Successful use of intra-arrest thrombolysis for electrical storm due to acute myocardial infarction.

Acute vascular thrombotic disease, including acute myocardial infarction and pulmonary embolism, accounts for 70% of sudden outpatient cardiac arrest. The role of intra-arrest thrombolytic administration aimed at reversing the underlying cause of cardiac arrest remains an area of debate with recent guidelines advising against routine use. We present a case of prolonged refractory ventricular fibrillation electrical storm in a patient who demonstrated intra-arrest electrocardiographic and sonographic markers confirming acute myocardial infarction. Return of spontaneous circulation was rapidly achieved after rescue intra-arrest bolus thrombolysis.Highlights of this case are discussed in the context of the current evidence for thrombolytic therapy in cardiac arrest with specific attention to the issue of patient selection.

The core content of clinical ultrasonography fellowship training.

The purpose of developing a core content for subspecialty training in clinical ultrasonography (US) is to standardize the education and qualifications required to provide oversight of US training, clinical use, and administration to improve patient care. This core content would be mastered by a fellow as a separate and unique postgraduate training, beyond that obtained during an emergency medicine (EM) residency or during medical school. The core content defines the training parameters, resources, and knowledge of clinical US necessary to direct clinical US divisions within medical specialties. Additionally, it is intended to inform fellowship directors and candidates for certification of the full range of content that might appear in future examinations. This article describes the development of the core content and presents the core content in its entirety.

Ultrasound-guided oblique approach for peripheral venous access in a phantom model.

BACKGROUND: Ultrasound (US) vascular guidance is traditionally performed in transverse (T) and longitudinal (L) axes, each with drawbacks. We hypothesized that the introduction of a novel oblique (O) approach would improve the success of US-guided peripheral venous access. We examined emergency physician (EP) performance using the O approach in a gel US phantom. METHODS: In a prospective, case control study, EPs were enrolled from four levels of physician experience including postgraduate years one to three (PGY1, PGY2, PGY3) and attending physicians. After a brief training session, each participant attempted vessel aspiration using a linear probe in T, L, and O axes on a gel US phantom. Time to aspiration and number of attempts to aspiration were recorded. The approach order was randomized, and descriptive statistics were used. RESULTS: Twenty-four physicians participated. The first-attempt success rate was lower for O, 45.83%, versus 70.83% for T (p = 0.03) and 83.33% for L (p = 0.01). The average time to aspiration was 12.5 s (O) compared with 9.47 s (T) and 9.74 s (L), respectively. There were no significant differences between all four groups in regard to total amount of time and number of aspiration attempts; however, a trend appeared revealing that PGY3 and attending physicians tended to aspirate in less time and by fewer attempts in all three orientations when compared with the PGY2 and PGY1 physicians. CONCLUSION: In this pilot study, US-guided simulated peripheral venous access using a phantom gel model in a mixed user group showed that the novel oblique approach was not initially more successful versus T and L techniques.

The effect of weight-based volume loading on the inferior vena cava in fasting subjects: a prospective randomized double-blinded trial.

OBJECTIVES: Inferior vena cava ultrasound (IVC-US) assessment has been proposed as a noninvasive method of assessing volume status. Current literature is divided on its ability to do so. The primary objective was to compare IVC-US changes in healthy fasting subjects randomized to either 10 or 30 mL/kg of intravenous (IV) fluid administration versus a control group that received only 2 mL/kg. METHODS: This was a prospective randomized double-blinded trial set in emergency department (ED) clinical care rooms. Volunteer subjects with no history of cardiac disease or hypertension fasted for 12 hours. Subjects were randomly assigned to receive IV 0.9% saline bolus of 2 (control group), 10, or 30 mL/kg over 30 minutes. IVC-US was performed before and 15 minutes after each fluid bolus. RESULTS: Forty-two fasting subjects were enrolled. Analysis of variance (ANOVA) comparison showed that IVC-US was unable to detect any significant difference between the control group and those given either 10 or 30 mL/kg fluid, whether using maximum or minimum IVC diameter or caval index (IVC-CI). The groups receiving 10 and 30 mL/kg each had a statistically significant change in IVC-CI; however, the 30 mL/kg group had no significant change in either of the mean IVC diameters. CONCLUSIONS: Overall, there were statistically significant differences in mean IVC-US measurements before and after fluid loading, but not between groups. Fasting asymptomatic subjects had a wide intersubject variation in both baseline IVC-US measurements and fluid-related changes. The degree of IVC-US change in association with graded acute volume loading was not predictably proportional between our subjects.

Comparison of serial qualitative and quantitative assessments of caval index and left ventricular systolic function during early fluid resuscitation of hypotensive emergency department patients.

OBJECTIVES: The objective was to determine whether serial bedside visual estimates of left ventricular systolic function (LVF) and respiratory variation of the inferior vena cava (IVC) diameter would agree with quantitative measurements of LVF and caval index in hypotensive emergency department (ED) patients during fluid challenges. The authors hypothesized that there would be moderate inter-rater agreement on the visual estimates. METHODS: This prospective observational study was performed at an urban, regional ED. Patients were eligible for enrollment if they were hypotensive in the ED as defined by a systolic blood pressure (sBP) of <100 mm Hg or mean arterial pressure of ≤65 mm Hg, exhibited signs or symptoms of shock, and the treating physician intended to administer intravenous (IV) fluid boluses for resuscitation. Sonologists performed a sequence of echocardiographic assessments at the beginning, during, and toward the end of fluid challenge. Both caval index and LVF were determined by the sonologist in qualitative then quantitative manners. Deidentified digital video clips of two-dimensional IVC and LVF assessments were later presented, in random order, to an ultrasound (US) fellowship-trained emergency physician using a standardized rating system for review. Statistical analysis included both descriptive statistics and correlation analysis. RESULTS: Twenty-four patients were enrolled and yielded 72 caval index and LVF videos that were scored at the bedside prior to any measurements and then reviewed later. Visual estimates of caval index compared to measured caval index yielded a correlation of 0.81 (p < 0.0001). Visual estimates of LVF compared to fractional shortening yielded a correlation of 0.84 (p < 0.0001). Inter-rater agreement of respiratory variation of IVC diameter and LVF scores had simple kappa values of 0.70 (95% confidence interval [CI] = 0.56 to 0.85) and 0.46 (95% CI = 0.29 to 0.63), respectively. Significant differences in mean values between time 0 and time 2 were found for caval index measurements, the visual scores of IVC diameter variation, and both maximum and minimum IVC diameters. CONCLUSIONS: This study showed that serial visual estimations of the respiratory variation of IVC diameter and LVF agreed with bedside measurements of caval index and LVF during early fluid challenges to symptomatic hypotensive ED patients. There was moderate inter-rater agreement in both visual estimates. In addition, acute volume loading was associated with detectable acute changes in IVC measurements.

Important historical efforts at emergency department categorization in the United States and implications for regionalization.

This article is drawn from a report created for the American College of Emergency Physicians (ACEP) Emergency Department (ED) Categorization Task Force and also reflects the proceedings of a breakout session, "Beyond ED Categorization-Matching Networks to Patient Needs," at the 2010 Academic Emergency Medicine consensus conference, "Beyond Regionalization: Integrated Networks of Emergency Care." The authors describe a brief history of the significant national and state efforts at categorization and suggest reasons why many of these efforts failed to persevere or gain wider implementation. The history of efforts to categorize hospital (and ED) emergency services demonstrates recognition of the potential benefits of categorization, but reflects repeated failures to implement full categorization systems or limited excursions into categorization through licensing of EDs or designation of receiving and referral facilities. An understanding of the history of hospital and ED categorization could better inform current efforts to develop categorization schemes and processes.

Categorization, designation, and regionalization of emergency care: definitions, a conceptual framework, and future challenges.

This article reflects the proceedings of a breakout session, "Beyond ED Categorization-Matching Networks to Patient Needs," at the 2010 Academic Emergency Medicine consensus conference, "Beyond Regionalization: Integrated Networks of Emergency Care." It is based on concepts and areas of priority identified and developed by the authors and participants at the conference. The paper first describes definitions fundamental to understanding the categorization, designation, and regionalization of emergency care and then considers a conceptual framework for this process. It also provides a justification for a categorization system being integrated into a regionalized emergency care system. Finally, it discusses potential challenges and barriers to the adoption of a categorization and designation system for emergency care and the opportunities for researchers to study the many issues associated with the implementation of such a system.

Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

The use of ultrasound has developed over the last 50 years into an indispensable first-line test for the cardiac evaluation of symptomatic patients. The technologic miniaturization and improvement in transducer technology, as well as the implementation of educational curriculum changes in residency training programs and specialty practice, have facilitated the integration of focused cardiac ultrasound into practice by specialties such as emergency medicine. In the emergency department, focused cardiac ultrasound has become a fundamental tool to expedite the diagnostic evaluation of the patient at the bedside and to initiate emergent treatment and triage decisions by the emergency physician.

Prospective comparative trial of endovaginal sonographic bimanual examination versus traditional digital bimanual examination in nonpregnant women with lower abdominal pain with regard to body mass index classification.

OBJECTIVE: We hypothesized that a sonographic bimanual examination (SBME) would improve confidence in the pelvic examination in adult nonpregnant women with lower abdominal conditions compared to a traditional digital bimanual examination (DBME). METHODS: In a prospective comparative study at an urban regional emergency department, an ultrasound-trained group of emergency clinicians performed both an SBME and a DBME on 30 women who required a DBME as part of their evaluation. Patients were divided into 3 groups based on their body mass index (BMI) weight class. Inclusion criteria included lower abdominal pain, age between 18 and 55 years, hemodynamic stability, and BMI of greater than 18.5. Exclusion criteria included pregnancy, hysterectomy, oophorectomy, and recent vaginal surgery. The patient's sequence of examinations was randomized and then performed by a different member of the study group. Examiners assessed their confidence (0%-100%) in 11 components of the pelvic examination. RESULTS: There were higher scores for the SBME compared to the DBME in the overall composite score, cervical position, uterine size, uterine position, uterine tenderness, ovarian size, ovarian tenderness, and presence of an adnexal mass (P < .05), whereas cervical motion tenderness, cervical os opening, and rectovaginal tenderness did not show significant differences. Across BMI classes, the SBME produced high composite and individual examination scores among all examination criteria. In contrast, the DBME revealed significant differences for uterine size, uterine alignment, uterine tenderness, ovarian size, and ovarian tenderness across BMI classes (P < .05). CONCLUSIONS: The SBME provides improved confidence in overall and key aspects of the pelvic examination across BMI classes compared to the DBME.

Emergency clinician-performed compression ultrasonography for deep venous thrombosis of the lower extremity.

STUDY OBJECTIVE: Emergency clinician-performed ultrasonography holds promise as a rapid and accurate method to diagnose and exclude deep venous thrombosis. However, the diagnostic accuracy of emergency clinician-performed ultrasonography performed by a heterogenous group of clinicians remains undefined. METHODS: Prospective, single-center study conducted at an urban, academic emergency department (ED). Clinician participants included ED faculty, supervised residents, and midlevel providers who completed a training course for above-calf, 3-point-compression, venous ultrasonography. Patient participants had suspected leg deep venous thrombosis and greater than or equal to 1 predefined sign or symptom. Before any imaging, clinicians classified patients as low (<15%), moderate (15% to 40%), or high (>40%) pretest probability of deep venous thrombosis, followed by emergency clinician-performed ultrasonography. A whole-leg reference venous ultrasonography was then performed and interpreted separately in the radiology department. Patients were followed for 30 days. The criterion standard for deep venous thrombosis(+), required thrombosis of any leg vein on a reference ultrasonograph and clinical plan to treat. RESULTS: We enrolled 183 patients, and 27 (15%) had deep venous thrombosis(+). The sensitivity and specificity emergency clinician-performed ultrasonography was 70% (95% confidence interval [CI] 60% to 80%) and 89% (95% CI 83% to 94%), respectively, with overall diagnostic accuracy of 85% (95% CI 79% to 90%). The posterior probability of deep venous thrombosis(+) among the 88 low-risk patients with a negative emergency clinician-performed ultrasonographic result was 1 of 88, or 1.1% (95% CI 0% to 6%), and the posterior probability of deep venous thrombosis(+) among 14 high-risk patients with a positive emergency clinician-performed ultrasonographic result was 11 of 14, or 79% (95% CI 49% to 95%). CONCLUSION: The overall diagnostic accuracy of single-visit emergency clinician-performed ultrasonography performed by a heterogeneous group of ED clinicians is intermediate but may be improved by pretest probability assessment.

ED endovaginal pelvic ultrasound in nonpregnant women with right lower quadrant pain.

INTRODUCTION: We hypothesized that emergency physician-performed endovaginal ultrasound (EVUS) would change diagnostic decision making in nonpregnant women with right lower quadrant (RLQ) pain. METHODS: A prospective cohort of female patients was enrolled at an urban emergency department (ED). Inclusion criteria were RLQ pain, hemodynamic stability, and a strong suspicion for appendicitis or right adnexal pathology. Treating physicians were queried regarding pre- and post-ED EVUS probability of disease, differential diagnoses, consultation, and management. Positive findings included large cysts or multitissue densities, tubal dilation, uterine enlargement/mass, and extensive peritoneal fluid. RESULTS: With a positive ED EVUS, mean physician probability increased for gynecologic (24%) and decreased for both surgical (14%) and medical (20%) disease. With a negative ED EVUS, mean physician probability increased for surgical disease (5.3%) and decreased for gynecologic disease (18.6%). CONCLUSION: Emergency department EVUS changes physician diagnostic decision making in nonpregnant women with undifferentiated RLQ pain.

Prospective use of ultrasound imaging to detect bony hand injuries in adults.

OBJECTIVE: We hypothesized that high-resolution linear ultrasound imaging performed by emergency sonologists would be accurate in the diagnosis of bony injuries of the hand. METHODS: This was a prospective observational study of adult patients with injuries of the hand at an urban emergency department with trained emergency sonologists. After informed consent, high-frequency linear ultrasound was used to evaluate the bony structures below the area of injury or tenderness of the hand. The presence of a fracture or dislocation was recorded. A standard radiograph was taken subsequently and read by a blinded radiologist. Standard descriptive statistics with confidence intervals were calculated. RESULTS: A total of 78 patients were enrolled in the study. The incidence of deformity was 28%; swelling, 90%; and erythema, 20%. Thirty patients had a total of 31 fractures: 21 metacarpal and 10 phalangeal. Ultrasound imaging identified 28 of 31 fractures found on standard radiographs, except for 1 patient's fractures, which were confirmed at surgery. One dislocation was found on ultrasound imaging and confirmed by radiographs. Ultrasound imaging showed the following accuracy for fracture: sensitivity, 90%; specificity, 98%; likelihood ratio (LR)(+), 42.5; and LR(-), 0.1. In comparison, individual physical examination findings of deformity, swelling, and erythema had a maximal LR(+) of 5.15 and minimum LR(-) of 0.51. One metacarpal fracture at the base of the first metacarpal, 1 spiral nondisplaced mid-third metacarpal fracture, and 1 distal tuft phalangeal fracture were missed by ultrasound imaging. There was 1 false-positive ultrasound finding. CONCLUSIONS: Ultrasound imaging performed by emergency sonologists showed excellent sensitivity and specificity in the diagnosis of hand fractures.

Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients.

STUDY OBJECTIVE: Our objective is to determine whether a bedside ultrasonographic measurement of optic nerve sheath diameter can accurately predict the computed tomographic (CT) findings of elevated intracranial pressure in adult head injury patients in the emergency department (ED). METHODS: We conducted a prospective, blinded observational study on adult ED patients with suspected intracranial injury with possible elevated intracranial pressure. Exclusion criteria were age younger than 18 years or obvious ocular trauma. Using a 7.5-MHz ultrasonographic probe on the closed eyelids, a single optic nerve sheath diameter was measured 3 mm behind the globe in each eye. A mean binocular optic nerve sheath diameter greater than 5.00 mm was considered abnormal. Cranial CT findings of shift, edema, or effacement suggestive of elevated intracranial pressure were used to evaluate optic nerve sheath diameter accuracy. RESULTS: Fifty-nine patients were enrolled in the study. Average age was 38 years, and median Glasgow Coma Scale score was 15 (interquartile 6 to 15). Eight patients with an optic nerve sheath diameter of 5.00 mm or more had CT findings that correlated with elevated intracranial pressure. The sensitivity for the ultrasonography in detecting elevated intracranial pressure was 100% (95% confidence interval [CI] 68% to 100%) and specificity was 63% (95% CI 50% to 76%). The sensitivity of ultrasonography for detection of any traumatic intracranial injury found by CT was 84% (95% CI 60% to 97%) and specificity was 73% (95% CI 59% to 86%). CONCLUSION: Bedside ED optic nerve sheath diameter ultrasonography has potential as a sensitive screening test for elevated intracranial pressure in adult head injury.

Accuracy of trauma ultrasound in major pelvic injury.

BACKGROUND: Trauma ultrasound (US) utilizing the focused assessment with sonography in trauma (FAST) is often performed to detect traumatic free peritoneal fluid (FPF). Yet its accuracy is unclear in certain trauma subgroups such as those with major pelvic fractures whose emergent diagnostic and therapeutic needs are unique. We hypothesized that in patients with major pelvic injury (MPI) trauma ultrasound would perform with lower accuracy than has previously been reported. METHODS: Retrospective analysis of adult trauma patients with pelvic fractures seen at an urban Level I emergency department and trauma center. Patients were identified from the institutional trauma registry and ultrasound database from 1999 to 2003. All patients aged >16 years with MPI (Tile classification A2, all type B and C pelvic fractures, and type C acetabular fractures determined by a blinded orthopedic traumatologist) and who had a trauma US performed during the initial emergency department evaluation were included. All ultrasounds were performed by emergency physicians or surgeons using the four-quadrant FAST evaluation. Results of US were compared with one of three reference standards: abdominal/pelvic computed tomography, diagnostic peritoneal tap, or exploratory laparotomy. Two-by-two tables were constructed for diagnostic indices. RESULTS: In all, 96 patients were eligible; 9 were excluded for indeterminate ultrasound results. Of the remaining 87 patients, the pelvic fracture types were distributed as follows: 9% type A2, 72% type B, 16% type C, and 3% type C acetabular fractures. Overall US sensitivity for detection of FPF was 80.8%, specificity was 86.9%, positive predictive value was 72.4%, and negative predictive value was 91.4%. Categorization of sensitivity according to pelvic ring fracture type is as follows: type A2 fractures: sensitivity and specificity, 75.0%; type B fractures: sensitivity, 73.3%, specificity, 85.1%; and type C fractures (pelvis and acetabulum): sensitivity and specificity, 100%. Of the true-positive US results, blood was the FPF in 16 of 21 (76%) and urine from intraperitoneal bladder rupture in 4 in 21 (19%) patients. CONCLUSION: US in the initial evaluation of traumatic peritoneal fluid in major pelvic injury patients has lower sensitivity and specificity than previously reported for blunt trauma patients. Additionally, uroperitoneum comprises a substantial proportion of traumatic free peritoneal fluid in patients with MPI.