A Case Report of Hematogenous Osteomyelitis of the Manubrium Caused by Seeding from a Colovesicular Fistula.

Introduction: Osteomyelitis can occur at various osseous locations and commonly presents in the emergency department (ED). The incidence of osteomyelitis is 21.8 cases per 100,000 persons annually.1 Hematogenous osteomyelitis typically occurs in the vertebrae; however, it may seldomly occur in the manubrium. Hematogenous osteomyelitis can be seen in patients with complicated thoracic surgery, radiation, fracture, diabetes, immunosuppression, steroid therapy, and malnutrition.2 Because signs and symptoms of osteomyelitis may be nonspecific, clinicians must have high suspicion based on history and physical. Workup should include identifying the source, imaging, and surgical cultures. Case Report: A 60-year-old male with hypertension and diabetes presented with atraumatic right shoulder and chest pain. The patient presented twice to the ED for clavicle pain five days prior. Computed tomography (CT) of the chest detected osseous infection of the manubrium and upper sternum, right clavicle, and mediastinal phlegmon. A CT of the abdomen and pelvis revealed osteomyelitis and discitis of the 12th thoracic and first lumbar vertebral body with gas at the psoas muscle, as well as sigmoid diverticulitis with colovesicular fistula. The patient was started on broad spectrum antibiotics and 1,500 milliliters of lactated Ringer's in the ED. After evaluation by cardiothoracic surgery, the patient was taken to the operating room for neck exploration, incision/drainage, manubriectomy, and right sternoclavicular joint resection. Surgical, blood, urine, and respiratory cultures grew Klebsiella pneumoniae. After a 34-day hospital course, the patient was discharged on two weeks of oral levofloxacin and follow-up appointments with cardiothoracic surgery and infectious disease. The patient had good prognosis and recovery. Conclusion: Hematogenous osteomyelitis to the manubrium is rare and may present with only chest pain. It is important to consider other sources that seed in the manubrium and imaging to evaluate multisite infection. Treatment should include intravenous antibiotics and/or surgical intervention for debridement with washout or manubriectomy.

Evaluating the Effect of Nursing-Performed Point-of-Care Ultrasound on Septic Emergency Department Patients.

Introduction Nursing-performed point-of-care ultrasound (NP-POCUS) studies have been performed on applications such as ultrasound-guided peripheral intravenous line placement and assessing bladder volume. However, research on the use of NP-POCUS in the management of septic patients remains limited. The purpose of this quality improvement study was to investigate how NP-POCUS could impact fluid treatment decisions affecting septic patients in the emergency department (ED) using a focused IVC and lung ultrasound protocol. Methods Nurses received standardized training in POCUS and performed inferior vena cava (IVC) and lung ultrasound scans on septic patients in the ED at predetermined intervals (hours: zero, three, and six). Based on their findings, they were asked to make recommendations on fluid management. Emergency physicians (EPs), both residents and attendings, are providing recommendations for fluid management without the use of ultrasound, which is being compared to the nurse-driven POCUS assessment of fluid management. EPs reviewed the NP-POCUS assessments of patient fluid status to determine nursing accuracy. Results A total of 104 patients were scanned, with a mean age of 60.7 years. EPs agreed with nursing ultrasound assessments in 99.1% of cases. Nursing ultrasound images changed management or increased physician confidence in current treatment plans 83.7% and 96.6% of the time, respectively. Before reviewing saved nursing ultrasound images, EPs underestimated fluid tolerance in 37.5% of cases, overestimated fluid tolerance in 26% of cases, and correctly estimated fluid tolerance (within 500 ml) in 36.5% of cases. Throughout resuscitation, IVCs became less collapsible, the number of cases with B-lines was essentially unchanged, and less fluid was recommended. Conclusion  This study demonstrated that nurse-performed POCUS is feasible and may have a meaningful impact on how physicians manage septic patients in the emergency department.

Pain Medicine Education in Emergency Medicine Residency Programs.

Background Pain is a common complaint in the emergency department (ED), yet there is a lack of robust pain curricula in emergency medicine (EM) residency programs. In this study, we investigated pain education in EM residencies and various factors related to educational development. Methodology This was a prospective study collecting online survey results sent to Program Directors, Associate Program Directors, and Assistant Program Directors of EM residencies in the United States. Descriptive analyses with nonparametric tests were performed to investigate relationships between these factors, including educational hours, level of educational collaboration with pain medicine specialists, and multimodal therapy utilization. Results The overall individual response rate was 39.8% (252 out of 634 potential respondents), representing 164 out of 220 identified EM residencies with 110 (50%) Program Directors responding. Traditional classroom lectures were the most common modality for the delivery of pain medicine content. EM textbooks were the most common resource utilized for curriculum development. An average of 5.7 hours per year was devoted to pain education. Up to 46.8% of respondents reported poor or absent educational collaboration with pain medicine specialists. Greater collaboration levels were associated with greater hours devoted to pain education (p = 0.01), perceived resident interest in acute and chronic pain management education (p < 0.001), and resident utilization of regional anesthesia (p = <0.01). Faculty and resident interest in acute and chronic pain management education were similar to each other and high on the Likert scale, with higher scores correlating to greater hours devoted to pain education (p = 0.02 and 0.01, respectively). Faculty expertise in pain medicine was rated the most important factor in improving pain education in their programs. Conclusions Pain education is a necessity for residents to adequately treat pain in the ED, but remains challenging and undervalued. Faculty expertise was identified as a factor limiting pain education among EM residents. Collaboration with pain medicine specialists and recruitment of EM faculty with expertise in pain medicine are ways to improve pain education of EM residents.

Paramedic-performed Prehospital Point-of-care Ultrasound for Patients with Undifferentiated Dyspnea: A Pilot Study.

INTRODUCTION: Thoracic ultrasound is frequently used in the emergency department (ED) to determine the etiology of dyspnea, yet its use is not widespread in the prehospital setting. We sought to investigate the feasibility and diagnostic performance of paramedic acquisition and assessment of thoracic ultrasound images in the prehospital environment, specifically for the detection of B-lines in congestive heart failure (CHF). METHODS: This was a prospective observational study of a convenience sample of adult patients with a chief complaint of dyspnea. Paramedics participated in a didactic and hands-on session instructing them how to use a portable ultrasound device. Paramedics assessed patients for the presence of B-lines. Sensitivity and specificity for the presence of bilateral B-lines and any B-lines were calculated based on discharge diagnosis. Clips archived to the ultrasound units were reviewed and paramedic interpretations were compared to expert sonologist interpretations. RESULTS: A total of 63 paramedics completed both didactic and hands-on training, and 22 performed ultrasounds in the field. There were 65 patients with B-line findings recorded and a discharge diagnosis for analysis. The presence of bilateral B-lines for diagnosis of CHF yielded a sensitivity of 80.0% (95% confidence interval [CI], 51.4-94.7%) and specificity of 72.0% (95% CI, 57.3-83.3), while presence of any B-lines was 93.3% sensitive (95% CI, 66.0-99.7%), and 50% specific (95% CI, 35.7-64.2%) for CHF. Paramedics archived 117 ultrasound clips of which 63% were determined to be adequate for interpretation. Comparison of paramedic and expert sonologist interpretation of images showed good inter-rater agreement for detection of any B-lines (k = 0.60; 95% CI, 0.36-0.84). CONCLUSION: This observational pilot study suggests that prehospital lung ultrasound for B-lines may aid in identifying or excluding CHF as a cause of dyspnea. The presence of bilateral B-lines as determined by paramedics is reasonably sensitive and specific for the diagnosis of CHF and pulmonary edema, while the absence of B lines is likely to exclude significant decompensated heart failure. The study was limited by being a convenience sample and highlighted some of the difficulties related to prehospital research. Larger funded trials will be needed to provide more definitive data.

Guiding Cardiopulmonary Resuscitation with Focused Echocardiography: A Report of Five Cases.

Background: Focused transthoracic echocardiography has been used to determine etiologies of cardiac arrest and evaluate utility of continuing resuscitation after cardiac arrest. Few guidelines exist advising ultrasound timing within the advanced cardiac life support algorithm. Natural timing of echocardiography occurs during the pulse check, when views are unencumbered by stabilization equipment or vigorous movements. However, recent studies suggest that ultrasound performance during pulse checks prolongs the pause duration of cardiopulmonary resuscitation. Transesophageal echocardiography studies have demonstrated benefits in this regard, but there have been no transthoracic echocardiography studies assessing the physical performance of compressions during cardiopulmonary resuscitation. Objective: The purpose of this study was to describe cases where echocardiography performed at the beginning of the cardiac arrest algorithm offers actionable information to cardiopulmonary resuscitation itself without delaying provision of compressions. Conclusion: Providers using focused echocardiography to evaluate cardiac arrest patients should consider initiating scans at the start of compressions to identify the optimal location for compression delivery and to detect inadequate compressions. Subsequent visualization of full left ventricular compression may be seen after a location change, and combined with end tidal carbon dioxide values, gives indication for improved forward circulatory flow. Although it is not possible in all patients, doing so hastens provision of quality compressions that affect hemodynamic parameters without causing prolongations to the pulse check pause. Further research is needed to determine patient outcomes from both out-of-hospital and in-hospital cardiac arrest when cardiopulmonary resuscitation is visually guided by focused echocardiography.