Feasibility, utility, and safety of fully incorporating transesophageal echocardiography into emergency medicine practice.

INTRODUCTION: Transthoracic echocardiography (TTE) is a standard procedure for emergency physicians (EPs). Transesophageal echocardiography (TEE) is known to have great utility in patients who are critically ill or in cardiac arrest and has been used by some EPs with specialized ultrasound (US) training, but it is generally considered outside the reach of the majority of EPs. We surmised that all of our EPs could learn to perform focused TEE (F-TEE), so we trained and credentialed all of the physicians in our group. METHODS: We trained 52 EPs to perform and interpret F-TEEs using a 4-h simulator-based course. We kept a database of all F-TEE examinations for quality assurance and continuous quality feedback. Data are reported using descriptive statistics. RESULTS: Emergency physicians attempted 557 total F-TEE examinations (median = 10, interquartile range = 5-15) during the 42-month period following training. Clinically relevant images were obtained in 99% of patients. EPs without fellowship or other advanced US training performed the majority of F-TEEs (417, 74.9%) and 94.3% (95% confidence interval [CI] = 91.4%-96.3%) had interpretable images recorded. When TTE and TEE were both performed (n = 410), image quality of TEE was superior in 378 (93.3%, 95% CI = 89.7%-95%). Indications for F-TEE included periarrest states (55.7%), cardiac arrest (32.1%), and shock (12.2%). There was one case of endotracheal tube dislodgement during TEE placement, but this was immediately identified and replaced without complication. CONCLUSION: After initiating a mandatory group F-TEE training and credentialing program, we report the largest series to date of EP-performed resuscitative F-TEE. The majority of F-TEE examinations (75%) were performed by EPs without advanced US training beyond residency.

Analysis of Prehospital Scene Times and Interventions on Mortality Outcomes in a National Cohort of Penetrating and Blunt Trauma Patients.

BACKGROUND: Recent studies have suggested improved outcomes in victims of penetrating trauma managed with shorter prehospital times and limited interventions. The purpose of the current study was to perform an outcome analysis of patients transported following penetrating and blunt traumatic injuries. METHODS: We performed a descriptive retrospective analysis of the 2014 National Emergency Medical Services Information System (NEMSIS) public release research data set for patients presenting after acute traumatic injury. RESULTS: A total of 2,018,141 patient encounters met criteria, of which 3.9% were penetrating trauma. Prehospital cardiac arrest occurred in 0.5% blunt and 4.2% penetrating trauma patients. Emergency department (ED) mortality was higher in penetrating than blunt trauma patients (4.1% vs. 0.8%). Scene times were 18.1 ± 36.5 minutes for blunt and 16.0 ± 45.3 minutes for penetrating trauma. Mean scene time for blunt trauma patients who died in the ED was 24.9 ± 58.0 minutes compared with 18.8 ± 38.5 minutes for those admitted; for penetrating trauma, scene times were 17.9 ± 23.5 and 13.4 ± 11.6 minutes, respectively. Mean number of procedures performed for blunt trauma patients who died in the ED was 6.5 ± 4.3 compared with 3.1 ± 2.3 for those who survived until admission; for penetrating trauma, the numbers of procedures performed were 5.7 ± 3.4 and 2.6 ± 2.0, respectively. CONCLUSIONS: Although less frequent than blunt trauma, penetrating trauma is associated with significantly higher prehospital and ED mortality. Increased scene time and number of procedures was associated with greater mortality for both blunt and penetrating trauma. Further study is required to better understand any causal relationships between prehospital times and interventions and patient outcomes.

Clopidogrel pretreatment in ST-elevation myocardial infarction patients transferred for percutaneous coronary intervention.

BACKGROUND: Pretreatment with clopidogrel reduces ischemic complications before percutaneous coronary intervention (PCI). Limited data exist regarding the effect of pretreatment for ST-segment elevation myocardial infarction (STEMI) patients undergoing primary PCI. METHODS: Prospective data were analyzed from a regional STEMI system using rapid transfer for primary PCI in 30 community hospitals. Zone 1 community hospitals are <60 miles and Zone 2 hospitals are 60 to 210 miles away from the PCI hospital. Compared with 63 minutes in the PCI hospital, median door-to-balloon times were 94 minutes in Zone 1 and 123 minutes in Zone 2 hospitals. All patients received aspirin, unfractionated heparin, and clopidogrel 600 mg in the emergency department of the presenting hospital within 15 minutes of diagnosis. RESULTS: From April 2003 through December 2008, 2,014 consecutive STEMI patients were pretreated with clopidogrel before PCI, with a median (25th-75th percentile) duration from pretreatment to PCI of 75 (58-93) minutes. Patients with longer pretreatment duration had significantly reduced reinfarction/reischemia at 30 days (Zone 1: 0.85%, Zone 2: 0.9%) compared with nontransferred patients (3.2%, P = .001) as well as reduced stent thrombosis (Zone 1: 0.6%, Zone 2: 0.6% vs Abbott Northwestern: 2.0%; P = .04). Similarly, pretreatment duration of >60 minutes before PCI had reduced 30-day reinfarction/reischemia (1.0% vs 2.9%, P = .003). There were no significant differences in mortality or major bleeding. CONCLUSION: ST-segment elevation myocardial infarction patients undergoing primary PCI in a regional STEMI network who received earlier pretreatment with a 600-mg loading dose of clopidogrel had less ischemic complications without increased bleeding or mortality.