Description of basic competencies in clinical ultrasound imaging for emergency departments. / Competencias básicas de la ecografía clínica en los servicios de urgencias y emergencias.

TEXT: Recent years have seen great advances in the use of clinical ultrasound imaging in both hospital emergency departments and out-of-hospital settings. However, all new techniques require up-to-date definitions of competencies relevant to the clinical realities of different specialties and the geographic settings in which specialists work. To that end, a group of experts in clinical ultrasound reviewed the evidence available in the literature and strictly applied the Delphi method to define the competencies relevant to emergency physicians. The group worked with the starting premise that clinical ultrasound imaging should be a common competency across the specialty.

TEXTO: En los últimos años, la ecografía clínica (EC) ha sufrido un avance muy importante en su implantación dentro de los servicios de urgencias, tanto hospitalarios como extrahospitalarios, pero como toda técnica requiere un ámbito competencial definido, actualizado y enmarcado, tanto en la realidad clínica de la especialidad que desempeñamos como en la geográfica del país donde ejercemos. Por ello, un grupo de expertos en la materia ha desarrollado el presente documento en el que basándose por un lado en la evidencia disponible en la bibliografía científica y por otro en una metodología Delphi, planteó el objetivo de establecer un claro marco competencial base para todos los urgenciólogos, asumiendo como premisa inicial que la EC debería ser una competencia transversal común.

Clinical features of pericarditis with and without myocardial involvement diagnosed in the emergency department and factors associated with need for hospitalization. / Características clínicas de las pericarditis y miopericarditis diagnosticadas en urgencias y factores asociados con la necesidad de hospitalización.

OBJECTIVES: To analyze the clinical features of acute pericarditis diagnosed in the emergency department according to patient age and myocardial involvement (myopericarditis) and to determine factors associated with hospitalization. MATERIAL AND METHODS: Retrospective, descriptive, observational, single-center study of consecutive patients. We analyzed all cases of pericarditis diagnosed in the emergency department over a period of 10 years (2008-2017), reviewing clinical, electrocardiographic, and laboratory findings as well as ultrasound imaging for myocardial involvement. Characteristics were analyzed by age (under 50 years or 50 or older) and presence or not of myocardial involvement. Factors associated with hospitalization for both pericarditis and myopericarditis were identified by crude and adjusted odds ratios (ORs). RESULTS: A total of 983 patients were diagnosed with pericarditis (34% women, mean age, 42 years). The younger patients more often reported sharp chest pain modified by breathing or posture changes. Older patients had more concurrent cardiovascular disease and described chest pain as pressure (oppressive); acute coronary syndrome was suspected more often in the older patients. The only independent predictor of myopericarditis was a finding of electrocardiographic abnormalities, recorded in 72 cases (7%) (OR, 4.26; 95% CI, 1.89-9.59). Sixty-two patients (6%) were admitted for pericarditis. Associated factors were renal insufficiency (OR, 4.83; 95% CI, 1.66-14.05), pain modified by breathing or posture changes (OR, 0.54; 95% CI, 0.29-0.99), tachycardia (OR, 2.29; 95% CI, 1.15- 4.55), and myopericarditis (OR, 8.73; 95% CI, 4.65-16.38). Admission of 24 patients (33%) for myocarditis was related to focused cardiac ultrasound findings (OR, 13.72; 95% CI, 1.80-104). CONCLUSION: Age may affect the presentation of pericarditis. ST segment abnormalities on an electrocardiogram suggest myocardial involvement. Renal insufficiency, tachycardia, and myocardial involvement are the factors associated with a decision to admit patients with pericarditis. Ultrasound findings are associated with admission for myopericarditis.

OBJETIVO: Analizar los episodios de pericarditis aguda (PA) diagnosticados en urgencias en función de la edad y de la afectación miocárdica (miopericarditis, MioP), y determinar los factores asociados a hospitalización. METODO: Estudio observacional, descriptivo, unicéntrico de casos consecutivos, con análisis retrospectivo de todos los casos diagnosticados de PA en urgencias durante 10 años (2008-2017), y revisión de las características clínicas, ECG, analíticas y ecográficas (en MioP). Se compararon características clínicas según la edad (< 50 y $ 50 años) y existencia de MioP. Los factores asociados a hospitalización (PA y MioP) se identificaron de forma cruda y ajustada por las diferencias clínicas entre grupos. RESULTADOS: Se diagnosticaron 983 PA (34% mujeres, mediana de edad: 42 años). Los pacientes más jóvenes referían con mayor frecuencia dolor torácico (DT) punzante y modificable con la respiración o cambios posturales, y los más mayores tenían más comorbilidades cardiovasculares, refirieron más frecuentemente DT opresivo y generaron mayor sospecha de síndrome coronario agudo. Las alteraciones en el ECG (OR = 4,26; IC95% = 1,89-9,59) se asociaron a MioP (72 casos, 7%). Ingresaron 62 PA (6%), hecho asociado a antecedente de insuficiencia renal (OR = 4,83; IC95% = 1,66-14,05), DT que se modifica con movimientos respiratorios/posturales (OR = 0,54, IC95% = 0,29-0,99), taquicardia (OR = 2,29, IC95% = 1,15-4,55) y MioP (OR = 8,73, IC95% = 4,65-16,38). Ingresaron 24 MioP (33%), hecho asociado a alteraciones en la ecoscopia dirigida (protocolo FOCUS; OR = 13,72, IC95% = 1,80-104). CONCLUSIONES: La edad puede condicionar la presentación clínica en los pacientes con PA. Las alteraciones en el segmento ST en el ECG son sugestivos de implicación miocárdica. La insuficiencia renal, la taquicardia y la MioP son factores que incrementan la decisión de hospitalización en las PA; mientras que en las MioP, las alteraciones ecográficas.

Ultrasound imaging obtained by emergency department physicians to diagnose deep vein thrombosis: accuracy, safety, and efficiency. / Precisión, seguridad y eficiencia de la ecografía realizada por urgenciólogos en el diagnóstico de la trombosis venosa profunda en servicios de urgencias hospitalarios.

OBJECTIVES: To assess the accuracy, safety, and efficiency of ultrasound images obtained by emergency physician to diagnose deep vein thrombosis (DVT). patients with acute heart failure (AHF) attended in a hospital emergency department (ED). MATERIAL AND METHODS: Prospective multicenter cohort study. We assigned patients suspected of having DVT to an intervention or control group. Emergency physicians took ultrasound images that were later evaluated by a radiologist in the intervention group. In the control group, images were evaluated only by the radiologist. We analyzed patient, physician, and episode variables. Test results, times until imaging, and 30-day adverse events were also analyzed. Sensitivity, specificity, positive and negative likelihood ratios, and agreement between physicians and radiologists (κ statistic) were calculated. RESULTS: A total of 304 patients (209 in the intervention group and 95 controls) were included. The groups were comparable. The overall prevalence of DVT was 35.5% (95% CI, 30.3-41.0). The sensitivity of ultrasound images obtained by emergency physicians was superior in relation to experience: 71.4 (95% CI, 50.0-86.0) for those in a training course, 75.0 (95% CI, 80.0-95.4) for those with at least 2 months' practical experience, and 94.7 (95% CI, 82.7-98.5) for routine users. Specificity statistics for the 3 levels of physician experience were 83.3 (95% CI 55.2- 95.2), 100 (95% CI 83.0-100), and 96.6 (95% CI 88.4-99.0), respectively. The positive and negative likelihood ratios for ultrasound imaging by physicians were 27.94 and 0.054, respectively. The κ statistic was 0.80. Mean (SD) time until a physician took ultrasound images was 1.81 (1.46) hours versus 4.39 (1.81) hours until a radiologist obtained images (P = .007). Three deaths occurred within 30 days. They were not attributable to recurrence or bleeding. CONCLUSION: Ultrasound images taken by emergency physicians to diagnose DVT are accurate and safe and may be efficient. However, routine experience with ultrasound is necessary.

OBJETIVO: Evaluar la precisión, la seguridad y la eficiencia de la ecografía realizada por urgenciólogos para el diagnóstico de la trombosis venosa profunda (TVP). METODO: Estudio prospectivo multicéntrico de cohortes que incluyó pacientes con sospecha de TVP asignados a un grupo intervención (evaluados ecográficamente por el urgenciólogo y posteriormente por el radiólogo) y a un grupo control (evaluados únicamente por el radiólogo). Se analizaron las variables relacionadas con el paciente, el urgenciólogo, el episodio, el resultado de la prueba y los tiempos de estancia y acontecimientos a 30 días. Se calcularon la sensibilidad, la especificidad, las razones de verosimilitud positiva y negativa, y el índice kappa. RESULTADOS: Se incluyeron 304 pacientes (95 control, 209 intervención). Ambos grupos fueron comparables. La prevalencia de TVP en la cohorte global fue de 35,5% (IC 95% 30,3-41,0). La sensibilidad de la ecografía realizada por urgenciólogos fue superior según la experiencia-curso vs meses vs uso habitual: 71,4 (IC 95% 50,0-86,0) vs 75,0 (IC 95% 80,0-95,4) vs 94,7 (IC 95% 82,7-98,5), así como la especificidad 83,3 (IC 95% 55,2-95,2) vs 100 (IC 95% 83,0- 100) vs 96,6 (IC 95% 88,4-99,0). Las razones de verosimilitud positiva y negativa para la ecografía realizada por urgenciólogos fueron del 27,94 y del 0,054, respectivamente. El índice de kappa fue de 0,80. El tiempo hasta la realización de la ecografía por el urgenciólogo fue de 1,81 (DE 1,46) frente a 4,39 (DE 1,81) horas del radiólogo (p = 0,007). Durante el seguimiento a 30 días, se registraron 3 muertes, ninguna de ellas por recurrencia o hemorragia. CONCLUSIONES: La ecografía realizada por urgenciólogos para el diagnóstico de TVP es precisa, segura y podría resultar eficiente. Sin embargo, se requiere de experiencia basada en el uso habitual de esta técnica.

[Evaluation of acute poisonings due to chemical agents treated in an emergency department]. / Evaluación de las intoxicaciones agudas por productos químicos atendidas en un servicio de urgencias.

BACKGROUND AND OBJECTIVES: The objective of this study is to evaluate the epidemiological and toxicological characteristics of chemical exposures requiring Emergency Department consultation. METHODOLOGY: Descriptive study of Hospital Emergency Department consultations between 2000 and 2008 derived from exposure to a chemical agent. RESULTS: A total of 992 patients were included; the mean age was 42.7+18 years and 58.1% were female. The main causes were domestic accidents (67.3%), occupational accidents (14.8%), attempted suicides (11.2%) and incidents of violence (3.2%). There was a significantly greater proportion of females involved in domestic accidents and males in occupational accidents (p<0.05). The most-frequently involved products were caustic substances (39.9%), irritating gases (13.8%), detergents (12.3%), solvents (12%) and asphyxiating gases (9.5%). Hospital admission was necessary in 10.8% of patients and 10 deaths occurred (1%), with non-occupational accidents being more severe (p<0.05). CONCLUSIONS: Exposures to chemical agents represent a high number of poisonings in Emergency Department. Domestic accidents, which mainly affect women and often involve caustic substances, are much more frequent than occupational accidents. The general prognosis is good and mortality is very low.