Abstract: In field medical operations, rapid diagnosis and triage of seriously injured patients is critical. With significant bulk and cost constraints placed on all equipment, it is important that any medical devices deployed in the field demonstrate high utility, durability, and ease of use. When medical ultrasound was first used in patient care, machine cost, bulk, and steep learning curves prevented use outside of the radiology department. Now, lightweight portable ultrasound is widely employed at the bedside by emergency physicians. The techniques and equipment have recently been extrapolated out of the hospital setting in a wide variety of environments in an effort to increase diagnostic accuracy in the field.
Abstract: With recent advances in ultrasound technology, it is now possible to deploy lightweight portable imaging devices in the field. Techniques and studies initially developed for hospital use have been extrapolated out of the hospital setting in a wide variety of environments in an effort to increase diagnostic accuracy in austere or prehospital environments.
Abstract: Over the past decade, some residency programs in emergency medicine (EM) have implemented scholarly tracks into their curricula. The goal of the scholarly track is to identify a niche in which each trainee focuses his or her scholarly work during residency. The object of this paper is to discuss the current use, structure, and success of resident scholarly tracks. A working group of residency program leaders who had implemented scholarly tracks into their residency programs collated their approaches, implementation, and early outcomes through a survey disseminated through the Council of Emergency Medicine Residency Directors (CORD) list-serve. At the 2009 CORD Academic Assembly, a session was held and attended by approximately 80 CORD members where the results were disseminated and discussed. The group examined the literature, discussed the successes and challenges faced during implementation and maintenance of the tracks, and developed a list of recommendations for successful incorporation of the scholarly track structure into a residency program. Our information comes from the experience at eight training programs (five 3-year and three 4-year programs), ranging from 8 to 14 residents per year. Two programs have been working with academic tracks for 8 years. Recommendations included creating clear goals and objectives for each track, matching track topics with faculty expertise, protecting time for both faculty and residents, and providing adequate mentorship for the residents. In summary, scholarly tracks encourage the trainee to develop an academic or clinical niche within EM during residency training. The benefits include increased overall resident satisfaction, increased success at obtaining faculty and fellowship positions after residency, and increased production of scholarly work. We believe that this model will also encourage increased numbers of trainees to choose careers in academic medicine.
Abstract: The present study was designed to assess the value of the presenting symptom of "typical" anginal pain, "atypical/nonanginal" pain, or the lack of chest pain in predicting the presence of inducible myocardial ischemia using cardiac stress testing in emergency department patients being evaluated for possible acute coronary syndrome. We performed a retrospective observational study of adult patients who were evaluated for acute coronary syndrome in an emergency department chest pain unit. The presenting symptoms were obtained from a structured questionnaire administered before stress testing. Patient chest pain was categorized according to the presence of substernal chest pain or discomfort that was provoked by exertion or emotional stress and was relieved by rest and/or nitroglycerin. Chest pain was classified as "typical" angina if all 3 descriptors were present and "atypical" or "nonanginal" if <3 descriptors were present. All patients underwent serial biomarker and cardiac stress testing before discharge. A total of 2,525 patients met the eligibility criteria. Inducible ischemia on stress testing was found in 33 (14%, 95% confidence interval 10% to 19%) of the 231 patients who had typical anginal pain, 238 (11%, 95% confidence interval 10% to 13%) of the 2,140 patients presenting with atypical/nonanginal chest pain, and 25 (16%, 95% confidence interval 11% to 22%) of the 153 patients who had no complaint of chest pain on presentation. Compared to patients with atypical or no chest pain, patients with typical chest pain were not significantly more likely to have inducible ischemia on stress testing (likelihood ratio +1.25, 95% confidence interval 0.89 to 1.78). In conclusion, in our study, the patients who presented with "typical" angina were no more likely to have inducible myocardial ischemia on stress testing than patients with other presenting symptoms.
Abstract: Administering analgesia to patients with abdominal pain before diagnostic imaging is now accepted as standard practice. However, analgesia before diagnostic right upper quadrant ultrasound continues to be controversial for fear of masking the sonographic Murphy's sign (SMS). This study sought to evaluate the impact of analgesia on the accuracy of the SMS in predicting cholecystitis. We hypothesized that the impact of analgesia on radiologist-performed ultrasound and emergency physician (EP)-performed ultrasound would be equivalent.
Abstract: Emergency physicians and intensivists are increasingly utilizing capnography and bedside echocardiography during medical resuscitations. These techniques have shown promise in predicting outcomes in cardiac arrest, and no cases of return of spontaneous circulation in the setting of sonographic cardiac standstill and low end-tidal carbon dioxide have been reported. This case report illustrates an example of such an occurrence. Our aims are to report a case of return of spontaneous circulation in a patient with sonographic cardiac standstill, electrocardiographic pulseless electrical activity, and low end-tidal carbon dioxide tensions and to place the case in the context of previous literature on this topic. Case report and brief review of the literature. In 254 cases reported, no patient has survived in the setting of sonographic cardiac standstill and low end-tidal carbon dioxide tension, making the reported case unique. This case should serve to illustrate the utility and limitations of combined cardiac sonography and end-tidal carbon dioxide measurement in determining prognosis during cardiac arrest.
Abstract: Straight suture needles are commonly employed to secure arterial and venous catheters to the skin. These needles have been demonstrated to be more dangerous than curved or blunt suture needles, with a higher rate of injury for health care workers. This article describes a technique for using the straight needle that may reduce the chances of injury. By utilizing the plastic needle sheath present in most central venous line kits as a "thimble," counter pressure and skin puncture may be achieved without bringing the fingers near the sharp end of the suture.
Abstract: Prehospital ultrasound has been deployed in certain areas of the USA and Europe. Physicians, emergency medical technicians, and flight nurses have utilized a variety of medical and trauma ultrasound assessments to impact patient care in the field. The goal of this review is to summarize the literature on emergency medical services (EMS) use of ultrasound to more clearly define the potential utility of this technology for prehospital providers.
Abstract: Optimal training required for proficiency in bedside ultrasound is unknown. In addition, the value of proctored training is often assumed but has never been quantified.
Abstract: In 2000, some 2.3 million Americans were affected by atrial fibrillation, and that number is expected to rise as our population ages. Atrial fibrillation is both a reflection of active physiologic stressors on the body and a marker of future cardiac disease progression. The disorganized atrial activity that characterizes atrial fibrillation affects cardiac function, metabolic demand, and quality of life. However, our understanding of the etiology and treatment of this condition continues to advance with the result of recent large-scale clinical trials. Diabetes, hypertension, congestive heart failure, valvular disease, and myocardial infarction are all risk factors in the development of atrial fibrillation. And the diagnosis confers a five-fold increase in the incidence of stroke. (Patients at increased risk for stroke include those with congestive heart failure, hypertension, age greater than 75, diabetes, and previous stroke.) Anticoagulation is a critical action in most cases of atrial fibrillation, as data show a 68% relative risk reduction of stroke when patients are treated with warfarin. Prior to recent trials, achieving sinus rhythm was thought to invariably improve symptoms, cardiac function, and mortality. The adverse effects of antiarrhythmic medications are now being recognized, and treatment strategies emphasizing ventricular rate control have been recommended in recent clinical practice guidelines. This shift in thinking is influencing both outpatient and emergency department management. Controlling the ventricular rate in atrial fibrillation increases cardiac output, decreases the metabolic demand of the heart, and avoids the potentially dangerous side effects of rhythm-control drugs. Rate-control agents should be selected based on the clinical profile of individual patients. A well-chosen subset of patients may benefit from either chemical or electrical cardioversion; this appears to be a reasonably safe procedure and can be accomplished on an outpatient basis. Understanding causal etiologies, managing risk for stroke (and need for anticoagulation), addressing rate, and assessing the risks of cardioversion are key elements in a comprehensive approach to atrial fibrillation.
Abstract: Administration of intravenous opioid analgesia to patients with undifferentiated abdominal pain remains a controversial topic in many emergency departments. To determine whether opioid analgesia impacts assessment of the sonographic Murphy sign (SM) in evaluating acute gallbladder disease (GBD), a retrospective chart review was undertaken. The chart review encompassed 119 patients, 21% of whom, having received opioid analgesia before ultrasound, constituted the opioid group. Between the opioid and control (i.e., no opioid analgesia) groups, there were no significant differences in SM sensitivity (48.2%; CI 28.7-68.1% vs. 68.8%; CI 41.3-89%, respectively) or specificity (92.5%; CI 83.4-97.5% vs. 88.9%; CI 51.8-99.7%, respectively) for GBD. There was no association between opioid analgesia and false-positive SM (OR 0.74, CI 0.08-6.65), or false-negative SM (OR 1.42, CI 0.46-4.43). We conclude that the test characteristics of SM are unaffected by opioid analgesia.
Abstract: A retrospective study design was used to determine the effect of introducing a mandated verbal numeric pain scale on the incidence and timing of analgesic administration in the ED. Consecutive patients presenting with renal colic, extremity trauma, headache, ophthalmologic trauma, and soft tissue injury were included. 521 encounters were reviewed before and 479 encounters after the introduction of the pain scale. Groups were similar in baseline characteristics. Analgesic use increased from 25% to 36% (p < 0.001), and analgesics were administered more rapidly after the scale was introduced (113 minutes vs. 152 minutes, p = 0.09). Analgesic use correlated with pain severity. Patients undergoing diagnostic testing were less likely to receive analgesics, especially when presenting with a headache (p < 0.001). We conclude that use of a pain scale at triage significantly increases use of analgesia, and shortens the time till its administration. Patients undergoing diagnostic workups were less likely to receive analgesia.
