A randomised experiment comparing low-cost ultrasound gel alternative with commercial gel.

OBJECTIVE: Point-of-care ultrasound is a portable, relatively low-cost imaging modality with great potential utility in low-resource settings. However, commercially produced ultrasound gel is often cost-prohibitive and unavailable. We investigated whether images obtained using an alternative cornstarch-based gel would be of comparable quality with those using commercial gel. METHODS: This was a blinded, randomised, cross-over study comparing commercially produced ultrasound gel with home-made cornstarch-based gel. Ultrasound-trained faculty obtained three video clips with each gel type from patients at one urban ED. The clips were evaluated by a radiologist and an ultrasound-trained emergency physician. Images were assessed in terms of overall adequacy (dichotomous) and quality, resolution and detail using a rating scale (0-10). All sonographers and physicians reviewing the images were blinded to the type of gel used. RESULTS: Thirty-four patients were enrolled in the study, producing 204 separate images (102 with each gel). The cornstarch gel clips were deemed accurate in 70.6% (95% CI 63.9% to 76.5%) of the scans, as compared with 65.2% (95% CI 58.4% to 71.4%) of those using commercial gel. There was no difference between the two groups with respect to image detail, resolution or quality. CONCLUSIONS: Images produced using the cornstarch-based alternative ultrasound gel were of similar quality to those using commercial gel. The low cost and easy preparation of the cornstarch-based gel make it an attractive coupling medium for use in low-resource settings.

Horner's Syndrome after Superficial Cervical Plexus Block.

Ultrasound-guided nerve blocks are becoming more essential for the management of acute pain in the emergency department (ED). With increased block frequency comes unexpected complications that require prompt recognition and treatment. The superficial cervical plexus block (SCPB) has been recently described as a method for ED management of clavicle fracture pain. Horner's syndrome (HS) is a rare and self-limiting complication of regional anesthesia in neck region such as brachial and cervical plexus blocks. Herein we describe the first reported case of a HS after an ultrasound-guided SCPB performed in the ED and discuss the complex anatomy of the neck that contributes to the occurrence of this complication.

Stimulant-related Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy (TC) is a rare but increasingly recognized mimic of acute coronary syndrome. Patients present with angina,ST-segment changes on electrocardiogram (both elevations and depressions),and rapid rises in cardiac biomarkers. Many kinds of stressful events have been associated with TC, but only a handful of drug-related cases have previously been reported. We describe the case of a 58-year-old woman who developed TC 2 days after crack cocaine use, a diagnosis first suggested as bedside echocardiography in the emergency department.Recognition of the classic echocardiographic appearance of TC­apical hypokinesis causing "ballooning" of the left ventricle during systole­may greatly assist providers in the early identification of this condition.

Gastrointestinal manifestations of hereditary angioedema diagnosed by ultrasound in the emergency department.

Abdominal angioedema is a less recognized type of angioedema, which can occur in patients with hereditary angioedema (HAE). The clinical signs may range from subtle, diffuse abdominal pain and nausea, to overt peritonitis. We describe two cases of abdominal angioedema in patients with known HAE that were diagnosed in the emergency department by point-of-care (POC) ultrasound. In each case, the patient presented with isolated abdominal complaints and no signs of oropharyngeal edema. Findings on POC ultrasound included intraperitoneal free fluid and bowel wall edema. Both patients recovered uneventfully after receiving treatment. Because it can be performed rapidly, requires no ionizing radiation, and can rule out alternative diagnoses, POC ultrasound holds promise as a valuable tool in the evaluation and management of patients with HAE.

From the heart: interatrial septal aneurysm identified on bedside ultrasound.

A 61 year-old man presented to the Emergency Department for one day of nonspecific chest pain. Bedside echocardiogram performed by the emergency physician revealed normal systolic cardiac function but also showed a large ( > 10mm) bicornuate interatrial septal aneurysm (IASA) projecting into the right atrium (Figure 1, Video 1). There was no evidence of intraatrial thrombus. A formal echocardiogram performed later that day confirmed the diagnosis and also detected a patent foramen ovale (PFO) with a left-to-right shunt that reversed with Valsalva maneuver.

Identification of high-risk patients with acute coronary syndrome using point-of-care echocardiography in the ED.

Stratifying risk of patients with acute coronary syndrome (ACS) in the emergency department (ED) remains a frequent challenge. When ST-elevation criteria are absent, current recommendations rely upon insensitive and time-intensive methods such as the electrocardiogram and cardiac enzyme testing. Here, we report on a series of cases, where emergency physicians used a simplified model for identifying regional wall motion abnormalities by point-of-care echocardiography in patients presenting with chest pain to the ED. With the use of a simplified model described herein, high-risk patients with ACS were identified rapidly in a cohort usually difficult to risk stratify.

The July Effect: is emergency department length of stay greater at the beginning of the hospital academic year?

INTRODUCTION: There has been concern of increased emergency department (ED) length of stay (LOS) during the months when new residents are orienting to their roles. This so-called "July Effect" has long been thought to increase LOS, and potentially contribute to hospital overcrowding and increased waiting time for patients. The objective of this study is to determine if the average ED LOS at the beginning of the hospital academic year differs for teaching hospitals with residents in the ED, when compared to other months of the year, and as compared to non-teaching hospitals without residents. METHODS: We performed a retrospective analysis of a nationally representative sample of 283,621 ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS), from 2001 to 2008. We stratified the sample by proportion of visits seen by a resident, and compared July to the rest of the year, July to June, and July and August to the remainder of the year. We compared LOS for teaching hospitals to non-teaching hospitals. We used bivariate statistics, and multivariable regression modeling to adjust for covariates. RESULTS: Our findings show that at teaching hospitals with residents, there is no significant difference in mean LOS for the month of July (275 minutes) versus the rest of the year (259 min), July and August versus the rest of the year, or July versus June. Non-teaching hospital control samples yielded similar results with no significant difference in LOS for the same time periods. There was a significant difference found in mean LOS at teaching hospitals (260 minutes) as compared to non-teaching hospitals (185 minutes) throughout the year (p<0.0001). CONCLUSION: Teaching hospitals with residents in the ED have slower throughput of patients, no matter what time of year. Thus, the "July Effect" does not appear to a factor in ED LOS. This has implications as overcrowding and patient boarding become more of a concern in our increasingly busy EDs. These results question the need for additional staffing early in the academic year. Teaching hospitals may already institute more robust staffing during this time, preventing any significant increase in LOS. Multiple factors contribute to long stays in the ED. While patients seen by residents stay longer in the ED, there is little variability throughout the academic year.

Evaluation of a cornstarch-based ultrasound gel alternative for low-resource settings.

BACKGROUND: Ultrasound is an ideal imaging modality for low-resource settings given its portability, ease of use, and wide range of applications. Commercially available ultrasound gels may be unavailable or cost prohibitive in low-resource settings. OBJECTIVE: Our aim was to investigate the quality of images obtained with an alternative ultrasound gel made from cornstarch and water in comparison with commercially available gel. METHODS: The cornstarch gel was made by heating water and cornstarch. The gel was used to obtain standard ultrasound images of the gallbladder, kidneys, bladder, heart, and neck vessels by the study investigators. Commercial gel was used as the control. Twenty-four ultrasound clips were shown to four blinded radiologists and two ultrasound-fellowship-trained emergency department physicians. They rated the images on adequacy (yes/no) and graded the images detail, resolution, and quality using a continuous 0-10 scale. RESULTS: A total of 144 video clips were shown to reviewers and 129 data-collection sheets were returned. There was no statistical difference in the proportion of images deemed to be of adequate quality: cornstarch-based gel = 0.97 (95% confidence interval [CI] 0.92-1.00) vs. commercially available gel = 0.85 (95% CI 0.75-0.94) (p = 0.053). The cornstarch gel was superior to commercial gel on all three image parameters: detail (p = 0.002), resolution (p = 0.018), and quality (p = 0.013). CONCLUSIONS: In this study, a gel made from cornstarch and water was an acceptable coupling medium and provided equally adequate images as compared with commercial ultrasound gel. This inexpensive gel made from ubiquitous materials can be an acceptable alternative to commercial gel in low-resource settings.

The implementation of therapeutic hypothermia in the emergency department: a multi-institution case review.

BACKGROUND: The use of therapeutic hypothermia (TH) is a burgeoning treatment modality for post-cardiac arrest patients. OBJECTIVES: We performed a retrospective chart review of patients who underwent post-cardiac arrest TH at eight different institutions across the United States. Our objectives were to assess how TH is currently being implemented in emergency departments and to examine the feasibility of conducting TH research using multi-institution prospective data. METHODS: A total of 94 cases were identified in a 3-year period and submitted for review by participating institutions of the Peri-Resuscitation Consortium. Of those, seven charts were excluded for missing data. Two independent reviewers performed the data abstraction. Results were subsequently compared, and discrepancies were resolved by a third reviewer. We assessed patient demographics, initial presenting rhythm, time until TH initiation, duration of TH, cooling methods and temperature reached, survival to hospital discharge, and neurological status on discharged. RESULTS: The majority of cases had initial cardiac rhythms of asystole or pulseless electrical activity (55.2%), followed by ventricular tachycardia or fibrillation (34.5%). The inciting cardiac rhythm was unknown in 10.3% of cases. Time to initiation of TH ranged from 0 to 783 minutes with a mean time of 99 minutes (SD=132). Length of TH ranged from 25 to 2,171 minutes with a mean time of 1,191 minutes (SD=536). The average minimum temperature achieved was 32.5°C, with a range from 27.6°C to 36.7°C (SD=1.5°C). Of the 87 charts reviewed, 29 (33.3%) of the patients survived to hospital discharge. CONCLUSION: The implementation of TH across the country is extremely varied with no universally accepted treatment. While our study is limited by sample size, it illustrates some compelling trends. A large, prospective, multicenter trial or registry is necessary to elucidate further the optimal parameters for TH and its benefit in various population subsets.