Establishing a rapid assessment service for patients with suspected malignancies for expedited outpatient management.

BACKGROUND: 11% of new cancer diagnoses occur in the emergency department. Historically, these diagnoses disproportionately affect underserved patient populations and are associated with poor outcomes. This is an observational study of the Rapid Assessment Service (RAS) program, which aims to provide timely outpatient follow-up and facilitate a diagnosis for patients discharged from the emergency department with suspected malignancies. METHODS: We performed a retrospective chart review of 176 patients who were discharged from the emergency department with RAS clinic follow up between February 2020 and March 2022. We manually chart reviewed 176 records in order to determine the average time to RAS clinic appointment, average time to diagnosis, and the final diagnosis based on biopsy. RESULTS: 163 of 176 patients (93%) discharged to RAS received reliable follow-up care. 62 of the 176 patients (35%) followed up in the RAS clinic with a mean of 4.6 days. 46 of the 62 patients (74%) who followed up in the RAS clinic were ultimately diagnosed with a new cancer, with a mean time to diagnosis of 13.5 days. The leading new cancer diagnoses included: lung, ovarian, hematologic, head and neck, and renal cancers. CONCLUSIONS: Creating a Rapid Assessment Service facilitated an expedited oncologic work-up and diagnosis in an outpatient setting.

Ocular Ultrasound: Review of Bioeffects and Safety, Including Fetal and Point of Care Perspective: Review of Bioeffects and Safety, Including Fetal and Point-of-Care Perspective.

Ocular ultrasound is an invaluable tool for the evaluation of the eye and orbit. However, the eye and orbit are potentially sensitive to the thermal and mechanical effects of ultrasound. When performing B-mode imaging, dedicated ocular settings should be used. If these settings are not available, limiting the acoustic output to Food and Drug Administration (FDA) recommended maximum levels is strongly advised. Especially important is the acoustic output in spectral (pulsed) and color Doppler modes, which can exceed the FDA's maximum recommended levels for the eye. Adjusting settings to decrease acoustic output and limiting the time of the examination should be done when performing a Doppler examination. The acoustic output of shear wave elastography is significantly higher than FDA guidelines for the eye and should be considered experimental.

Diagnostic Accuracy of Point-Of-Care Ultrasound for Intussusception Performed by Pediatric Emergency Medicine Physicians.

BACKGROUND: Intussusception (INT) is a common cause of bowel obstruction in young children. Delay in diagnosis can lead to significant morbidity and mortality. There have been several studies evaluating early point-of-care ultrasound (POCUS) in the diagnosis of INT by nonradiologists. OBJECTIVE: Our objective was to determine the diagnostic accuracy of POCUS by novice sonographer pediatric emergency medicine physicians (PEM-Ps) who received focused US training for diagnosing INT. METHODS: We performed a prospective observational study including 17 PEM-Ps (14 attendings, 3 fellows) trained to perform abdominal US for INT. Children suspected of having INT received POCUS performed and interpreted by a PEM-P, followed by a US study performed by a certified ultrasonographer and interpreted by an attending pediatric radiologist. Diagnostic concordance between PEM-P-and radiology-performed US (RPUS) results was assessed. RESULTS: One hundred patients were enrolled; median patient age was 24 months. There was excellent diagnostic agreement for presence or absence of INT between PEM-Ps and RPUS (97% of cases; κ = 0.826). POCUS-diagnosed INT was present in 8 of 9 patients with RPUS-diagnosed INT (sensitivity 89%; 95% confidence interval [CI] 51-99%; specificity 98%; 95% CI 92-100%; positive predictive value 80%; 95% CI 44-96%; negative predictive value 99%; 95% CI 93-100%). Likelihood ratio for INT with a positive POCUS was 40.44 (95% CI 10.07-162.36) and with a negative POCUS was 0.11 (95% CI 0.02-0.72). CONCLUSIONS: POCUS performed by novice sonographers to diagnose INT has high diagnostic concordance with RPUS. Emergency department-performed POCUS is a rapid and accurate method for diagnosing INT.

Does Orally-Administered Radiocontrast Impair Ultrasound Image Quality in Pediatric Patients?

INTRODUCTION: It is commonly assumed that orally-administered radiocontrast material (ORC) preceding abdominal ultrasound (US) performance can obscure image quality and potentially impair diagnostic accuracy when assessing patients with abdominal pain. Due to this concern, ORC administration per protocol for computed tomography (CT) is often delayed until after US performance, potentially contributing to prolonged length of stay in the emergency department (ED) in patients with concern for abdominal pathology. The objective of this study was to evaluate whether early administration of ORC in children with abdominal pain receiving abdominal CT for possible appendicitis obscures subsequent abdominal US image quality. METHODS: We designed a prospective observational study of children <18 years of age presenting to a pediatric ED with abdominal pain who were set to receive ORC prior to obtaining an abdominal CT. These patients received a point-of-care ultrasound (POCUS) of the abdomen to assess the abdominal aorta and right lower quadrant (RLQ) structures (psoas muscle and iliac vessels) pre- and post-ORC administration. Images were compared independently by two blinded emergency US-certified physician-assessors for quality, specifically to determine whether ORC obscured the anatomical structures in question. RESULTS: A total of 17 subjects were enrolled, and each subject had two POCUS studies of the abdomen, one pre- and one post-ORC administration looking to visualize the anatomy of the RLQ and abdominal aorta in both studies. Statistical analysis showed no significant differences in mean values of POCUS image quality scoring by two blinded US-trained physician-assessors for either RLQ structures or abdominal aorta when performed pre- and post-administration of ORC. CONCLUSION: Early ORC administration in children with abdominal pain does not adversely affect image quality of a subsequently performed abdominal US. Patients who may require abdominal CT to determine the etiology of abdominal pain can receive early administration of ORC prior to US performance to help minimize ED length of stay without impairing US diagnostic accuracy.

Urban Emergency Department Response to Measles Outbreak.

In the last year, New York City has had more than 600 confirmed measles cases. For each patient with measles, numerous neonates, unimmunized children, and susceptible adults can be exposed to the highly contagious virus. Working in an emergency department amid such an outbreak presents several challenges because of the crowded nature of the environment, the imperative for rapid identification and isolation of infected patients, and identification of vulnerable individuals who have been in the vicinity when a patient with measles presents. In this report, we discuss our process in navigating these challenges, collaboration with the city's health department, postexposure prophylaxis for individuals exposed in the hospital and the community, and prevention initiatives.

Association of ultrasound-related interruption during cardiopulmonary resuscitation with adult cardiac arrest outcomes: A video-reviewed retrospective study.

OBJECTIVES: To determine the association of focused transthoracic echocardiography (ECHO) related interruption during cardiopulmonary resuscitation (CPR) with patient outcomes in the Emergency Department (ED). METHODS: This was a retrospective, single center, cohort study, conducted in an urban community teaching ED. Eligible study subjects were adult patients in the ED with sustained cardiac arrest. Exclusion criteria include traumatic cardiac arrest and age less than 18. All resuscitations were video recorded and were subsequently reviewed by 2 study investigators. The no-flow time from chest compression interruption was analyzed using video review and separated into ECHO-related and non-ECHO related. Our primary outcome was patient survival to hospital discharge and the secondary outcome was the rate of return of spontaneous circulation (ROSC). Multivariate logistic regression analyses were performed to examine the associations between independent variables and outcomes. RESULTS: From January 2016 to May 2017, a total of 210 patients were included for final analysis. The median total no-flow time observed on video was 99.5 s (IQR: 54.0-160.0 s). Among these, a median of 26.5 s (IQR: 0.0-59.0 s) was ECHO-related and a median of 60.5 s (IQR: 34.0-101.9) was non-ECHO-related. The ECHO-related no-flow time between 77 and 122 s (OR: 7.31, 95 % confidence interval [CI]: 1.59-33.59; p-value = 0.01) and ECHO-related interruption ≦ 2 times (OR: 8.22, 95% CI: 1.51-44.64; p-value = 0.01) were positively associated with survival to hospital discharge. ECHO-related interruption ≦ 2 times (OR: 5.55, 95% CI: 2.44-12.61; p-value < 0.001) was also positively associated with ROSC. CONCLUSION: Short ECHO-related interruption during CPR was positively associated with ROSC and survival to hospital discharge. While ECHO can be a valuable diagnostic tool during CPR, the no-flow time associated with ECHO should be minimized.

Diagnostic Ultrasound Safety Review for Point-of-Care Ultrasound Practitioners.

Potential ultrasound exposure safety issues are reviewed, with guidance for prudent use of point-of-care ultrasound (POCUS). Safety assurance begins with the training of POCUS practitioners in the generation and interpretation of diagnostically valid and clinically relevant images. Sonographers themselves should minimize patient exposure in accordance with the as-low-as-reasonably-achievable principle, particularly for the safety of the eye, lung, and fetus. This practice entails the reduction of output indices or the exposure duration, consistent with the acquisition of diagnostically definitive images. Informed adoption of POCUS worldwide promises a reduction of ionizing radiation risks, enhanced cost-effectiveness, and prompt diagnoses for optimal patient care.

Interscalene brachial plexus nerve block in the emergency department: an effective and practice-changing workshop.

BACKGROUND: The interscalene brachial plexus nerve block (ISNB) is a potentially useful method of regional analgesia for humerus fracture and shoulder dislocation reduction in the Emergency Department (ED). We examined the effectiveness of an ISNB workshop given to emergency medicine (EM) residents. We also explored complication rates and effectiveness of ISNBs performed in the ED. METHODS: One-hour evidence-based ISNB workshops were conducted with EM residents. Participants were given pre-, post-, and 3-month post-workshop knowledge and technical assessments. Results were analyzed using descriptive statistics. A pre- and post-workshop chart review examined ISNB utilization, complications, post-ISNB opiate administration, and post-ISNB procedural sedation. RESULTS: 41 residents enrolled in the workshop. Pre-workshop pass rate: knowledge assessment 22%. Immediate post-workshop pass rates: knowledge assessment 100%, image acquisition 93%, needle placement 100%. Three months post-workshop pass rates: knowledge assessment 73%, image acquisition 76%, needle placement 100%. Areas of poorest knowledge retention were anatomical landmarks, block distribution, and early signs of LAST. In the chart review, 2 ISNBs were performed in the pre-workshop period, and 12 in the post-workshop period. No serious complications were recorded. 78.5% of attempted ISNBs were successful, without need for procedural sedation. Of the 11 successfully performed ISNBs, 91% received no opiates after the procedure. CONCLUSIONS: Our study suggests that EM residents can learn the ISNB, perform it safely in the emergency department, and that the ISNB may be an alternative to procedural sedation and opiate use for shoulder dislocation. Residents are adept at ISNB technical skills but demonstrate some deficits in knowledge retention.

Ultrasound-guided regional anesthesia simulation: use of meat glue in inexpensive and realistic nerve block models.

BACKGROUND: Ultrasound-guided regional anesthesia (UGRA) is increasingly used by emergency physicians to provide safe and effective pain relief for patients. However, one of the factors limiting its widespread use is the lack of realistic models available for learners to train on. There are currently no inexpensive nerve block models available that are injectable and that closely mimic nerves, fascial planes, muscles, and other landmarks. Our aim is to create inexpensive, injectable nerve block models that can be used as effective medical training tools for UGRA. METHODS: By using a lean cut of pork such as pork loin, yarn soaked in ultrasound gel to simulate peripheral nerves, and drinking straws filled with gel to represent vascular structures, we created various nerve block models. Meat glue applied between sections of meat appears hyperechoic under ultrasound, thereby mimicking fascial planes and has the added benefit of helping to secure the components of the model together. Using these elements, we were able to create realistic peripheral nerve, fascia iliaca compartment, serratus anterior plane, and interscalene brachial plexus models. RESULTS: One of the necessary skills in performing UGRA involves placing the needle tip along a fascial plane and visualizing hydrodissection of this plane with the local anesthetic. When meat glue (transglutaminase) is applied between layers of meat such as pork loin, the meat binds together and creates a hyperechoic line that mimics a fascial plane. When meat glue is applied to two apposing fascial layers naturally occurring on the meat, the fascial plane can be injected, and fluid can be seen hydrodissecting in this space. We created several nerve block models using meat glue and other components to mimic normal landmarks. CONCLUSIONS: We have developed inexpensive and easily reproducible models that create the realistic appearance of tissues, nerves, and fascial planes under ultrasound. They can also accurately simulate hydrodissection of fluid in fascial planes. We hope these nerve block models will allow for the education in UGRA to be more widespread and accessible to learners from all specialties.

The use of point of care ultrasound in the evaluation of pediatric soft tissue neck masses.

OBJECTIVE: Most soft tissue neck masses represent benign inflammatory or infectious processes; however, in some cases the diagnosis is not clear and a broader differential must be considered. The aim of this study was to compare point-of-care ultrasound (POCUS) to radiology department imaging (RDI) in the diagnosis of soft tissue neck masses. METHODS: This prospective pilot study involved a convenience sample of patients ranging in age from 1 month to 18 years of age presenting to the Pediatric Emergency Department (PED) with a soft tissue neck mass. All children who presented to the PED with soft tissue neck mass at times when an investigator was in the department, and who were candidates for enrollment, underwent a POCUS. The managing pediatric emergency medicine (PEM) provider determined whether RDI was indicated. The results of the POCUS sonologist and radiologist were compared. The kappa statistic was used to analyze agreement with p < 0.05 denoting statistical significance. RESULTS: Twenty-seven patients were enrolled into the study. Twenty-two received radiology ultrasound (RUS), 3 patients received CT, and 2 patients received both RUS and CT. There was agreement between POCUS and RDI diagnoses in 21/27 cases (78%). Accordingly, overall concordance between POCUS and RDI diagnoses was good: the kappa statistic comparing diagnoses obtained by POCUS versus RDI was 0.69 (p < 0.001). CONCLUSION: This prospective pilot study describes the reliability of POCUS as an imaging modality in the management of patients with undifferentiated soft tissue neck masses. POCUS demonstrated good agreement with RDI as a bedside imaging tool in the evaluation of pediatric soft tissue neck masses.

WITHDRAWN: Relocation of blood gas laboratory to the emergency department helps decrease lactic acid values.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.ajem.2018.03.017. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Relocation of blood gas laboratory to the emergency department helps decrease lactic acid values.

IMPORTANCE: Emergency Physicians often rely on Lactic Acid (LA) values to make important clinical decisions. Accuracy of LA values improve when blood gas analysis is performed in the emergency department (ED) as opposed to a satellite laboratory (SL). OBJECTIVE: To investigate an association between blood gas laboratory location and accuracy of ED lactic acid samples. METHODS: The study team evaluated lactic acid values from venous and arterial blood gas samples drawn between June 1, 2015 and September 30, 2016. The study was exempt from institutional review board approval. Samples were separated into two groups: those which were drawn prior to and after relocation of the blood gas laboratory to the ED. The data, including patient demographic characteristics, acute illness severity indices, and blood gas results were compared within and between each group using t-test for continuous variables and chi-square test for categorical variables. The primary outcome was the mean lactate value measured in the SL group in 2015 compared to the ED group in 2016. Potassium and creatinine values were measured between the two groups as secondary outcomes. RESULTS: Of the 21,595 consecutive samples drawn, 10,363 samples were from the SL group and 11,232 from the ED group. The SL group included 5458 (52.7%) women; mean (SD) age was 61.8 (21.0). The ED group contained 5860 (52.2%) women; mean (SD) age was 61.7 (20.5). Mean Emergency Severity Index (ESI) were the same in each group at 2.31 and rates of Systemic Inflammatory Response Syndrome (SIRS) were also equivalent in each group at 22.2%. Significant differences were found between LA values in the SL group (mean 2.21mmol/L) and in the ED group (mean 1.99mmol/L) with a p value of <0.0001. There was a small statistical significance between the difference in potassium values in the SL group (mean 3.98meq/L) compared to the ED Group (mean 3.96meq/L) with a p value of 0.022. No significant difference was found between the creatinine values. CONCLUSIONS AND RELEVANCE: These results suggest that mean lactate values decreased when measured in an ED blood gas laboratory and may provide more accurate LA results than blood gas samples analyzed at an SL blood gas laboratory within the same institution. Hospitals may consider moving blood gas laboratories to the ED to improve accuracy of one of the most important early blood markers used in the definition of sepsis and in the identification of the critically ill.

Does oral radiocontrast affect image quality of abdominal sonography?

OBJECTIVE: Emergency Department patients with abdominal pain may require both an ultrasound (US) and computed tomography (CT) for an accurate diagnosis. Patients are often asked to drink oral radiocontrast while awaiting ultrasound, in order to better expedite a CT in the case of a non-diagnostic US. The impact of oral radiocontrast on US image quality has not been studied. We compared the quality of US images obtained before and after the ingestion of oral radiocontrast in healthy adult volunteers. METHODS: This was a prospective study in which adult volunteer subjects underwent sonographic studies of the aorta, the right upper quadrant, the right lower quadrant, and the Focused Assessment with Sonography in Trauma (FAST) examination. Initial studies were performed prior to ingestion of oral radiocontrast, with subsequent imaging occurring at 1 and 2hour post-ingestion. All of the images from the sonographic exams were randomized and subsequently scored for quality by two emergency ultrasound fellowship trained emergency physicians with extensive experience in performing and interpreting US. RESULTS: 638 images from 240 exams were obtained from 20 subjects at three time points. Six exams were not scored due to inadequate images. There were no significant differences in image quality for any of the US exam types after the ingestion of oral radiocontrast at 1 and 2h. CONCLUSION: Ingestion of oral radiocontrast did not affect image quality of four common abdominal ultrasound examinations.

When Fever, Leukocytosis, and Right Lower Quadrant Pain Is Not Appendicitis.

Mesenteric cystic lymphangioma (MCL) is an uncommon, benign, slow-growing abdominal tumor that is derived from the lymphatic vessels (World J Gastroenterol. 2012;18:6328-6332, Radiographics. 1994;14:729-737). It is most often diagnosed in the head and neck of affected children. Rarely, a lymphangioma can develop within the small bowel (Pan Afr Med J. 2012;12:7). The clinical presentation of patients with an abdominal MCL can range from asymptomatic to acute abdominal pain (J Korean Surg Soc. 2012;83:102-106). We report a case of small bowel volvulus caused by an MCL in a 3-year-old child who presented to the pediatric emergency department with right lower quadrant pain. The child was thought to have a perforated appendicitis and was taken to the operating room where an MCL was identified and resected. This case illustrates the need to consider MCL when a patient presents to the emergency department with right lower quadrant pain.

A Knotted Urethral Catheter in the Emergency Department.

Inadvertent knotting of urethral catheters and enteric feeding tubes is a rare complication in pediatric patients. If a small flexible tube is used and advanced too far, upon withdrawal, the catheter may knot in the bladder. Surgical intervention for retrieval is required in most cases. We present a case of a 26-day-old female neonate who was catheterized with a 5 French enteric feeding tube, which was later removed in the emergency department with gentle traction alone. After removal, a knot was noted at the tip. It is important for emergency physicians to be aware of this complication, because this particular size feeding tube is most susceptible to kinking inside of the urinary tract.

Delayed cardiac tamponade: A rare but life-threatening complication of catheter ablation.

Delayed cardiac tamponade (DCT) is a rare and life-threatening complication of catheter ablation performed as a treatment of atrial fibrillation, with few cases described in the medical literature. We present the case of a 57year-old man presenting with DCT 61days following a catheter ablation procedure. To the best of our knowledge, this is the most delayed case of cardiac tamponade (CT) following catheter ablation described in the literature. We also discuss the importance of point of care ultrasound (POCUS) in the diagnosis and treatment of CT. Emergency physicians must maintain a high index of suspicion in making the diagnosis of CT as patients may present with vague symptoms such as neck or back pain, shortness of breath, fatigue, dizziness, or altered mental status, often without chest pain. Common risk factors for CT include cancer, renal failure, pericarditis, cardiac surgery, myocardial rupture, trauma, and retrograde aortic dissection. In addition, although rare, both catheter ablation and use of anticoagulation carry risks of developing CT. A worldwide survey of medical centers performing catheter ablation found CT as a complication in less than 2% of cases [1]. Some proposed mechanisms of DCT include small pericardial hemorrhages following post-procedural anticoagulation or rupture of the sealed ablation-induced left atrial wall [2]. Clinical examination and electrocardiography may be helpful. However, the criterion standard for diagnosing CT is echocardiography [3].

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial.

OBJECTIVES: To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture. DESIGN: Multisite randomized controlled trial from April 2009 to March 2013. SETTING: Three New York hospitals. PARTICIPANTS: Individuals with hip fracture (N = 161). INTERVENTION: Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82). MEASUREMENTS: Pain (0-10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects. RESULTS: Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3-232 vs 100.0 feet, 95% CI = 65.1-134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6-11.0) vs 9.1 (95% CI = 8.2-10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents. CONCLUSION: Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.