Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department.

This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic "low-risk, recurrent abdominal pain in the emergency department." The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.

Depression and anxiety screening in emergency department patients with recurrent abdominal pain: An evidence synthesis for a clinical practice guideline.

BACKGROUND: Recurrent abdominal pain in the emergency department (ED) might represent an opportunity for screening of depression and/or anxiety. METHODS: We systematically searched five databases for studies evaluating the effect of screening for depression and/or anxiety in ED patients with recurrent and undifferentiated abdominal pain. Given paucity of direct evidence, we also searched for indirect evidence including studies that assessed prevalence of depression and/or anxiety in EDs (not necessarily recurrent abdominal pain), diagnostic accuracy of screening tools, effectiveness of screening in other settings, and outcomes such as repeat ED visits of patients with abdominal pain who were screened in the ED. Two methodologists evaluated certainty in the evidence using the GRADE approach. RESULTS: A total of 4,337 citations were reviewed, and zero studies were found on the effect of screening in patients with recurrent and undifferentiated abdominal pain in the ED. A total of 35 studies were included as relevant indirect evidence. In studies of ED patients with abdominal pain, depression ranged from 10% to 29%, while anxiety ranged from 18% to 50%. False positives appear to be an issue given relatively low specificity of screening tools. One randomized trial including ED patients with vague symptoms evaluated the effect of depression screening on a composite outcome of depression recognition, psychiatric consultation, or referral by the emergency physician (risk ratio = 1.49, 95% confidence interval [CI] = 0.49 to 4.53, very low certainty). One study reported that patients with undifferentiated abdominal pain who screened positive for depression have had increased ED recidivism (odds ratio = 3.17, 95% CI = 1.14 to 8.85, very low certainty). CONCLUSIONS: We were unable to identify any evidence that confirms that depression or anxiety screening in ED patients with recurrent and undifferentiated abdominal pain improves outcomes or changes management downstream.

Repeat computed tomography in recurrent abdominal pain: An evidence synthesis for guidelines for reasonable and appropriate care in the emergency department.

OBJECTIVE: Computed tomography (CT) imaging is frequently obtained for recurrent abdominal pain after a prior emergency department (ED) evaluation. We evaluate the utility of repeat CT imaging following an indeterminate index CT in low-risk abdominal pain adult ED patients. METHODS: An electronic search was designed for the patient-intervention-control-outcome-timing (PICOT) question: (P) adult patients with low-risk, recurrent, and previously undifferentiated atraumatic abdominal pain presenting to the ED after an index-negative CT within 12 months; (I) repeat CT versus (C) no repeat CT; for (O) abdominal surgery or other invasive procedure, mortality, identification of potentially life-threatening diagnosis, and hospital and intensive care unit admission rates; and return ED visit (T), all within 30 days. Four reviewers independently selected evidence for inclusion and then synthesized the results around the most prevalent themes of repeat CT timing, diagnostic yield, ionizing radiation exposure, and predictors of repetitive imaging. RESULTS: Although 637 articles and abstracts were identified, no direct evidence was found. Thirteen documents were synthesized as indirect evidence. None of the indirect evidence defined a low-risk subset of abdominal pain nor did investigators describe whether reimaging occurred for complaints similar to the initial ED evaluation. Included studies did not describe the index CT findings and some reported explanatory findings noted on the original CT for which repeat CTs might have been indicated. The time frame for a repeat CT ranged from hours to 1 year. The frequency of repeat CTs (2%-47%) varied across studies as did the yield of imaging to alter downstream clinical decision making (range = 5%-67%). CONCLUSION: Due to the absence of direct evidence our scoping review is unable to provide high-quality evidence-based recommendations upon which to confidently base an imaging practice guideline. There is no evidence to support or refute performing a CT for low-risk recurrent abdominal pain.

ACR Appropriateness Criteria® Head Trauma: 2021 Update.

Head trauma (ie, head injury) is a significant public health concern and is a leading cause of morbidity and mortality in children and young adults. Neuroimaging plays an important role in the management of head and brain injury, which can be separated into acute (0-7 days), subacute (<3 months), then chronic (>3 months) phases. Over 75% of acute head trauma is classified as mild, of which over 75% have a normal Glasgow Coma Scale score of 15, therefore clinical practice guidelines universally recommend selective CT scanning in this patient population, which is often based on clinical decision rules. While CT is considered the first-line imaging modality for suspected intracranial injury, MRI is useful when there are persistent neurologic deficits that remain unexplained after CT, especially in the subacute or chronic phase. Regardless of time frame, head trauma with suspected vascular injury or suspected cerebrospinal fluid leak should also be evaluated with CT angiography or thin-section CT imaging of the skull base, respectively. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A prospective blinded comparison of second trimester fetal measurements by expert and novice readers using low-cost novice-acquired 3D volumetric ultrasound.

RATIONALE AND OBJECTIVES: Two-dimensional (2D) ultrasound (US) is operator dependent, requiring operator skill and experience to selectively identify and record planes of interest for subsequent interpretation. This limits the utility of US in settings in which expert sonographers are unavailable. Three-dimensional (3D) US acquisition of an anatomic target, which enables reconstruction of any plane through the acquired volume, might reduce operator dependence by providing any desired image plane for interpretation, without identification of target planes of interest at the time of acquisition. We applied a low-cost 3DUS technology because of the wider potential application compared with dedicated 3DUS systems. We chose second trimester fetal biometric parameters for study because of their importance in maternal-fetal health globally. We hypothesized that expert and novice interpretations of novice-acquired 3D volumes would not differ from each other nor from expert measurements of expert-acquired 2D images, the clinical reference standard. MATERIALS AND METHODS: This was a prospective, blinded, observational study. Expert sonographers blinded to 3DUS volumes acquired 2DUS images of second trimester fetuses from 32 subjects, and expert readers performed interpretation, during usual care. A novice sonographer blinded to other clinical data acquired oriented 3DUS image volumes of the same subjects on the same date. Expert readers blinded to other data assessed placental location (PL), fetal presentation (FP), and amniotic fluid volume (AFV) in novice-acquired 3D volumes. Novice and expert raters blinded to other data independently measured biparietal diameter (BPD), humerus length (HL), and femur length (FL) for each fetus from novice-acquired 3D volumes. Corresponding gestational age (GA) estimates were calculated. Inter-rater reliability of measurements and GAs (expert 3D versus expert 2D, novice 3D versus expert 2D, and expert 3D versus novice 3D) were assessed by intraclass correlation coefficient (ICC). Mean inter-rater measurement differences were analyzed using one-way ANOVA. RESULTS: 3D volume acquisition and reconstruction required mean 30.4 s (±5.7) and 70.0 s (±24.0), respectively. PL, FP, and AFV were evaluated from volumes for all subjects; mean time for evaluation was 16 s (±0.0). PL, FP, and AFV could be evaluated for all subjects. At least one biometric measurement was possible for 31 subjects (97%). Agreement between rater pairs for a composite of all measures was excellent (ICCs ≥ 0.95), and for individual measures was good to excellent (ICCs ≥ 0.75). Inter-rater differences were not significant (p > .05). CONCLUSIONS: Expert and novice interpretations of novice-acquired 3DUS volumes of second trimester fetuses provided reliable biometric measures compared with expert interpretation of expert-acquired 2DUS images. 3DUS volume acquisition with a low-cost system may reduce operator dependence of ultrasound.

ACR Appropriateness Criteria® Seizures and Epilepsy.

Seizures and epilepsy are a set of conditions that can be challenging to diagnose, treat, and manage. This document summarizes recommendations for imaging in different clinical scenarios for a patient presenting with seizures and epilepsy. MRI of the brain is usually appropriate for each clinical scenario described with the exception of known seizures and unchanged semiology (Variant 3). In this scenario, it is unclear if any imaging would provide a benefit to patients. In the emergent situation, a noncontrast CT of the head is also usually appropriate as it can diagnose or exclude emergent findings quickly and is an alternative to MRI of the brain in these clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Pigtail Catheter Insertion Error: Root Cause Analysis and Recommendations for Patient Safety.

BACKGROUND: Small-caliber chest tubes are used to treat pneumothorax and pleural fluid collections. Although commonly considered a less invasive alternative to large-caliber thoracostomy tubes, small-caliber tubes have a high complication rate. Emergency physicians must be familiar with common and dangerous procedure complications associated with these devices and have a systematic and rapid approach to identify and solve malfunctions. Structured root cause analysis can facilitate identification of problems. METHODS: We reviewed the medical literature for complications of small-caliber chest tubes and searched the U.S. Food and Drug Administration (FDA) database for complications of a specific pigtail catheter kit. Using a structured root cause analysis (RCA), we examined two cases of retained pigtail catheter obturators resulting in catheter malfunction and unresolved pneumothorax. RESULTS: We identified common complications of pigtail catheters from the medical literature, as well as 28 reports to FDA of complications with the kit used in the analyzed cases; ours were the only reports of the obturator error. RCA identified multiple contributing factors, including unrecognized and novel radiographic clues, human errors, communication breakdown, device design, and opportunities for improved systematic procedural approach. DISCUSSION: We discuss factors identified in RCA and regulatory considerations relevant to emergency physicians, including FDA reporting mechanisms. CONCLUSIONS: A structured review of complications of pigtail catheter insertion revealed opportunities for improved patient safety. We highlight a preventable error in insertion of a percutaneous catheter and describe radiographic features to enhance error detection. Improved design, systematic processes for device insertion and troubleshooting, and enhanced provider education could reduce the risk of medical device errors. An end-of-procedure time-out including instrument counts and systematic assessment of device function is a generalizable patient safety measure for bedside procedures.

Duplicated or Ectopic Renal Collecting System in Two Adult Emergency Department Patients.

BACKGROUND: Duplicated renal collecting system is a urological anomaly often found in pediatric patients. It is less commonly diagnosed in adulthood, particularly in a pregnant patient. Many point-of-care ultrasonography users may not be aware of this diagnosis, particularly in patients in the emergency department. It is important to recognize the duplicated system because in general, patients will often have hydronephrosis in only one renal pole rather than the entire kidney, which corresponds to an unequal renal function as documented on renal nuclear medicine functional scans. As a consequence, if the sonographer only identifies one ureter and incompletely visualizes the kidney, obstruction of one of the duplicated structures may be missed. CASE REPORT: We report 2 cases of duplicated ureter in patients in the emergency department who present with flank pain and urinary symptoms. Both patients were adult females, one pregnant, with duplicated ureter and severe right upper pole hydroureteronephrosis. The first patient was admitted for intravenous antibiotic therapy for pyelonephritis in pregnancy. The second was discharged with oral antibiotics and urgent urologic follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Duplicated ureter should be considered in patients with recurrent urinary tract infections or enuresis. Point-of-care ultrasonography users should note the differential hydronephrosis between upper and lower renal poles and may visualize duplicate or ectopic ureteronephrosis or ureterocele. Patients should be prescribed prophylactic antibiotics and have urgent urologic follow-up because the untreated condition can lead to irreversible renal damage.

ACR Appropriateness Criteria® Suspected Spine Trauma.

Injuries to the cervical and thoracolumbar spine are commonly encountered in trauma patients presenting for treatment. Cervical spine injuries occur in 3% to 4% and thoracolumbar fractures in 4% to 7% of blunt trauma patients presenting to the emergency department. Clear, validated criteria exist for screening the cervical spine in blunt trauma. Screening criteria for cervical vascular injury and thoracolumbar spine injury have less validation and widespread acceptance compared with cervical spine screening. No validated criteria exist for screening of neurologic injuries in the setting of spine trauma. CT is preferred to radiographs for initial assessment of spine trauma. CT angiography and MR angiography are both acceptable in assessment for cervical vascular injury. MRI is preferred to CT myelography for assessing neurologic injury in the setting of spine trauma. MRI is usually appropriate when there is concern for ligament injury or in screening obtunded patients for cervical spine instability. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Acute Mental Status Change, Delirium, and New Onset Psychosis.

Acute changes in mental status represent a broad collection of symptoms used to describe disorders in mentation and level of arousal, including the more narrowly defined diagnoses of delirium and psychosis. A wide range of precipitating factors may be responsible for symptom onset including infection, intoxication, and metabolic disorders. Neurologic causes that may be detected on neuroimaging include stroke, traumatic brain injury, nonconvulsive seizure, central nervous system infection, tumors, hydrocephalus, and inflammatory disorders. Not infrequently, two or more precipitating factors may be found. Neuroimaging with CT or MRI is usually appropriate if the clinical suspicion for an acute neurological cause is high, where the cause of symptoms is not found on initial assessment, and for patients whose symptoms do not respond appropriately to management. There was disagreement regarding the appropriateness of neuroimaging in cases where a suspected, nonneurologic cause is found on initial assessment. Neuroimaging with CT is usually appropriate for patients presenting with delirium, although the yield may be low in the absence of trauma or a focal neurological deficit. Neuroimaging with CT or MRI may be appropriate in the evaluation of new onset psychosis, although the yield may be low in the absence of a neurologic deficit. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Versatile Low-Cost Volumetric 3-D Ultrasound Platform for Existing Clinical 2-D Systems.

Ultrasound imaging has indications across many areas of medicine, but the need for training and the variability in skill and acquired image quality among 2-D ultrasound users have limited its wider adoption and utilization. Low-cost volumetric ultrasound with a known frame of reference has the potential to lower these operator-dependent barriers and enhance the clinical utility of ultrasound imaging. In this paper, we improve upon our previous research-scanner-based prototype to implement a versatile volumetric imaging platform for existing clinical 2-D ultrasound systems. We present improved data acquisition and image reconstruction schemes to increase quality, streamline workflow, and provide real-time visual feedback. We present initial results using the platform on a Vimedix simulator, as well as on phantom and in vivo targets using a variety of clinical ultrasound systems and probes.

Low-cost Volumetric Ultrasound by Augmentation of 2D Systems: Design and Prototype.

Conventional two-dimensional (2D) ultrasound imaging is a powerful diagnostic tool in the hands of an experienced user, yet 2D ultrasound remains clinically underutilized and inherently incomplete, with output being very operator dependent. Volumetric ultrasound systems can more fully capture a three-dimensional (3D) region of interest, but current 3D systems require specialized transducers, are prohibitively expensive for many clinical departments, and do not register image orientation with respect to the patient; these systems are designed to provide improved workflow rather than operator independence. This work investigates whether it is possible to add volumetric 3D imaging capability to existing 2D ultrasound systems at minimal cost, providing a practical means of reducing operator dependence in ultrasound. In this paper, we present a low-cost method to make 2D ultrasound systems capable of quality volumetric image acquisition: we present the general system design and image acquisition method, including the use of a probe-mounted orientation sensor, a simple probe fixture prototype, and an offline volume reconstruction technique. We demonstrate initial results of the method, implemented using a Verasonics Vantage research scanner.