Implementation of an Ultrasound-Guided Regional Anesthesia Program in the Emergency Department of a Community Teaching Hospital.

STUDY OBJECTIVE: We sought to initiate an emergency department (ED)-based ultrasound-guided regional anesthesia (UGRA) program in our community teaching hospital system. Here, we present our development process and protocol. We also sought to assess the types, indications, and associated adverse event rates for the UGRA procedures in this study. METHODS: We conducted a retrospective analysis of prospectively collected quality assurance data from a case series of patients who underwent an UGRA procedure in the ED. In August 2020, we developed an UGRA program for our community teaching hospital and its 2 affiliated freestanding EDs. For quality assurance purposes, we tracked all UGRA procedures performed in the ED, and we specifically assessed adverse events using structured follow-up. We subsequently obtained approval from our institutional review board to perform chart reviews of the patients in our dataset to abstract additional data and formally perform a research study. We determined the frequency with which different UGRA procedures were performed, and we calculated the adverse event rate. RESULTS: Between August 24, 2020, and July 15, 2022, a total of 18 different sonographers performed and documented 229 UGRA procedures on 206 unique patients. This included 28 different types of procedures. Follow-up after disposition was successful in 82.0% of patients. In 2 cases, the patient reported no pain relief at all from the procedure, but no patients reported complications related to the procedure. CONCLUSION: We successfully initiated a robust ED-based UGRA program in our community teaching hospital system. Among patients with successful follow-up, no adverse events were identified.

The use of additional imaging studies after biliary point-of-care ultrasound in the emergency department.

PURPOSE: We sought to determine the test characteristics of biliary point-of-care ultrasound (POCUS) and to assess the usefulness of obtaining radiology ultrasound (RUS) or cholescintigraphy (HIDA) after biliary POCUS. METHODS: We conducted a retrospective review of emergency department patients who underwent biliary POCUS between May 4, 2018 and November 28, 2021. To be included, patients had to have at least one of the following confirmatory evaluations (considered in this order): surgery, HIDA, RUS, or abdominal CT scan. When a discrepancy existed between the POCUS and the RUS or HIDA, they were compared to a higher criterion standard (if available). RESULTS: Using 348 patients who had a confirmatory evaluation after biliary POCUS, we found the sensitivity and specificity of biliary POCUS for gallstones to be 97.0% (95% CI 92.6 to 99.2%) and 99.5% (95% CI 97.3 to 100%), respectively. For cholecystitis, the sensitivity and specificity were 83.8% (95% CI 72.9 to 91.6%) and 98.6% (95% CI 96.4 to 99.6%), respectively. RUS and POCUS were concordant in 72 (81.8%) of 88 cases in which the patient had both studies while HIDA and POCUS were concordant in 24 (70.6%) of 34 cases. POCUS was deemed correct in at least 50% of discrepant cases with RUS and at least 30% of discrepant cases with HIDA. CONCLUSION: Biliary POCUS has excellent sensitivity and specificity for cholelithiasis; it has lower sensitivity for cholecystitis, but the specificity remains high. Performing a confirmatory RUS or cholescintigraphy after a positive biliary POCUS adds little value, but additional imaging may be useful when POCUS is negative for cholecystitis.

A Pop from a Shock: A Case Report of an Unusual Cause of Achilles Tendon Rupture.

INTRODUCTION: Achilles tendon ruptures often occur during physical activity where the tendon is frequently stressed. Although rare, rupture can also result from electric shock. CASE REPORT: We present the case of a 63-year-old female who presented with pain in the lower leg after enduring an electric shock. She was diagnosed with a ruptured Achilles tendon based on physical exam and ultrasound. CONCLUSION: This case highlights an uncommon mechanism for a relatively common injury. Because Achilles tendon ruptures are frequently misdiagnosed, clinicians need to be aware of unusual causes and use tools at their disposal to ensure timely and accurate diagnosis.

Clinical Considerations in Initial Evaluation and Treatment of Hardhead Catfish Spine Puncture Wounds.

A 17-year-old male presented to our ED complaining of pain and swelling at the base of the first metacarpal after attempting to remove a catfish from his fishing line 12 hours prior to arrival. Radiographic images demonstrated a foreign body (FB), which was detectable by ultrasound. Hand surgery was consulted and took the patient to the operating room for exploration and removal of two serrated radiopaque catfish spines that were deeply embedded in the left thumb. Conclusion. Penetrating injury from hardhead catfish (Ariopsis felis) spines can cause hidden FB, envenomation, infection, and secondary damage to nearby structures. Imaging should be done for these patients to ensure they obtain timely and complete extraction of the venomous structures. Surgery should be consulted for operative management to avoid damage on removal of the catfish spine remnants.

Barriers to point-of-care ultrasound utilization during cardiac arrest in the emergency department: a regional survey of emergency physicians.

INTRODUCTION: Though point-of-care ultrasound (POCUS) is recognized as a useful diagnostic and prognostic intervention during cardiac arrest (CA), critics advise caution. The purpose of this survey study was to determine the barriers to POCUS during CA in the Emergency Department (ED). METHODS: Two survey instruments were distributed to emergency medicine (EM) attending and resident physicians at three academic centers in the South Florida. The surveys assessed demographics, experience, proficiency, attitudes and barriers. Descriptive and inferential statistics along with Item Response Theory Logistic Model and the Friedman Test with Wilcoxon Signed Rank tests were used to profile responses and rank barriers. RESULTS: 206 EM physicians were invited to participate in the survey, and 187 (91%) responded. 59% of attending physicians and 47% of resident physicians reported that POCUS is performed in all their cases of CA. 5% of attending physicians and 0% of resident physicians reported never performing POCUS during CA. The top-ranked departmental barrier for attending physicians was "No structured curriculum to educate physicians on POCUS." The top-ranked personal barriers were "I do not feel comfortable with my POCUS skills" and "I do not have sufficient time to dedicate to learning POCUS." The top-ranked barriers for resident physicians were "Time to retrieve and operate the machine" and "Chaotic milieu." CONCLUSIONS: While our study demonstrates that most attending and resident physicians utilize POCUS in CA, barriers to high-quality implementation exist. Top attending physician barriers relate to POCUS education, while the top resident physician barriers relate to logistics and the machines. Interventions to overcome these barriers might lead to optimization of POCUS performance during CA in the ED.

Point-of-Care Ultrasound Identifies Decompensated Heart Failure in a Young Male with Methamphetamine-Associated Cardiomyopathy Presenting in Severe Sepsis to the Emergency Department.

We describe a case of a young male who presents to the emergency department with severe sepsis and decompensated heart failure with underlying Methamphetamine-Associated Cardiomyopathy that was previously undiagnosed. This presentation is unique because Methamphetamine-Associated Cardiomyopathy is an uncommonly reported condition that presented in a complex clinical scenario of severe sepsis and decompensated congestive heart failure. We discuss how we used point-of-care ultrasound (POCUS) in this case to identify an unsuspected disease process and how it changed our initial resuscitation strategy and management. Emergency physicians can utilize point-of-care ultrasound (POCUS) to help identify these high-risk patients in the emergency department and guide appropriate resuscitation. Methamphetamine-Associated Cardiomyopathy (MAC) is an infrequently described complication of methamphetamine abuse, most commonly presented as a nonischemic dilated cardiomyopathy. With the rise in methamphetamine abuse in the United States, complications from methamphetamine use are more commonly presenting to the emergency department. Proper education and rehabilitation, with a goal of abstinence from amphetamine use, may allow patients to potentially regain normal cardiac function. Since the majority of patients present late with severe cardiac dysfunction, early detection is essential amongst critically ill patients since recognition may significantly influence ED management.

Can laypersons be trained to effectively deliver osteopathic manual therapy to patients with HIV?: a pilot study.

CONTEXT: Osteopathic manipulative treatment (OMT) may provide added benefits to standard human immunodeficiency virus (HIV) and AIDS treatments. However, lack of access to trained OMT providers is a potential barrier to the widespread use of OMT in the management of HIV and AIDS. OBJECTIVES: To determine the best time to measure the short-term impact of a brief OMT protocol on white blood cell counts in individuals with HIV and AIDS. Also, to explore recruiting and training laypersons to administer select osteopathic manual techniques. METHODS: Participants were HIV-positive men aged between 18 and 65 years who had not undergone antiretroviral therapy in the past 12 months, had CD4(+) lymphocyte counts of 200 to 700 cells/mm(3), and had viral load levels of less than 100,000 copies/mL. Participants were randomly assigned to an OMT group or a control group; those in the OMT group recruited a layperson for training in osteopathic manual therapy. Participants in the OMT group received a 15-minute OMT protocol consisting of myofascial release of the thoracic inlet, pectoral traction, rib raising, thoracic pump, and abdominal pump. Participants in the control group engaged in conversation with the researcher for 15 minutes. Between-group differences for each white blood cell type were examined at varying time intervals after the protocols. Laypersons were trained to administer thoracic and abdominal pump techniques. They were tested by multiple choice examinations and by an independent rater for fidelity of administration. RESULTS: Twenty-one participants met the eligibility criteria. Of those, 18 returned for their study visit (OMT group, n=9; control group, n=9). An optimal time interval for measurement of white blood cell changes across the 5 cell types was not determined. However, P values for the 30-minute interval were consistently below 0.18 for neutrophils, eosinophils, and monocytes. Nine laypersons were trained in osteopathic manual therapy, 5 of whom scored 100% on initial completion of the multiple-choice examination; the remaining 4 laypersons scored 80% on the first try and 100% on the second try. All laypersons appropriately administered the manual therapy protocol. CONCLUSION: It is feasible to recruit and train laypersons to administer selected osteopathic manual therapy techniques with fidelity. Longitudinal studies on this concept are needed to examine patient outcomes and to evaluate the retention and fidelity of laypersons over time.