Surgical and Radiological Management of Complicated Uterine Leiomyoma Aided by 3D Models in a Patient with Fibrodysplasia Ossificans Progressiva.

BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder of the connective tissue. Over time, patients with FOP experience decreased range of motion in the joints and the formation of a second skeleton, limiting mobility. Patients with FOP are advised to avoid any unwarranted surgery owing to the risk of a heterotopic ossification flare-up. For patients who do require a surgical procedure, a multidisciplinary team is recommended for comprehensive management of the patient's needs. CASE REPORT A 27-year-old woman with FOP underwent a hysterectomy for removal of a suspected necrotic uterine fibroid. To aid in presurgical planning and management, patient-specific 3-dimensional (3D) models of the patient's tracheobronchial tree, thorax, and lumbosacral spine were printed from the patient's preoperative computed tomography (CT) imaging. The patient required awake nasal fiberoptic intubation for general anesthesia and transversus abdominus plane block for regional anesthesia. Other anesthesia modalities, including spinal epidural, were ruled out after visualizing the patient's anatomy using the 3D model. Postoperatively, the patient was started on a multi-modal analgesic regimen and a course of steroids, and early ambulation was encouraged. CONCLUSIONS Patients with FOP are high-risk surgical patients requiring the care of multiple specialties. Advanced visualization methods, including 3D printing, can be used to better understand their anatomy and locations of heterotopic bone ossification that can affect patient positioning. Our patient successfully underwent supracervical hysterectomy and bilateral salpingectomy with no signs of fever or sepsis at follow-up.

Posthumously Assessing a Homeless Population: Services Use and Characteristics.

OBJECTIVE: Data on services use, characteristics, and geographic distribution of homeless individuals who died in Philadelphia from 2009 to 2011 provided perspective on assessments of the homeless population that rely on conventional counts and surveys. METHODS: Data from the City of Philadelphia Medical Examiner's Office were used to parse homeless decedents into three groups on the basis of use of homelessness services (known users, occasional users, and nonusers), and differences among the groups were assessed by using descriptive and multivariate methods. RESULTS: Of 141 adult decedents, 49% made substantial use of the homelessness services system (known users), 27% made occasional use of these services (occasional users), and 24% had no record of use of homelessness services (nonusers). Compared with known users, nonusers and occasional users were less likely to have had a severe mental illness diagnosis or to have received either disability benefits or Medicaid coverage and were more likely to be white. Nonusers and occasional users were also more likely than known users to have died in outlying parts of the city. CONCLUSIONS: More conventional homeless surveys and enumerations miss a substantial portion of the homeless population. Including these "hidden homeless" persons would alter perceptions about the composition of Philadelphia's homeless population, lowering estimates of the incidence of psychiatric disability and increasing estimates of racial diversity.

Ultrasound measurement of inferior vena cava collapse predicts propofol-induced hypotension.

STUDY OBJECTIVES: Hypotension is a common side effect of propofol, but there are no reliable methods to determine which patients are at risk for significant propofol-induced hypotension (PIH). Ultrasound has been used to estimate volume status by visualization of inferior vena cava (IVC) collapse. This study explores whether IVC assessment by ultrasound can assist in predicting which patients may experience significant hypotension. METHODS: This was a prospective observational study conducted in the operating suite of an urban community hospital. A convenience sample of consenting adults planned to receive propofol for induction of anesthesia during scheduled surgical procedures were enrolled. Bedside ultrasound was used to measure maximum (IVCmax) and minimum (IVCmin) IVC diameters. IVC-CI was calculated as [(IVCmax-IVCmin)/IVCmax × 100%]. The primary outcome was significant hypotension defined as systolic blood pressure (BP) below 90mmHg and/or administration of a vasopressor to increase BP during surgery. RESULTS: The study sample comprised 40 patients who met inclusion criteria. Mean age was 55years, (95%CI, 49-60) with 53% female. 55% of patients had significant hypotension after propofol administration. 76% of patients with IVC-CI≥50% had significant hypotension compared to 39% with IVC-CI<50%, P=.02. IVC-CI≥50% had a specificity of 77.27% (95%CI, 64.29%-90.26%) and sensitivity of 66.67% (95%CI, 52.06%-81.28%) in predicting PIH. The odds ratio for PIH in patients with IVC-CI≥50% was 6.9 (95%CI, 1.7-27.5). CONCLUSION: Patients with IVC-CI≥50% were more likely to develop significant hypotension from propofol. IVC ultrasound may be a useful tool to predict which patients are at increased risk for PIH.

Association between multiple IV attempts and perceived pain levels in the emergency department.

PURPOSE: Intravenous (IV) access is the most commonly performed procedure in the emergency department (ED). Patients with difficult venous access require multiple needlesticks (MNS) for successful IV cannulation and may experience increased pain with many attempts. OBJECTIVE: To determine the association between number of IV attempts and overall pain experienced by the patient from IV placement. METHODS: Cross-sectional observational study on consecutive patients undergoing IV placement with a 20-gauge IV in the upper extremity in an urban academic hospital. Exclusion criteria included refusal to participate or fully complete all survey questions. The total number of IV attempts and patient pain scores marked on a standardized visual analog scale was recorded. Mean pain scores of two groups, single needlestick (SNS) and MNS, were compared using Student's t-test. RESULTS: A total of 760 patients were approached, of whom 31 were excluded, leaving 729 patients in the analysis; 556 with SNS (76%) and 173 with MNS (24%). The mean pain score (95% CI) was 51 mm (46-55 mm) for the MNS group and 25 mm (23-28 mm) for the SNS group, p<0.001. Compared to patients who underwent one IV attempt, patients with two and three attempts had an average 19 mm and 33 mm increase in pain scores, respectively, with the highest average pain associated with five attempts. A total of 58% of MNS patients rated IV placement as the most painful experience while in the ED. CONCLUSIONS: Patients experience increased pain in association with multiple IV attempts.

Risk factors associated with difficult venous access in adult ED patients.

OBJECTIVE: The objective was to determine risk factors associated with difficult venous access (DVA) in the emergency department (ED). METHODS: This was a prospective, observational study conducted in the ED of an urban tertiary care hospital. Adult patients undergoing intravenous (IV) placement were consecutively enrolled during periods of block enrollment. The primary outcome was DVA, defined as 3 or more IV attempts or use of a method of rescue vascular access to establish IV access. Univariate and multivariate analyses for factors predicting DVA were performed using logistic regression. RESULTS: A total of 743 patients were enrolled, of which 88 (11.8%) met the criteria for DVA. In the adjusted analysis, only 3 medical conditions were significantly associated with DVA: diabetes (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.1-2.8), sickle cell disease (OR 3.8, 95% CI 1.5-9.5), and history of IV drug abuse (OR 2.5, 95% CI 1.1-5.7). Notably, age, body mass index, and dialysis were not. Of patients who reported a history of requiring multiple IV attempts in the past for IV access, 14% met criteria for DVA on this visit (OR 7.7 95% CI 3-18). Of the patients who reported a history of IV insertion into the external jugular, ultrasound-guided IV placement, or a central venous catheter for IV access, 26% had DVA on this visit (OR 16.7, 95% CI 6.8-41). CONCLUSIONS: Nearly 1 of every 9 to 10 adults in an urban ED had DVA. Diabetes, IV drug abuse, and sickle cell disease were found to be significantly associated with DVA.

The urban homeless: super-users of the emergency department.

In the United States, patient usage of costly emergency departments (EDs) has been portrayed as a major factor contributing to health care expenditures. The homeless are associated with ED frequent users, a population often blamed for inappropriate ED use. This study examined the characteristics and costs associated with homeless ED frequent users. A retrospective cross-sectional review of hospital records for ED visits in 2006 at an urban academic medical center was performed. Frequent users were defined as having greater than 4 ED visits in one year. Homeless status was determined by self-report and review by an interdisciplinary team. A total of 5440 (8.9%) ED visits were made by 542 frequent users, 74 (13.7%) of whom were homeless and made 845 ED visits. Homeless frequent users had a median age of 47 years (39-56 interquartile range), were predominantly male (85.1%), and insured by Medicaid (59.5%). Most (44.2%) visits by homeless frequent users occurred between 1500-2259 hours and had an Emergency Severity Index of Level 3 (55.5%). Sixty-four percent of visits resulted in homeless patients being discharged back to the street; only 4.0% had a specific discharge plan addressing homelessness. Total charges and payments for all homeless frequent users were $4,812,615 and $802,600, respectively. The single top frequent user accrued charges of $482,928. ED frequent users are disproportionately homeless and their costs are significant. ED discharge planning should address the additional risks faced by homeless individuals. ED-based interventions that specifically target the most expensive homeless frequent users may prove to be cost-effective.

Clinician-performed Beside Ultrasound for the Diagnosis of Traumatic Pneumothorax.

INTRODUCTION: Prior studies have reported conflicting results regarding the utility of ultrasound in the diagnosis of traumatic pneumothorax (PTX) because they have used sonologists with extensive experience. This study evaluates the characteristics of ultrasound for PTX for a large cohort of trauma and emergency physicians. METHODS: This was a prospective, observational study on a convenience sample of patients presenting to a trauma center who had a thoracic ultrasound (TUS) evaluation for PTX performed after the Focused Assessment with Sonography for Trauma exam. Sonologists recorded their findings prior to any other diagnostic studies. The results of TUS were compared to one or more of the following: chest computed tomography, escape of air on chest tube insertion, or supine chest radiography followed by clinical observation. RESULTS: There were 549 patients enrolled. The median injury severity score of the patients was 5 (inter-quartile range [IQR] 1-14); 36 different sonologists performed TUS. Forty-seven of the 549 patients had traumatic PTX, for an incidence of 9%. TUS correctly identified 27/47 patients with PTX for a sensitivity of 57% (confidence interval [CI] 42-72%). There were 3 false positive cases of TUS for a specificity of 99% (CI 98%-100%). A "wet" chest radiograph reading done in the trauma bay showed a sensitivity of 40% (CI 23-59) and a specificity of 100% (99-100). CONCLUSION: In a large heterogenous group of clinicians who typically care for trauma patients, the sonographic evaluation for pneumothorax was as accurate as supine chest radiography. Thoracic ultrasound may be helpful in the initial evaluation of patients with truncal trauma.

Resuscitation of the pregnant patient: What is the effect of patient positioning on inferior vena cava diameter?

STUDY OBJECTIVE: Patients in the third trimester of pregnancy presenting to the emergency department (ED) with hypotension are routinely placed in the left lateral tilt (LLT) position to relieve inferior vena cava (IVC) compression from the gravid uterus thereby increasing venous return. However, the relationship between patient position and proximal intrahepatic IVC filling has never assessed directly. This study set out to determine the effect of LLT position on intrahepatic IVC diameter in third trimester patients under real-time visualization with ultrasound. METHODS: This prospective observational study on the labor and delivery floor of a large urban academic teaching hospital enrolled patients between 30 and 42 weeks estimated gestational age from August 2011 to March 2012. Patients were placed in three different positions: supine, LLT, and right lateral tilt (RLT). After the patient was in each position for at least 3 min, IVC ultrasound using the intercostal window was performed by one of three study sonologists. Maternal and fetal hemodynamics were also monitored and recorded in each position. RESULTS: A total of 26 patients were enrolled with one excluded from data analysis due to inability to obtain IVC measurements. The median IVC maximum diameter was 1.26 cm (95% confidence interval [CI] 1.13-1.55) in LLT compared to 1.13 cm (95% CI 0.89-1.41) in supine, p=0.01. When comparing each individual patient's LLT to supine measurement, LLT lead to an increase in maximum IVC diameter in 76% (19/25) of patients with the average LLT measurement 29% (95% confidence interval 10-48%) larger. Six patients had the largest maximum IVC measurement in the supine position. No patients experienced any hemodynamic instability or distress during the study. CONCLUSION: IVC ultrasound is feasible in late pregnancy and demonstrates an increase in diameter with LLT positioning. However, a quarter of patients had a decrease in IVC diameter with tilting and, instead, had the largest IVC diameter in the supine position suggesting that uterine compression of the IVC may not occur universally. IVC assessment at the bedside may be a useful adjunct in determining optimal positioning for resuscitation of third trimester patients.

Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters.

STUDY OBJECTIVES: Obtaining intravenous (IV) access in the emergency department (ED) can be especially challenging, and physicians often resort to placement of central venous catheters (CVCs). Use of ultrasound-guided peripheral IV catheters (USGPIVs) can prevent many "unnecessary" CVCs, but the true impact of USGPIVs has never been quantified. This study set out to determine the reduction in CVCs by USGPIV placement. METHODS: This was a prospective, observational study conducted in 2 urban EDs. Patients who were to undergo placement of a CVC due to inability to establish IV access by other methods were enrolled. Ultrasound-trained physicians then attempted USGPIV placement. Patients were followed up for up to 7 days to assess for CVC placement and related complications. RESULTS: One hundred patients were enrolled and underwent USGPIV placement. Ultrasound-guided peripheral IV catheters were initially successfully placed in all patients but failed in 12 patients (12.0%; 95 confidence interval [CI], 7.0%-19.8%) before ED disposition, resulting in 4 central lines, 7 repeated USGPIVs, and 1 patient requiring no further intervention. Through the inpatient follow-up period, another 11 patients underwent CVC placement, resulting in a total of 15 CVCs (15.0%; 95 CI, 9.3%-23.3%) placed. Of the 15 patients who did receive a CVC, 1 patient developed a catheter-related infection, resulting in a 6.7% (95 CI, 1.2%-29.8%) complication rate. CONCLUSION: Ultrasound prevented the need for CVC placement in 85% of patients with difficult IV access. This suggests that USGPIVs have the potential to reduce morbidity in this patient population.

The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity.

INTRODUCTION: Ultrasound-guided peripheral intravenous catheters (USGPIVs) have been observed to have poor durability. The current study sets out to determine whether vessel characteristics (depth, diameter, and location) predict USGPIV longevity. METHODS: A secondary analysis was performed on a prospectively gathered database of patients who underwent USGPIV placement in an urban, tertiary care emergency department. All patients in the database had a 20-gauge, 48-mm-long catheter placed under ultrasound guidance. The time and reason for USGPIV removal were extracted by retrospective chart review. A Kaplan-Meier survival analysis was performed. RESULTS: After 48 hours from USGPIV placement, 32% (48/151) had failed prematurely, 24% (36/151) had been removed for routine reasons, and 44% (67/151) remained in working condition yielding a survival probability of 0.63 (95% confidence interval [CI], 0.53-0.70). Survival probability was perfect (1.00) when placed in shallow vessels (<0.4 cm), moderate (0.62; 95% CI, 0.51-0.71) for intermediate vessels (0.40-1.19 cm), and poor (0.29; 95% CI, 0.11-0.51) for deep vessels (≥1.2 cm); P < .0001. Intravenous survival probability was higher when placed in the antecubital fossa or forearm locations (0.83; 95% CI, 0.69-0.91) and lower in the brachial region (0.50; 95% CI, 0.38-0.61); P = .0002. The impact of vessel depth and location was significant after 3 hours and 18 hours, respectively. Vessel diameter did not affect USGPIV longevity. CONCLUSION: Cannulation of deep and proximal vessels is associated with poor USGPIV survival. Careful selection of target vessels may help improve success of USGPIV placement and durability.

Factors associated with use of urban emergency departments by the U.S. homeless population.

OBJECTIVE: Homeless individuals frequently use emergency departments (EDs), but previous studies have investigated local rather than national ED utilization rates. This study sought to characterize homeless people who visited urban EDs across the U.S. METHODS: We analyzed the ED subset of the National Hospital Ambulatory Medical Care Survey (NHAMCS-ED), a nationally representative probability survey of ED visits, using methods appropriate for complex survey samples to compare demographic and clinical characteristics of visits by homeless vs. non-homeless people for survey years 2005 and 2006. RESULTS: Homeless individuals from all age groups made 550,000 ED visits annually (95% confidence interval [CI] 419,000, 682,000), or 72 visits per 100 homeless people in the U.S. per year. Homeless people were older than others who used EDs (mean age of homeless people = 44 years compared with 36 years for others). ED visits by homeless people were independently associated with male gender, Medicaid coverage and lack of insurance, and Western geographic region. Additionally, homeless ED visitors were more likely to have arrived by ambulance, to be seen by a resident or intern, and to be diagnosed with either a psychiatric or substance abuse problem. Compared with others, ED visits by homeless people were four times more likely to occur within three days of a prior ED evaluation, and more than twice as likely to occur within a week of hospitalization. CONCLUSIONS: Homeless people who seek care in urban EDs come by ambulance, lack medical insurance, and have psychiatric and substance abuse diagnoses more often than non-homeless people. The high incidence of repeat ED visits and frequent hospital use identifies a pressing need for policy remedies.

Myopericarditis diagnosed by a 64-slice coronary CT angiography "triple rule out" protocol.

We report a case of myopericarditis in a 30-year-old male complaining of shortness of breath. In an emergency department (ED) setting, the symptoms of myopericarditis may overlap with many disease entities and can be a challenging diagnosis to make. However, with the use of a 64-section coronary CT angiography in a "triple rule out" (TRO) protocol, we were able to detect a large pericardial effusion surrounding the heart and moderate global hypokinesis in the setting of normal-sized heart chambers and normal coronary arteries. We were further able to exclude pulmonary embolism and thoracic dissection. This is the first reported case of diagnosing myopericarditis using a TRO protocol. It demonstrates the usefulness of TRO in making an emergent diagnosis of myopericarditis while excluding other life-threatening diseases that can lead to earlier appropriate ED disposition and care.

Emergency ultrasound usage among recent emergency medicine residency graduates of a convenience sample of 14 residencies.

BACKGROUND: Emergency Medicine (EM) residency graduates are trained to perform Emergency Medicine bedside ultrasound (EMBU). However, the degree to which they use this skill in their practice after graduation is unknown. OBJECTIVES: We sought to test the amount and type of usage of EMBU among recent residency graduates, and how usage and barriers vary among various types of EM practice settings. METHODS: Graduates from 14 EM residency programs in 2003-2005 were surveyed on their current practice setting and use of EMBU. RESULTS: There were 252 (73%) graduates who completed the survey. Of the 73% of respondents reporting access to EMBU, 98% had used it within the past 3 months. Access to EMBU was higher in academic (97%) vs. community teaching (79%) vs. community non-teaching settings (62%) (p < 0.001), and in Emergency Departments (EDs) where yearly census exceeded 60,000 visits (87% vs. 65%, p < 0.001). Physicians in academic settings reported "high use" of EMBU more frequently than those in community settings for most modalities. FAST (focused assessment by sonography in trauma) was the most common high-use application and the most useful in practice. The greatest impediment to EMBU use was "not enough time" (61%). CONCLUSIONS: Ultrasound usage among recent EM residency graduates is significantly higher in teaching than in community settings and in high-volume EDs. Its use is more widespread than in previous reports in all types of practice. There is a wide range of utilization of ultrasound in the various applications in emergency practice, with the evaluation of trauma being the most common.

Intensivist bedside ultrasound (INBU) for volume assessment in the intensive care unit: a pilot study.

BACKGROUND: Estimation of volume status in the high-acuity surgical population can be challenging. The use of intensivist bedside ultrasound (INBU) to rapidly assess volume status in the surgical intensive care unit (SICU) was hypothesized to be feasible and as accurate as invasive measures. METHODS: Clinician sonographers (CSs) were trained to perform basic cardiac ultrasound and sonographic assessment of the inferior vena cava (IVC). A convenience sample of general surgery and trauma patients was enrolled in the SICU. The CS interpreted IVC and cardiac parameters and then categorized the subject as hypovolemic or not hypovolemic. Intensivists caring for the patients were blinded to the INBU findings and made a real-time expert clinical judgment (ECJ) of the patient's volume status (hypovolemic vs. not hypovolemic) using all available traditional data. RESULTS: A total of nine CSs performed 70 studies; three of the CSs performed the majority of the studies (86%). Adequate ultrasound (US) views for cardiac and IVC assessment were obtained in 96% and 89% of studies, respectively. The ECJ was considered to be the standard to which comparisons were made. The concordance rate between ECJ and central venous pressure was 62%. ECJ concordance with sonographic measures were similar (cardiac US = 75%, IVC US = 67%, and IVC collapse index = 65%). All pairwise comparisons against the ECJ/CVP agreement were not significantly different. CONCLUSIONS: INBU is feasible in the SICU and is equivalent to central venous pressure in assessing volume status. Noninvasive methods to assess volume status may decrease the need for invasive procedures.

Directed bedside transthoracic echocardiography: preferred cardiac window for left ventricular ejection fraction estimation in critically ill patients.

BACKGROUND: Bedside transthoracic echocardiography (TTE) performed by emergency physicians (EPs) is valuable in the rapid assessment and treatment of critically ill patients. We sought to determine the preferred cardiac window for left ventricular ejection fraction (LVEF) estimation by EP sonographers in a critically ill patient population. METHODS: Prospective investigator-blinded study of focused bedside TTE in a convenience sample of surgical intensive care patients. Investigators were faculty, fellows, or residents from an academic emergency medicine department. Five standard cardiac views were performed: parasternal long axis (PSLA), parasternal short axis (PSSA), subxiphoid 4-chamber, subxiphoid short axis, and apical 4-chamber (AFC). LVEF was determined using at least 1 cardiac view. Investigators rated their preference for each cardiac view on a 5-point Likert scale. RESULTS: A total of 70 studies were performed on 70 patients during a 6-month period. Users rated the PSLA as the most useful view for estimation of LVEF (mean 4.23; 95% confidence interval, 3.95-4.51). Pairwise comparisons of cardiac ultrasound views revealed PSLA was preferred over all other views (P < .05) except PSSA (P = .23). Complete 5 view examinations were not achieved in all patients (PSLA in 98%, PSSA in 96%, apical 4-chamber in 74%, subxiphoid 4-chamber in 35%, and subxiphoid short axis in 18%). Interobserver correlation of LVEF estimation was good (r = 0.86, r2 = 0.74, P < .0001). CONCLUSION: Parasternal long axis and PSSA are the preferred echocardiographic windows for EP estimation of LVEF using focused bedside TTE in critical care patients. This may be an important consideration in patients who often have physical barriers to optimal echocardiographic evaluation, are relatively immobile, and have unstable conditions requiring rapid assessment and intervention.

The utility of handheld ultrasound in an austere medical setting in Guatemala after a natural disaster.

OBJECTIVE: To identify equipment needs, utility, clinical applications, and acuity of diagnoses made by hand-carried ultrasound (HCU) after a natural disaster. METHODS: An HCU with four probes (curved array, linear array, phased array, and endocavitary) was taken to the site of a natural disaster in Guatemala as part of the relief effort after mudslides killed approximately 1,000 people. Ultrasound (US) scans were classified by transducer type, anatomic region, presenting complaint, and therapeutic urgency of treatment. RESULTS: Ninety-nine patients received 137 US: 58 pelvic, 34 right upper quadrant, 23 renal, six other abdominal, five orthopedic, four cardiac, three pleura and lung, three soft tissue, and one focused assessment by sonography in trauma. Acuity of presenting illness: 23 percent <24 hours, 15 percent 1-14 days, 44 percent >14 days. Eighteen percent were performed in prenatal clinic. Results of US ruled in 12 percent with an emergent problem and excluded disease in 42 percent. In 14 percent, US diagnosed a problem needing flu in <2 weeks, and 32 percent with a problem needing long-term observation. Transducer utilization was general purpose curved array 88 percent, linear array 10 percent, endocavitary 8 percent, and phased array 4 percent. CONCLUSIONS: HCU has a range of applications in an austere medical setting after a natural disaster. Most can be dealt with using a single transducer.