Serial lung and IVC ultrasound in the assessment of congestive heart failure.

BACKGROUND: Management of congestive heart failure (CHF) is dependent on clinical assessments of volume status, which are subjective and imprecise. Point-of-care ultrasound (POCUS) is useful in the diagnosis of CHF, but how POCUS findings correlate with therapy remains unknown. This study aimed to determine whether the changes in clinical evaluation of CHF with treatment are mirrored with changes in the number of B lines on lung ultrasound (LUS) and inferior vena cava (IVC) size. In this prospective observational study, investigators performed serial clinical and ultrasound assessments within 24 h of admission (T1), day 1 in hospital (T2) and within 24 h of discharge (T3). Clinical assessments included an evaluation of the jugular venous distension (JVD), hepatojugular reflux (HJR), pulmonary rales and a clinical congestion score was calculated. Ultrasound assessment included the IVC size and collapsibility, and the number of B lines in an 8-point scan. RESULTS: Fifty consecutive patients were recruited with a mean age of 71.2 years (SD 12.7). Mean clinical congestion score on admission was 5.6 (SD 1.4) and declined significantly over time to 1.3 (0.91), as did the JVP, HJR and pulmonary rales. No significant changes were found in the IVC size between T1 [1.9 (0.65)] and T3 [2.0 (0.50)] or in the IVC collapsibility index [T1 0.3 (0.19) versus T3 0.25 (0.16)]. The mean number of B lines decreased from 11 (6.1) at T1 to 8.3 (5.5) at T3, although this decrease did not reach statistical significance. Spearman correlation between JVP and HJR versus IVC collapsibility and total B lines did not yield significant results. CONCLUSIONS: Clinical exam findings correlate over time during the management of CHF, whereas LUS and IVC results did not. The number of B lines did decrease with therapy, but did not reach statistical significance likely because the sampled population was small and had only mild heart failure. Further studies are warranted to further explore the use of lung ultrasound in this patient population.

Validity of ultrasonography to diagnosing pneumothorax: a critical appraisal of two meta-analyses.

CLINICAL QUESTION: Can ultrasonography be used in lieu of chest radiography to diagnose pneumothorax? Articles chosen 1. Ding W, Shen Y, Yang J, et al. Diagnosis of pneumothorax by radiography and ultrasonography: a metaanalysis. Chest 2011;140:859-66. [Epub 2011 May 5] 2. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. Chest 2012; 141:703-8

Improved neurologic outcomes after cardiac arrest with combined administration of vasopressin, steroids, and epinephrine compared to epinephrine alone.

CLINICAL QUESTION: Is a vasopressin, steroid, and epinephrine (VSE) protocol for in-hospital cardiac arrest resuscitation associated with better survival to hospital discharge with favourable neurologic outcome compared to epinephrine alone? Article chosen Mentzelopoulos S, Malachias S, Konstantopoulos D, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA 2013;310:270-9. OBJECTIVE: To determine if a VSE protocol during cardiopulmonary resuscitation with hydrocortisone administration in patients with postresuscitative shock at 4 hours after return of spontaneous circulation would improve survival to hospital discharge with favourable neurologic outcome.

An exploration of Canadian emergency physicians' and residents' knowledge of computed tomography radiation dosing and risk.

OBJECTIVE: The objective of this study was to measure the current knowledge of Canadian emergency physicians and emergency medicine residents regarding computed tomography (CT) radiation dosing and its associated risks. METHODS: Three focus groups were conducted as the qualitative element of this study. Cognitive debriefing was carried out to ensure the validity and reliability of the focus group findings and to aid with survey development. A 26-item electronic survey was developed and pilot tested for distribution to the membership of the Canadian Association of Emergency Physicians. RESULTS: Eighteen emergency medicine physicians and three emergency medicine residents participated in the focus groups. Four major themes emerged: 1) physician knowledge of risks associated with CT, 2) risk management strategies, 3) communication, and 4) knowledge translation. The survey response rate was 49.8% (638 of 1,281). The mean respondent age was 40.9±9.9 years, and 70.7% were male. Of all respondents, 82.5% were actively practicing attending physicians, 56.4% of all respondents practiced in urban academic emergency departments, and the average time practicing was 10.7±9.6 years. Radiography and CT were correctly identified by 92.2% and 95.1% of respondents, respectively, as sources of ionizing radiation, whereas magnetic resonance imaging and ultrasonography were selected by 1.0% and 0.5%, respectively. With respect to the lifetime attributable risk (LAR) of malignancy due to CT, 82.2% of participants correctly identified that abdominal CT increases the risk of cancer by 0.2 to 2%, whereas 51.3% correctly identified that the LAR increases twofold in a 7- year-old boy. When asked to identify populations at risk for potential harm due to ionizing radiation, 92.2% of respondents identified children, 80.3% identified pregnant women, and 71.4% identified women of reproductive age. A minority (37.2%) reported communicating the potential risks of CT to a majority of their patients. Electronic platforms were identified by 74.8% of respondents as their preferred method of knowledge translation on this topic. CONCLUSIONS: Canadian emergency medicine physicians and emergency medicine residents demonstrated identifiable gaps in knowledge surrounding CT radiation dose and risk.

Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis.

OBJECTIVES: Acute dyspnea is a common presenting complaint to the emergency department (ED), and point-of-care (POC) lung ultrasound (US) has shown promise as a diagnostic tool in this setting. The primary objective of this systematic review was to determine the sensitivity and specificity of US using B-lines in diagnosing acute cardiogenic pulmonary edema (ACPE) in patients presenting to the ED with acute dyspnea. METHODS: A systematic review protocol adhering to Cochrane Handbook guidelines was created to guide the search and analysis, and we searched the following databases: PubMed, EMBASE, Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, and the Cochrane Database of Systematic Reviews. References of reviewed articles were hand-searched, and electronic searches of conference abstracts from major emergency medicine, cardiology, and critical care conferences were conducted. The authors included prospective cohort and prospective case-control studies that recruited patients presenting to hospital with symptomatic, acute dyspnea, or where there was a clinical suspicion of congestive heart failure, and reported the sensitivity and specificity of B-lines in diagnosing ACPE. Studies of asymptomatic individuals or in patients where there was no suspicion of ACPE were excluded. The outcome of interest was a diagnosis of ACPE using US B-lines. A final diagnosis from clinical follow-up was accepted as the reference standard. Two reviewers independently reviewed all citations to assess for inclusion, abstracted data, and assessed included studies for methodologic quality using the QUADAS-2 tool. Contingency tables were used to calculate sensitivity and specificity. Three subgroup analyses were planned a priori to examine the effects of the type of study, patient population, and lung US protocol employed. RESULTS: Seven articles (n = 1,075) were identified that met inclusion criteria (two studies completed in the ED, two in the intensive care unit [ICU], two on inpatient wards, and one in the prehospital setting). The seven studies were rated as average to excellent methodologic quality. The sensitivity of US using B-lines to diagnosis ACPE is 94.1% (95% confidence interval [CI] = 81.3% to 98.3%) and the specificity is 92.4% (95% CI = 84.2% to 96.4%). Preplanned subgroup analyses did not reveal statistically significant changes in the overall summary estimates, nor did exclusion of three potential outlier studies. CONCLUSIONS: This study suggests that in patients with a moderate to high pretest probability for ACPE, an US study showing B-lines can be used to strengthen an emergency physician's working diagnosis of ACPE. In patients with a low pretest probability for ACPE, a negative US study can almost exclude the possibility of ACPE. Further studies including large numbers of ED patients presenting with undifferentiated dyspnea are required to gain more valid and reliable estimates of test accuracy in ED patients.

Detection and correction of prescription errors by an emergency department pharmacy service.

OBJECTIVES: Emergency departments (EDs) are recognized as a high-risk setting for prescription errors. Pharmacist involvement may be important in reviewing prescriptions to identify and correct errors. The objectives of this study were to describe the frequency and type of prescription errors detected by pharmacists in EDs, determine the proportion of errors that could be corrected, and identify factors associated with prescription errors. METHODS: This prospective observational study was conducted in a tertiary care teaching ED on 25 consecutive weekdays. Pharmacists reviewed all documented prescriptions and flagged and corrected errors for patients in the ED. We collected information on patient demographics, details on prescription errors, and the pharmacists' recommendations. RESULTS: A total of 3,136 ED prescriptions were reviewed. The proportion of prescriptions in which a pharmacist identified an error was 3.2% (99 of 3,136; 95% confidence interval [CI] 2.5-3.8). The types of identified errors were wrong dose (28 of 99, 28.3%), incomplete prescription (27 of 99, 27.3%), wrong frequency (15 of 99, 15.2%), wrong drug (11 of 99, 11.1%), wrong route (1 of 99, 1.0%), and other (17 of 99, 17.2%). The pharmacy service intervened and corrected 78 (78 of 99, 78.8%) errors. Factors associated with prescription errors were patient age over 65 (odds ratio [OR] 2.34; 95% CI 1.32-4.13), prescriptions with more than one medication (OR 5.03; 95% CI 2.54-9.96), and those written by emergency medicine residents compared to attending emergency physicians (OR 2.21, 95% CI 1.18-4.14). CONCLUSIONS: Pharmacists in a tertiary ED are able to correct the majority of prescriptions in which they find errors. Errors are more likely to be identified in prescriptions written for older patients, those containing multiple medication orders, and those prescribed by emergency residents.

Is lumbar puncture still needed in suspected subarachnoid hemorrhage after a negative head computed tomographic scan?

CLINICAL QUESTION: Is lumbar puncture still needed in suspected subarachnoid hemorrhage with a negative head computed tomographic scan performed within 6 hours of headache onset? ARTICLE CHOSEN: Perry JJ, Stiell IG, Sivilotti ML, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 2011;343:d4277. OBJECTIVE: To determine whether lumbar puncture can be safely omitted after a negative head computed tomographic scan in the workup of a suspected subarachnoid hemorrhage.

Oral rivaroxaban for the treatment of symptomatic pulmonary embolism: are we ready?

CLINICAL QUESTION: Can an oral regimen of rivaroxaban be used for the treatment of symptomatic pulmonary embolism? ARTICLE CHOSEN: Büller H, Prins M, Lensing A, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 2012;366:1287-97. OBJECTIVE: To determine the effectiveness and safety of oral rivaroxaban in the treatment of symptomatic pulmonary embolism when compared to current standard therapy.

Epinephrine compared to placebo in cardiac arrest resuscitation.

CLINICAL QUESTION: Does epinephrine (adrenaline) used in the context of out-of-hospital cardiac arrest improve outcomes? ARTICLE CHOSEN: Jacobs IG, Finn JC, Jelinek GA, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial. Resuscitation 2011;82:1138-43. OBJECTIVE: To determine the effect of epinephrine in out-of-hospital cardiac arrest on patient survival to hospital discharge, prehospital return of spontaneous circulation, and neurologic outcomes.

Critical predictors of pulmonary embolism.

CLINICAL QUESTION: Do specific elements of the history and physical examination predict the presence of pulmonary embolism in the emergency department? ARTICLE CHOSEN: Courtney DM, Kline JA, Kabrhel C, et al. Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: results of a prospective, multicenter study. Ann Emerg Med 2010;55:307-15 . OBJECTIVE: To determine whether implicit clinical predictors previously untested predict the presence of pulmonary embolism in the emergency department.

Thoracic ultrasound.

Dyspnea and hypotension often present a diagnostic challenge to the emergency physician. With limitations on traditional methods of evaluating these patients, lung ultrasound has become an essential assessment tool. With the sensitivity of lung ultrasound approaching that of CT scan for many indications, it is quickly becoming a fundamental technique in assessing patients with thoracic emergencies. This article reviews the principles of thoracic ultrasound; describes the important evidence-based sonographic features found in pneumothorax, pleural effusion, pneumonia, and pulmonary edema; and provides a framework of how to use thoracic ultrasound to aid in assessing a patient with severe dyspnea.

Emergency physician recognition of adverse drug-related events in elder patients presenting to an emergency department.

OBJECTIVES: The authors examined the ability of emergency physicians (EPs) to recognize adverse drug-related events (ADREs) in elder patients presenting to the emergency department (ED). METHODS: This was a prospective observational study of patients at least 65 years of age who presented to the ED. ADREs were identified using a validated, standardized scoring system. EP recognition of ADREs was assessed through physician interview and subsequent chart review. RESULTS: A total of 161 patients were enrolled in the study. Thirty-seven ADREs were identified, which occurred in 26 patients (16.2%; 95% confidence interval [CI] = 10.5% to 22.0%). The treating EPs recognized 51.2% (95% CI = 35.2% to 67.4%) of all ADREs. There was better recognition of those ADREs related to the patient's chief complaint (91%; 95% CI = 74.1% to 100%) as compared with recognition of ADREs that were not associated with the chief complaint (32.1%; 95% CI = 14.8% to 49%). EPs recognized six of seven severe ADREs (85.7%), 13 of 23 moderate ADREs (56.5%; 95% CI = 36.8% to 77%), and none of the mild ADREs. Recognition of ADREs varied with medication class. CONCLUSIONS: EP performance was superior at identifying severe ADREs relating to the patients' chief complaints. However, EP performance was suboptimal with respect to identifying ADREs of lower severity, having missed a significant number of ADREs of moderate severity as well as ones unrelated to the patients' chief complaints. ADRE detection methods need to be developed for the ED to aid EPs in detecting those ADREs that are most likely to be missed.