Pseudoaneurysm of the superficial femoral artery detected by emergency medicine bedside ultrasound

Background

Femoral artery pseudoaneurysm following by cardiac catheterization is a serious groin complication requiring careful assessment and prompt intervention.

Aims

Risk of femoral artery pseudoaneurysm is estimated at 0.6 to 17 following diagnostic and interventional procedures.

Methods

The clinical usage of bedside ultrasonography as part of the physical examination by attending emergency physicians has increased significantly over recent years.

Results

Bedside Emergency Department ultrasonography provides the clinician with critical information noninvasively, rapidly determining various anatomical structures.

Conclusions

We presented the case of a femoral artery pseudoaneurysm detected by the bedside emergency department ultrasonography secondary to angiographic catheterization.     

Bedside Ultrasound Diagnosis of Acute Embolic Femoral Artery Occlusion

Background

Acute limb ischemia is both a limb-threatening and life-threatening disease process. Nontraumatic acute peripheral arterial occlusion is most commonly caused by a thrombosis or an embolism.

Objectives

There is limited evidence on the use of bedside ultrasound for the detection of acute limb ischemia, but duplex ultrasonography is standard in the diagnosis and operative planning in chronic limb ischemia. Emergency physicians may use bedside ultrasound in the evaluation of patients with symptoms and signs suggestive of this disease entity.

Case Report

A 64-year-old man with a past medical history of hypertension and an ischemic stroke presented to the Emergency Department with <2 h of severe upper left leg pain that radiated down to his foot. A bedside ultrasound of the left lower extremity was emergently performed. On B-mode ultrasound evaluation, echogenic material was visualized in the left common femoral artery, the artery was noncompressible, and there was an absence of Doppler flow signal. He was then directly taken to the operating room for an emergent limb-saving procedure.

Conclusion

A focused examination of the aorta, iliac vessels, and femoral artery bifurcation with bedside ultrasonography may help to localize peripheral arterial occlusions and can assist the emergency physician in seeking timely surgical consultation and management.     

Traumatic Pseudoaneurysm and Arteriovenous Fistula Detected by Bedside Ultrasound

Background

The case of late presentation of a pseudoaneurysm and an arteriovenous fistula (AVF) of the common femoral artery and vein secondary to penetrating trauma is reported. Traumatic AVF and pseudoaneurysm may be present within a variety of clinical conditions, which sometimes makes it difficult to detect them clinically. Undiagnosed AVF can lead to clinical manifestations mostly secondary to increased output generated by the fistula.

Case Report

A 31-year-old man presented to the Emergency Department (ED) for wound care follow-up. A week before, he had suffered a stab wound to the medial thigh and the primary suture was performed in our ED. During his first visit to our ED, the vascular examination revealed palpable dorsalis pedis and tibialis posterior pulses. The formal Doppler ultrasound was negative. During his second presentation, however, the physical examination was remarkable for a palpable thrill and continuous bruit in the left mid-thigh region. Also, an ultrasound with a 7.5-MHz linear probe demonstrated a pseudoaneurysm and an AVF between the femoral artery and vein.

Conclusion

The mechanism of the injury, wound location and tract, and physical findings after a penetrating thigh trauma can help to predict femoral artery injury. Also, occult injuries to the medial thigh after penetrating trauma may be easily overlooked on the physical examination. Furthermore, bedside ultrasound performed by an emergency physician may be helpful in diagnosing occult vascular injuries.     

Systematic review of emergency department central venous and arterial catheter infection

Background

There is an extensive critical care literature for central venous catheter and arterial line infection, duration of catheterization, and compliance with infection control procedures. The emergency medicine literature, however, contains very little data on central venous catheters and arterial lines. As emergency medicine practice continues to incorporate greater numbers of critical care procedures such as central venous catheter placement, infection control is becoming a greater issue.

Aims

We performed a systematic review of studies reporting baseline data of ED-placed central venous catheters and arterial lines using multiple search methods.

Methods

Two reviewers independently assessed included studies using explicit criteria, including the use of ED-placed invasive lines, the presence of central line-associated bloodstream infection, and excluded case reports and review articles. Finding significant heterogeneity among studies, we performed a qualitative assessment.

Results

Our search produced 504 abstracts, of which 15 studies were evaluated, and 4 studies were excluded because of quality issues leaving 11 cohort studies. Four studies calculated infection rates, ranging 0–24.1/1,000 catheter-days for central line-associated and 0–32.8/1,000 catheter-days for central line-related bloodstream infection. Average duration of catheterization was 4.9 days (range 1.6–14.1 days), and compliance with infection control procedures was 33–96.5%. The data were too poor to compare emergency department to in-hospital catheter infection rates.

Conclusions

The existing data for emergency department-placed invasive lines are poor, but suggest they are a source of infection, remain in place for a significant period of time, and that adherence to maximum barrier precautions is poor. Obtaining accurate rates of infection and comparison between emergency department and inpatient lines requires prospective study.     

Simple technique for evacuation of traumatic subcutaneous haematomas under tension

Background

Traumatic subcutaneous haematomas are common cases in the accident and emergency department. Occasionally, urgent evacuation is required to prevent skin necrosis.

Methods

We present a simple and safe technique, based on a principle similar to liposuction to evacuate traumatic subcutaneous haematomas under tension. Instruments readily available in the accident and emergency department are used without the need of general anaesthesia.

Results

The technique was performed in six cases without complication such as infection or re-collection of the haematoma under tension. We present two typical scenarios where urgent evacuation was indicated and the technique performed.

Conclusion

The technique is useful as an urgent and safe procedure in the accident and emergency department setting.     

Addition of levalbuterol to a pediatric emergency department automated medication management system does not increase its use

Background

Although adding a drug to an emergency department-based automated medication management system is known to increase how frequently it is ordered, little is known about this effect when the added drug does not offer substantial benefit over a substitute drug that was already available.

Aims

We studied the effect of adding nebulized levalbuterol to a pediatric emergency department-based automated medication management system that already included albuterol.

Methods

All completed orders for nebulized levalbuterol or nebulized albuterol from our academic pediatric emergency department were retrospectively identified using a computerized pharmacy database. We compared ordering of these drugs for the year before levalbuterol was added to the automated medication management system, during which it was available only from the hospital central pharmacy via a pneumatic tube system, with the year following its inclusion in the system.

Results

There were 6 orders for nebulized levalbuterol and 1,295 orders for nebulized albuterol during the year that levalbuterol was only available from the hospital central pharmacy, and 7 orders for nebulized levalbuterol and 1,108 orders for nebulized albuterol during the year following levalbuterol’s inclusion in the automated medication management system. There was no significant difference (p?=?0.78).

Conclusions

Use of nebulized levalbuterol, in relation to that of nebulized albuterol, for which it is a substitute, did not significantly change when it was included in the pediatric emergency department automated medication management system. This may reflect the lack of substantial benefit that levalbuterol offers over nebulized albuterol in managing children in the emergency department.     

Artificial neural network, genetic algorithm, and logistic regression applications for predicting renal colic in emergency settings

Background

Logistic regression is the most common statistical model for processing multivariate data in the medical literature. Artificial intelligence models like an artificial neural network (ANN) and genetic algorithm (GA) may also be useful to interpret medical data.

Aims

The purpose of this study was to perform artificial intelligence models on a medical data sheet and compare to logistic regression.

Methods

ANN, GA, and logistic regression analysis were carried out on a data sheet of a previously published article regarding patients presenting to an emergency department with flank pain suspicious for renal colic.

Results

The study population was composed of 227 patients: 176 patients had a diagnosis of urinary stone, while 51 ultimately had no calculus. The GA found two decision rules in predicting urinary stones. Rule 1 consisted of being male, pain not spreading to back, and no fever. In rule 2, pelvicaliceal dilatation on bedside ultrasonography replaced no fever. ANN, GA rule 1, GA rule 2, and logistic regression had a sensitivity of 94.9, 67.6, 56.8, and 95.5%, a specificity of 78.4, 76.47, 86.3, and 47.1%, a positive likelihood ratio of 4.4, 2.9, 4.1, and 1.8, and a negative likelihood ratio of 0.06, 0.42, 0.5, and 0.09, respectively. The area under the curve was found to be 0.867, 0.720, 0.715, and 0.713 for all applications, respectively.

Conclusion

Data mining techniques such as ANN and GA can be used for predicting renal colic in emergency settings and to constitute clinical decision rules. They may be an alternative to conventional multivariate analysis applications used in biostatistics.     

Middle-Aged Man with Left Neck Pain and Swelling

Background

Disorders of the salivary glands can be evaluated by bedside ultrasonography and should be considered in patients presenting with undifferentiated neck swelling.

Objective

Our aim was to describe the sonographic findings present in sialolithiasis and sialadenitis.

Case Report

A 61-year-old man presented to the emergency department with 2 days of neck swelling. Initial evaluation included a bedside ultrasound that demonstrated sialolithiasis, which was later confirmed by computed tomography.

Conclusions

Bedside ultrasound can be a useful imaging modality in the evaluation of the patient with neck swelling.     

Emergency Bedside Ultrasound Diagnosis of Superior Mesenteric Artery Dissection Complicating Acute Aortic Dissection

Background

A timely diagnosis of aortic dissection is associated with lower mortality. The use of emergent bedside ultrasound has been described to diagnose aortic dissection. However, there is limited literature regarding the use of bedside ultrasound to identify superior mesenteric artery dissection, a known high-risk feature of aortic dissection.

Objective

Our aim was to present a case of superior mesenteric artery dissection identified by bedside ultrasound and review the utility of bedside ultrasound in the diagnosis of aortic emergencies.

Case Report

We report a case of superior mesenteric artery dissection found on emergent bedside ultrasound in a 46-year-old male complaining of abdominal pain with a history of cocaine abuse and prior aortic dissection. Bedside ultrasound in the emergency department revealed an intimal flap in the descending aorta with extension into the superior mesenteric artery prompting early surgical consultation before computed tomography because of concern for acute mesenteric ischemia.

Conclusion

Superior mesenteric artery dissection is a high-risk feature of aortic dissection and can be identified with emergent bedside ultrasound.     

Alcohol-related emergency department attendances: is preloading a risk factor? Cross-sectional survey

Introduction

‘Preloading’ is a phenomenon where people drink alcohol at a private residence before going out. We aimed to identify whether preloading is a risk factor for alcohol-related emergency department attendance. We also wanted to identify where people became injured or unwell.

Methods

We conducted a cross-sectional, anonymous, survey at peak drinking times in our emergency department. We interviewed adult patients who presented to our emergency department with an alcohol-related presentation over an 8-week period.

Results

We approached 1,079 patients. One hundred sixty-one had suffered an alcohol-related problem while out drinking; 27% of women and 14% of men had their first drink at home. There was no particular presentation or age group that was associated with preloading. Seventy percent of patients stated that they had drunk most of their alcohol at a public place; 76% of patients suffered their alcohol-related problem at a site different from where they had drunk most of their alcohol or where they had had their first drink.

Conclusion

Preloading is more common in women than men. Preloading is common in alcohol-related emergency department attendances. The proportions of patients preloading in this study are lower than in other studies conducted in different environments. Preloading is not a risk factor for alcohol-related emergency department attendance. Polices to reduce alcohol-related harm should continue to focus on bars, nightclubs and pubs.     

The accuracy of bedside USG in the diagnosis of nasal fractures

A comparison of the sensitivity and specificity of bedside ultrasonography with conventional radiography for the evaluation of nasal fractures.

Hepatic Artery Pseudoaneurysm Rupture: A Case Report and Review of the Literature

Background

Ruptured hepatic artery pseudoaneurysm, a type of visceral artery aneurysm, is a rare condition that is life threatening if not diagnosed and treated rapidly in the emergency department (ED). Patients presenting with this condition require aggressive resuscitation. Endovascular embolization is the first-line treatment option.

Objectives

We present a case of spontaneously ruptured hepatic artery pseudoaneurysm and provide a review of the current literature on this topic, focusing on appropriate ED management.

Case Report

A 41-year-old woman with a history of systemic lupus erythematosus and multiple hepatic bilomas presented to the ED in critical condition with sudden onset of severe abdominal pain and hemodynamic instability. She was found to have a ruptured hepatic artery pseudoaneurysm with marked hemoperitoneum on computed tomography angiography. She was aggressively resuscitated and successfully managed via endovascular embolization.

Conclusion

Ruptured hepatic artery pseudoaneurysm is a life-threatening condition that must be rapidly diagnosed and managed in the ED. Visceral artery aneurysm rupture is a diagnosis that should be considered in any patient presenting to the ED with hemodynamic instability and abdominal pain. Definitive management is with endovascular embolization.     

Intraosseous vascular access in adults using the EZ-IO in an emergency department

Background

Intraosseous (IO) access is an alternative to conventional intravenous access.

Aims

We evaluate the use of the EZ-IO? as an alternative vascular access for patients in the emergency department.

Methods

A non-randomized, prospective, observational study was performed in adults using the EZ-IO? powered drill device.

Results

Twenty-four patients were recruited. There were 35 intraosseous insertions, including 24 tibial and 11 humeral insertions. All EZ-IO? insertions were achieved within 20 s and were successful at the first attempt except for one. Of the intraosseous insertions, 88.6% were reported to be easier than intravenous cannulation. We found flow rates to be significantly faster using a pressure bag. The seniority of operators did not affect the success of insertion. Complications included a glove being caught in the drill device and extravasation of fluid although they were easily preventable.

Conclusion

The use of the EZ-IO? provides a fast, easy and reliable alternative mode of venous access, especially in the resuscitation of patients with no venous vascular access in the emergency department. Flow rates may be improved by the use of pressure bags.     

Diagnosis of enteric fever in the emergency department: a retrospective study from Pakistan

Background

Enteric fever is one of the top differential diagnoses of fever in many parts of the world. Generally, the diagnosis is suspected and treatment is initiated based on clinical and basic laboratory parameters.

Aims

The present study identifies the clinical and laboratory parameters predicting enteric fever in patients visiting the emergency department of a tertiary care hospital in Pakistan.

Methods

This is a retrospective chart review of all adult patients with clinically suspected enteric fever admitted to the hospital through the emergency department during a 5-year period (2000–2005).

Results

A total of 421 emergency department patients were admitted to the hospital with suspected enteric fever. There were 53 cases of blood culture-positive enteric fever and 296 disease-negative cases on culture. The mean age in the blood culture-positive group was 27 years (SD: 10) and in the group with negative blood culture for enteric fever, 35 years (SD: 15) with a male to female ratio of 1:0.6 in both groups. Less than half (48%) of all patients admitted with suspected enteric fever had the discharge diagnosis of enteric fever, of which only 13% of the patients had blood culture/serologically confirmed enteric fever. None of the common clinical and laboratory parameters differed between enteric fever-positive patients and those without it.

Conclusion

Commonly cited clinical and laboratory parameters were not able to predict enteric fever.     

State of emergency medicine in Azerbaijan

Background

There has been no previous study into the state of emergency medicine in Azerbaijan. As a legacy of the Soviet Semashko system, the “specialty” model of emergency medicine and integrated emergency departments do not exist here. Instead, pre-hospital emergency care is delivered by ambulance physicians and in-hospital care by individual departments, often in specialty hospitals. Emergency care is therefore fragmented, highly specialized and inefficient.

Aims

The Emergency Medicine Development Initiative (EMDI) of the International Medical Corps (IMC) was designed to improve the quality of emergency care in four pilot regional centers in Azerbaijan. The objective of this study was to assess the baseline emergency medical capacity of these four centers.

Methods

EMDI staff conducted a four-part baseline survey in April 2006 to assess emergency care in Ganja (the second largest city in Azerbaijan), Kurdamir, Shamkir and Yevlakh. Data collection involved interviews with relevant personnel and a retrospective records review in each city.

Results

Pre-hospital: The number of ambulance teams per 10,000 inhabitants is below the number required by local regulations. On average, 45% of 27 medications and 37% of 17 pieces of critical equipment were available. Of the emergency procedures, 21% could be performed in the pre-hospital setting. In-hospital: Admission rates were near 100% for the admissions department–an area that is supposed to function as an emergency department would. On average 57% of 40 medications and 42% of 22 pieces of critical equipment were available. Of the emergency procedures, 62% could be performed in the in-hospital setting.

Conclusions

The emergency medical system surveyed in Azerbaijan is inefficiently organized, under-financed, poorly equipped and lacks adequately trained staff. Reforms need to be directed towards achieving international standards, while adapting new models for service delivery into the existing framework and improving system capacity as highlighted by this baseline assessment.     

Safety and Efficacy of the StarClose Vascular Closure System following 8-Fr Sheath Placement for Intra-Aortic Balloon Pump: A Single-Center Analysis of 42 Consecutive Patients

Objective

To assess the safety and efficacy of the StarClose device following intra-aortic balloon pump (IABP) counterpulsation using 8-Fr femoral sheaths.

Subjects and Methods

From June 2008 to August 2012, 42 consecutive patients who received IABP implantation via common femoral artery (CFA) punctures with an 8-Fr sheath (which were then sealed with the StarClose Vascular Closure System at the bedside) were included in this retrospective single-arm study. All the patients underwent duplex control of the puncture site 24 h after deployment of the device, in order to determine the presence or absence of vascular complications including hematoma, pseudoaneurysm, arteriovenous fistula and arterial/venous thrombosis or stenosis. The safety end points were the vascular complications during the hospital stay, and the efficacy end points included device and procedure success.

Results

The procedure success rate was 92.9% (39/42) and the device success rate was 88.1% (37/42). Major vascular complications occurred in 3 (7.1%) patients; 1 developed a massive hematoma >10 cm which was managed by blood transfusion and surgical reconstruction, and the other 2 developed pseudoaneurysm which was cured by ultrasound-guided thrombin injection or manual compression. Minor vascular complications occurred in 5 (11.9%) patients, including blood oozing in 2, hematoma <5 cm in 2 and severe pain in the remaining patient.

Conclusion

CFA closure with the StarClose device was safe, feasible and effective in patients undergoing IABP support using 8-Fr sheath sizes.Key Words: Intra-aortic balloon pump, Vascular closure device, StarClose, Femoral artery     

Analysis of trends in emergency department attendances, hospital admissions and medical staffing in a Hong Kong university hospital: 5-year study

Background

The workload of emergency departments (ED) continually changes in response to presentations, overcrowding and availability of expertise and investigations.

Aims

To investigate changes in ED presentations and care processes, and the relationship of patient demand and ED staff resources to waiting times and processing times.

Methods

Retrospective analysis of prospectively collected administrative data from January 1999 to April 2005 in an emergency department in a university teaching hospital in Hong Kong. All patients attending the emergency department during the study period were included. Monthly attendance data were retrieved and analysed to determine both qualitative and quantitative changes in the patterns of presentation to the ED using prospectively gathered data.

Results

Total ED attendances decreased by 25% during the study with little seasonal variation. The admission rate and the use of ambulances increased steadily and significantly. Medical patients are increasing proportionately, but trauma patients are decreased in number.

Conclusion

There have been major changes in the patterns of ED attendances and ED waiting times over the study period in this teaching hospital ED. Decreasing overall ED numbers are offset by an increasingly elderly population and a more complex case mix. Reducing clinical staff numbers appears to reduce the ED’s capacity to provide timely assessments and care and to function as hospital gatekeepers. Restoring staff numbers to previous levels may improve the quality and timeliness of ED services. It is necessary to refine measures of ED complexity and workload to determine appropriate staffing levels in the future.     

Emergency department triage: an ethical analysis

Background

Emergency departments across the globe follow a triage system in order to cope with overcrowding. The intention behind triage is to improve the emergency care and to prioritize cases in terms of clinical urgency.

Discussion

In emergency department triage, medical care might lead to adverse consequences like delay in providing care, compromise in privacy and confidentiality, poor physician-patient communication, failing to provide the necessary care altogether, or even having to decide whose life to save when not everyone can be saved. These consequences challenge the ethical quality of emergency care. This article provides an ethical analysis of "routine" emergency department triage. The four principles of biomedical ethics - viz. respect for autonomy, beneficence, nonmaleficence and justice provide the starting point and help us to identify the ethical challenges of emergency department triage. However, they do not offer a comprehensive ethical view. To address the ethical issues of emergency department triage from a more comprehensive ethical view, the care ethics perspective offers additional insights.

Summary

We integrate the results from the analysis using four principles of biomedical ethics into care ethics perspective on triage and propose an integrated clinically and ethically based framework of emergency department triage planning, as seen from a comprehensive ethics perspective that incorporates both the principles-based and care-oriented approach.     

A national Internet survey on rapid sequence intubation patterns from Turkey

Aim

To determine which specialty was performing rapid sequence intubation (RSI) in the emergency departments and to determine drug preferences of emergency physicians during RSI in Turkey.

Method

All emergency departments were contacted via e-mail, and the chiefs of the departments were requested to answer a survey consisting of six questions. Hospitals within the specified regions were selected with the only inclusion criteria being that the hospital had an emergency medicine department. We determined that there were 32 university and 9 state hospital emergency medicine residency programs.

Results

Thirty-five emergency departments responded. In 31 (73%) departments emergency medicine physicians, in 4 (10%) departments anesthetists, and in 7 (17%) departments physicians of either specialty were routinely performing RSI. The most commonly preferred drugs were fentanyl for premedication, vecuronium for defasciculation, etomidate for induction, and succinylcholine for neuromuscular blocking.

Conclusion

In the majority of the emergency departments in Turkey, emergency medicine physicians perform the RSI; the anesthetists perform it in only a few departments.