressure versus no pressure following FNB in patients with hip fractures. Their VAS scores were recorded and an ultrasound-guided 3-in-1 FNB was performed as a standardized procedure. After the procedure, patients were randomized into two groups and a weight with 2 kg pressure was applied to the treated area in one group. After 30 min, VAS scores were recorded again. VAS scores of all patients recorded before and after the procedure, and post-procedural VAS scores of pressure-applied and no pressure-applied groups were statistically compared. RESULTS: 34 patients were included in this study with 17 patients falling in the compression group (group C), and the remaining half in the non-compression group (group NC). The pre-procedural mean VAS scores were 9.35 (95% CI; 8.95-9.76)), while the post-procedural mean VAS scores dropped to 2.35 (95% CI; 1.65-3.06) in group C. The pre-procedural mean VAS score was 9.12 (95% CI; 8.64-9.59), while the post-procedural mean VAS score was 5.06 (95% CI; 4.09-6.03) in group NC. When the average reductions in VAS score following the procedure were compared, the mean difference between the two groups was calculated to be 2.94 (95% CI; 1.69-4.19) which favours group C. This difference was statistically significant (p < 0.001). CONCLUSION: Our study shows that, the application of simple compression after 3-in-1 FNB in patients with hip fractures provides a significant reduction in VAS scores.

Accuracy of Bedside Lung Ultrasound as a Rapid Triage Tool for Suspected Covid-19 Cases.

OBJECTIVES: The novel coronavirus disease 2019 (Covid-19) outbreak began in China. The characteristic of the disease is development of pneumonia. We aimed to investigate the accuracy of bedside lung ultrasound (BLUS) for diagnosing Covid-19 pneumonia, and its effectiveness for the correct triage of patients with suspected Covid-19 in the emergency department (ED). METHODS: This study was a prospective, cross-sectional cohort study. During their shifts, 3 accredited and certificated emergency physicians performed BLUS using BLUE protocol at the triage area of the ED on patients with suspected Covid-19. All of the patients underwent chest computed tomography. The BLUS findings were statistically compared with formal radiology reports of computed tomographies as the criterion standard for the diagnosis of Covid-19 pneumonia. Kolmogorov-Smirnov analysis, Shapiro-Wilk test, and Q-Q plots were performed with 95% confidence intervals (CIs) for statistical analysis. RESULTS: A total of 72 patients were included in the study. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of BLUS were 96.9% (95% CI, 84.2%-99.9%), 92.3% (95% CI, 79.1%-98.3%), 84.3% (95% CI, 64.5%-94.1%), 98.6% (95% CI, 91.1%-99.8%), and 93.7% (95% CI, 85.3%-98.0%), respectively. The positive and negative predictive values were 84.3% (95% CI, 64.5%-94.1%) and 98.6% (95% CI, 91.1%-99.8%), respectively. The area under curve was found to be 0.946 (95% CI, 0.866-0.986; P < 0.0001). CONCLUSIONS: Bedside lung ultrasound can be used to detect the presence of pulmonary involvement in suspected cases of Covid-19 for the effective triage of patients in the ED.

Effectiveness of Bedside Lung Ultrasound for Clinical Follow-Up of Primary Spontaneous Pneumothorax Patients Treated With Tube Thoracostomy.

Primary spontaneous pneumothorax (PSP) is a common cause of presentation to emergency departments and subsequent hospitalization. Patients with large PSP are treated with tube thoracostomy (TT) and followed up with x-rays. In this study, we investigated the efficiency of bedside ultrasound and compared it with x-ray imaging for the clinical follow-up of PSP patients treated with TT.This is a prospective observational study. After ethical committee approval and written informed consent were obtained, patients who were treated with TT because of PSP were screened. In the follow-up of these patients, a bedside lung ultrasound (BLUS) was performed before every chest x-ray by an emergency physician experienced in performing BLUSs. The performance of BLUSs in detecting free air in the pleural cavity was compared statistically with that of x-rays.Sixty-two patients were enrolled in the study. In total, 166 BLUSs and x-rays were compared. The sensitivity of BLUS was 95.65% (85.20-99.50), specificity was 100% (79.40-100.00), positive predictive value was 100% (92-100), negative predictive value was 88.90% (65.30-98.60), and the area under the curve was 0.99 (0.974-1.000; P = 0.001) for detecting air in the pleural cavity. These results showed that there was no statistically significant difference between BLUS and x-ray methods for detecting air in the pleural cavity.Our study revealed that BLUS can be safely used for the follow-up of PSP patients treated with TT to determine if air is present in the pleural cavity. Further studies are needed.

Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis.

BACKGROUND: Appendicitis is a common disease requiring surgery. Bedside ultrasound (BUS) is a core technique for emergency medicine (EM). The Alvarado score is a well-studied diagnostic tool for appendicitis. This study aimed to investigate the relationship between patients' symptoms, Alvarado score and ultrasound (US) findings, as performed by emergency physicians (EPs) and radiologists, of patients with suspected appendicitis. METHODS: Three EM specialists underwent the BUS course and core course for appendicitis assessment. Patients suspected of having appendicitis were selected and their Alvarado and modified (m) Alvarado scores calculated. The specialists performed the BUS. Then, patients were given a formal US and surgery consultation if necessary. Preliminary diagnoses, admission or discharge from the emergency department (ED) and final diagnosis were documented. The patients were also followed up after discharge from the hospital. RESULTS: The determined cut-off value was 2 for Alvarado and 3 for mAlvarado scores. The sensitivities of the two scores were 100%. Each score was used to rule out appendicitis. The results of EP-performed BUS were as follows: accuracy 70%, sensitivity 0.733, specificity 0.673, + LR 2.24, and - LR 0.40 (95%CI). Radiologists were better than EPs at diagnosing appendicitis and radiologists and EPs were equally strong at ruling out appendicitis by US. When US was combined with Alvarado and mAlvarado scores, EP US+Alvarado/mAlvarado scores <3 and radiology US+Alvarado/mAlvarado scores <4 perfectly ruled out appendicitis. CONCLUSION: BUS performed by EPs is moderately useful in detecting appendicitis. Combined with scoring systems, BUS may be a perfect tool for ruling out decisions in EDs.

An uncommon cause of abdominal pain: Mesenteric cyst.

Mesenteric cysts are benign cystic lesions. Here, we present the case of a patient with abdominal pain, which was diagnosed as mesenteric cyst. A 28-year-old male patient was admitted to the emergency department (ED) with abdominal pain and distention. Abdominal palpation revealed a smooth-surfaced mass palpable in the left upper quadrant. Ultrasonography depicted a hypoechoic heterogeneous mass-like structure with a size of 15 × 12 cm. Computerized tomography (CT) showed a well-defined cystic structure with a size of 12 × 12.5 cm near to the duodenum and pancreas. The patient was admitted, and the cystic structure was drained with a percutaneous drainage catheter; then, sclerotherapy was performed using ethyl alcohol with the aid of ultrasonography. The material was sent to the pathology lab and revealed negative results for malignant cell and mucin. The patient underwent a control CT with contrast, which revealed the catheter at the site of the operation and no cystic lesion after procedure. He was discharged 1 week after the procedure. Mesenteric cysts are extremely rare benign lesions of the abdomen, and emergency physicians must consider this disease in the differential diagnosis of abdominal pain. The percutaneous drainage technique performed on our patient is a safe technique for the treatment of selected patients.

A rare case of abdominal infection: Emphysematous pyelonephritis without diabetes.

Emphysematous pyelonephritis (EP) is a rare form of necrotizing pyelonephritis. It is a life-threatening condition that usually affects patients with diabetes, and a small percentage may be due to urinary tract obstruction. Here, we present the case of an EP caused by urinary tract obstruction without diabetes. A 45-year-old woman presented to the emergency department with fever, chills, and abdominal pain. There was no significant past history. Physical examination depicted bilateral lower abdominal and right flank knocking tenderness. Laboratory exams revealed leukocytosis, neutrophilia, a high C-reactive protein level, and pyuria. Abdominal computerized tomography (CT) showed diffuse gas in the right renal collecting system and dilatation of the right renal pelvis compared to the right side, in addition to multiple millimetric stones located in the right kidney and right ureter. After emergent placement of a percutaneous nephrostomy, she was admitted. Control abdominal CT without contrast revealed the absence of gas, hydronephrosis of the right renal pelvis, and the presence of nephrolithiasis. The patient was discharged 10 days of post-procedure with instructions for follow-up. Emergency physicians need to remain alert about this life-threatening disease and the typical CT findings of this disease to make a timely diagnosis and navigate management.

A case of luftsichel sign for left upper lobe collapse.

The differential diagnosis of dyspnea in Emergency Department (ED) patients is broad and atelectasis is one of the differentials among these. We present a 29-year-old women presented to our ED for evaluation of shortness of breath. On her chest examination, air entry and breath sounds were diminished on the left side but normal on the right. A posteroanterior chest radiograph showed radioluscent area in the upper zone of the left lung, around the aortic arch and also hyperdens area neighbouring this, like covered by a veil. Luftsichel sign together with this hiperdensity were consistent with the diagnose of left lung upper lobe collapse. The Luftsichel sign represents the hyperexpanded superior segment of the left lower lobe interposed between the atelectatic left upper lobe and aortic arch. Patient was discharged to home with chest physiotherapy and breathing exercises together with analgesic prescreption.

Stethoscope versus point-of-care ultrasound in the differential diagnosis of dyspnea: a randomized trial.

We aimed to determine the accuracies of point-of-care ultrasound (PoCUS) and stethoscopes as part of the physical examinations of patients with dyspnea. Three emergency medicine specialists in each of two groups of ultrasound and stethoscope performers underwent didactic and hands-on training on PoCUS and stethoscope usage. All the patients enrolled were randomized to one of two predetermined PoCUS or stethoscope groups. The diagnostic performance of ultrasonography was higher than that of the stethoscope in the diagnoses of heart failure (90 vs. 86%, 1.00 vs. 0.89, and 5.00 vs. 4.92, respectively) and pneumonia (90 vs. 86.7%, 0.75 vs. 0.73, and 16.50 vs. 13.82, respectively). No significant differences were observed in the utility parameters of these modalities in these diagnoses. Although some authors argue that it is time to abandon the 'archaic tools' of past centuries, we believe that it is too early to discontinue the use of the stethoscope.

Bedside ultrasonographic diagnosis of pneumothorax.

Pneumothorax (PTX) is the presence of an excessive amount of air between the two layers of the pleura. The clinical results depend on the extent of lung collapse. Bedside lung ultrasonography (BLUS) is a valuable way to diagnose PTX in the emergency department. The lung point is a pathognomonic sign of PTX. Here, we present a previously healthy 17-year-old male with left shoulder pain for 2 days, who was referred to the emergency department (ED). He had no history of trauma. BLUS was performed by the emergency physician. The lung point was detected with BLUS, and he was diagnosed with primary spontaneous PTX. Needle aspiration was performed. The patient was followed up with BLUS. Evidence of PTX was absent in BLUS after 6 h, and the patient was discharged for follow-up by a respiratory physician. In this case, the lung point in BLUS helped us make an accurate diagnosis of primary spontaneous PTX and invasive management of disease was arranged accordingly.