Emergency physician focused cardiac ultrasound improves diagnosis of ascending aortic dissection.

STUDY OBJECTIVE: Ascending aortic dissection (AAD) is an uncommon, time-sensitive, and deadly diagnosis with a nonspecific presentation. Ascending aortic dissection is associated with aortic dilation, which can be determined by emergency physician focused cardiac ultrasound (EP FOCUS). We seek to determine if patients who receive EP FOCUS have reduced time to diagnosis for AAD. METHODS: We performed a retrospective review of patients treated at 1 of 3 affiliated emergency departments, March 1, 2013, to May 1, 2015, diagnosed as having AAD. All autopsies were reviewed for missed cases. Primary outcome measure was time to diagnosis. Secondary outcomes were time to disposition, misdiagnosis rate, and mortality. RESULTS: Of 386547 ED visits, targeted review of 123 medical records and 194 autopsy reports identified 32 patients for inclusion. Sixteen patients received EP FOCUS and 16 did not. Median time to diagnosis in the EP FOCUS group was 80 (interquartile range [IQR], 46-157) minutes vs 226 (IQR, 109-1449) minutes in the non-EP FOCUS group (P = .023). Misdiagnosis was 0% (0/16) in the EP FOCUS group vs 43.8% (7/16) in the non-EP FOCUS group (P = .028). Mortality, adjusted for do-not-resuscitate status, for EP FOCUS vs non-EP FOCUS was 15.4% vs 37.5% (P = .24). Median rooming time to disposition was 134 (IQR, 101-195) minutes for EP FOCUS vs 205 (IQR, 114-342) minutes for non-EP FOCUS (P = .27). CONCLUSIONS: Patients who receive EP FOCUS are diagnosed faster and misdiagnosed less compared with patients who do not receive EP FOCUS. We recommend assessment of the thoracic aorta be performed routinely during cardiac ultrasound in the emergency department.

The "5Es" of emergency physician-performed focused cardiac ultrasound: a protocol for rapid identification of effusion, ejection, equality, exit, and entrance.

Emergency physician (EP)-performed focused cardiac ultrasound (EP FOCUS) has been increasingly recognized as a crucial tool to help clinicians diagnose and treat potentially life-threatening conditions. The existing literature demonstrates a variety of EP FOCUS applications and protocols; however, EP FOCUS is not taught, practiced, or interpreted consistently between institutions. Drawing on over 12 years of experience in a large-volume, high-acuity academic emergency department, we have developed a protocol for teaching and performing EP FOCUS known as "The 5Es," where each E represents a specific assessment for immediately relevant clinical information. These include pericardial effusion, qualitative left ventricular ejection, ventricular equality, exit (aortic root diameter), and entrance (inferior vena cava diameter and respirophasic variation). Each of these assessments has been well described in the emergency medicine literature and is within the scope of EP-performed echocardiography. This approach provides a reliable and easily recalled framework for assessing, teaching, and communicating EP FOCUS findings that are essential in caring for the patient in the emergency setting.

The effect of cellobiose, glucose, and cellulose on the survival of Fibrobacter succinogenes A3C cultures grown under ammonia limitation.

The ruminal, cellulolytic bacterium, Fibrobacter succinogenes A3C, grew rapidly on cellulose, cellobiose, or glucose, but it could not withstand long periods of energy source starvation. If ammonia was limiting and either cellobiose or glucose was in excess, the viability declined even faster. The carbohydrate-excess, ammonia-limited cultures did not spill energy, but they accumulated large amounts of cellular polysaccharide. Cultures that were carbohydrate-limited had approximately 4 nmol ATP mg cell protein(-1), but ATP could not be detected in cultures that had an excess of soluble carbohydrates. However, if F. succinogenes A3C was provided with excess cellulose and ammonia was limiting, ATP did not decline, and the cultures digested the cellulose soon after additional nitrogen sources were added. From these results, it appears that excess soluble carbohydrates can promote the death of F. succinogenes, but cellulose does not.