Dengue Management in Triage using Ultrasound in children from Cambodia: a prospective cohort study.

BACKGROUND: Dengue is a mosquito-borne viral infection with increasing global prevalence. It is endemic in more than 100 countries, with a heavy burden in Asia. Ultrasound findings including gallbladder wall thickening, ascites, and pleural effusions secondary to plasma leakage have been described in dengue. We aimed to determine if the presence of point-of-care ultrasound findings early in suspected dengue could predict clinical worsening in ambulatory pediatric patients. METHODS: We did a prospective, single-blinded, observational cohort study at a children's hospital in Siem Reap, Cambodia during periods of dengue outbreak. Ambulatory patients were screened and children ages > 3 month and ≤ 16 years with suspected acute, non-severe dengue were enrolled. Subjects had chest and abdominal ultrasound exams. Independently, subjects were evaluated by a blinded physician who determined a treatment plan as per usual practice. Follow-up was conducted 7-10 days after the initial visit. Analysis of ultrasound findings was performed to determine their relationship with outcome measures including need for unplanned hospital visits or admissions. FINDINGS: A total of 2,186 children were screened during periods of national dengue outbreak in Cambodia in consecutive years 2018-2019, and 253 children met eligibility criteria. Results showed patients with gallbladder wall thickening (> 3·0 mm) who were discharged had a significantly more likely need for unplanned visit or hospitalization than those with normal gallbladder wall, 67% (95% CI 44 - 84) versus 17% (95% CI 12 - 24), p < 0.0001. Subjects with any abnormal ultrasound finding were more likely to be directly admitted versus discharged upon initial presentation, 62·2% (95% CI 46.1 - 76.0) versus 19.5% (95% CI 14.8 - 25.4), p < 0.0001. INTERPRETATION: Point-of-care ultrasound findings, particularly gallbladder wall thickening, in suspected early dengue can help predict disease progression in ambulatory patients. Ultrasound has potential to help guide management of suspected dengue patients and resource management during periods of dengue outbreak. FUNDING: Society for Academic Emergency Medicine Foundation.

Clinical failure in abscess treatment: the role of ultrasound and incision and drainage.

PURPOSE: Skin and soft tissue abscesses are commonly treated in emergency departments (ED). The use of bedside ultrasound may improve patient outcomes. The primary objective of this study was to examine the relationship between ultrasound use and risk of treatment failure in ED patients treated for abscesses. METHODS: In this multi-center observational study, we reviewed medical records of adult patients evaluated for abscesses. Demographics, infection characteristics, treatments rendered, use of ultrasound (for diagnosis and/or treatment) and follow-up data were collected from electronic medical record review. Treatment failure, the primary outcome, was defined as any surgical intervention after the initial ED visit. Multivariable logistic regression tested whether incision and drainage utilizing ultrasound was associated with reduced treatment failure. RESULTS: We identified 609 patients diagnosed with abscesses over a 22-month period. Of them 75% were treated with incision and drainage, 55% had an ultrasound and 15% failed treatment. Multi-variable analysis demonstrated an 8% probability of failure with ultrasound plus incision and drainage, 14% with blind incision and drainage and 25% without incision and drainage. Individuals with incision and drainage performed were 50% less likely to fail treatment (RR 0.53, 95%CI 0.35-0.81) and 70% less likely to fail treatment (RR 0.30, 95%CI 0.18-0.51) with ultrasound and incision and drainage. CONCLUSIONS: The use of ultrasound in diagnosing and or/treating patients with abscesses in the ED is associated with decreased treatment failure risk when utilized with incision and drainage. Consideration of ultrasound use in other studies which assess treatment methods in relation to patient outcomes may be warranted.

RéSUMé : OBJECTIF: Les abcès de la peau et des tissus mous sont couramment traités dans les services d'urgence (SU). L'utilisation de l'échographie au chevet du patient peut améliorer les résultats des patients. L'objectif principal de cette étude était d'examiner la relation entre l'utilisation de l'échographie et le risque d'échec du traitement chez les patients des urgences traités pour des abcès. MéTHODES: Dans cette étude d'observation multicentrique, nous avons examiné les dossiers médicaux des patients adultes évalués pour les abcès. Les données démographiques, les caractéristiques de l'infection, les traitements rendus, l'utilisation de l'échographie (pour le diagnostic et/ou le traitement) et les données de suivi ont été recueillies à partir de l'examen des dossiers médicaux électroniques. L'échec du traitement, le critère de jugement principal, a été défini comme toute intervention chirurgicale après la visite initiale au service d'urgence. Une régression logistique multivariable a permis de vérifier si l'incision et le drainage par ultrasons étaient associés à une réduction de l'échec du traitement. RéSULTATS: Nous avons identifié 609 patients diagnostiqués avec des abcès sur une période de 22 mois. Parmi eux, 75 % ont été traités par incision et drainage, 55% ont eu une échographie et 15 % ont échoué le traitement. L'analyse multivariée a démontré une probabilité d'échec de 8 % avec échographie plus incision et drainage, 14 % avec incision et drainage aveugle et 25 % sans incision et drainage. Les personnes chez qui l'on a pratiqué une incision et un drainage avaient 50 % moins de risques d'échouer le traitement (RR 0,53, 95 % IC 0,35-0,81) et 70 % moins de risques d'échouer le traitement (RR 0,30, 95 % IC 0,18-0,51) avec l'échographie et l'incision et le drainage. CONCLUSIONS: L'utilisation de l'échographie pour le diagnostic et/ou le traitement des patients atteints d'abcès aux urgences est associée à une diminution du risque d'échec du traitement lorsqu'elle est utilisée avec l'incision et le drainage. Il peut être justifié d'envisager l'utilisation de l'échographie dans d'autres études qui évaluent les méthodes de traitement en fonction des résultats pour les patients.

Accuracy of emergency physicians' self-estimates of CT scan utilization and its potential effect on an audit and feedback intervention: a randomized trial.

BACKGROUND: Audit and feedback (A&F) has been used as a strategy to modify clinician behavior with moderate success. Although A&F is theorized to work by improving the accuracy of clinicians' estimates of their own behavior, few interventions have included assessment of clinicians' estimates at baseline to examine whether they account for intervention success or failure. We tested an A&F intervention to reduce computed tomography (CT) ordering by emergency physicians, while also examining the physicians' baseline estimates of their own behavior compared to peers. METHODS: Our study was a prospective, multi-site, 20-month, randomized trial to examine the effect of an A&F intervention on CT ordering rates, overall and by test subtype. From the electronic health record, we obtained 12 months of baseline CT ordering per 100 patients treated for every physician from four emergency departments. Those who were randomized to receive A&F were shown a de-identified graph of the group's baseline CT utilization, asked to estimate wherein the distribution of their own CT order practices fell, and then shown their actual performance. All participants also received a brief educational intervention. CT ordering rates were collected for all physicians for 6 months after the intervention. Pre-post ordering rates were compared using independent and repeated measures t tests. RESULTS: Fifty-one of 52 eligible physicians participated. The mean CT ordering rate increased significantly in both experimental conditions after the intervention (intervention pre = 35.7, post = 40.3, t = 4.13, p < 0.001; control pre = 33.9, post = 38.9, t = 3.94, p = 0.001), with no significant between-group difference observed at follow-up (t = 0.43, p = 0.67). Within the intervention group, physicians had poor accuracy in estimating their own ordering behavior at baseline: most overestimated and all guessed that they were in the upper half of the distribution of their peers. CT ordering increased regardless of self-estimate accuracy. CONCLUSIONS: Our A&F intervention failed to reduce physician CT ordering: our feedback to the physicians showed most of them that they had overestimated their CT ordering behavior, and they were therefore unlikely to reduce it as a result. After "audit," it may be prudent to assess baseline clinician awareness of behavior before moving toward a feedback intervention.

Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial.

STUDY OBJECTIVE: We hypothesize that clinical failure rates will be lower in patients treated with point-of-care ultrasonography and incision and drainage compared with those who undergo incision and drainage after physical examination alone. METHODS: We performed a prospective randomized clinical trial of patients presenting with a soft tissue abscess at a large, academic emergency department. Patients presenting with an uncomplicated soft tissue abscess requiring incision and drainage were eligible for enrollment and randomized to treatment with or without point-of-care ultrasonography. The diagnosis of an abscess was by physical examination, bedside ultrasonography, or both. Patients randomized to the point-of-care ultrasonography group had an incision and drainage performed with bedside ultrasonographic imaging of the abscess. Patients randomized to the non-point-of-care ultrasonography group had an incision and drainage performed with physical examination alone. Comparison between groups was by comparing means with 95% confidence intervals. The primary outcome was failure of therapy at 10 days, defined as a repeated incision and drainage, following a per-protocol analysis. Multivariate analysis was performed to control for study variables. Our study was designed to detect a clinically important difference between groups, which we defined as a 13% difference. RESULTS: A total of 125 patients were enrolled, 63 randomized to the point-of-care ultrasonography group and 62 to physical examination alone. After loss to follow-up and misallocation, 54 patients in the ultrasonography group and 53 in the physical examination alone group were analyzed. The overall failure rate for all patients enrolled in the study was 10.3%. Patients who were evaluated with ultrasonography were less likely to fail therapy and have repeated incision and drainage, with a difference between groups of 13.3% (95% confidence interval 0.0% to 19.4%). Abscess locations were predominantly torso (21%), buttocks (21%), lower extremity (18%), and axilla or groin (16%). There was no difference in baseline characteristics between groups relative to abscess size, duration of symptoms before presentation, percentage with cellulitis, and treatment with antibiotics. CONCLUSION: Patients with soft tissue abscesses who were undergoing incision and drainage with point-of-care ultrasonography demonstrated less clinical failure compared with those treated without point-of-care ultrasonography.

Ultrasound-Guided Drainage for Pediatric Soft Tissue Abscesses Decreases Clinical Failure Rates Compared to Drainage Without Ultrasound: A Retrospective Study.

OBJECTIVES: Soft tissue abscesses are common in the pediatric emergency department (ED). Ultrasound (US) can be used to both diagnose soft tissue abscesses as well as guide drainage. We hypothesized that clinical failure rates would be less in pediatric patients with suspected skin abscesses when evaluated with US. METHODS: We performed a retrospective review of suspected pediatric skin abscesses at 4 EDs over a 22-month period. Cases were identified through electronic medical record descriptions, discharge diagnoses, and US database records. Data on US use, findings, and outcomes were abstracted to an electronic database. Comparisons between groups included US versus non-US (primary outcome) as well as surgical drainage vs nonsurgical drainage (secondary outcome). RESULTS: A total of 377 patients were seen with concern for a potential skin abscess; 141 patients (37.4%) underwent US imaging during their visit, and 239 (63.4%) underwent incision and drainage (I&D) during their ED stay: 90 with US and 149 without. The failure rate for patients evaluated with US was significantly lower than that for those evaluated without US (4.4% versus 15.6%; P < .005). Thirty-four (11.3%) of the 302 patients with a diagnosis of an abscess failed therapy: 19 (8.2%) after I&D and 15 (21.1%) after nonsurgical management. Failure after I&D was associated with a smaller abscess cavity on US imaging (17.2 versus 44.8 mm3 ; P < .05). CONCLUSIONS: The use of US for patients with a suspected skin abscess was associated with a reduction in the amount of clinical failure rates after both surgical drainage and nonsurgical therapy. Ultrasound should be used when evaluating or treating patients with abscesses.

Comparison of Four Views to Single-view Ultrasound Protocols to Identify Clinically Significant Pneumothorax.

OBJECTIVE: Ultrasound (US) has been shown to be effective at identifying a pneumothorax (PTX); however, the additional value of adding multiple views has not been studied. Single- and four-view protocols have both been described in the literature. The objective of this study was to compare the diagnostic accuracy of single-view versus four-view lung US to detect clinically significant PTX in trauma patients. METHODS: This was a randomized, prospective trial on trauma patients. Adult patients with acute traumatic injury undergoing computed tomography (CT) scan of the chest were eligible for enrollment. Patients were randomized to a single view or four views of each hemithorax prior to any imaging. USs were performed and interpreted by credentialed physicians using a 7.5-Mhz linear array transducer on a portable US machine with digital clips recorded for later review. Attending radiologist interpretation of the chest CT was reviewed for presence or absence of PTX with descriptions of small foci of air or minimal PTX categorized as clinically insignificant. RESULTS: A total of 260 patients were enrolled over a 2-year period. A total of 139 patients received a single view of each chest wall and 121 patients received four views. There were a total of 49 patients that had a PTX (19%), and 29 of these were clinically significant (11%). In diagnosis of any PTX, both single-view and four-view techniques showed poor sensitivity (54.2 and 68%) but high specificity (99 and 98%). For clinically significant PTX, single-view US demonstrated a sensitivity of 93% (95% confidence interval [CI] = 64.1% to 99.6%) and a specificity of 99.2% (95% CI = 95.5% to 99.9%), with sensitivity of 93.3% (95% CI = 66% to 99.7%) and specificity of 98% (95% CI = 92.1% to 99.7%) for four views. CONCLUSIONS: Single-view and four-view chest wall USs demonstrate comparable sensitivity and specificity for PTX. The additional time to obtain four views should be weighed against the absence of additional diagnostic yield over a single view when using US to identify a clinically significant PTX.

Use of point-of-care lactate in the prehospital aeromedical environment.

INTRODUCTION: Lactate measurement has been used to identify critical medical illness and initiate early treatment strategies. The prehospital environment offers an opportunity for very early identification of critical illness and commencement of care. HYPOTHESIS: The investigators hypothesized that point-of-care lactate measurement in the prehospital aeromedical environment would: (1) identify medical patients with high mortality; (2) influence fluid, transfusion, and intubation; and (3) increase early central venous catheter (CVC) placement. METHODS: Critically ill, medical, nontrauma patients who were transported from September 2007 through February 2009 by University of Massachusetts (UMass) Memorial LifeFlight, a university-based emergency medical helicopter service, were eligible for enrollment. Patients were prospectively randomized to receive a fingerstick whole-blood lactate measurement on an alternate-day schedule. Flight crews were not blinded to results. Flight crews were asked to inform the receiving attending physician of the results. The primary endpoint was the ability of a high, prehospital lactate value [> 4 millimoles per liter (mmol/L)] to identify mortality. Secondary endpoints included differences in post-transport fluid, transfusion, and intubation, and decrease in time to central venous catheter (CVC) placement. Categorical variables were compared between groups by Fisher's Exact Test, and continuous variables were compared by t-test. RESULTS: Patients (N = 59) were well matched for age, gender, and acuity. In the lactate cohort (n = 20), mean lactate was 7 mmol/L [Standard error of the mean, SEM = 1]. Initial analysis revealed that prehospital lactate levels of ≥ 4 mmol/L did show a trend toward higher mortality with an odds ratio of 2.1 (95% CI, 0.3-13.8). Secondary endpoints did not show a statistically significant change in management between the lactate and non lactate groups. There was a trend toward decreased time to post-transport CVC in the non lactate faction. CONCLUSION: Prehospital aeromedical point-of-care lactate measurement levels ≥ 4 mmol/L may help stratify mortality. Further investigation is needed, as this is a small, limited study. The initial analysis did not find a significant change in post-transport management.