Point-of-care ultrasound thoracic "Quick Look" identifies potentially dangerous chest tube insertion sites.

PURPOSE: Emergency and trauma physicians typically rely on anatomic landmarks to determine the proper intercostal space for emergent tube thoracostomy. However, physicians using this technique select a potentially dangerous insertion site too inferior in nearly one-third of cases, which have the potential to result in subdiaphragmatic puncture. We investigated a point-of-care ultrasound (POCUS) thoracic "Quick Look" procedure as a technique to allow visualization of underlying structures to avoid tube misplacement. METHODS: We performed an observational study of adult emergency department patients and their treating physicians. The patient's emergency physician was asked to rapidly identify and mark a hypothetical tube thoracostomy insertion site on the patient's chest wall. An ultrasound fellow then performed a POCUS thoracic "Quick Look" exam with a phased-array probe placed directly over the marked site. Over one regular respiratory cycle, the identification of standard lung pattern was considered a negative scan whereas visualization of the diaphragm with underlying liver or spleen was considered a positive scan. Time for completion of the "Quick Look" scan was measured and inter-rater reliability was determined through image review by a single, blinded ultrasound director. RESULTS: Seventy-six thoracic "Quick Look" scans were performed on patient subjects, of which 17% (13/76, 95%CI 8-26%) were positive. The average time for performing the "Quick Look" exam was 43 s (95%CI 30-57). Inter-rater reliability of the thoracic "Quick Look" was excellent (κ = 0.95). CONCLUSION: Thoracic "Quick Look" exams performed at mock chest tube insertion sites demonstrated potentially dangerous insertions in 17% of the cases. POCUS thoracic "Quick Look" may be a rapid and reliable technique that improves safety when placing an emergent chest tube.

A Multicenter, Prospective Study Comparing Subxiphoid and Parasternal Views During Brief Echocardiography: Effect on Image Quality, Acquisition Time, and Visualized Anatomy.

BACKGROUND: Recent literature has suggested echocardiography (echo) may prolong pauses in chest compressions during cardiac arrest. OBJECTVES: We sought to determine the impact of the sonographic approach (subxiphoid [SX] vs. parasternal long [PSL]) on time to image completion, image quality, and visualization of cardiac anatomy during echo, as performed during Advanced Cardiac Life Support. METHODS: This was a multicenter, randomized controlled trial conducted at 29 emergency departments (EDs) assessing the time to image acquisition and image quality between SX and PSL views for echo. Patients were enrolled in the ED and imaged in a simulated cardiac arrest scenario. Clinicians experienced in echo performed both SX and PSL views, first view in random order. Image quality and time to image acquisition were recorded. Echos were evaluated for identification of cardiac landmarks. Data are presented as percentages or medians with interquartile ranges (IQRs). RESULTS: We obtained 6247 echo images, comprising 3124 SX views and 3123 PSL. Overall time to image acquisition was 9.0 s (IQR 6.7-14.1 s). Image acquisition was shorter using PSL (8.8 s, IQR 6.5-13.5 s) compared with SX (9.3 s, IQR 6.7-15.0 s). The image quality was better with the PSL view (3.86 vs. 3.54; p < 0.0001), twice as many SX images scoring in the worst quality category compared with PSL (8.6% vs. 3.7%). Imaging of the pericardium, cardiac chambers, and other anatomic landmarks was superior with PSL imaging. CONCLUSIONS: Echo was performed in < 10 s in > 50% of patients using either imaging technique. Imaging using PSL demonstrated improved image quality and improved identification of cardiac landmarks.

Ultrasound Visualization of Atypical Abscess Ultimately Containing Bot Fly Larva.

BACKGROUND: Because of the rise in community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), presentations to the emergency department for the evaluation of cutaneous abscesses have risen dramatically over the past 2 decades. Soft tissue point of care ultrasound (POCUS) differentiates abscess from cellulitis, determines the size and shape, and characterizes the contents of the abscess. It has been shown to improve medical decision-making and therefore the emergency management of cutaneous abscesses over physical examination alone. CASE REPORT: We report a case of an unusual nonhealing abscess in an 18-year-old woman with a recent history of foreign travel where soft tissue POCUS identified motion within the abscess pocket. This changed the management of the case, leading to the diagnosis of bot fly myiasis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians should entertain a broader differential for an apparent abscess and consider liberal use of soft tissue POCUS in these cases.

Identification of fall risk factors in older adult emergency department patients.

OBJECTIVES: Falls represent an increasingly frequent source of injury among older adults. Identification of fall risk factors in geriatric patients may permit the effective utilization of scarce preventative resources. The objective of this study was to identify independent risk factors associated with an increased 6-month fall risk in community-dwelling older adults discharged from the emergency department (ED). METHODS: This was a prospective observational study with a convenience sampling of noninstitutionalized elders presenting to an urban teaching hospital ED who did not require hospital admission. Interviews were conducted to determine the presence of fall risk factors previously described in non-ED populations. Subjects were followed monthly for 6 months through postcard or telephone contact to identify subsequent falls. Univariate and Cox regression analysis were used to determine the association of risk factors with 6-month fall incidence. RESULTS: A total of 263 patients completed the survey, and 161 (61%) completed the entire 6 months of follow-up. Among the 263 enrolled, 39% reported a fall in the preceding year, including 15% with more than one fall and 22% with injurious falls. Among those completing the 6 months of follow-up, 14% reported at least one fall. Cox regression analysis identified four factors associated with falls during the 6-month follow-up: nonhealing foot sores (hazard ratio [HR] = 3.71, 95% confidence interval [CI] = 1.73 to 7.95), a prior fall history (HR = 2.62, 95% CI = 1.32 to 5.18), inability to cut one's own toenails (HR = 2.04, 95% CI = 1.04 to 4.01), and self-reported depression (HR = 1.72, 95% CI = 0.83 to 3.55). CONCLUSIONS: Falls, recurrent falls, and injurious falls in community-dwelling elder ED patients being evaluated for non-fall-related complaints occur at least as frequently as in previously described outpatient cohorts. Nonhealing foot sores, self-reported depression, not clipping one's own toenails, and previous falls are all associated with falls after ED discharge.

Descriptive analysis of 258 emergency department visits by spina bifida patients.

To provide a descriptive analysis of emergency department (ED) patients with spina bifida, a retrospective chart review was conducted of ED patients with spina bifida. Data describing demographics, chief complaints, diagnostics, diagnoses, and disposition were collected. There were 125 patients with 258 ED visits. The most common presenting complaints included fever (n = 55), vomiting (36), headache (32), abdominal pain (23), and genitourinary symptoms (20). The most common diagnoses included urinary tract infection (n = 55), cellulitis (26), seizure (21), headache (17), dehydration (12), and shunt failure (11). Atypical presentations of conditions commonly associated with spina bifida occurred frequently. Forty-three percent of patients were admitted. In conclusion, spina bifida patients often present with serious illness requiring admission and with complications of their underlying condition. Therefore, atypical presentations of commonly associated conditions must be considered.

Bacteremic elder emergency department patients: procalcitonin and white count.

OBJECTIVES: To assess serum procalcitonin (PCT) and white blood cell (WBC) count in detecting bacteremia in elder emergency department (ED) patients. METHODS: A prospective, observational study of ED patients aged > or =65 years in whom blood cultures were drawn was conducted at an urban, tertiary care, academic ED. Serum for PCT and WBC count was obtained at the time of ED visit. Receiver-operating characteristic (ROC) curves, proportions, and likelihood ratios were calculated. RESULTS: One hundred eight patients met entry criteria, 14 with bacteremia. In comparing bacteremic patients versus all others, PCT > 0.2 ng/mL was 93% sensitive (95% confidence interval [CI] = 79% to 100%) and 38% specific (95% CI = 28% to 48%) with a negative likelihood ratio (LR(-)) of 0.18. Abnormal WBC count was 64% sensitive (95% CI = 39% to 89%) and 54% specific (95% CI = 44% to 64%) with an LR(-) of 0.78. The presence of either abnormal WBC count or left shift was 93% sensitive (95% CI = 74% to 100%) but 11% specific (95% CI = 4% to 11%) with an LR(-) of 0.64. When considering only bacteremic patients versus noninfected patients, PCT at a cutoff of 0.2 ng/mL had an LR(-) of 0.12. Area under a ROC curve was significantly greater for PCT (0.7; 95% CI = 0.6 to 0.9) than for abnormal WBC count (0.5; 95% CI = 0.3 to 0.7; p < 0.05). CONCLUSIONS: In elder ED patients, a PCT level of 0.2 ng/mL is sensitive for bacteremia and, based on its negative likelihood ratio, is moderately helpful in ruling out the diagnosis. WBC count with or without left shift performed poorly in the diagnosis of bacteremia.