Left bundle branch block without a typical contraction pattern is associated with increased risk of ventricular arrhythmias in cardiac resynchronization therapy patients

The International Journal of Cardiovascular Imaging - Cardiac resynchronization therapy (CRT) reduces the risk of ventricular arrhythmias (VA) in heart failure (HF) patients with left bundle branch...     

Determination of Left Ventricular Function by Emergency Physician Echocardiography of Hypotensive Patients

OBJECTIVE: To determine whether emergency physicians (EPs) with goal-directed training can use echocardiography to accurately assess left ventricular function (LVF) in hypotensive emergency department (ED) patients. METHODS: Prospective, observational study at an urban teaching ED with >100,000 visits/year. Four EP investigators with prior ultrasound experience underwent focused echocardiography training. A convenience sample of 51 adult patients with symptomatic hypotension was enrolled. Exclusion criteria were a history of trauma, chest compressions, or electrocardiogram diagnostic of acute myocardial infarction. A five-view transthoracic echocardiogram was recorded by an EP investigator who estimated ejection fraction (EF) and categorized LVF as normal, depressed, or severely depressed. A blinded cardiologist reviewed all 51 studies for EF, categorization of function, and quality of the study. Twenty randomly selected studies were reviewed by a second cardiologist to determine interobserver variability. RESULTS: Comparison of EP vs. primary cardiologist estimate of EF yielded a Pearson's correlation coefficient R = 0.86. This compared favorably with interobserver correlation between cardiologists (R = 0.84). In categorization of LVF, the weighted agreement between EPs and the primary cardiologist was 84%, with a weighted kappa of 0.61 (p < 0.001). Echocardiographic quality was rated by the primary cardiologist as good in 33%, moderate in 43%, and poor in 22%. The EF was significantly lower in patients with a cardiac cause of hypotension vs. other patients (25 +/- 10% vs. 48 +/- 17%, p < 0.001). CONCLUSIONS: Emergency physicians with focused training in echocardiography can accurately determine LVF in hypotensive patients.     

Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients

OBJECTIVE: We examined a physician-performed, goal-directed ultrasound protocol for the emergency department management of nontraumatic, symptomatic, undifferentiated hypotension. DESIGN: Randomized, controlled trial of immediate vs. delayed ultrasound. SETTING: Urban, tertiary emergency department, census >100,000. PATIENTS: Nontrauma emergency department patients, aged >17 yrs, and initial emergency department vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion. INTERVENTIONS: Group 1 (immediate ultrasound) received standard care plus goal-directed ultrasound at time 0. Group 2 (delayed ultrasound) received standard care for 15 mins and goal-directed ultrasound with standard care between 15 and 30 mins after time 0. MEASUREMENTS AND MAIN RESULTS: Outcomes included the number of viable physician diagnoses at 15 mins and the rank of their likelihood of occurrence at both 15 and 30 mins. One hundred eighty-four patients were included. Group 1 (n = 88) had a smaller median number of viable diagnoses at 15 mins (median = 4) than did group 2 (n = 96, median = 9, Mann-Whitney U test, p <.0001). Physicians indicated the correct final diagnosis as most likely among their viable diagnosis list at 15 mins in 80% (95% confidence interval, 70-87%) of group 1 subjects vs. 50% (95% confidence interval, 40-60%) in group 2, difference of 30% (95% confidence interval, 16-42%). CONCLUSIONS: Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic, symptomatic, undifferentiated hypotension in adult patients results in fewer viable diagnostic etiologies and a more accurate physician impression of final diagnosis.     

Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states

OBJECTIVES: Emergency echocardiography (EM echo) has been proposed to assist in decision-making in patients with pulseless electric activity (PEA) or PEA-like states. We observed the value of EM echo by emergency physicians in detecting pericardial effusion in patients in PEA and near PEA states. MATERIALS AND METHODS: Observational, prospective series at a Level 1 urban ED of patients with non-traumatic PEA or near PEA states who had EM echoes performed by emergency physicians during an 18-month period. Outcomes of patients with EM echoes were established by review of clinical course, formal echocardiography, radiography, operation or autopsy. RESULTS: Twenty patients had EM echo for non-traumatic hemodynamic collapse. Eight of 20 patients (40%) were without cardiac ventricular motion and were refractory to ACLS measures. Twelve of 20 (60%) patients had cardiac kinetic motion observed on echo. Eight of the 12 (67%) patients with cardiac motion had a pericardial effusion observed on EM echo. Formal echocardiography or other imaging studies confirmed all pericardial effusion cases. The following diagnoses were subsequently confirmed in patients with pericardial effusion: one aortic aneurysm, two aortic dissections, two metastatic cancers, one post-dialysis effusion, two minimal effusions. Three patients had tamponade with emergency pericardial drainage or surgery. In two of four patients with cardiac activity without pericardial effusion, EM echo was useful by detecting pacer capture and ROSC, respectively. CONCLUSIONS: Emergency echocardiography performed by emergency physicians in patients in PEA or near PEA states can detect pericardial effusions with correctable etiologies versus true PEA with ventricular standstill.     

Residency Training in Emergency Ultrasound: Fulfilling the Mandate

Although bedside ultrasound is listed in the Model of the Clinical Practice of Emergency Medicine as an integral diagnostic procedure, the manner in which the didactic, hands-on, and experiential components of emergency ultrasound are taught is not specifically prescribed by the Residency Review Committee for Emergency Medicine (RRC-EM) or any single sponsoring group. Seven professional organizations [the American Board of Emergency Medicine (ABEM), the American College of Emergency Medicine (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents Association (EMRA), the National Association of EMS Physicians (NAEMSP), the RRC-EM, and the Society for Academic Emergency Medicine (SAEM)] developed the Scope of Training Task Force, with the goal of identifying emerging areas of clinical importance to the specialty of emergency medicine, including emergency department (ED) ultrasound. The Task Force then identified a group of recognized authorities to thoughtfully address the issue of ED ultrasound training. This report represents a consensus of these identified experts on how emergency ultrasound training should be incorporated into emergency medicine residency programs.     

The Effect of Soft-tissue Ultrasound on the Management of Cellulitis in the Emergency Department

Objectives: To evaluate the effect of diagnostic soft-tissue ultrasound (US) on management of emergency department (ED) patients with clinical cellulitis.
Methods: This was a prospective observational study in an urban ED of adult patients with clinical soft-tissue infection without obvious abscess. The treating physician's pretest opinions regarding the need for further drainage procedures and the probability of subcutaneous fluid collection were determined. Emergency sonologists then performed US of the infected area, and the effect on management plan was recorded.
Results: Ultrasound changed the management of patients with cellulitis in 71/126 (56%) of cases. In the pretest group that was believed not to need further drainage, US changed the management in 39/82 (48%), with 33 receiving drainage and 6 receiving further diagnostics or consultation. In the pretest group in which further drainage was believed to be needed, US changed the management in 32/44 (73%), including 16 in whom drainage was eliminated and 16 who had further diagnostic interventions. US had a management effect in all pretest probabilities for fluid from 10% to 90%.
Conclusions: Soft-tissue US changes physician management in approximately half of patients in the ED with clinical cellulitis. US may guide management of cellulitis by detection of occult abscess, prevention of invasive procedures, and guidance for further imaging or consultation.     

An indolent penile herpetic ulcer in a patient with previously undiagnosed human immunodeficiency virus infection

We report a case of an atypical penile herpetic ulcer in a man with previously undiagnosed human immunodeficiency virus (HIV) infection. Swabs of the lesion were negative for herpes simplex virus (HSV) by culture and electron microscopy. However, histopathology of biopsy material showed characteristic herpetic multinucleate giant cells. Immunochemistry using polyclonal antibodies was positive for HSV1 and HSV2. The lesion completely resolved after treatment with aciclovir and the patient subsequently tested positively for HIV antibodies.