Point-of-care ultrasound findings in unselected patients in an emergency department <Emphasis Type="Italic">—results from a prospective observational trial</Emphasis>

Background

Point-of-care ultrasound (POCUS) can improve patient management in the emergency department (ED). However, previous studies have focused only on selected groups of patients, such as trauma, shock, dyspnea, or critically ill patients, or patients with an already known diagnosis. Most patients seen in the ED do not match these criteria. We aim to present total prevalence of positive findings when basic POCUS is applied to the broad population of patients seen in an emergency department.

Methods

We conducted a single-center prospective explorative observational study of 405 unselected patients aged 18?years or over. A structured whole-body ultrasound examination was performed on all patients within 2?h of arrival to the ED. The ultrasound examination consisted of focused cardiac ultrasound, focused abdominal ultrasound, focused assessment with sonography for trauma (FAST), and focused lung ultrasound.

Results

We managed to perform 94.5% of all planned examinations. The study revealed positive findings in 39.3% of all included patients. This study presents the prevalence of positive findings among subgroups of patients. Divided among the categories of chief complaint, we found 62 positive examinations in 58 (14.3%; 95% CI, 10.9–17.7) unique patients with orthopedic complaints, 77 positive examinations among 59 (14.6%; 95% CI, 11.1–18.0) unique patients with medical complaints, and 55 positive examinations among 42 (10.4%; 95% CI, 7.4–13.3) unique patients with abdominal surgical complaints.

Conclusion

POCUS revealed positive findings in more than one third of unselected patients in the emergency department. The study presents the findings and distribution among categories of chief complaints. Future investigations are necessary to elucidate the implication of the findings.

     

The fast is positive,now what? Derivation of a clinical decision rule to determine the need for therapeutic laparotomy in adults with blunt torso trauma and a positive trauma ultrasound

INTRODUCTION: The object of this study was to derive a clinical decision rule for therapeutic laparotomy among adult blunt trauma patients with a positive abdominal ultrasound for trauma (FAST) examination. METHODS: We retrospectively reviewed the trauma registry and medical records of all critical trauma patients who underwent a FAST examination in the emergency department (ED) in a university Level I trauma center over a 3-year period. Blunt trauma patients aged >16 years who had a positive FAST examination (defined as the presence of intraperitoneal fluid) were eligible. We selected seven clinical and ultrasound variables available during ED resuscitation for analysis: age, presence of an episode of hypotension (systolic blood pressure <90 torr in the ED), presence of abdominal tenderness, chest injury, pelvic fracture, femur fracture, and FAST fluid location (right upper quadrant [RUQ] only; RUQ plus other location; other location only). The primary outcome variable was whether a laparotomy was performed and whether this laparotomy was needed to provide the definitive surgical intervention ("therapeutic laparotomy"). We analyzed the variables using binary recursive partitioning analysis to create a decision rule. RESULTS: There were 2336 FAST examinations performed during the study period, resulting in 230 (9.8%) positive examinations in patients meeting inclusion criteria. There were 135 patients who had therapeutic laparotomies and 95 who did not need laparotomy. The groups were similar in baseline characteristics. In the recursive partitioning analysis, the first node in the decision tree was the presence of fluid in the RUQ. Of the 144 patients with RUQ fluid, 105 (73%, 95% confidence interval [CI] 64%-80%) required therapeutic laparotomy. Of the 86 patients without RUQ fluid, 30 (35%, 95% CI 25%-46%) nevertheless required therapeutic laparotomies, and the variables blood pressure, femur fracture, abdominal tenderness, and age further divided these patient into high- and low-risk groups. Of the 12 patients without RUQ fluid who had normal blood pressures, no femur fractures, no abdominal tenderness, and were aged 60 years and younger, none (95% CI 0%-22%) required therapeutic laparotomy. In conclusion, given a positive FAST examination, the presence of fluid in the RUQ is an important predictor of the need for therapeutic laparotomy. CONCLUSION: In the absence of fluid in the RUQ, there are other clinical variables that may allow for the development of a clinical decision rule regarding the need for therapeutic laparotomy.     

Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum

Objectives: To evaluate non-radiologist performed emergency ultrasound for the detection of haemoperitoneum after abdominal trauma in a British accident and emergency department.

Methods: Focused assessment with sonography for trauma (FAST) was performed during the primary survey on adult patients triaged to the resuscitation room with suspected abdominal injury over a 12 month period. All investigations were performed by one of three non-radiologists trained in FAST. The ultrasound findings were compared against the investigation of choice of the attending surgeon/accident and emergency physician. The patients were followed up for clinically significant events until hospital discharge or death.

Results: One hundred patients who had sustained blunt abdominal trauma, were evaluated by FAST. Nine true positive scans were detected and confirmed by computed tomography, diagnostic peritoneal lavage, or laparotomy. There was one false positive in this group, giving a sensitivity of 100%, specificity 99%, and positive predictive value of 90%. Ten patients with penetrating injuries were evaluated with a sensitivity and specificity for FAST of 33% and 86% respectively.

Conclusions: Emergency torso ultrasound for the detection of haemoperitoneum can be successfully performed by trained non-radiologists within a British accident and emergency system. It is an accurate and rapid investigation for blunt trauma, but the results should be interpreted with caution in penetrating injury.

     

W IRELESS AND S ATELLITE T RANSMISSION OF P REHOSPITAL F OCUSED A BDOMINAL S ONOGRAPHY FOR T RAUMA

Objective. As military operations become smaller and more remote and as humanitarian missions increase, ultrasound technology is emerging as a valuable asset for defining injuries in austere settings. This study evaluated the feasibility of focused abdominal sonography for trauma (FAST) examinations in a field environment with real-time images sent wireless to an antenna and over satellite. Methods. Using a 6-lb SonoSite portable ultrasound device with battery pack, FAST examinations were performed on a healthy volunteer, transferred wireless at distances of 1,000 and 1,500 feet from the receiving antenna using a vest-mounted microwave transmitter, and then redirected over satellite (INMARSAT) to a remote hospital for review by emergency physicians, and a radiologist. Results. Real-time wireless transmissions at 1,500 feet reliably yielded images without quality or interpretability drop compared with those recorded digitally at the examination site. A 32% reduction in image quality and interpretability was seen with still images and a 42% reduction was noted with cine loops using INMARSAT. The authors did not find the upper distance limit of the wireless transmitter used. Conclusion. This study suggests 1) that remote FAST examinations are plausible for prehospital care and triage using new-generation portable ultrasound units, 2) that line-of-sight transmission of FAST examinations when compared with on-site images results in no degradation in image quality or interpretability at distances used, 3) that ranges greater than 1,500 feet are feasible for interpretable examinations and therefore line-of-site mass casualty or field triage sites, and 4) that real-time INMARSAT transmission of FAST examinations at 64?kbps may serve a limited role for remote clinical interpretation.     

D ETERMINATION OF M EDICAL N ECESSITY FOR A IR AND C RITICAL C ARE M EDICAL T RANSPORTATION

Abstract

Objective. We aimed to assess the diagnostic accuracy of focused assessment with sonography for trauma (FAST) examinations when used by emergency medical technicians (EMTs) to detect the presence of free abdominal fluid. Methods. Six level 1 EMTs (similar to intermediate EMTs in the United States) who worked at a tertiary emergency department in Korea underwent an educational program consisting of two one-hour didactic lectures that included the principles of ultrasonography, the anatomy of the abdomen, and two hours of hands-on practice. After this educational session, the EMTs performed FAST examinations on a convenience sample of patients from July 1 to October 5, 2009. These patients also received an abdominal computed tomography (CT) scan regardless of their chief complaints. The CT findings served as the definitive standard and were interpreted routinely and independently by emergency radiologists who were blinded to the study protocol. In addition, the EMTs were blinded to the CT findings. A positive CT finding was defined as the presence of free fluid, as interpreted by the radiologist. The sensitivity, specificity, predictive values, and their 95% confidence intervals (CIs) were calculated. Informed consent was obtained from all participating patients. Results. Among the 1,060 eligible patients with abdominal CT scans, 403 patients were asked to participate in the study, and 240 patients agreed. Of these 240 patients, 80 (33.3%) had results showing the presence of free fluid. Fourteen patients had a significant amount of peritoneal cavity fluid, 15 had a moderate amount of peritoneal cavity fluid, and 51 had a minimal amount of peritoneal cavity fluid. Compared with the CT findings, the diagnostic performance of the FAST examination had a sensitivity of 61.3% (95% CI, 50.3%–71.2%), specificity of 96.3% (95% CI, 92.1%–98.3%), positive predictive value of 89.1% (95% CI, 77.0%–95.4%), and negative predictive value of 83.2% (95% CI, 76.9%–88.2%). For a significant or moderate amount of peritoneal cavity fluid, the sensitivity was considerably higher (86.2%). Conclusion. EMTs in Korea showed a high diagnostic performance that was comparable to that of surgeons and physicians when detecting peritoneal cavity free fluid in a Korean emergency department setting. The validity of FAST examinations in prehospital care situations should be investigated further.     

FAST Ultrasound as an Adjunct to Triage Using the START Mass Casualty Triage System:

Objective. To determine whether the FAST examination might be a useful adjunct to simple triage andrapid treatment (START) in the secondary triage of mass-casualty victims already classified as delayed (Yellow). Methods. A retrospective chart review was conducted of all adult trauma patients evaluated by the trauma surgery service at a level 1 trauma center between January 1 andDecember 31, 2003. Patients were retrospectively triaged to one of three START categories: immediate (Red), delayed (Yellow), or expectant (Black). The FAST results were obtained from the medical records. Results. FAST results were available for 359 patients, of which 27 were classified as positive. Twenty (6.9%) of 286 patients retrospectively triaged as delayed (Yellow) had positive FAST studies. Of these, six underwent operative intervention within 24 hours of arrival. A total of 232 patients had both FAST andcomputed tomography (CT) studies performed, of which 19 FAST studies were inconclusive. In the remaining 213 patients, six of 27 had falsely positive studies, while 24 of 186 had falsely negative studies. Conclusions. Portable ultrasound technology might have identified 20 delayed (Yellow) patients with evidence of hemoperitoneum, thereby expediting evacuation to definitive care. However, only 30% of these patients subsequently underwent an operative intervention within 24 hours of arrival. Both over- andundertriage were significant problems. As such, the current study does not support the routine use of FAST ultrasound as a secondary triage tool.     

Prospective analysis of the effect of physician experience with the FAST examination in reducing the use of CT scans

Objective: The objective of this study was to examine the effect of ultrasound experience level on emergency physicians’ Focused Assessment with Sonography for Trauma (FAST) exam accuracy and emergency physicians’ confidence in using FAST findings to assist in managing patients with blunt trauma. Methods: This prospective, consecutive enrolment study evaluated adult trauma team activation blunt trauma patients. Based on the number of post‐training FAST exams carried out, 11 attending emergency physicians were grouped into A (<25 exams, n = 4), B (26–50 exams, n = 4) or C (>50 exams, n = 3). The FAST exam was carried out prior to other diagnostic studies. The emergency physicians were asked to prospectively judge their perception of the need for surgery, abdominal CT or no further tests. All study patients ultimately underwent CT, diagnostic peritoneal lavage or laparotomy. Among each physician group, the number of subsequent CT scans deemed necessary by the emergency physician after a ‘normal’ FAST was calculated and compared. Results: Accuracy was greatest in group C. Sixty‐nine of 80 patients in group A had a normal FAST exam; emergency physicians deemed CT necessary in 68/69 cases (99%; confidence interval [CI] 92–100%). Eighty‐two of 98 patients in group C had a normal FAST exam; emergency physicians deemed CT necessary in 19/82 cases (23%; CI 15–34%). Physicians in groups B and C were less likely to order CT after a normal FAST than group A (P < 0.001). Conclusions: FAST accuracy was greatest among more experienced emergency physicians. A normal FAST exam assisted more experienced emergency physicians with the perceived need to order significantly fewer CT scans than less experienced emergency physicians.     

Fetal outcomes following emergency department point-of-care ultrasound for vaginal bleeding in early pregnancy

ObjectiveTo determine 20- and 40-week fetal outcomes following documentation of fetal cardiac activity (FCA) and intrauterine pregnancy (IUP) in women at less than 20 weeks’ gestation presenting to the emergency department (ED) with vaginal bleeding.DesignProspective observational cohort study.SettingSingle-centre tertiary care ED.ParticipantsPregnant women at less than 20 weeks’ gestation presenting to the ED with vaginal bleeding.InterventionAll study participants underwent ED point-of-care ultrasound (POCUS) to document IUP and FCA.ResultsA total of 85 of 111 eligible patients were enrolled; FCA and IUP were detected in 43 (50.6%) and 54 (63.5%) participants, respectively. Participants with documented FCA on ED POCUS were less likely to experience pregnancy loss than participants without documented FCA were (5.0% vs 92.7%; Δ = 87.7%; 95% CI 71.0% to 93.7%), and participants with documented IUP were less likely to experience pregnancy loss than participants without documented IUP were (22.0% vs 93.5%; Δ = 71.5%; 95% CI 52.1% to 81.9%). Compared with radiologist-interpreted ultrasound, ED POCUS had sensitivity of 88.9% (95% CI 75.9% to 96.2%) and specificity of 100.0% (95% CI 89.6% to 100.0%) for documenting FCA, and sensitivity of 96.0% (95% CI 86.3% to 99.4%) and specificity of 93.1% (95% CI 77.2% to 99.0%) for documenting IUP.ConclusionIn this cohort of women presenting to the ED with bleeding in the first 20 weeks of pregnancy, detection of IUP and especially FCA using POCUS performed by providers certified by the Canadian Emergency Ultrasound Society was associated with ongoing viable pregnancy at 20 and 40 weeks’ gestational age. These data might be useful for ED physicians counseling women with symptomatic early pregnancies about the chance of miscarriage after an episode of vaginal bleeding.     

Impact of an epic-integrated point-of-care ultrasound workflow on ultrasound performance,compliance, and potential revenue

ObjectivesThe purpose of this study was to describe the design and impact of a point-of-care ultrasound (PoCUS) workflow integrated into the electronic medical record (EMR) on PoCUS utilization, documentation compliance, and resultant revenue potential.MethodsThis was a single-center retrospective study at an academic center. The study period spanned from December 1, 2018 to June 30, 2019 (pre-implementation) to August 1, 2019 to February 29, 2020 (post-implementation). The implementation date was July 11, 2019 at which time a PoCUS workflow was integrated into the EMR in the emergency department without the purchase of middleware. Prior to this new workflow, a non-automated workflow was in place. PoCUS scan data were extracted from the EMR and archived examinations. The mean number of PoCUS examinations performed per month per 100 ED visits before and after implementation of the new workflow were compared using an unpaired t-test, stratified by all health care professionals, and attending physicians alone. The rate of documentation compliance before and after implementation of the new workflow were compared using a chi square contingency test. Potential revenue was calculated for each period by multiplying the number of eligible examinations by the respective 2020 Medicare conversion factor Relative Value Units.ResultsUtilization of PoCUS from pre-implementation to post-implementation increased 28.7% from 5.01 to 6.45 mean examinations per month per 100 ED visits by all health care professionals (p = 0.063), and 75.1% from 2.01 to 3.52 by attending physicians (p = 0.0001). Examinations in compliance with workflow requirements increased from 153 (14.7%) to 1307 (94.0%). The rate of workflow compliance improved from 14.7% to 94.0% of examinations (p < 0.0001). Potential revenue increased from $546.01 to $22,014.47.ConclusionsThe implementation of a middleware-free PoCUS workflow at our institution was associated with increased PoCUS utilization, documentation compliance, and potential revenue.     

Impact of a Statewide Trauma System on Rural Emergency Department Patient Assessment Documentation

Objective: To determine the association of rural ED patient assessment documentation with state trauma system implementation, hospital trauma categorization level (i.e., Level-3 vs Level-4), injury diagnosis, and patient demographics. Methods: A pre- vs post-system implementation (historical control) analysis of trauma documentation was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. The medical records of patients with specific index diagnoses in 4 anatomic regions (head, chest, liver/spleen, and femur/open-tibia) were reviewed for 3-year periods before statewide trauma system implementation and after hospital categorization. Vital sign, % inspired O², and O² saturation determinations were identified relative to the first and the last vital signs documented on the ED record. If not documented in the medical chart within 5 minutes of the first or last ED vital sign assessment, these measurements were considered missing. Separately, neurologic documentation (initial and final) also was sought for patients meeting criteria for an index head injury. Results: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had a head injury, 34% had a chest injury, 23% had a femur/open-tibia injury, and 12% had a spleen/liver injury. There were 142 (13%) patients with an injury in >1 index area. Except for initial systolic blood pressure, documentation of all other initial and final patient vital signs increased significantly (p < 0.05). Documentation of the Glasgow Coma Scale score (initial and final; p = 0.0001) and a final pupil examination on head-injured patients (p = 0.025) also increased. The effects of hospital level, injury diagnosis, and patient demographics on documentation rate were minimal. Conclusion: The study found overall improved ED documentation of trauma patient status in association with implementation of a statewide trauma system. This improvement in documentation suggests an enhanced process of care with trauma system participation.     

Retrospective analysis of eFAST ultrasounds performed on trauma activations at an academic level-1 trauma center

BACKGROUND:Point-of-care ultrasound(POCUS)has become increasingly integrated into the practice of emergency medicine.A common application is the extended focused assessment with sonography in trauma(eFAST)exam.The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation.The objective of this study was to conduct a review of performed,documented and billed eFAST ultrasounds on trauma activation patients.METHODS:This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center.A list comparing all trauma activations was crossreferenced with a list of all billed eFAST scans.Medical records were reviewed to determine whether an eFAST was indicated,performed,and appropriately documented.RESULTS:We found that 1,507 of 1,597 trauma patients had indications for eFAST,but 396(27%)of these patients did not have a billed eFAST.Of these 396 patients,87(22%)had documentation in the provider note that an eFAST was performed but there was no separate procedure note.The remaining 309(78%)did not have any documentation of the eFAST in the patient’s chart although an eFAST was recorded and reviewed during ultrasound quality assurance.CONCLUSION:A significant proportion of trauma patients had eFAST exams performed but were not documented or billed.Lack of documentation was multifactorial.Emergency ultrasound programs require appropriate reimbursement to support training,credentialing,equipment,quality assurance,and device maintenance.Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.     

Ultrasonography in patients without trauma in the emergency department: impact on discharge diagnosis.

OBJECTIVE: The aim of this study was to examine to what extent findings on ultrasonography performed in the emergency department (ED) after hours confirm or alter the referral diagnosis in patients without trauma as reflected in the discharge diagnosis. METHODS: In this prospective study, data from 136 ultrasonographic examinations performed in patients without trauma after hours in the ED during January and February 2002 were evaluated against the suspected preimaging diagnosis of the referring ED physician and the actual discharge diagnosis from the ED or after hospitalization. The rate of preimaging and postimaging concordance was statistically analyzed and compared by calculation of confidence intervals and by the McNemar test. RESULTS: Normal ultrasonographic findings were documented in 54 patients (40%), and pathologic findings were documented in 82 (60%). Thirty-four (25%) of the 136 examinations were concordant with the initial referring physician's diagnosis. Of the 102 studies that were not concordant with the initial referral suspected diagnoses, that is, being either a study with normal findings or offering an alternative diagnosis, 81 (79.4%) were concordant with the discharge diagnosis. CONCLUSIONS: After-hours ultrasonographic findings in patients without trauma seen in the ED seem to have a high impact on the discharge diagnosis and are concordant with it in more than 80% of cases.     

National specialty trends in billable diagnostic ultrasound in the ED: analysis of Medicare claims data

ObjectiveTo assess recent national specialty trends in the use of diagnostic ultrasound (US) services in the Emergency Department (ED) setting.MethodsWe searched aggregated 1998-2012 Medicare Part B Master Files for ED diagnostic US studies, excluding cardiac and ophthalmic examinations. Studies were classified by body part and interpreting specialty. Subsequent analysis was performed for higher-volume services rendered by emergency physicians for which discrete codes were present longitudinally for complete vs limited examinations. National trends were analyzed.ResultsFrom 1998 to 2012, paid ED US studies interpreted by radiologists, emergency physicians, and all other physicians increased by 332% (from 221 712 to 735 858 examinations), 4454% (from 561 to 24 992), and 251% (from 26 961 to 67 787), respectively. The fraction of ED US examinations interpreted remained around 90% for radiologists, increased from 0.2% to 3% for emergency physicians, and decreased from 11% to 8% for other physicians. The fraction of complete abdominal and complete retroperitoneal studies interpreted by emergency physicians remained less than 1% from 1998 through 2012. However, emergency physicians experienced disproportionate growth in limited examinations (from 1% to 9% for abdominal studies and from < 1% to 20% for retroperitoneal studies). Likewise, the fraction of (typically targeted) chest studies interpreted by emergency physicians increased from less than 1% to 63%.ConclusionFrom 1998 to 2012, there was substantial growth in ED US studies for Medicare beneficiaries interpreted by radiologists and emergency physicians alike. For more commonly performed services distinguishable as complete vs limited in nature, growth in services by emergency physicians was most dramatic for less complex services.     

A Narrative Review of Common Uses of Ophthalmic Ultrasound in Emergency Medicine

BackgroundThe timely evaluation of ocular conditions in the emergency department (ED) can be difficult due to a general lack of specialized equipment, trained personnel, and the time-sensitive nature of emergent ocular conditions. Recently, the use of ocular point-of-care ultrasound (POCUS) has been shown to be particularly useful in the ED. POCUS can be used to promptly diagnose various ocular pathologies, which include ocular trauma, vitreous hemorrhage, central retinal artery occlusion, and retinal detachment.ObjectivesThis narrative review seeks to inform the reader of current literature regarding the use of POCUS for the assessment of various ocular emergencies in the ED. The goal of this review is to provide the emergency physician with succinct and up-to-date information and instruction regarding the current uses of POCUS for patients presenting with particular ocular emergencies. Ocular pathologies that are common (ocular trauma) or for which ultrasound is particularly useful (such as retinal detachment) are discussed. Other ocular pathologies are also briefly discussed, such as central retinal artery occlusion, which is a promising new application for ultrasound evaluation.DiscussionThere have been many studies that provide evidence for the utility of POCUS in the evaluation of trauma and other ocular pathologies, including vitreous hemorrhage, retinal detachment, and central retinal artery occlusion.ConclusionsOcular POCUS is a useful modality in the evaluation of acute ocular complaints in the ED. Emergency physicians should be aware of these findings and feel confident in the utility of ocular POCUS in the ED.     

Utility of the Cardiac Component of FAST in Blunt Trauma

Background

Focused assessment with sonography in trauma (FAST) is widely used and endorsed by guidelines, but little evidence exists regarding the utility of the cardiac portion in blunt trauma. The traditional FAST includes the routine performance of cardiac sonography, regardless of risk for hemopericardium.

Study Objectives

Our goal was to estimate the prevalence of hemopericardium due to blunt trauma and determine the sensitivity of certain variables for the presence of blunt hemopericardium.

Methods

We performed a retrospective chart review of two institutional databases at a large urban Level I trauma center to determine the prevalence of blunt hemopericardium and cardiac rupture and incidental or insignificant effusions. We evaluated the sensitivity of major mechanism of injury, hypotension, and emergent intubation for blunt hemopericardium and cardiac rupture.

Results

Eighteen patients had hemopericardium and cardiac rupture (14 and 4, respectively) out of 29,236 blunt trauma patients in the Trauma Registry over an 8.5-year period. The prevalence was 0.06% (95% confidence interval [CI] 0.04–0.09%). The prevalence of incidental or insignificant effusions was 0.13% (95% CI 0.09–0.18%). One case of blunt hemopericardium was identified in the emergency ultrasound database out of 777 cardiac ultrasounds over a 3-year period. No patient with blunt hemopericardium or cardiac rupture presented without a major mechanism of injury, hypotension, or emergent intubation.

Conclusion

Blunt hemopericardium is rare. High-acuity variables may help guide the selective use of echocardiography in blunt trauma.     

A Potential Pitfall of Using Focused Assessment With Sonography for Trauma in Pediatric Trauma

Prospective studies have shown sensitivities of 73% to 88% and specificities of 98% to 100% for using the focused assessment with sonography for trauma (FAST) examination to identify free fluid in adult trauma patients. However, the efficacy of FAST examinations for pediatric trauma patients has not been well defined, and studies looking at diagnostic performance have had varied results. We describe 3 cases of the potential pitfalls of the pediatric FAST examination in pediatric trauma patients using an advanced‐processing ultrasound machine. We hypothesize several etiologies for these false‐positive findings in the setting of advanced image‐processing capabilities of point‐of‐care ultrasound. We also discuss the reevaluation of clinical algorithms and interpretation practices when using the FAST examination in pediatric trauma.     

Incidental findings detected on abdomino-pelvic multidetector computed tomography performed in the acute setting

Objective

The objective of the study is to determine the prevalence and significance of incidental findings in patients with a chief complaint of abdominal pain presenting to the emergency department (ED) who received abdomino-pelvic multidetector computed tomography.

Materials and methods

We conducted a retrospective review of data collected for 290 patients over a period of 5 months (April to September 2012) from 3 different university-affiliated EDs. Two board-certified radiologists reviewed the original images independently and recorded the incidental findings. These findings were classified as benign, indeterminate, and worrisome. Only those findings present in the original report were included in the study. If an indeterminate or worrisome incidental finding was identified, the patient's medical records were reviewed to determine if the incidental finding was previously known, whether recommendation was made for further evaluation, and whether this recommendation led to any change in management.

Results

We identified 283 incidental findings—144 benign (51%), 114 indeterminate (40%), and 25 worrisome (9%) findings. A statistically significant difference was observed in the percentage of patients who experienced a change in management among those who received recommendations as compared with those who did not, in both previously known (87% vs 22%, P = .001) and previously unknown (70% vs 2%, P = .001) indeterminate findings.

Conclusion

Unlike benign incidental findings, indeterminate and worrisome findings frequently alter the course of management. Recommendation from radiologists appears to significantly contribute to the management of indeterminate incidental findings.     

Time to analgesia for care delivered by nurse practitioners in the emergency department – a retrospective chart audit

ObjectivesTo evaluate quality of care delivered to patients presenting to the emergency department (ED) with pain and managed by emergency nurse practitioners by:

• 1Evaluating time to analgesia from initial presentation
• 2Evaluating time from being seen to next analgesia
• 3Measuring pain score documentation

BackgroundThe delivery of quality care in the emergency department (ED) is emerging as one of the most important service indicators being measured by health services. Emergency nurse practitioner services are designed to improve timely, quality care for patients. One of the goals of quality emergency care is the timely and effective delivery of analgesia for patients. Timely analgesia is an important indicator of ED service performance.MethodsA retrospective explicit chart review of 128 consecutive patients with pain and managed by emergency nurse practitioners was conducted. Data collected included demographics, presenting complaint, pain scores, and time to first dose of analgesia. Patients were identified from the ED patient information system (Cerner log) and data were extracted from electronic medical records.ResultsPain scores were documented in 67 (52.3%; 95% CI: 43.3–61.2) patients. The median time to analgesia from presentation was 60.5 (IQR 30–87) minutes, with 34 (26.6%; 95% CI: 19.1–35.1) patients receiving analgesia within 30 minutes of presentation to hospital. There were 22 (17.2%; 95% CI: 11.1–24.9) patients who received analgesia prior to assessment by a nurse practitioner. Among patients who received analgesia after assessment by a nurse practitioner, the median time to analgesia after assessment was 25 (IQR 12–50) minutes, with 65 (61.3%; 95% CI: 51.4–70.6) patients receiving analgesia within 30 minutes of assessment.ConclusionsThe majority of patients assessed by nurse practitioners received analgesia within 30 minutes after assessment. However, opportunities for substantial improvement in such times along with documentation of pain scores were identified and will be targeted in future research.