Diagnostic Accuracy of Emergency Bedside Ultrasonography to Detect Cutaneous Wooden Foreign Bodies: Does Size Matter?

BACKGROUND: Soft-tissue occult foreign bodies are a concerning cause of morbidity in the emergency department. The identification of wooden foreign bodies is a unique challenge because they are often not detectable by plain radiography. The purpose of this study was to determine the diagnostic accuracy of emergency physician-performed ultrasonography to detect wooden foreign bodies of varying sizes. We hypothesized that sonographic sensitivity would improve with increasing foreign body size. METHODS: We conducted a blinded, prospective evaluation using a previously validated, chicken, soft-tissue model to simulate human tissue. We inserted wooden toothpicks of varying lengths (1mm, 2.5mm, 5mm, 7.5mm, 10mm) to a depth of 1cm in five tissue models. Five additional models were left without a foreign body to serve as controls. Fifty emergency physicians with prior ultrasonography training performed sonographic examinations of all 10 models and reported on the presence or absence of wooden foreign bodies. RESULTS: Subjects performed 10 ultrasonography examinations each for a total of 500 examinations. For the detection of wooden foreign bodies, overall test characteristics for sonography included sensitivity 48.4% (95% confidence interval [CI], 42.1%-54.8%) and specificity 67.6% (95% CI, 61.3%- 73.2%). Sensitivity did not change as object size increased (ρ = s.709). CONCLUSION: Emergency physician bedside ultrasonography demonstrated poor diagnostic accuracy for the detection of wooden foreign bodies. Accuracy did not improve with increasing object size up to 10mm. Providers should consider alternative diagnostic modalities if there is persistent clinical concern for a retained, radiolucent, soft-tissue foreign body.

Security, Violent Events, and Anticipated Surge Capabilities of Emergency Departments in Washington State.

INTRODUCTION: Over the past 15 years, violent threats and acts against hospital patients, staff, and providers have increased and escalated. The leading area for violence is the emergency department (ED) given its 24/7 operations, role in patient care, admissions gateway, and center for influxes during acute surge events. This investigation had three objectives: to assess the current security of Washington State EDs; to estimate the prevalence of and response to threats and violence in Washington State EDs; and to appraise the Washington State ED security capability to respond to acute influxes of patients, bystanders, and media during acute surge events. METHODS: A voluntary, blinded, 28-question Web-based survey developed by emergency physicians was electronically delivered to all 87 Washington State ED directors in January 2013. We evaluated responses by descriptive statistical analyses. RESULTS: Analyses occurred after 90% (78/87) of ED directors responded. Annual censuses of the EDs ranged from < 20,000 to 100,000 patients and represented the entire spectrum of practice environments, including critical access hospitals and a regional quaternary referral medical center. Thirty-four of 75 (45%) reported the current level of security was inadequate, based on the general consensus of their ED staff. Nearly two-thirds (63%) of EDs had 24-hour security personnel coverage, while 28% reported no assigned security personnel. Security personnel training was provided by 45% of hospitals or healthcare systems. Sixty-nine of 78 (88%) respondents witnessed or heard about violent threats or acts occurring in their ED. Of these, 93% were directed towards nursing staff, 90% towards physicians, 74% towards security personnel, and 51% towards administrative personnel. Nearly half (48%) noted incidents directed towards another patient, and 50% towards a patient's family or friend. These events were variably reported to the hospital administration. After an acute surge event, 35% believed the initial additional security response would not be adequate, with 26% reporting no additional security would be available within 15 minutes. CONCLUSION: Our study reveals the variability of ED security staffing and a heterogeneity of capabilities throughout Washington State. These deficiencies and vulnerabilities highlight the need for other EDs and regional emergency preparedness planners to conduct their own readiness assessments.

Evaluation of Contingency Telemedical Support to Improve Casualty Care at a Simulated Military Intermediate Resuscitation Facility: The EM-ANGEL Study.

OBJECTIVE: We sought to determine whether Contingency Telemedical Support (CTS) improves the success rate and efficiency of primary care providers performing critical actions during simulated combat trauma resuscitation. Critical actions included advanced airway, chest decompression, extremity hemorrhage control, hypothermia prevention, antibiotics and analgesics, and hypotensive resuscitation, among others. BACKGROUND: Recent studies report improved survival associated with skilled triage and treatment in the out-of-hospital/preoperative phase of combat casualty care. Historically, ground combat units are assigned primary care physicians and physician assistants as medical staff, due to resource limitations. Although they are recognized as optimal resuscitators, demand for military trauma surgeons and emergency physicians exceeds supply and is unlikely to improve in the near term. METHODS: A prospective trial of telemedical mentoring during a casualty resuscitation encounter was studied using a high-fidelity patient simulator (HFPS). Subjects were randomized and formed into experimental (CTS) or control teams. CTS team leaders were equipped with a headset/microphone interface and telementored by a combat-experienced emergency physician or trauma surgeon. A standardized, scripted clinical scenario and HFPS were used with 14 critical actions. At completion, subjects were surveyed. Statistical approach included contingency table analysis, two-tailed t-test, and correlation coefficient. This study was reviewed and approved by our institutional review board (IRB). RESULTS: Eighteen CTS teams and 16 control teams were studied. By intention-to-treat ITT analysis, 89% of CTS teams versus 56% of controls completed all life-threatening inventions (LSIs) (p<.01); 78% versus 19% completed all critical actions (p<.01); and 89% versus 56% established advanced airways within 8 minutes (p<.06). Average time to completion in minutes (95% confidence interval [CI] 95) was 12 minutes (10?14) for CTS versus 18 (16?20) for controls, with 75% of control teams not completing all critical actions. CONCLUSION: In this model, real-time telementoring of simulated trauma resuscitation was feasible and improved accuracy and efficiency of non?emergency-trained resuscitators. Clinical validation and replicated study of these findings for guiding remote damage control resuscitation are warranted.

Clinical effects and antivenom use for snake bite victims treated at three US hospitals in Afghanistan.

OBJECTIVE: Annually, more than 100,000 US and international military and civilian personnel work in Afghanistan within terrain harboring venomous snakes. Current literature insufficiently supports Afghan antivenom treatment and stocking guidelines. We report the clinical course and treatments for snakebite victims presenting to US military hospitals in Afghanistan. METHODS: All snakebite victims presenting to 3 US military emergency departments between July 2010 and August 2011 in northern and southern Afghanistan were examined via chart review. Case information included patient demographics, snake description, bite details and complications, laboratory results, antivenom use and adverse effects, procedures performed, and hospital course. RESULTS: Of 17 cases, median patient age was 20 years (interquartile range [IQR], 12-30), 16 were male, and 82% were Afghans. All bites were to an extremity, and median time to care was 2.8 hours (IQR, 2-5.8). On arrival, 8 had tachycardia and none had hypotension or hypoxia. A viper was implicated in 5 cases. Ten cases received at least 1 dose of polyvalent antivenom, most commonly for coagulopathy, without adverse effects. Six received additional antivenom, 6 had an international normalized ratio (INR) > 10, and none developed delayed coagulopathy. Three received blood transfusions. Hospital stay ranged from 1 to 4 days. None required vasopressors, fasciotomy, or other surgery, and none died. All had resolution of marked coagulopathies and improved swelling and pain on discharge. CONCLUSIONS: We report the largest series of snake envenomations treated by US physicians in Afghanistan. Antivenom was tolerated well with improvement of coagulopathy and symptoms. All patients survived with minimal advanced interventions other than blood transfusion.

Endometriosis presenting with hemorrhagic ascites, severe anemia, and shock.

Hemorrhagic ascites due to endometriosis is an exceedingly uncommon diagnosis rarely reported in the medical literature. We present a case of a 27-year-old woman who presented to the emergency department for flank and neck pain and was found to be hypotensive with massive hemorrhagic ascites and severe anemia. After emergency department resuscitation and hospitalization, her condition was found to be due to complications of endometriosis. A paracentesis of more than 4000 mL of bloody ascitic fluid revealed no evidence of cancer, and she was discharged on hospital day 3 with hormone therapy and no recurrence of symptoms upon outpatient follow-up. This case illustrates the clinical management, diagnostic approach, and underlying etiology of an infrequent but life-threatening complication of endometriosis.

Detection of increased intracranial pressure by ultrasound.

Increases in intracranial pressure (ICP) may damage the brain by compression of its structures or restriction of its blood flow, and medical providers my encounter elevated ICP in conventional and non-conventional medical settings. Early identification of elevated ICP is critical to ensuring timely and appropriate management. However, few diagnostic methods are available for detecting increased ICP in an acutely ill patient, which can be performed quickly and noninvasively at the bedside. The optic nerve sheath is a continuation of the dura mater of the central nervous system and can be viewed by ocular ultrasound. Pressure changes within the intracranial cavity affect the diameter of the optic nerve sheath. Data acquired from multiple clinical settings suggest that millimetric increases in the optic nerve sheath diameter detected via ocular ultrasound correlate with increasing levels of ICP. In this review, we discuss the use of ocular ultrasound to evaluate for the presence of elevated ICP via assessment of optic nerve sheath diameter, and describe critical aspects of this valuable diagnostic procedure. Ultrasound is increasingly becoming a medical fixture in the modern battlefield where other diagnostic modalities can be unavailable or impractical to employ. As Special Forces and other austere medical providers become increasingly familiar with ultrasound, ocular ultrasound for the assessment of increased intracranial pressure may help optimize their ability to provide the most effective medical management for their patients.

Fournier's Gangrene due to Masturbation in an Otherwise Healthy Male.

Fournier's gangrene is a rare and often fulminant necrotizing fasciitis of the perineum and genital region frequently due to a synergistic polymicrobial infection. This truly emergent condition is typically seen in elderly, diabetic, or otherwise immune-compromised individuals. Here, we report an unusual case of Fournier's gangrene due to excessive masturbation in an otherwise healthy 29-year-old male who presented to the emergency department complaining of two days of fever, vomiting, and diffuse myalgias. Upon further questioning, he also endorsed severe scrotal pain and swelling and frequent masturbation with soap as a lubricant resulting in recurrent penile erythema and minor skin abrasions. Examination of the patient's perineum was consistent with Fournier's gangrene and included significant erythema, edema, and calor of the penis and scrotum with a large malodorous eschar. He was given intravenous antibiotics and immunoglobulin and promptly underwent three surgical debridements of the scrotum and penis with split-thickness skin grafting. Complications from excessive masturbation are exceedingly rare, but as this case illustrates, they can be life threatening.

A blinded, randomized, palatability study comparing variations of 2 popular field water disinfection tablets.

OBJECTIVE: Halogen-based water disinfection tablets may render an unpleasant taste to treated water. Proposed safe additives such as ascorbic acid may reduce this objectionable taste. We compared the palatability of 2 field water disinfectants: iodine-based tetraglycine hydroperiodide (TGHP) and chlorine-based chlorine dioxide (CD) both with and without the concomitant use of an ascorbic acid taste neutralizer. METHODS: Blinded participants randomly sampled 5 different distilled water samples containing combinations of disinfectant tablets and ascorbic acid: 1) water; 2) water with TGHP; 3) water with CD; 4) water with TGHP plus ascorbic acid; and 5) water with CD plus ascorbic acid. Participants rated beverage taste via a 100 mm visual analogue scale (VAS) and ranked the samples from "most pleasant" to "least pleasant." RESULTS: Sixty participants evaluated the samples. On the VAS, water with TGHP tasted worst and water with CD tasted second worst. Water with TGHP plus ascorbic acid, water alone, and water with CD plus ascorbic acid measured similarly as significantly best tasting. Water with TGHP was ranked by 58% as "least pleasant" tasting, while water with TGHP and ascorbic acid was ranked by 40% as "most pleasant" tasting. CONCLUSIONS: Participants found halogen-based disinfected water significantly less palatable prior to the addition of ascorbic acid. Addition of ascorbic acid to treated water created a beverage of similar preference to distilled water. These results may increase compliance with the use of disinfecting tablets by increasing the palatability of drinking water made potable via addition of ascorbic acid to halogen-based chemical disinfection.

Deadly proposal: a case of catecholaminergic polymorphic ventricular tachycardia.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare adrenergically mediated arrhythmogenic disorder classically induced by exercise or emotional stress and found in structurally normal hearts. It is an important cause of cardiac syncope and sudden death in childhood. Catecholaminergic polymorphic ventricular tachycardia is a genetic cardiac channelopathy with known mutations involving genes affecting intracellular calcium regulation. We present a case of a 14-year-old boy who had cardiopulmonary arrest after an emotionally induced episode of CPVT while attempting to invite a girl to the school dance. Review of his presenting cardiac rhythm, induction of concerning ventricular arrhythmias during an exercise stress test, and genetic testing confirmed the diagnosis of CPVT. He recovered fully and was treated with ß-blocker therapy and placement of an implantable cardioverter-defibrillator. In this report, we discuss this rare but important entity, including its molecular foundation, clinical presentation, basics of diagnosis, therapeutic options, and implications of genetic testing for family members. We also compare CPVT to other notable cardiomyopathic and channelopathic causes of sudden death in youth including hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, long QT syndrome, short QT syndrome, and Brugada syndrome.

The ability of emergency nurses to detect simulated long bone fractures with portable ultrasound.

Fractures are a common emergency department (ED) diagnosis. Ultrasound is a useful tool to evaluate for the presence of long bone fractures and can be performed by minimally trained individuals. We examined the ability of ED nurses to sonographically detect long bone fractures using a recently described training model. The fracture model consisted of a turkey long bone within a firm gelatin matrix. Emergency nurses examined five fracture models with a portable ultrasound machine to determine the presence or absence of a fracture. Overall accuracy was compared via chi-square analysis to the ability of physicians to complete the same assessment. Thirty nurses sonographically assessed the models. An overall sensitivity of 98% (95% confidence interval: 92-99%) and specificity of 93% (95% confidence interval: 76-99%) was observed for the detection of a fractured model. No difference in fracture detection accuracy (p>0.05) was revealed compared to an evaluation by 30 ED physicians. While the clinical impact of this ability remains uncertain, future utilization of nursing ability to detect fractures by ultrasound may improve patient care in ways such as more efficient triaging of radiographs and the mobilization of resources for fracture reduction.