Evaluation and Management of Urinary Tract Infection in the Emergency Department.

Urinary tract infection (UTI) affects patients of all ages and is a diagnosis that emergency physicians might make multiple times per shift. This article reviews the evaluation and management of patients with infections of the urinary tract. Definitions of asymptomatic bacteriuria, uncomplicated UTI, and complicated UTI are presented, as well as techniques for distinguishing them. The pathophysiology and clinical and laboratory diagnoses of UTI are described. Treatment of UTI is reviewed, with attention to bacteriuria and special populations, including pregnant, elderly/geriatric, and spinal cord injury patients.

How we started an elective in emergency bedside ultrasound.

The expanding use of bedside ultrasonography in the practice of emergency medicine and other specialties is accompanied by the need to train medical students in its applications and interpretation of its results. In this article, the authors describe their successful design, launch, and management of the ultrasound elective at the University of Maryland School of Medicine. Because the course has been so well received, the authors are now exploring ways of presenting its content and skills-building opportunities in more venues, including the Introduction to Clinical Medicine course.

Evaluation and management of oral lesions in the emergency department.

This article reviews the emergency diagnosis and treatment of oral lesions. It presents a framework for developing a differential diagnosis based on the color of the lesions, describes emergency department interventions, and identifies pitfalls for the emergency physician.

No effect of Valsalva maneuver or Trendelenburg angle on axillary vein size.

BACKGROUND: A new technique for establishing ultrasound-guided central access involves the use of the axillary vein, the distal projection of the subclavian vein, via the lateral chest. OBJECTIVE: To examine the effects of Valsalva maneuver and Trendelenburg positioning on axillary vein cross-sectional area (CSA). METHODS: Using a group-sequential design, we enrolled stable emergency patients and measured their axillary veins sonographically. Patients were measured while supine, then after a Valsalva maneuver, and then at 5°, 10°, 15°, and 17° of Trendelenburg positioning, pausing 2 min after each change. We asked patients to score their discomfort from 0 to 10 in each position. RESULTS: We enrolled 30 adult patients with a median age of 39 years (range, 20-66 years). Treating physicians considered 11 of these patients to have hypovolemia. The Valsalva maneuver decreased CSA (Mean difference = -0.03 cm(2)), (95% confidence interval [CI] -0.10-0.04). Trendelenburg positioning did not statistically increase CSA. The 5° position caused the largest increase, that is, 0.04 cm(2) (95% CI -0.04-0.12) in the entire group and 0.1 cm(2) (95% CI -0.07-0.28) in the hypovolemic subgroup. At greater degrees of Trendelenburg positioning, patients reported higher discomfort scores or simply dropped out. CONCLUSION: The Valsalva maneuver and Trendelenburg angles above 10° do not increase axillary vein area but do increase patient discomfort. Our data suggest optimal positioning in the supine resting position or at a 5° Trendelenburg position.

A comparison of longitudinal and transverse approaches to ultrasound-guided axillary vein cannulation.

OBJECTIVE: The axillary vein is an easily accessible vessel that can be used for ultrasound-guided central vascular access and offers an alternative to the internal jugular and subclavian veins. The objective of this study was to identify which transducer orientation, longitudinal or transverse, is better for imaging the axillary vein with ultrasound. METHODS: Emergency medicine physicians at an inner-city academic medical center were asked to cannulate the axillary vein in a torso phantom model. They were randomized to start with either the longitudinal or transverse approach and completed both sequentially. Participants answered questionnaires before and after the cannulation attempts. Measurements were taken regarding time to completion, success, skin punctures, needle redirections, and complications. RESULTS: Fifty-seven operators with a median experience of 85 ultrasound procedures (interquartile range, 26-120) participated. The frequency of first-attempt success was 39 (0.69) of 57 for the longitudinal method and 21 (0.37) of 57 for the transverse method (difference, 0.32; 95% confidence interval [CI], 0.12-0.51 [P = .001]); this difference was similar regardless of operator experience. The longitudinal method was associated with fewer redirections (difference, 1.8; 95% CI, 0.8-2.7 [P = .0002]) and skin punctures (difference, 0.3; 95% CI, -2 to +0.7 [P = .07]). Arterial puncture occurred in 2 of 57 longitudinal and 7 of 57 transverse attempts; no pleural punctures occurred. For successful attempts, the time spent was 24 seconds less for the longitudinal method (95% CI, 3-45 [P = .02]). CONCLUSIONS: The longitudinal method of visualizing the axillary vein during ultrasound-guided venous access is associated with greater first-attempt success, fewer needle redirections, and a trend of fewer arterial punctures compared with the transverse orientation.

Cardiovascular disasters in pregnancy.

Cardiovascular emergencies in pregnancy are rare but often catastrophic. This article reviews the diagnosis and management of venous thromboembolism, aortic dissection, acquired heart disease and cardiomyopathy, acute myocardial infarction, and cardiac dysrhythmias in the setting of pregnancy. It also reviews updated resuscitation guidelines for cardiac arrest and perimortem cesarean section.