Adverse events related to ultrasound-guided regional anesthesia performed by Emergency Physicians: Systematic review protocol.

The use of ultrasound-guided regional anesthesia for pain management has become increasingly prevalent in Emergency Medicine, with studies noting excellent pain control while sparing opioid use. However, the use of ultrasound-guided regional anesthesia may be hampered by concern about risks for patient harm. This systematic review protocol describes our approach to evaluate the incidence of adverse events from the use of ultrasound-guided regional anesthesia by Emergency Physicians as described in the literature. This project will also seek to document the scope of ultrasound-guided regional anesthesia applications being performed in Emergency Medicine literature, and potentially serve as a framework for future systematic reviews evaluating adverse events in Emergency Medicine.

Helicopter Emergency Medical Services Performed Extended Focused Assessment With Sonography: Training, Workflow, and Sustainable Quality.

The extended focused assessment of trauma (EFAST) examination is an invaluable tool for the initial evaluation of the trauma patient. Miniaturization of ultrasound has enabled helicopter emergency medical services (HEMS) to use point-of-care ultrasound to care for trauma patients on scene. Our study demonstrated that HEMS crews accurately performed EFAST examinations after the implementation of a novel HEMS EFAST workflow, multifaceted training, and ongoing quality assurance. The HEMS crews' overall sensitivity was 53%, and specificity was 98%. The obtained image quality was highest for the lung, cardiac, and right upper quadrant components of the EFAST. Our results suggest that with a structured multifaceted training program, user-friendly workflow, and ongoing quality assurance, HEMS crews can perform EFAST examinations safely and reliably in the field. This would allow HEMS crews to detect life-threatening, time-sensitive conditions such as a pneumothorax, pericardial effusion, and intraperitoneal hemorrhage. HEMS EFAST has the potential to triage certain trauma patients directly to the operating room or newly emerging hybrid suites, bypassing the emergency room and saving crucial time.

An investigation of clinical decisionmaking: identifying important factors in treatment planning for suicidal patients in the emergency department.

OBJECTIVE: We sought to evaluate the influence of several well-documented, readily available risk factors that may influence a psychiatric consultant's decision to admit an emergency department (ED) patient reporting suicidal ideation for psychiatric hospitalization. METHODS: We conducted a retrospective study of adult patients presenting to six affiliated EDs within Pennsylvania from January 2015 to June 2017. We identified 533 patients reporting current active suicidal ideation and receiving a complete psychiatric consultation. Socio-demographic characteristics, psychiatric presentation and history, and disposition were collected. Decision tree analysis was conducted with disposition as the outcome. RESULTS: Four of 27 variables emerged as most influential to decisionmaking, including psychiatric consultant determination of current suicide risk, patient age, current depressive disorder diagnosis, and patient history of physical violence. Likelihood of admission versus discharge ranged from 97% to 58%, depending on the variables considered. Post hoc analysis indicated that current suicide plan, access to means, lack of social support, and suicide attempt history were significantly associated with psychiatric consultant determination of moderate-to-high suicide risk, with small-to-medium effect sizes emerging. CONCLUSIONS: Only a handful of variables drive disposition decisions for ED patients reporting current active suicidal ideation, with both high and low fidelity decisions made. Patient suicide risk, determined by considering empirically supported risk factors for suicide attempt and death, contributes the greatest influence on a psychiatric consultant's decision to admit. In line with American College of Emergency Physicians (ACEP) recommendations, this study accentuates the importance of using clinical judgment and adjunct measures to determine patient disposition within this population.

Pseudogout Diagnosed By Point-of-care Ultrasound.

A 71-year-old male presented to the emergency department (ED) for worsening right knee pain for the prior 3-4 weeks. Point-of-care ultrasound (POCUS) of the right knee showed a pseudo-double contour sign. Subsequent ultrasound-guided arthrocentesis of the knee joint was performed, and fluid studies showed the presence of calcium pyrophosphate crystals, which was consistent with pseudogout. Ultrasound for detection of calcium pyrophosphate crystals in pseudogout and chondrocalcinosis has sensitivity of 86.7% and specificity of 96.4% making POCUS a valuable tool for diagnosing crystalline-induced arthropathy in the ED.

Point-of-Care Ultrasound-Directed Evaluation of Elbow Effusion.

A 53-year-old male presented with pain in the right elbow that was sudden in onset and progressively worsening over approximately eight hours. The pain was exacerbated with any movement of the elbow. Of note, he had been recently admitted for robotic prostatectomy and had a prolonged hospital stay requiring a course of antibiotics. This case report details the emergency department evaluation of septic arthritis of the elbow with a focus on best practices for ultrasound- guided elbow arthrocentesis.

Erratum: This Article Corrects: "Systemwide Clinical Ultrasound Program Development: An Expert Consensus Model".

[This corrects the article on p. 649 in vol. 19, PMID: 30013699.].

Systemwide Clinical Ultrasound Program Development: An Expert Consensus Model.

Clinical ultrasound (CUS) is integral to the practice of an increasing number of medical specialties. Guidelines are needed to ensure effective CUS utilization across health systems. Such guidelines should address all aspects of CUS within a hospital or health system. These include leadership, training, competency, credentialing, quality assurance and improvement, documentation, archiving, workflow, equipment, and infrastructure issues relating to communication and information technology. To meet this need, a group of CUS subject matter experts, who have been involved in institution- and/or systemwide clinical ultrasound (SWCUS) program development convened. The purpose of this paper was to create a model for SWCUS development and implementation.

Diagnosing acute aortic dissection with aneurysmal degeneration with point of care ultrasound.

OBJECTIVE: To present a case with visual images of an aortic dissection with aneurysmal degeneration. METHODS: A case report was described of a patient presenting to the emergency department with back pain. An aortic dissection with aneurysmal degeneration was rapidly identified with bedside ultrasound in the emergency department. RESULTS: An aortic dissection was detected rapidly by emergency physician preformed bedside ultrasound. This led to rapid identification and treatment CONCLUSION: Rapid bedside emergency ultrasound can quickly and accurately diagnosis an aortic dissection and lead to rapid treatment.

Spontaneous Isolated Visceral Artery Dissection in a Middle Aged Male.

Epigastric pain is a common complaint made by patients being evaluated in the emergency department. Spontaneous isolated visceral artery dissection is a rare cause with no reported prevalence. We present a case of a 37-year-old male evaluated in the emergency department for epigastric pain and subsequently diagnosed with a spontaneous isolated celiac artery dissection with involvement of the hepatic and splenic arteries. Recent case series suggest this disease may be managed medically in most cases. Surgical intervention may be considered for significant bleeding or signs of intestinal ischemia.

Goal-directed Focused Ultrasound Milestones Revised: A Multiorganizational Consensus.

In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 (PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision.

Ultrasound-assisted lumbar puncture in obese patients.

The use of ultrasound to mark landmarks for diagnostic lumbar puncture has been described in emergency medicine as well as in the anesthesia literature. One of the most difficult scenarios arises when obese patients with a body mass index (BMI) of greater than 30 present to an acute care setting, such as the emergency department or intensive care unit and require diagnostic LP. This article discusses lumbar puncture in patients with a high BMI.

Pott puffy tumor in a 4-year-old boy presenting in status epilepticus.

Pott puffy tumor is an osteomyelitis of the frontal bone with the development of a subperiosteal abscess manifesting as a puffy swelling of the forehead or scalp. It is believed to occur as a complication of frontal sinusitis. The modern antibiotic era has made it a rarely encountered entity. This case describes a 4-year-old boy who presented in status epilepticus secondary to Pott puffy tumor.

NeuroM and MyoD are expressed in separate subpopulations of cells in the pregastrulating epiblast.

Epiblast cells form skeletal muscle and neurons in culture and some express mRNA for the skeletal muscle specific transcription factor MyoD in vivo. The following experiments were designed to determine whether the neurogenic transcription factor NeuroM is expressed in the epiblast and if NeuroM and MyoD are present in separate subpopulations of epiblast cells that can differentiate into neurons and muscle, respectively. In situ hybridization revealed that NeuroM was present in the anterior region of the pregastrulating epiblast. Some cells with NeuroM were proliferating and expressed two molecules present in neurogenic cells, NCAM and the Zn-12/HNK-1 carbohydrate. The G8 antibody labeled cells with MyoD but not NeuroM. When G8 positive cells were isolated by magnetic cell sorting and placed in culture, nearly all differentiated into skeletal muscle in serum free medium. A subpopulation of cells isolated with antibodies that bound to cells expressing NeuroM formed neurons when cultured in medium supplemented with sera and embryo extract. These experiments demonstrate that NeuroM and MyoD are present in separate subpopulations of cells in the pregastrulating epiblast. Epiblast cells with NeuroM are more dependent on exogenous factors to differentiate than those with MyoD.