Current Applications of Pediatric Abdominal Point-of-Care Ultrasound.

Point-of-care ultrasound (POCUS) for pediatric abdominal symptoms has expanded in both the inpatient and outpatient settings. POCUS may be used to aid in the diagnosis of appendicitis, hypertrophic pyloric stenosis, and intussusception in the pediatric population. This article reviews the benefits of POCUS for the diagnosis of these pediatric pathologies. This article also provides instruction on how to perform these important examinations. [Pediatr Ann. 2021;50(10):e419-e423.].

Electronic Health Record-Embedded Individualized Pain Plans for Emergency Department Treatment of Vaso-occlusive Episodes in Adults With Sickle Cell Disease: Protocol for a Preimplementation and Postimplementation Study.

BACKGROUND: Individuals living with sickle cell disease often require aggressive treatment of pain associated with vaso-occlusive episodes in the emergency department. Frequently, pain relief is poor. The 2014 National Heart, Lung, and Blood Institute evidence-based guidelines recommended an individualized treatment and monitoring protocol to improve pain management of vaso-occlusive episodes. OBJECTIVE: This study will implement an electronic health record-embedded individualized pain plan with provider and patient access in the emergency departments of 8 US academic centers to improve pain treatment for adult patients with sickle cell disease. This study will assess the overall effects of electronic health record-embedded individualized pain plans on improving patient and provider outcomes associated with pain treatment in the emergency department setting and explore barriers and facilitators to the implementation process. METHODS: A preimplementation and postimplementation study is being conducted by all 8 sites that are members of the National Heart, Lung, and Blood Institute-funded Sickle Cell Disease Implementation Consortium. Adults with sickle cell disease aged 18 to 45 years who had a visit to a participating emergency department for vaso-occlusive episodes within 90 days prior to enrollment will be eligible for inclusion. Patients will be enrolled in the clinic or remotely. The target analytical sample size of this study is 160 patient participants (20 per site) who have had an emergency department visit for vaso-occlusive episode treatment at participating emergency departments during the study period. Each site is expected to enroll approximately 40 participants to reach the analytical sample size. The electronic health record-embedded individualized pain plans will be written by the patient's sickle cell disease provider, and sites will work with the local informatics team to identify the best method to build the electronic health record-embedded individualized pain plan with patient and provider access. Each site will adopt required patient and provider implementation strategies and can choose to adopt optional strategies to improve the uptake and sustainability of the intervention. The study is informed by the Technology Acceptance Model 2 and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Provider and patient baseline survey, follow-up survey within 96 hours of an emergency department vaso-occlusive episode visit, and selected qualitative interviews within 2 weeks of an emergency department visit will be performed to assess the primary outcome, patient-perceived quality of emergency department pain treatment, and additional implementation and intervention outcomes. Electronic health record data will be used to analyze individualized pain plan adherence and additional secondary outcomes, such as hospital admission and readmission rates. RESULTS: The study is currently enrolling study participants. The active implementation period is 18 months. CONCLUSIONS: This study proposes a structured, framework-informed approach to implement electronic health record-embedded individualized pain plans with both patient and provider access in routine emergency department practice. The results of the study will inform the implementation of electronic health record-embedded individualized pain plans at a larger scale outside of Sickle Cell Disease Implementation Consortium centers. TRIAL REGISTRATION: ClinicalTrials.gov NCT04584528; https://clinicaltrials.gov/ct2/show/NCT04584528. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24818.

General Pediatric Clinical Applications of POCUS: Part 2.

The use of point-of-care ultrasound (POCUS) performed by non-radiologists has become more widespread and is entering new arenas of clinical care, particularly in the world of pediatrics. Children are prime candidates for ultrasound because they are more at risk to the harmful effects of ionizing radiation than adults. This is the second part of a two-part article reviewing 10 uses of POCUS that pediatricians can apply to their practice in both inpatient and outpatient settings. [Pediatr Ann. 2020;49(4):e196-e200.].

General Pediatric Clinical Applications of POCUS: Part 1.

The use of point-of-care ultrasound (POCUS) performed by non-radiologists has become more widespread and is entering new arenas of clinical care. Children in particular are prime candidates for ultrasound, as they are both usually thinner than adults and are particularly at risk from the harmful effects of ionizing radiation. In this two-part article, we propose 10 uses of POCUS that pediatricians can apply to their practice in both inpatient and outpatient settings. [Pediatr Ann. 2020;49(3):e147-e152.].

Bedside Use of Speckle Tracking Echocardiography in the Emergency Department to Identify Acute Myocardial Infarction.

BACKGROUND: Rapid diagnosis of acute myocardial infarction (AMI) in the emergency department (ED) is often hindered by the limitations of the electrocardiogram (ECG). Speckle tracking echocardiography (STEch) is a semiautomated, computer-assisted process that provides accurate detection of regional ventricular wall motion abnormalities and can be performed at the bedside by operators with limited experience. CASE REPORTS: Two separate patients, each with history and ECG findings concerning for AMI, were evaluated using STEch performed by an emergency physician. Ventricular wall motion abnormalities found on STEch accurately reflected the findings of emergent cardiac catheterization, with one patient requiring urgent coronary artery revascularization and the other with no coronary artery occlusion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: STEch is a novel, easy-to-use form of echocardiography that can be used in the ED to identify patients with AMI who would benefit from emergent revascularization.

Strain analysis for the identification of hypertensive cardiac end-organ damage in the emergency department.

Hypertensive emergency is a life-threatening state. End-organ damage affecting the heart accounts for up to 52% of hypertensive emergencies commonly encountered in the emergency department. Recent evidence indicates that strain echocardiography with computerized speckle-tracking is more sensitive at identifying hypertension induced changes in the left ventricle (LV) mechanical function than traditional 2-D echocardiography. We present a case demonstrating the use of emergency physician performed point-of-care strain echocardiography to identify and quantify LV mechanical dysfunction during a hypertensive crisis and to monitor improvement over 6 h.

Bedside ultrasound as a predictive tool for acute chest syndrome in sickle cell patients.

BACKGROUND: Acute chest syndrome (ACS) is the leading cause of death for patients with sickle cell disease (SCD). Early recognition of ACS improves prognosis. OBJECTIVE: Investigate the use of bedside lung ultrasound (BLU) in identification of early pulmonary findings associated with ACS in SCD patients. METHODS: Prospective, observational study of a convenience sample of SCD patients presenting to the Emergency Department (ED) for a pain crisis. BLU interpretations were made by an emergency physician blinded to the diagnosis of ACS, and were validated by a second reviewer. The electronic medical record was reviewed at discharge and at 30 days. RESULTS: Twenty SCD patients were enrolled. Median age was 31 years, median hemoglobin was 7.7 g/dL. Six patients developed ACS. Five patients in the ACS group had lung consolidations on BLU (83%) compared to 3 patients in the non-ACS group (21%), p = 0.0181, (OR = 12.05, 95% CI 1.24 to 116.73). The ACS group was also more likely to have a pleural effusion and B-lines on BLU than the non-ACS group, p = 0.0175; 0.1657, respectively. In the ACS group, peripheral and frank consolidations on BLU was 83% and 50% sensitive, 79% and 100% specific for ACS, respectively; whereas an infiltrate on initial chest X-ray (CXR) was only 17% sensitive. BLU identified lung abnormalities sooner than CXR (median 3.6 vs. 31.8 h). CONCLUSIONS: Pulmonary abnormalities on BLU of an adult SCD patient presenting to the ED for a painful crisis appear before CXR, and highly suggest ACS. BLU is a promising predictive tool for ACS.

Emergency physician use of tissue Doppler bedside echocardiography in detecting diastolic dysfunction: an exploratory study.

INTRODUCTION: This study evaluates the agreement between emergency physician (EP) assessment of diastolic dysfunction (DD) by a simplified approach using average peak mitral excursion velocity (e'A) and an independent cardiologist's diagnosis of DD by estimating left atrial (LA) pressure using American Society of Echocardiography (ASE) guidelines. METHODS: This was a secondary analysis of 48 limited bedside echocardiograms (LBE) performed as a part of a research study of patients presenting to the Emergency Department (ED) with elevated blood pressure but without decompensated heart failure. EPs diagnosed DD based on e'A < 9 cm/s alone. A blinded board-certified cardiologist reviewed LBEs to estimate LA filling pressures following ASE guidelines. An unweighted kappa measure was calculated to determine agreement between EP and cardiologist. RESULTS: Six LBEs were deemed indeterminate by the cardiologist and excluded from the analysis. Agreement was reached in 41 out of 48 cases (85.4%). The unweighted kappa coefficient was 0.74 (95% CI 0.57-0.92). EPs identified 18 out of 20 LBEs diagnosed with diastolic dysfunction by the cardiologist. CONCLUSION: There is a good agreement between (e'A) by EP and cardiologist interpretation of LBEs. Future studies should investigate this simplified approach as a one-step method of screening for LV diastolic dysfunction in the ED.

A hypertension emergency department intervention aimed at decreasing disparities: Design of a randomized clinical trial.

Effective interventions to identify and treat uncontrolled hypertension (HTN), particularly in underrepresented populations that use the emergency department (ED) for primary care, are critically needed. Uncontrolled HTN contributes significantly to cardiovascular morbidity and mortality and is more frequently encountered among patients presenting to the ED as compared to the primary care setting. EDs serve as the point of entry into the health care system for high-risk patient populations, including minority and low-income patients. Previous studies have demonstrated that the prevalence of uncontrolled/undiagnosed HTN in patients presenting to the ED is alarmingly high. Thus ED engagement and early risk assessment/stratification is a feasible innovation to help close health disparity gaps in HTN. A Hypertension Emergency Department Intervention Aimed at Decreasing Disparities (AHEAD2) trial, funded by the National Heart, Lung, and Blood Institute (NHLBI) is a three-arm single site randomized clinical pilot trial of adults presenting to the ED with Stage 2 hypertension (blood pressure [BP]>160/100) comparing (1) an ED-initiated Screening, Brief Intervention, and Referral for Treatment (SBIRT) focused on HTN, (2) the same ED-initiated SBIRT coupled with a Post-Acute Care Hypertension Transition Consultation by ED Clinical Pharmacists, and (3) usual care. The primary outcome is mean BP differences between study arms. Secondary outcomes are proportion of participants with BP control (BP<140/90mmHg), and improvements in HTN knowledge and medication adherence scores between study arms. The objective of this report is to describe the development of the AHEAD2 trial, including the methods, research infrastructure, and other features of the randomized clinical trial design.

Correlation between Subclinical Heart Disease and Cardiovascular Risk Profiles in an Urban Emergency Department Population with Elevated Blood Pressures: A Pilot Study.

BACKGROUND: Uncontrolled hypertension is a primary risk factor for development of cardiovascular complications. OBJECTIVE: Determine the point prevalence of left ventricular hypertrophy (LVH) and diastolic dysfunction in an urban emergency department (ED) population with elevated blood pressures (BP) and examine correlations between subclinical disease and patient cardiovascular risk profiles. METHODS: A convenience sample of patients with EBP (>140/90 on two measurements) had limited bedside echocardiograms (LBE). Subclinical hypertensive heart disease was classified as the presence of: LVH, abnormal ejection fraction (EF), or diastolic dysfunction. RESULTS: Thirty-nine patients with EBP were enrolled. The mean age was 46 years (SD = 10.9), 59% were women, 21% were smokers, and 92% had a history of hypertension. The average body mass index was 30.7 (SD = 8.7). Patients were 67% African American, 23% Latino, 5% Caucasian, 3% Asian, and 3% Native American. Subclinical disease was found in 39%: 31% had LVH, 15% had diastolic dysfunction, and 8% had abnormal EF. On bivariate analysis, elevated BP (p = 0.039) and blood urea nitrogen (p = 0.016) were correlated with subclinical heart disease. After adjusting for other covariates, receiving oral/intravenous antihypertensive medications in the ED (p = 0.005) was associated with subclinical heart disease. CONCLUSIONS: We found a point prevalence of subclinical heart disease of 39% in this urban ED population, using LBE. Real-time identification of subclinical heart disease at early stages in the ED in conjunction with abnormal renal function can help emergency physicians identify those patients in need of more aggressive therapy and urgent follow-up.