Bedside echocardiography by emergency physicians.

STUDY OBJECTIVE: Timely diagnosis of a pericardial effusion is often critical in the emergency medicine setting, and echocardiography provides the only reliable method of diagnosis at the bedside. We attempt to determine the accuracy of bedside echocardiography as performed by emergency physicians to detect pericardial effusions in a variety of high-risk populations. METHODS: Emergency patients presenting with high-risk criteria for the diagnosis of pericardial effusion underwent emergency bedside 2-dimensional echocardiography by emergency physicians who were trained in ultrasonography. The presence or absence of a pericardial effusion was determined, and all images were captured on video or as thermal images. All emergency echocardiograms were subsequently reviewed by the Department of Cardiology for the presence of a pericardial effusion. RESULTS: During the study period, a total of 515 patients at high risk were enrolled. Of these, 103 patients were ultimately deemed to have a pericardial effusion according to the comparative standard. Emergency physicians detected pericardial effusion with a sensitivity of 96% (95% confidence interval [CI] 90.4% to 98.9%), specificity of 98% (95% CI 95.8% to 99.1%), and overall accuracy of 97.5% (95% CI 95.7% to 98.7%). CONCLUSION: Echocardiography performed by emergency physicians is reliable in evaluating for pericardial effusions; this bedside diagnostic tool may be used to examine specific patients at high risk. Emergency departments incorporating bedside ultrasonography should teach focused echocardiography to evaluate the pericardium.

The importance of serial neurologic examination and repeat cranial tomography in acute evolving epidural hematoma.

Computed tomography (CT) has revolutionized the diagnosis and management of head-injured patients, and its increasing availability has led to its liberal use. CT scanning provides excellent anatomic detail of the brain as fixed static images, but the dynamic nature of human physiology means that many injury patterns will evolve in time. We describe an 8-year-old child who had fallen 8 feet from a tree. He had a brief loss of consciousness but a normal neurologic evaluation on arrival to the emergency department (ED). He underwent expedited cranial CT scanning, which revealed no acute brain injury. Two and one half hours later, the patient had a mild depression in consciousness, prompting a second CT scan in the ED, which revealed an acute epidural hematoma. He had acute surgical evacuation of the hematoma and made a full neurologic recovery. This case illustrates that a single early CT examination may at times provide a false sense of security and underscores the importance of serial neurologic examinations.

Ultrasound training for emergency physicians--a prospective study.

OBJECTIVES: Bedside ultrasound examination by emergency physicians (EPs) is being integrated into clinical emergency practice, yet minimum training requirements have not been well defined or evaluated. This study evaluated the accuracy of EP ultrasonography following a 16-hour introductory ultrasound course. METHODS: In phase I of the study, a condensed 16-hour emergency ultrasound curriculum based on Society for Academic Emergency Medicine guidelines was administered to emergency medicine houseofficers, attending staff, medical students, and physician assistants over two days. Lectures with syllabus material were used to cover the following ultrasound topics in eight hours: basic physics, pelvis, right upper quadrant, renal, aorta, trauma, and echo-cardiography. In addition, each student received eight hours of hands-on ultrasound instruction over the two-day period. All participants in this curriculum received a standardized pretest and posttest that included 24 emergency ultrasound images for interpretation. These images included positive, negative, and nondiagnostic scans in each of the above clinical categories. In phase II of the study, ultrasound examinations performed by postgraduate-year-2 (PGY2) houseofficers over a ten-month period were examined and the standardized test was readministered. RESULTS: In phase I, a total of 80 health professionals underwent standardized training and testing. The mean +/- SD pretest score was 15.6 +/- 4.2, 95% CI = 14. 7 to 16.5 (65% of a maximum score of 24), and the mean +/- SD posttest score was 20.2 +/- 1.6, 95% CI = 19.8 to 20.6 (84%) (p < 0. 05). In phase II, a total of 1,138 examinations were performed by 18 PGY2 houseofficers. Sensitivity was 92.4% (95% CI = 89% to 95%), specificity was 96.1% (95% CI = 94% to 98%), and overall accuracy was 94.6% (95% CI = 93% to 96%). The follow-up ultrasound written test showed continued good performance (20.7 +/- 1.2, 95% CI = 20.0 to 21.4). CONCLUSIONS: Emergency physicians can be taught focused ultrasonography with a high degree of accuracy, and a 16-hour course serves as a good introductory foundation.

Emergency airway management in penetrating neck injury.

STUDY OBJECTIVES: Airway management in the context of penetrating neck injury is a challenging scenario. Management decisionmaking has not been well studied and the initial airway approach remains controversial. We examined various initial emergency airway techniques and their success in the setting of penetrating neck trauma. METHODS: A retrospective study was conducted of emergency department intubations in penetrating neck injury from January 1, 1993, to December 31, 1996, at a Level I trauma center. Cases of out-of-hospital traumatic arrest or out-of-hospital intubation were excluded. Successful airway management was defined as endotracheal tube placement confirmed by clinical evaluation, pulse oximetry, chest radiography, and end-tidal CO(2) detection. RESULTS: During the study period, 748 consecutive patients with penetrating neck injury were evaluated in the ED. Of these, 82 (11%) were deemed to require immediate airway management. Twenty-four of the 82 were excluded because of out-of-hospital traumatic arrest or out-of-hospital intubation, resulting in a study population of 58 patients. Of these 58 patients, 39 had initial rapid sequence intubation using succinylcholine with a 100% success rate. Five comatose patients had successful orotracheal intubation without paralysis, and 2 patients underwent successful emergency tracheostomy. The remaining 12 patients had initial fiberoptic intubation by otolaryngology clinicians, which was unsuccessful in 3 patients. All 3 of these patients were subsequently successfully orotracheally intubated using the rapid sequence intubation technique. Therefore, oral endotracheal intubation was the definitive method of airway management in 47 (81%) of the 58 patients and was successful in all cases. CONCLUSION: Rapid sequence intubation was the most commonly performed initial technique by emergency physicians and was safe and effective in all cases attempted. Furthermore, rapid sequence intubation methodology resulted in successful intubation of the fiberoptic intubation failures. Physicians with airway expertise should consider using rapid sequence intubation as an initial airway technique in managing patients with penetrating neck injury who require airway control.

Ultrasonography of flank pain in the emergency department: renal cell carcinoma as a diagnostic concern.

Acute flank pain is a common emergency department presenting symptom, and bedside ultrasound is being used increasingly in its evaluation. Emergency renal ultrasonography concentrates on the focused presence or absence of hydronephrosis as is often seen in patients with acute flank pain secondary to renal colic. We present three cases in which other abnormal sonographic signs not commonly taught prompted further investigation, revealing renal cell carcinoma. Baseline knowledge of sonographic characteristics of tumors will benefit the occasional emergency patient who has unsuspected renal carcinoma.

Cardioversion of paroxysmal atrial fibrillation in the emergency department.

STUDY OBJECTIVE: Patients presenting to the emergency department with acute atrial fibrillation are traditionally admitted to hospital. The objective of this study was to review the success and safety of ED cardioversion and discharge of patients with acute atrial fibrillation. METHODS: This health records survey included a cohort sample of consecutive patients presenting with acute atrial fibrillation to the ED of a university-affiliated tertiary hospital. Patients who were in unstable condition on presentation, who had a complicating cardiac diagnosis, or those with other medical or surgical conditions requiring admission were excluded from the study analysis. Patient visit information was entered into a database that included demographics and clinical presentation, investigations, ED therapy, complications, consultations, disposition, and follow up. Patient visits were then categorized into the following groups: no ED intervention, spontaneous resolution, heart rate control, attempted chemical cardioversion, or electrical cardioversion. The data were analyzed using descriptive methods. RESULTS: Of the 289 eligible patients seen during an 18-month period, 62% (180) underwent attempted chemical cardioversion with a 50% success rate and 28% (80) had attempted electrical cardioversion with a 89% success rate. Ninety-three percent of electrical cardioversions were performed by emergency physicians. There was an overall 6% (19) complication rate, 95% of which were regarded as minor. One patient had a complication caused by a rate control medication, which necessitated hospital admission. Ninety-seven percent (280) of the patients were discharged home directly from the ED. CONCLUSION: Cardioversion and immediate discharge of patients who present to the ED with acute atrial fibrillation appears to be both safe and effective. This management approach should be prospectively evaluated in multiple settings.