Emergency Department Right Upper Quadrant Ultrasound Is Associated with a Reduced Time to Diagnosis and Treatment of Ruptured Ectopic Pregnancies

OBJECTIVE: To determine whether the time to diagnosis and treatment of patients with ruptured ectopic pregnancy is significantly less for patients who had emergency department (ED) right upper quadrant (RUQ) ultrasound (US) compared with those who had US in the radiology department. METHODS: The authors conducted a retrospective review of eligible patients presenting to an urban ED between January 1990 and December 1998. Patients were included in the study if they were seen in the ED, had a discharge diagnosis of ruptured ectopic pregnancy, were brought immediately to the operating room after a definitive diagnosis of ectopic pregnancy rupture was made, and had more than 400 mL of intraperitoneal blood found at the time of surgery. The ED, hospital, radiology, and operative records were reviewed to determine presenting vital signs, intraperitoneal blood loss, time to diagnosis, time to treatment, and type of US performed. RESULTS: There were 37 patients enrolled; 16 received ED RUQ US (group I) and 21 had a formal US in radiology (group II). The ages, pulses, systolic blood pressures, and volumes of hemoperitoneum were similar between the two groups. The average time to diagnosis from ED arrival was 58 minutes for group I (SD = 57; 95% CI = 28 to 87) and 197 minutes for group II (SD = 82; 95% CI = 162 to 232) (p < or = 0.0001). The average time to operative treatment was 111 minutes (group I) (SD = 86; 95% CI = 69 to 153) and 322 minutes (group II) (SD = 107; 95% CI = 270 to 364) (p < or = 0.0001), respectively. CONCLUSIONS: Patients with ruptured ectopic pregnancy, who were selected to have RUQ US performed in the ED by emergency physicians, had an average decrease in time to diagnosis of two and a quarter hours, and an average decrease in time to treatment of three and a half hours, compared with those having a formal pelvic US in the radiology department. Further prospective investigation is needed to determine whether ED RUQ US can safely expedite care of patients with suspected ectopic pregnancy.     

Dedicated Asthma Center Improves the Quality of Care and Resource Utilization for Pediatric Asthma: A Multicenter Study

OBJECTIVES: To determine the relative effectiveness of pediatric asthma care among patients treated by a dedicated asthma center (AC) vs children who use the emergency department (ED) as a site of primary asthma care. METHODS: A retrospective case-control design was used. A random sample of AC cases was selected from a designated comprehensive AC over a 12-month period. Concurrent ED control patients were identified from all cases of pediatric asthma from five urban hospitals based on two or more ED visits. Cases and controls were matched (1:2) based on age and National Heart, Lung, and Blood Institute (NHLBI) asthma severity of illness classification. A telephone survey was administered to the caregivers of all enrolled patients in the study sample. RESULTS: Four elements of pediatric asthma care were examined: quality, access, hospital utilization, and functional impact of disease. Demographic data were similar between the ED cases and the AC controls. In terms of quality of care, the AC patients were more likely to use maintenance antiinflammatory medications, 60.2% vs 22.5% (OR = 5.3; 95% CI = 2.9 to 9.7) and more likely to be taking medications at school, 71.4% vs 48.1% (OR = 2.7; 95% CI = 1.5 to 4.7). In terms of access to care, the AC families were more likely to have a physician to call to assist with outpatient management, 98.2% vs 65.0% (OR = 25.3; 95% CI = 9.0 to 76.9). Frequent ED utilization (> or = 1 visit/month) was less likely in the AC patients, 9.2% vs 22.0% (OR = 0.35; 95% CI = 0.16 to 0.79) and school absenteeism was lower as well (9.5 +/- 6.7 days vs 16.6 +/- 10.3, p < 0.001). Additionally, the caregivers of the AC patients missed fewer workdays (4.7 +/- 2.8 vs 7.4 +/- 4.1; p = 0.03). CONCLUSIONS: Significant disparities in quality, access, resource utilization, and functional impact exist between AC and ED patients. Emergency physicians have a unique opportunity to improve the public health by directing ED patients toward pediatric AC treatment.     

Bedside Ultrasound Maximizes Patient Satisfaction

Background

Bedside ultrasound (US) is associated with improved patient satisfaction, perhaps as a consequence of improved time to diagnosis and decreased length of stay (LOS).

Objectives

Our study aimed to quantify the association between beside US and patient satisfaction and to assess patient attitudes toward US and perception of their interaction with the clinician performing the examination.

Methods

We enrolled a convenience sample of adult patients who received a bedside US. The control group had similar LOS and presenting complaints but did not have a bedside US. Both groups answered survey questions during their emergency department (ED) visit and again by telephone 1 week later. The questionnaire assessed patient perceptions and satisfaction on a 5-point Likert scale.

Results

Seventy patients were enrolled over 10 months. The intervention group had significantly higher scores on overall ED satisfaction (4.69 vs. 4.23; mean difference 0.46; 95% confidence interval [CI] 0.17–0.75), diagnostic testing (4.54 vs. 4.09; mean difference 0.46; 95% CI 0.16–0.76), and skills/abilities of the emergency physician (4.77 vs. 4.14; mean difference 0.63; 95% CI 0.29–0.96). A trend to higher scores for the intervention group persisted on follow-up survey.

Conclusions

Patients who had a bedside US had statistically significant higher satisfaction scores with overall ED care, diagnostic testing, and with their perception of the emergency physician. Bedside US has the potential not only to expedite care and diagnosis, but also to maximize satisfaction scores and improve the patient–physician relationship, which has increasing relevance to health care organizations and hospitals that rely on satisfaction surveys.     

The Potential Role of Ultrasound in the Work-up of Appendicitis in the Emergency Department

Background

Acute appendicitis is common in the adult emergency department (ED). Computed tomography (CT) scan is frequently used to diagnose this condition, but ultrasound (US)—commonly used in pediatric diagnosis—may also have a role.

A Prospective Comparison of Supine Chest Radiography and Bedside Ultrasound for the Diagnosis of Traumatic Pneumothorax

Background: Supine anteroposterior (AP) chest radiography may not detect the presence of a small or medium pneumothorax (PTX) in trauma patients. Objectives: To compare the sensitivity and specificity of bedside ultrasound (US) in the emergency department (ED) with supine portable AP chest radiography for the detection of PTX in trauma patients, and to determine whether US can grade the size of the PTX. Methods: This was a prospective, single‐blinded study with convenience sampling, based on researcher availability, of blunt trauma patients at a Level 1 trauma center with an annual census of 75,000 patients. Enrollment criteria were adult trauma patients receiving computed tomography (CT) of the abdomen and pelvis (which includes lung windows at the authors' institution). Patients in whom the examination could not be completed were excluded. During the initial evaluation, attending emergency physicians performed bedside trauma US examinations to determine the presence of a sliding lung sign to rule out PTX. Portable, supine AP chest radiographs were evaluated by an attending trauma physician, blinded to the results of the thoracic US. The CT results (used as the criterion standard), or air release on chest tube placement, were compared with US and chest radiograph findings. Sensitivities and specificities with 95% confidence intervals (95% CIs) were calculated for US and AP chest radiography for the detection of PTX, and Spearman's rank correlation was used to evaluate for the ability of US to predict the size of the PTX on CT. Results: A total of 176 patients were enrolled in the study over an eight‐month period. Twelve patients had a chest tube placed prior to CT. Pneumothorax was detected in 53 (30%) patients by US, and 40 (23%) by chest radiography. There were 53 (30%) true positives by CT or on chest tube placement. The sensitivity for chest radiography was 75.5% (95% CI = 61.7% to 86.2%) and the specificity was 100% (95% CI = 97.1% to 100%). The sensitivity for US was 98.1% (95% CI = 89.9% to 99.9%) and the specificity was 99.2% (95% CI = 95.6% to 99.9%). The positive likelihood ratio for a PTX was 121. Spearman's rank correlation showed at ρ of 0.82. Conclusions: With CT as the criterion standard, US is more sensitive than flat AP chest radiography in the diagnosis of traumatic PTX. Furthermore, US allowed sonologists to differentiate between small, medium, and large PTXs with good agreement with CT results.     

Thoracic point-of-care ultrasound is an accurate diagnostic modality for clinically significant traumatic pneumothorax

Objective

There are conflicting data regarding the accuracy of thoracic point-of-care ultrasound (POCUS) in detecting traumatic pneumothorax (PTX). The purpose of our study was to determine the accuracy of thoracic POCUS performed by emergency physicians for the detection of clinically significant PTX in blunt and penetrating trauma patients.

Methods

We conducted a retrospective institutional review board–approved study of trauma patients 15 years or older presenting to our urban Level I academic trauma center from December 2021 to June 2022. All study patients were imaged with single-view chest radiography (CXR) and thoracic POCUS. The presence or absence of PTX was determined by multidetector computed tomography (CT) or CXR and ultrasound (US) with tube thoracostomy placement.

Results

A total of 846 patients were included, with 803 (95%) sustaining blunt trauma. POCUS identified 13/15 clinically significant PTXs (defined as ≥35 mm of pleural separation on a blinded overread or placement of a tube thoracostomy prior to CT) with a sensitivity of 87% (95% confidence interval [CI] 58–97), specificity of 100% (95% CI 99–100), positive predictive value of 81% (95% CI 54%–95%), and negative predictive value of 100% (95% CI 99%–100%). The positive likelihood ratio was 484 and the negative likelihood ratio was 0.1. CXR identified eight (53%) clinically significant PTXs, with a sensitivity of 53% (95% CI 27%–78%) and a specificity of 100%, when correlated with the CT. The most common reason for a missed PTX identified on expert-blinded overread was failure to recognize a lung point sign that was present on US.

Conclusions

Thoracic POCUS accurately identifies the majority of clinically significant PTXs in both blunt and penetrating trauma patients. Common themes for false-negative thoracic US in the expert-blinded overread process identified key gaps in training to inspire US education and medical education research.     

Emergency Evaluation of Patients Presenting with Acute Scrotum Using Bedside Ultrasonography

Acute scrotal pain is not a rare emergency department (ED) complaint. Traditional reliance on medical history and physical examination can be precarious as signs and symptoms can overlap in various etiologies of acute scrotal pain. OBJECTIVE: To determine the accuracy with which emergency physicians (EPs) using bedside ultrasonography are able to evaluate patients presenting to the ED with acute scrotal pain. METHODS: The study was performed at an urban community hospital ED with a residency program and an annual census of 70,000. A retrospective chart review identified 36 patients who presented with complaints of acute scrotal pain and were evaluated by EPs using bedside ultrasound. A 5.0- or 7.5-MHz linear-array transducer with color and power Doppler capability was used to scan the scrotum. Patients were seen between July 1998 and September 1999. Diagnoses were verified by radiology or surgery. Sensitivity and specificity with 95% confidence intervals were calculated. RESULTS: The EP ultrasound examinations agreed with confirmatory studies for 35 of 36 patients, resulting in a sensitivity of 95% (95% CI = 0.78 to 0.99) and a specificity of 94% (95% CI = 0.72 to 0.99). Diagnoses included three testicular torsions, six cases of epididymitis, four cases of orchitis, one testicular fracture, three hernias, three hydroceles, and 15 normal examinations. One case of epididymitis was misdiagnosed as an epididymal mass. CONCLUSIONS: This study suggests that EPs using bedside ultrasonography are able to accurately diagnose patients presenting with acute scrotal pain. In addition, they appear able to differentiate between surgical emergencies, such as testicular torsion, and other etiologies.     

Goal-directed abdominal ultrasonography: impact on real-time decision making in the emergency department

The impact of “goal-directed” abdominal ultrasound (US) on real-time decision making in the Emergency Department (ED) was studied, with specific emphasis on the certainty of diagnosis, treatment, and disposition plans. A prospective, interventional study enrolled 212 patients at a county teaching hospital ED, who underwent bedside US by experienced ED sonographers. A study questionnaire was completed documenting the US indication, working diagnosis, treatment, and disposition plan. The physicians assigned pre-test and post-test levels of certainty for the diagnosis, treatment plan, and disposition on an integral scale from 1 to 10. Scores for diagnosis were further categorized into low (1–3), moderate (4–7) and high certainty of disease. Absolute mean changes in level of certainty for diagnosis, treatment, and disposition were 3.2 (95% CI 3.1–3.3), 2.0 (95% CI 1.9–2.1), and 1.9 (95% CI 1.8–2.0), respectively. The direction of change after US for certainty of diagnosis was evenly split, with 47% increasing and 47% decreasing. The majority of patients categorized as either high or low certainty of disease had US results concordant with the physician’s initial assessment. However, 16% moved from either high to low or from low to high certainty categories after US. Patients with moderate certainty moved evenly to either the low or high post-test category in 97% of cases. Treatment and disposition decisions were less impacted by US, with the majority of cases increasing in certainty irrespective of the US results. Bedside ultrasonography in the ED has an important impact on real-time decision-making, particularly in terms of the certainty of diagnosis.     

Emergency department diagnosis of pulmonary embolism is associated with significantly reduced mortality: A linked data population study

Objectives: We characterized patients admitted via ED with a principal hospital discharge diagnosis of pulmonary embolism (PE) and compared mortality of those diagnosed in the ED with those diagnosed after admission. Methods: Patients with a hospital discharge diagnosis ICD 10 I26 presenting to the ED in Perth, Western Australia between 1 July 2000 and 30 December 2006 had records from the Emergency Department Information System linked to the Western Australian Hospital Morbidity Data System and the death registry. Results: Of 2250 patients (mean age 60.4), 1227 (54.5%) were female. Of 1931 patients with an ED diagnosis recorded, 1207 (62.5%) were diagnosed with PE in ED. Of these, 383 (17.0%) had presented to an ED within 28 days previously, 142 (37.1%) with either chest pain or breathing problems, with 207 (54.0%) admitted but not receiving a principal hospital discharge diagnosis of PE. There were 127 (5.6%) in‐hospital deaths. Controlling for age and comorbidity with logistic regression, patients diagnosed with PE in ED were less likely to die in hospital, within 7 and 30 days of ED arrival, than those diagnosed after admission (adjusted OR 0.31, 95% CI 0.20–0.47; adjusted OR 0.32, 95% CI 0.19–0.53; adjusted OR 0.30, 95% CI 0.20–0.44; respectively). Conclusion: Making the diagnosis of PE in ED was associated with a substantial survival advantage that persisted after hospital discharge.     

Factors Associated with Prehospital Delay for Acute Stroke in Ulsan, Korea

Background: Early hospital presentation is critical in the treatment of acute ischemic stroke with thrombolysis. Objectives: The aim of this study was to investigate the factors associated with prehospital delay in acute ischemic stroke. Methods: Data were retrospectively collected over a 1-year period from 247 acute ischemic stroke patients who presented to the emergency department (ED) within 7 days after symptom onset. To investigate the factors associated with prehospital delay, sociodemographic data, initial symptoms, risk factor, National Institutes of Stroke Scale in the ED, and use of emergency medical services (EMS) were evaluated. Univariate and multivariate analysis were used to evaluate delay factors. Results: Of 247 patients (mean age 64.4 ± 12.6 years, 149 male patients), the non-delay group (≤ 2 h after symptom onset) included 45 patients (mean age 60.0 ± 13.1 years, 31 male patients) and the delay group (> 2 h after symptom onset) included 202 patients (mean age 65.4 ± 12.3 years, 118 male patients). Advanced age (odds ratio [OR] 1.056, 95% confidence interval [CI] 1.024-1.089), no consciousness disturbance at symptom onset (OR 2.938, 95% CI 1.066-8.104), presentation to ED by self (OR 3.826, 95% CI 1.580-9.624), referral from other hospital (OR 16.787, 95% CI 5.445-51.750), and worsened symptoms at the ED compared to symptom onset (OR 7.708, 95% CI 1.557-38.151) were associated with a prehospital delay. Conclusion: Elderly patients with progressive symptom worsening had delayed arrival, but those who used EMS or had disturbed consciousness at symptom onset had early arrival.     

ABSCESS: Applied Bedside Sonography for Convenient Evaluation of Superficial Soft Tissue Infections

Objectives: Soft tissue infections are a common presenting complaint in the emergency department (ED). The authors sought to determine the utility of ED bedside ultrasonography (US) in detecting subcutaneous abscesses. Methods: Between August 2003 and November 2004, a prospective, convenience sample of adult patients with a chief complaint suggestive of cellulitis and/or abscess was enrolled. US was performed by attending physicians or residents who had attended a 30‐minute training session in soft tissue US. The treating physician recorded a yes/no assessment of whether he or she believed an abscess was present before and after the US examination. Incision and drainage (I + D) was the criterion standard when performed, while resolution on seven‐day follow‐up was the criterion standard when I + D was not performed. Results: Sixty‐four of 107 patients had I + D–proven abscess, 17 of 107 had negative I + D, and 26 of 107 improved with antibiotic therapy alone. The sensitivity of clinical examination for abscesses was 86% (95% confidence interval [CI] = 76% to 93%), and the specificity was 70% (95% CI = 55% to 82%). The positive predictive value was 81% (95% CI = 70% to 90%), and the negative predictive value was 77% (95% CI = 62% to 88%). The sensitivity of US for abscess was 98% (95% CI = 93% to 100%), and the specificity was 88% (95% CI = 76% to 96%). The positive predictive value was 93% (95% CI = 84% to 97%), and the negative predictive value was 97% (95% CI = 88% to 100%). Of 18 cases in which US disagreed with the clinical examination, US was correct in 17 (94% of cases with disagreement, χ²= 14.2, p = 0.0002). Conclusions: ED bedside US improves accuracy in detection of superficial abscesses.     

Comparison of the Accuracy of Emergency Department-Performed Point-of-Care-Ultrasound (POCUS) in the Diagnosis of Lower-Extremity Deep Vein Thrombosis

Background

Compression ultrasonography is the most effective diagnostic tool in the emergency department (ED) for the diagnosis of deep vein thrombosis (DVT). It has been demonstrated to be highly accurate and cost-effective.

The Learning Curve of Resident Physicians Using Emergency Ultrasonography for Obstructive Uropathy

Background: Given the time, expense, and radiation exposure associated with computed tomography (CT), ultrasonography (US) is considered an alternative imaging study that could expedite patient care in patients with suspected obstructive uropathy. However, there is a paucity of literature regarding bedside US for obstructive uropathy in the emergency department (ED), and it is unknown how much experience is required for competency in such exams. Objectives: The objective was to assess the learning curve for the detection of obstructive uropathy of resident physicians training in ED bedside US (EUS) during a dedicated EUS elective. Methods: This was a prospective cohort study of residents participating in an EUS elective. Patients presenting with acute abdominal or flank pain suggestive of an obstructive uropathy were enrolled and underwent EUS prior to noncontrast CT. Physicians who had previously performed at least 10 EUS exams for obstructive uropathy recorded results on a standardized data sheet, which was subsequently compared to the results of noncontrast CT read by board‐certified radiologists blinded to the results of the EUS. In addition to an unadjusted chi‐square test for trend, a multivariable logistic regression analysis, adjusting for stone size and operator, was performed. Finally, generalized estimating equations were used to describe test characteristics while accounting for potential clustering between exams by operator. Results: Twenty‐three resident physicians participated and enrolled a convenience sample of 393 patients. A total of 157 patients (40%) were diagnosed with an obstructing ureterolith, and three (1%) were diagnosed with nonobstructing ureterolithiasis. An unadjusted chi‐square test for trend demonstrated a statistically significant increase in both sensitivity (χ² = 11.4, p = 0.02) and specificity (χ² = 6.4, p = 0.04) for each level of increase in number of exams. On multivariable regression analysis, when adjusting for size of stone and operator, for every five additional exams after the first 10 EUS exams, the odds ratio for a true positive for obstruction increased by 1.7 (95% confidence interval [CI] = 1.2 to 2.5, p = 0.003). After accounting for clustering of exams by operator, overall EUS sensitivity and specificity for obstructive uropathy were 82% (95% CI = 77% to 87%) and 88% (95% CI = 85% to 92%). Stratifying by number of exams, the sensitivity was 72% (95% CI = 62% to 80%) for the 11th through 20th exams, 90% (95% CI = 83% to 96%) for the 21st through 30th exams, and 95% (95% CI = 91% to 99%) for the 31st through 43rd exams. Likewise, specificity was 82% (95% CI = 75% to 89%) for the 11th through 20th exams, 90% (95% CI = 85% to 95%) for the 21st through 30th exams, and 92% (95% CI = 86% to 98%) for the 31st through 50th exams. Conclusions: Physicians training in EUS may be able to accurately assess for obstructive uropathy after 30 exams. ACADEMIC EMERGENCY MEDICINE 2010; 17:1024–1027 © 2010 by the Society for Academic Emergency Medicine     

Emergency Thoracic Ultrasound in the Differentiation of the Etiology of Shortness of Breath (ETUDES): Sonographic B-lines and N-terminal Pro-brain-type Natriuretic Peptide in Diagnosing Congestive Heart Failure

Objectives: Sonographic thoracic B‐lines and N‐terminal pro‐brain‐type natriuretic peptide (NT‐ProBNP) have been shown to help differentiate between congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The authors hypothesized that ultrasound (US) could be used to predict CHF and that it would provide additional predictive information when combined with NT‐ProBNP. They also sought to determine optimal two‐ and eight‐zone scanning protocols when different thresholds for a positive scan were used. Methods: This was a prospective, observational study of a convenience sample of adult patients presenting to the emergency department (ED) with shortness of breath. Each patient had an eight‐zone thoracic US performed by one of five sonographers, and serum NT‐ProBNP levels were measured. Chart review by two physicians blinded to the US results served as the criterion standard. The operating characteristics of two‐ and eight‐zone thoracic US alone, compared to, and combined with NT‐ProBNP test results for predicting CHF were calculated using both dichotomous and interval likelihood ratios (LRs). Results: One‐hundred patients were enrolled. Six were excluded because of incomplete data. Results of 94 patients were analyzed. A positive eight‐zone US, defined as at least two positive zones on each side, had a positive likelihood ratio (LR+) of 3.88 (99% confidence interval [CI] = 1.55 to 9.73) and a negative likelihood ratio (LR?) of 0.5 (95% CI = 0.30 to 0.82), while the NT‐ProBNP demonstrated a LR+ of 2.3 (95% CI = 1.41 to 3.76) and LR? of 0.24 (95% CI = 0.09 to 0.66). Using interval LRs for the eight‐zone US test alone, the LR for a totally positive test (all eight zones positive) was infinite and for a totally negative test (no zones positive) was 0.22 (95% CI = 0.06 to 0.80). For two‐zone US, interval LRs were 4.73 (95% CI = 2.10 to 10.63) when inferior lateral zones were positive bilaterally and 0.3 (95% CI = 0.13 to 0.71) when these were negative. These changed to 8.04 (95% CI = 1.76 to 37.33) and 0.11 (95% CI = 0.02 to 0.69), respectively, when congruent with NT‐ProBNP. Conclusions: Bedside thoracic US for B‐lines can be a useful test for diagnosing CHF. Predictive accuracy is greatly improved when studies are totally positive or totally negative. A two‐zone protocol performs similarly to an eight‐zone protocol. Thoracic US can be used alone or can provide additional predictive power to NT‐ProBNP in the immediate evaluation of dyspneic patients presenting to the ED.     

Elevated Intracranial Pressure Detected by Bedside Emergency Ultrasonography of the Optic Nerve Sheath

Patients with altered level of consciousness may be suffering from elevated intracranial pressure (EICP) from a variety of causes. A rapid, portable, and noninvasive means of detecting EICP is desirable when conventional imaging methods are unavailable. OBJECTIVES: The hypothesis of this study was that ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) could accurately predict the presence of EICP. METHODS: The authors performed a prospective, blinded observational study on emergency department (ED) patients with a suspicion of EICP due to possible focal intracranial pathology. The study was conducted at a large community ED with an emergency medicine residency program and took place over a six-month period. Patients suspected of having EICP by an ED attending were enrolled when study physicians were available. Unstable patients were excluded. ONSD was measured 3 mm behind the globe using a 10-MHz linear probe on the closed eyelids of supine patients, bilaterally. Based on prior literature, an ONSD above 5 mm on ultrasound was considered abnormal. Computed tomography (CT) findings defined as indicative of EICP were the presence of mass effect with a midline shift 3 mm or more, a collapsed third ventricle, hydrocephalus, the effacement of sulci with evidence of significant edema, and abnormal mesencephalic cisterns. For each patient, the average of the two ONSD measurements was calculated and his or her head CT scans were evaluated for signs of EICP. Student's t-test was used to compare ONSDs in the normal and EICP groups. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Thirty-five patients were enrolled; 14 had CT results consistent with EICP. All cases of CT-determined EICP were correctly predicted by ONSD over 5 mm on US. One patient with ONSD of 5.7 mm in one eye and 3.7 mm in the other on US had a mass abutting the ipsilateral optic nerve; no shift was seen on CT. He was placed in the EICP category on his data collection sheet. The mean ONSD for the 14 patients with CT evidence of EICP was 6.27 mm (95% CI = 5.6 to 6.89); the mean ONSD for the others was 4.42 mm (95% CI = 4.15 to 4.72). The difference of 1.85 mm (95% CI = 1.23 to 2.39 mm) yielded a p = 0.001. The sensitivity and specificity for ONSD, when compared with CT results, were 100% and 95%, respectively. The positive and negative predictive values were 93% and 100%, respectively. CONCLUSIONS: Despite small numbers and selection bias, this study suggests that bedside ED US may be useful in the diagnosis of EICP.     

Validation of emergency physician ultrasound in diagnosing hydronephrosis in ureteric colic

Objective: Patients presenting to the ED with obstructive nephropathies benefit from early detection of hydronephrosis. Out of hours radiological imaging is expensive and disruptive to arrange. Emergency physician ultrasound (EPU) could allow rapid diagnosis and disposition. If accurate it might avert the need for formal radiological imaging, exclude an obstruction and improve patient flow through the ED. Methods: This was a prospective study of a convenience sample of all adult non‐pregnant patients with presumed ureteric colic attending the ED with prior ethics committee approval. An emergency physician or registrar performed a focused ultrasound scan and were blinded to the patient’s other management. A computerized tomography scan was also performed for all patients while in the ED or within 24 h of the EPU. The accuracy of EPU detection of hydronephrosis was determined; using computerized tomography scans reported by a senior radiologist as the ‘gold‐standard’. Results: Sixty‐three patients with suspected ureteric colic were enrolled of whom 57 completed both EPU and computerized tomography imaging. Forty‐nine had confirmed nephrolithiasis by computerized tomography with 39 having evidence of hydronephrosis. Overall prevalence of hydronephrosis was 68% (95% confidence interval [CI] 56–79%); compared with computerized tomography, EPU had a sensitivity of 80% (95% CI 65–89%); specificity of 83% (95% CI 61–94%); positive predictive value of 91% (95% CI 75–98%) and negative predictive value of 65% (95% CI 43–83%). The overall accuracy was 81% (95% CI 69–89%). Conclusion: Although the accuracy of detection of hydronephrosis after focused training in EPU is encouraging, further experience and training might improve the accuracy of EPU and allow its use as a screening tool.     

Do Emergency Physicians Save Time When Locating a Live Intrauterine Pregnancy with Bedside Ultrasonography?

OBJECTIVE: To determine whether patients presenting to the emergency department (ED) with first-trimester pregnancy complications have a decreased length of stay (LOS) when a live intrauterine pregnancy (IUP) is diagnosed by emergency physicians (EPs). METHODS: This study was performed at an urban community ED with a residency program and an annual census of 65,000. A retrospective chart review from October 1995 to August 1998 identified 1,419 patients who received ultrasound examinations confirming live IUP in the first trimester with pain and/or bleeding. Two hundred seventy-seven of these patients received their ultrasound examinations from EPs; 1, 142 patients received a study from radiology and were not scanned by EPs. The LOSs for the two groups were compared and defined as the time from being placed into a room to discharge from the ED. Significance was determined using a two-tailed t-test. Median times with confidence intervals were calculated. RESULTS: When patients had a live IUP confirmed by an EP, the median LOS was 21% (59 min) less than those who received an ultrasound examination by radiology (p = 0.0001; 95% CI = 49 min to 1 hr 17 min). When evaluated by time of day, patients who presented after hours (6 PM to 6 AM) and were scanned by EPs spent 28% (1 hr 17 min) less time in the ED (p = 0.0001; 95% CI = 55 min to 1 hr 37 min). CONCLUSIONS: Emergency physicians identifying live IUP with bedside ultrasonography significantly decreased patients' LOSs in the ED. The decrease in LOS was most apparent for patients presenting during evening and nighttime hours.     

Cancer diagnosis and outcomes in Michigan EDs vs other settings

Objective

This study determined the proportion of incident colorectal and lung cancers with a diagnosis associated with an emergency department (ED) visit. The characteristics of these patients and the correlation between diagnosis near an ED visit and stage at diagnosis were also examined.

Methods

A population-based sample of all Michigan cancer cases diagnosed in all EDs and other health care settings was used to extract a sample of patients >65 years old, diagnosed with colorectal and lung cancers between January 1, 1996, and June 30, 2000 (n = 20 311). Logistic regressions were used for the statistical analysis.

Results

Patients with a colorectal cancer diagnosis associated with an ED visit were more likely insured by Medicaid before diagnosis (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.17-1.60), had an inpatient admission before diagnosis (OR, 1.29; 95% CI, 1.06-1.56), had 3 or more comorbidities (OR, 4.11; 95% CI, 3.53-4.79), were more likely to be female (OR, 1.18; 95% CI, 1.07-1.31), and were more likely to be aged 85 years and older (OR, 1.89; 95% CI, 1.57-2.27). Patients who had at least one primary care physician (PCP) visit before diagnosis were less likely to have a diagnosis associated with an ED visit (OR, 0.68; 95% CI, 0.61-0.76). Patients diagnosed with lung cancer in association with an ED visit were also more likely to have an inpatient admission before diagnosis (OR, 1.21; 95% CI, 1.02-1.43), a higher comorbidity burden (OR, 12.44; 95% CI, 10.18-15.20), be female (OR, 1.13; 95% CI, 1.02-1.25), African-American (OR, 1.42; 95% CI, 1.21-1.66), and older (80 years and older) (ages 80-84 years: OR, 1.33; 95% CI, 1.13-1.57; age 85 years and older: OR, 1.52; 95% CI, 1.25-1.85). Patients with an ED visit near a colorectal cancer (OR, 1.28; 95% CI, 1.15-1.42) or lung cancer diagnosis (OR, 1.65; 95% CI, 1.44-1.88) were more likely to be diagnosed at a later stage compared with patients diagnosed in other settings.

Conclusions

An examination of patients' patterns of care leading to a cancer diagnosis in association with an ED visit lends insight to conditions precipitating a more immediate diagnosis and their associated outcomes.     

Diagnostic Accuracy of Point-Of-Care Ultrasound for Intussusception Performed by Pediatric Emergency Medicine Physicians

BackgroundIntussusception (INT) is a common cause of bowel obstruction in young children. Delay in diagnosis can lead to significant morbidity and mortality. There have been several studies evaluating early point-of-care ultrasound (POCUS) in the diagnosis of INT by nonradiologists.ObjectiveOur objective was to determine the diagnostic accuracy of POCUS by novice sonographer pediatric emergency medicine physicians (PEM-Ps) who received focused US training for diagnosing INT.MethodsWe performed a prospective observational study including 17 PEM-Ps (14 attendings, 3 fellows) trained to perform abdominal US for INT. Children suspected of having INT received POCUS performed and interpreted by a PEM-P, followed by a US study performed by a certified ultrasonographer and interpreted by an attending pediatric radiologist. Diagnostic concordance between PEM-P–and radiology-performed US (RPUS) results was assessed.ResultsOne hundred patients were enrolled; median patient age was 24 months. There was excellent diagnostic agreement for presence or absence of INT between PEM-Ps and RPUS (97% of cases; κ = 0.826). POCUS-diagnosed INT was present in 8 of 9 patients with RPUS-diagnosed INT (sensitivity 89%; 95% confidence interval [CI] 51–99%; specificity 98%; 95% CI 92–100%; positive predictive value 80%; 95% CI 44–96%; negative predictive value 99%; 95% CI 93–100%). Likelihood ratio for INT with a positive POCUS was 40.44 (95% CI 10.07–162.36) and with a negative POCUS was 0.11 (95% CI 0.02–0.72).ConclusionsPOCUS performed by novice sonographers to diagnose INT has high diagnostic concordance with RPUS. Emergency department–performed POCUS is a rapid and accurate method for diagnosing INT.     

The Association Between Emergency Department Crowding and Adverse Cardiovascular Outcomes in Patients with Chest Pain

Objectives: While emergency department (ED) crowding is a worldwide problem, few studies have demonstrated associations between crowding and outcomes. The authors examined whether ED crowding was associated with adverse cardiovascular outcomes in patients with chest pain syndromes (chest pain or related complaints of possible cardiac origin). Methods: A retrospective analysis was performed for patients ≥30 years of age with chest pain syndrome admitted to a tertiary care academic hospital from 1999 through 2006. The authors compared rates of inpatient adverse outcomes from ED triage to hospital discharge, defined as delayed acute myocardial infarction (AMI), heart failure, hypotension, dysrhythmias, and cardiac arrest, which occurred after ED arrival using five separate crowding measures. Results: Among 4,574 patients, 251 (4%) patients developed adverse outcomes after ED arrival; 803 (18%) had documented acute coronary syndrome (ACS), and of those, 273 (34%) had AMI. Compared to less crowded times, ACS patients experienced more adverse outcomes at the highest waiting room census (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.3 to 11.0) and patient-hours (OR = 5.2, 95% CI = 2.0 to 13.6) and trended toward more adverse outcomes during time of high ED occupancy (OR = 3.1, 95% CI = 1.0 to 9.3). Adverse outcomes were not significantly more frequent during times with the highest number of admitted patients (OR = 1.6, 95% CI = 0.6 to 4.1) or the highest trailing mean length of stay (LOS) for admitted patients transferred to inpatient beds within 6 hours (OR = 1.5, 95% CI = 0.5 to 4.0). Patients with non-ACS chest pain experienced more adverse outcomes during the highest waiting room census (OR = 3.5, 95% CI = 1.4 to 8.4) and patient-hours (OR = 4.3, 95% CI = 2.6 to 7.3), but not occupancy (OR = 1.8, 95% CI = 0.9 to 3.3), number of admitted patients (OR = 0.6, 95% CI 0.4 to 1.1), or trailing LOS for admitted patients (OR = 1.2, 95% CI = 0.6 to 2.0). Conclusions: There was an association between some measures of ED crowding and a higher risk of adverse cardiovascular outcomes in patients with both ACS-related and non–ACS-related chest pain syndrome.