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2.
CJEM ; 21(3): 406-417, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30696496

RESUMO

OBJECTIVE: The aim of this study was to perform a systematic review and meta-analysis of the diagnostic accuracy of a point-of-care ultrasound exam for undifferentiated shock in patients presenting to the emergency department. METHODS: Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, and research meeting abstracts were searched from 1966 to June 2018 for relevant studies. QUADAS-2 was used to assess study quality, and meta-analysis was conducted to pool performance data of individual categories of shock. RESULTS: A total of 5,097 non-duplicated studies were identified, of which 58 underwent full-text review; 4 were included for analysis. Study quality by QUADAS-2 was considered overall a low risk of bias. Pooled positive likelihood ratio values ranged from 8.25 (95% CI 3.29 to 20.69) for hypovolemic shock to 40.54 (95% CI 12.06 to 136.28) for obstructive shock. Pooled negative likelihood ratio values ranged from 0.13 (95% CI 0.04 to 0.48) for obstructive shock to 0.32 (95% CI 0.16 to 0.62) for mixed-etiology shock. CONCLUSION: The rapid ultrasound for shock and hypotension (RUSH) exam performs better when used to rule in causes of shock, rather than to definitively exclude specific etiologies. The negative likelihood ratios of the exam by subtype suggest that it most accurately rules out obstructive shock.

3.
Shock ; 51(5): 613-618, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30052580

RESUMO

PURPOSE: Although routine chest radiographs (CXR) to verify correct central venous catheter (CVC) position and exclude pneumothorax are commonly performed, emerging evidence suggests that this practice can be replaced by point of care ultrasound (POCUS). POCUS is advantageous over CXR because it avoids radiation while verifying correct placement and lack of pneumothorax without delay. We hypothesize that a knowledge translation gap exists in this area. We aim to describe the current clinical practice regarding POCUS alone for CVC position confirmation and pneumothorax exclusion as compared with chest radiography. METHODS: We used a modified Dillman technique to conduct a brief web-based survey to Critical Care Medicine and Emergency Medicine physicians (targeted group of early adopters) evaluating the current practice related to CVC position confirmation and PTX exclusion via CXR or POCUS. RESULTS: Of 200 post-training clinicians contacted, 136 (68%) responded to the survey. For routine CVC confirmation and PTX evaluation, 50.7% of Critical Care Medicine physicians and 65.4% of Emergency Medicine physicians reported using CXR alone while 49.3% and 33.1% respectively reported using CXR and ultrasound together. Though 84.6% of clinicians use ultrasound for CVC insertion "most of the time" or "always," none use ultrasound alone for CVC position confirmation, and only 1% has used ultrasound alone for PTX exclusion. CONCLUSIONS: Though data support its utility and advantages for POCUS as a sole modality for CVC position confirmation and PTX evaluation, POCUS is rarely used for this indication. We identified several perceived barriers toward widespread utilization suggesting areas for dissemination and implementation strategy development that will benefit patient care practices.

4.
Thromb Res ; 166: 63-70, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29656169

RESUMO

INTRODUCTION: We sought to determine the test characteristics of an automated INNOVANCE D-dimer assay for the exclusion of pulmonary embolism (PE) and deep venous thrombosis (DVT) in emergency department (ED) patients using standard and age-adjusted cut-offs. METHODS: Cross-sectional, international, multicenter study of consecutive patients with suspected DVT or PE in 24 centers (18 USA, 6 Europe). Evaluated patients had low or intermediate Wells PE or DVT scores. For the standard cut-off, a D-dimer result <500 ng/ml was negative. For the age adjusted cut-off, we used the formula: Age (years) ∗ 10. The diagnostic standard was imaging demonstrating PE or DVT within 3 months. We calculated test characteristics using standard methods. We also explored modifications of the age adjustment multiplier. RESULTS: We included 3837 patients and excluded 251. The mean age of patients evaluated for PE (n = 1834) was 48 ±â€¯16 years, with 676 (37%) male, and 1081 (59%) white. The mean age of evaluated for DVT (n = 1752) was 53 ±â€¯16 years, with 710 (41%) male, and 1172 (67%) white. D-dimer test characteristics for PE were: sensitivity 98.0%, specificity 55.4%, negative predictive value (NPV) 99.8%, positive predictive value (PPV) 11.4%, and for DVT were: sensitivity 92.0%, specificity 44.8%, NPV 98.8%, PPV 10.3%. Age adjustment increased specificity (59.6% [PE], 51.1% [DVT]), but increasing the age-adjustment multiplier decreased sensitivity without increasing specificity. CONCLUSIONS: INNOVANCE D-dimer is highly sensitive and can exclude PE and DVT in ED patients with low- and intermediate- pre-test probability. Age-adjustment increases specificity, without increasing false negatives.


Assuntos
Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Tromboembolia Venosa/diagnóstico , Fatores Etários , Bioensaio , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Tromboembolia Venosa/patologia
7.
Resuscitation ; 120: 103-107, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28916478

RESUMO

OBJECTIVE: Our objective was to determine whether organized or disorganized cardiac activity is associated with increased survival in patients who present in pulseless electrical activity (PEA) treated with either 1) standard advanced cardiac life support (ACLS) medications or 2) other interventions. METHODS: This was a secondary analysis of a prospective, multi-center observational study utilizing ultrasound in out-of-hospital or inemergency department PEA arrest. Bedside ultrasound was performed as ACLS protocol started and during pulse checks. Only cases with visible cardiac activity on ultrasound were included in the present analysis. Cardiac activity was categorized as disorganized (agonal twitching) or organized (contractions with changes in ventricular dimensions). Patients were categorized as receiving either standard bolus ACLS medications or alternative medications during the resuscitation (continuous adrenergic agents, thrombolytics, others). The primary outcome was survival to hospital admission. The secondary outcome was return of spontaneous circulation (ROSC). Multivariate modeling was performed to assess association between survival to hospital admission in patients with intravenous adrenergic agents and cardiac activity. RESULTS: In our cohort of 225 patients in PEA cardiac arrest with cardiac activity on ultrasound, the overall survival rate was higher in patients with organized cardiac activity than with disorganized cardiac activity. PEA cardiac arrest patients with organized cardiac activity treated with standard ACLS interventions demonstrated improved survival to hospital admission compared to those with disorganized activity (37.7% (95%CI 24.8-50.2%) versus 17.9% (95%CI 10.9-28%). PEA cardiac arrest patients with organized cardiac activity who received continuous adrenergic agents during the resuscitation and prior to ROSC demonstrated higher survival to hospital admission 45.5% (95%CI 26.9-65.4%) and ROSC 90.9% (95%CI 71.0-98.7%) compared to those with disorganized cardiac activity who received continuous adrenergic agents during the resuscitation 0% (95%CI 0-23.0%) and 47.1% (95%CI 26-69%). Regression analysis demonstrates an association between increased survival in patients receiving intravenous adrenergic agents and organized cardiac activity. CONCLUSION: Survival in patients following PEA arrest is higher in patients with organized cardiac activity. The initiation of continuous adrenergic agents during PEA was associated with improved survival to hospital admission in patients with organized cardiac activity on bedside ultrasound, but this improvement was not seen in patients in PEA with disorganized cardiac activity. Bedside ultrasound may identify a subset of patients that respond differently to ACLS interventions.


Assuntos
Suporte Vital Cardíaco Avançado/métodos , Parada Cardíaca Extra-Hospitalar , Sistemas Automatizados de Assistência Junto ao Leito , Administração Intravenosa , Adrenérgicos/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Ecocardiografia , Serviço Hospitalar de Emergência , Epinefrina/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/diagnóstico por imagem , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/fisiopatologia , Parada Cardíaca Extra-Hospitalar/terapia , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Ultrassonografia
8.
Am J Infect Control ; 45(8): 905-910, 2017 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-28410824

RESUMO

BACKGROUND: The prevalence and difference in likely indications of urinary catheterization (UC) in treated-and-released emergency department (ED) visits between men and women are currently unknown. METHODS: This was a cross-sectional analysis using the 2013 National Emergency Department Sample for all treated-and-released visits in persons aged ≥18 years. The prevalence of conditions associated with UC visits in men and women were identified. A hierarchical ranking was used to categorize diagnosis codes identified during ED visits into clinically meaningful categories to assess conditions for UC. RESULTS: In 2013, there were 87,797,062 treated-and-released ED visits in adults. The rate of UC in treated-and-released ED visits in adults was 4.3 per 1,000 visits, with 6.5 per 1,000 visits in men and 2.7 per 1,000 visits in women. Using the hierarchal ranking, a higher proportion of UC visits in men were coded for acute urinary retention, and a higher proportion of UC visits in women were coded for neurologic, cognitive, and psychiatric conditions. CONCLUSIONS: The rate of UC in treated-and-released ED visits was higher in men than women, and UC rate increased with age. The heterogeneity of conditions coded in UC visits in women compared with men may suggest more potentially avoidable UC in women in the treated-and-released ED population. If confirmed, this would suggest opportunities for quality improvement in the ED to prevent overutilization of urinary catheters.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Cateterismo Urinário/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Envelhecimento , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
10.
Crit Care Med ; 45(4): 715-724, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27922877

RESUMO

OBJECTIVE: We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography. DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov. STUDY SELECTION: Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 × 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position. DATA EXTRACTION: Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. DATA SYNTHESIS: Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high. CONCLUSIONS: Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.


Assuntos
Cateterismo Venoso Central , Pneumotórax/diagnóstico por imagem , Radiografia Torácica , Ultrassonografia , Cateterismo Venoso Central/efeitos adversos , Estado Terminal , Humanos , Veias Jugulares/diagnóstico por imagem , Pneumotórax/etiologia , Sistemas Automatizados de Assistência Junto ao Leito , Veia Subclávia/diagnóstico por imagem
11.
Resuscitation ; 109: 33-39, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27693280

RESUMO

BACKGROUND: Point-of-care ultrasound has been suggested to improve outcomes from advanced cardiac life support (ACLS), but no large studies have explored how it should be incorporated into ACLS. Our aim was to determine whether cardiac activity on ultrasound during ACLS is associated with improved survival. METHODS: We conducted a non-randomized, prospective, protocol-driven observational study at 20 hospitals across United States and Canada. Patients presenting with out-of-hospital arrest or in-ED arrest with pulseless electrical activity or asystole were included. An ultrasound was performed at the beginning and end of ACLS. The primary outcome was survival to hospital admission. Secondary outcomes included survival to hospital discharge and return of spontaneous circulation. FINDINGS: 793 patients were enrolled, 208 (26.2%) survived the initial resuscitation, 114 (14.4%) survived to hospital admission, and 13 (1.6%) survived to hospital discharge. Cardiac activity on US was the variable most associated with survival at all time points. On multivariate regression modeling, cardiac activity was associated with increased survival to hospital admission (OR 3.6, 2.2-5.9) and hospital discharge (OR 5.7, 1.5-21.9). No cardiac activity on US was associated with non-survival, but 0.6% (95% CI 0.3-2.3) survived to discharge. Ultrasound identified findings that responded to non-ACLS interventions. Patients with pericardial effusion and pericardiocentesis demonstrated higher survival rates (15.4%) compared to all others (1.3%). CONCLUSION: Cardiac activity on ultrasound was the variable most associated with survival following cardiac arrest. Ultrasound during cardiac arrest identifies interventions outside of the standard ACLS algorithm.


Assuntos
Suporte Vital Cardíaco Avançado/métodos , Parada Cardíaca/diagnóstico por imagem , Sistemas Automatizados de Assistência Junto ao Leito , Ultrassonografia , Idoso , Idoso de 80 Anos ou mais , Canadá , Serviço Hospitalar de Emergência , Feminino , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/diagnóstico por imagem , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/terapia , Estudos Prospectivos , Sensibilidade e Especificidade , Análise de Sobrevida , Estados Unidos
12.
J Ultrasound Med ; 34(11): 2065-70, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26453126

RESUMO

OBJECTIVES: To assess the self-reported frequency of use of ultrasound guidance for central venous catheterization by emergency medicine (EM) residents, describe residents' perceptions regarding the use of ultrasound guidance, and identify barriers to the use of ultrasound guidance. METHODS: A longitudinal cross-sectional study was conducted at 5 academic institutions. A questionnaire on the use of ultrasound guidance for central venous catheterization was initially administered to EM residents in 2007. The same questionnaire was distributed again in the 5 EM residency programs in 2013. RESULTS: In 2007 and 2013, 147 and 131 residents completed questionnaires, respectively. A significant increase in the use of ultrasound guidance for central venous catheterization was reported in 2013 compared to 2007 (P< .001). In 2007, 53% (95% confidence interval, 44%-61%) of residents reported that they were initially trained in central venous catheterization using ultrasound guidance compared to 96% (95% confidence interval, 92%-99%) in 2013 (P < .0001). In 2007, more residents thought that faculty were insufficiently adopting ultrasound (42% versus 9%), and there was a lack of ultrasound teaching during residency training (14% versus 5%) compared to 2013. CONCLUSIONS: The use of self-reported ultrasound guidance for central venous catheterization significantly increased from 2007 to 2013 at academic institutions. Most residents were aware of the benefits of using ultrasound guidance. Although faculty adoption of ultrasound for central venous catheterization remains a barrier, it has decreased.


Assuntos
Centros Médicos Acadêmicos/estatística & dados numéricos , Cateterismo Venoso Central/estatística & dados numéricos , Medicina de Emergência/estatística & dados numéricos , Internato e Residência/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Ultrassonografia de Intervenção/estatística & dados numéricos , Centros Médicos Acadêmicos/tendências , Adulto , Arizona/epidemiologia , Cateterismo Venoso Central/tendências , Medicina de Emergência/tendências , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Internato e Residência/tendências , Estudos Longitudinais , Masculino , Padrões de Prática Médica/tendências , Ultrassonografia de Intervenção/tendências
13.
Acad Emerg Med ; 22(9): 1048-55, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26336036

RESUMO

OBJECTIVES: The incidence of central line-associated bloodstream infections (CLABSI) attributed to central venous catheters (CVCs) inserted in the emergency department (ED) is not widely reported. The goal was to report the incidence of ED CLABSI. Secondary goals included determining the effect of a CVC bundle introduced by the hospital infection prevention department to decrease CLABSI during the surveillance period. METHODS: This was a prospective observational study over a 28-month period at an academic tertiary care center. A standardized electronic CVC procedure note identified CVC insertions in the ED. Abstractors reviewed inpatient records to determine ED CVC catheter-days. An infection prevention specialist identified CLABSIs originating in the ED using National Hospital Safety Network definitions from blood culture results collected up to 2 days after ED CVC removal. During the period of surveillance, a hospital-wide CVC insertion bundle was introduced to standardize insertion practices and prevent CLABSIs. Institutional CLABSI rates were determined by infection prevention from routine surveillance data. RESULTS: Over the 28-month study period, 98 emergency physicians inserted 994 CVCs in 940 patients. The ED CVCs remained in place for more than 2 days in 679 patients, and the median number of days an ED CVC remained in use during the hospital stay was 3 (interquartile range = 2 to 7 days). There were 4,504 ED catheter-days and nine CLABSIs attributed to ED CVCs. The ED CLABSI rate was 2.0/1,000 catheter-days (95% confidence interval [CI] = 1.0 to 3.8). The concurrent institutional intensive care unit (ICU) CLABSI rate was 2.3/1,000 catheter-days (95% CI = 1.9 to 2.7). The ED CLABSI rate prebundle was 3.0/1,000 catheter-days and postbundle was 0.5/1,000 catheter-days (p = 0.038). CONCLUSIONS: The CLABSI rates in this academic medical center ED were in the range of those reported by the ICU. The effect of ED CLABSI prevention practices requires further research dedicated to surveying ED CLABSI rates.


Assuntos
Infecções Relacionadas a Cateter/epidemiologia , Cateteres Venosos Centrais , Infecção Hospitalar/epidemiologia , Unidades de Terapia Intensiva , Centros Médicos Acadêmicos , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções Relacionadas a Cateter/prevenção & controle , Infecção Hospitalar/prevenção & controle , Serviço Hospitalar de Emergência , Feminino , Humanos , Incidência , Controle de Infecções/métodos , Masculino , Pessoa de Meia-Idade , Pacotes de Assistência ao Paciente/métodos , Estudos Prospectivos , Centros de Atenção Terciária
14.
Br J Sports Med ; 49(3): 161-5, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25385167

RESUMO

The use of point-of-care ultrasound (US) by non-radiologists is not new and the expansion into sports medicine practice is relatively young. US has been used extensively to evaluate the musculoskeletal system including the diagnosis of muscle, tendon and bone injuries. However, as sports medicine practitioners we are responsible for the care of the entire athlete. There are many other non-musculoskeletal applications of US in the evaluation and treatment of the athlete. This paper highlights the use of US in the athlete to diagnose pulmonary, cardiac, solid organ, intra-abdominal and eye injuries.


Assuntos
Traumatismos em Atletas/diagnóstico por imagem , Medicina Esportiva/métodos , Traumatismos Abdominais/diagnóstico por imagem , Volume Sanguíneo/fisiologia , Pressão Venosa Central , Traumatismos Oculares/diagnóstico por imagem , Humanos , Hipovolemia/diagnóstico por imagem , Derrame Pericárdico/diagnóstico por imagem , Sistemas Automatizados de Assistência Junto ao Leito , Ultrassonografia , Veia Cava Inferior/diagnóstico por imagem
15.
Ann Emerg Med ; 64(3): 299-313, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24721718

RESUMO

Infection prevention remains a major challenge in emergency care. Acutely ill and injured patients seeking evaluation and treatment in the emergency department (ED) not only have the potential to spread communicable infectious diseases to health care personnel and other patients, but are vulnerable to acquiring new infections associated with the care they receive. This article will evaluate these risks and review the existing literature for infection prevention practices in the ED, ranging from hand hygiene, standard and transmission-based precautions, health care personnel vaccination, and environmental controls to strategies for preventing health care-associated infections. We will conclude by examining what can be done to optimize infection prevention in the ED and identify gaps in knowledge where further research is needed. Successful implementation of evidence-based practices coupled with innovation of novel approaches and technologies tailored specifically to the complex and dynamic environment of the ED are the keys to raising the standard for infection prevention and patient safety in emergency care.


Assuntos
Infecção Hospitalar/prevenção & controle , Serviço Hospitalar de Emergência , Infecções Relacionadas a Cateter/prevenção & controle , Infecção Hospitalar/transmissão , Pessoal de Saúde , Humanos , Imunização , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Cateterismo Urinário/efeitos adversos
16.
Crit Care Med ; 42(3): 554-64, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24145846

RESUMO

OBJECTIVES: Clinical guidelines for the acute management of emergency department patients with severe sepsis encourage the placement of central venous catheters. Data examining the timing of central venous catheter insertion among critically ill patients admitted from the emergency department are limited. We examined the hypothesis that prompt central venous catheter insertion during hospitalization among patients admitted from the emergency department acts as a surrogate marker for early aggressive care in the management of critically ill patients. DESIGN: Retrospective cross-sectional analysis of emergency department visits using 2003-2006 discharge data from California, State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. SETTING: General medical or general surgical hospitals (n = 310). PATIENTS: Patient hospitalizations beginning in the emergency department with the two most common diagnoses associated with central venous catheter (sepsis and respiratory arrest). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified the occurrence and timing of central venous catheter using International Classification of Diseases, 9th Revision, Clinical Modifications procedure codes. The primary outcomes measured were annual central venous catheters per 1,000 hospitalizations that began in the emergency department occurring emergently (procedure day 0), urgently (procedure day 1-2), or late (procedure day 3 or later). A total of 129,288 hospital discharges had evidence of central venous catheter. In 2003, 5,759 central venous catheters were placed emergently compared with 10,469 in 2006. The rate of emergent central venous catheter/1,000 increased annually from 228 in 2003, 239 in 2004, 257 in 2005, up to 269 in 2006. Urgent and late central venous catheter rates trended down (p < 0.001). In a multilevel model, the odds of undergoing emergent central venous catheter relative to 2003 increased annually: 1.08 (95% CI, 1.03-1.12) in 2004, 1.19 (95% CI, 1.14-1.23) in 2005, and 1.28 (95% CI, 1.23-1.33) in 2006. CONCLUSIONS: Central venous catheters are inserted earlier and more frequently among critically ill patients admitted from the emergency department. Earlier central venous catheter insertion may require systematic changes to meet increasing utilization and enhanced mechanisms to measure central venous catheter outcomes.


Assuntos
Cateterismo Venoso Central/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/terapia , Sepse/diagnóstico , Sepse/terapia , California , Cateterismo Venoso Central/métodos , Estado Terminal/mortalidade , Estado Terminal/terapia , Estudos Transversais , Bases de Dados Factuais , Diagnóstico Precoce , Feminino , Mortalidade Hospitalar/tendências , Humanos , Tempo de Internação , Masculino , Análise Multivariada , Admissão do Paciente/estatística & dados numéricos , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Sepse/mortalidade
17.
Acad Emerg Med ; 20(7): 740-5, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23859589

RESUMO

In 2012, the Accreditation Council for Graduate Medical Education (ACGME) designated ultrasound (US) as one of 23 milestone competencies for emergency medicine (EM) residency graduates. With increasing scrutiny of medical educational programs and their effect on patient safety and health care delivery, it is imperative to ensure that US training and competency assessment is standardized. In 2011, a multiorganizational committee composed of representatives from the Council of Emergency Medicine Residency Directors (CORD), the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine (SAEM), the Ultrasound Section of the American College of Emergency Physicians (ACEM), and the Emergency Medicine Residents' Association was formed to suggest standards for resident emergency ultrasound (EUS) competency assessment and to write a document that addresses the ACGME milestones. This article contains a historical perspective on resident training in EUS and a table of core skills deemed to be a minimum standard for the graduating EM resident. A survey summary of focused EUS education in EM residencies is described, as well as a suggestion for structuring education in residency. Finally, adjuncts to a quantitative measurement of resident competency for EUS are offered.


Assuntos
Acreditação/normas , Competência Clínica , Medicina de Emergência/educação , Ultrassonografia Doppler/normas , Consenso , Estudos Transversais , Educação de Pós-Graduação em Medicina/normas , Feminino , Humanos , Internato e Residência/normas , Masculino , Diretores Médicos/organização & administração , Qualidade da Assistência à Saúde/normas , Estados Unidos
18.
Can J Rural Med ; 17(3): 99-104, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22735086

RESUMO

INTRODUCTION: The Canadian Association of Emergency Physicians (CAEP) published a position statement in 2006 encouraging immediate access to emergency medicine ultrasonography (EMUS) 24 hours a day, 7 days a week. However, barriers to advanced imaging care still exist in many rural hospitals. Our study investigated the current availability of EMUS in rural communities and physicians' ability to use this technology. METHODS: A literature review and interviews with rural physicians were conducted in the summer of 2010 to design a questionnaire focusing on EMUS. The survey was then sent electronically or via regular mail in November 2010 to all Ontario physicians self-identified as "rural." Descriptive statistics and the Fisher exact test were used to analyze the data. RESULTS: A total of 207 rural physicians responded to the survey (response rate 28.6%). Of the respondents, 70.9% were male, median age was 49 years and median year of graduation was 1988. The respondents had been in practice for a median of 20 years and had been in their present community for a median of 15 years. More than two-thirds of physicians (69.5%) practised in communities with populations of less than 10 000. Nearly three-quarters (72.6%) worked in a rural emergency department (ED). Almost all (96.9%) reported having access to ultrasonography in the hospital. However, only 60.6% had access to ultrasonography in the ED. Less than half (44.4%) knew how to perform ultrasonography, with 77.3% citing lack of training. Of those using EMUS, 32.5% were using it at least once per shift. The most common reason to use EMUS was to rule out abdominal aortic aneurysm (58.3%). Most respondents (71.5%) agreed or strongly agreed that EMUS is a skill that all rural ED physicians should have. CONCLUSION: Patients in many rural EDs do not have immediate access to EMUS, as advocated by CAEP. This gap in care needs to be addressed to ensure that all patients, no matter where they live, have access to this proven imaging modality.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Serviços de Saúde Rural/estatística & dados numéricos , Ultrassonografia/estatística & dados numéricos , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Canadá , Coleta de Dados , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade
19.
Acad Emerg Med ; 19(4): 421-9, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22506946

RESUMO

OBJECTIVES: This study assessed the feasibility of an investigational vagus nerve stimulation (VNS) device for treating acute asthma exacerbations in patients not responding to at least 1 hour of initial standard care therapy. METHODS: This was a prospective, nonrandomized study of patients treated in the ED for moderate to severe acute asthma (forced expiratory volume in 1 second [FEV(1)] 25% to 70% of predicted). Treatment entailed percutaneous placement of an electrode near the right carotid sheath and 60 minutes of VNS and continued standard care. VNS voltage was adjusted to perceived improvement, muscle twitching, or adverse events (AEs). All AEs, vital signs, FEV(1), perceived work of breathing (WOB), and final disposition were recorded. RESULTS: Twenty-five subjects were enrolled. There were no serious AEs and no significant changes in vital signs. No subject required terminating VNS. One patient had minor bleeding from the procedure, and one had a hematoma and withdrew prior to VNS. AEs related to VNS were temporary and included cough (1 of 24), swallowing difficulty (2 of 24), voice change (2 of 24), and muscle twitching (14 of 24). These resolved when VNS ended. The FEV(1) improved at 15 minutes (median = 15.8%, 95% confidence interval [CI] = 9.3% to 22.4%), 30 minutes (median = 21.3%, 95% CI = 8.1% to 36.5%), and 60 minutes (median = 27.5%, 95% CI = 11.3% to 43.5%). WOB improved at 15 minutes (median = 53.9%, 95% CI = 33.7% to 73.9%), 30 minutes (median = 69.1%, 95% CI = 56.4% to 81.8%), and 60 minutes (median = 81.0%, 95% CI = 68.5% to 93.5%). CONCLUSIONS: Percutaneous VNS did not result in serious AEs and was associated with improvements in FEV(1) and perceived dyspnea. Percutaneous VNS appears to be feasible for use in the treatment of moderate to severe acute asthma in patients unresponsive to initial standard care treatment.


Assuntos
Asma/terapia , Serviço Hospitalar de Emergência , Estimulação do Nervo Vago/métodos , Doença Aguda , Adulto , Idoso , Estudos de Viabilidade , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Espirometria , Resultado do Tratamento , Sinais Vitais , Trabalho Respiratório
20.
Acad Emerg Med ; 17(10): 1055-61, 2010 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-21040106

RESUMO

BACKGROUND: Ultrasound (US) greatly facilitates cannulation of the internal jugular vein. Despite the ability to visualize the needle and anatomy, adverse events still occur. The authors hypothesized that the technique has limitations among certain patients and clinical scenarios. OBJECTIVES: The purpose of this study was to identify characteristics of adverse events surrounding US-guided central venous cannulation (CVC). METHODS: The authors assembled a prospective observational cohort of emergency department (ED) patients undergoing consecutive internal jugular CVC with US. The primary outcome of interest was a composite of acute mechanical adverse events including hematoma, arterial cannulation, pneumothorax, and unsuccessful placement. Physicians performing the CVC recorded anatomical site, reason for insertion, and acute complications. The patients with catheters were followed until the catheters were removed based on radiographic evidence or hospital nursing records. ED charts and pharmacy records contributed variables of interest. A self-reported online survey provided physician experience information. Logistic regression was used to calculate the odds of an adverse outcome. RESULTS: Physicians attempted 289 CVCs on 282 patients. An adverse outcome occurred in 57 attempts (19.7%, 95% confidence interval [CI] = 15.5 to 24.7), the most common being 31 unsuccessful placements (11%, 95% CI = 7.7 to 14.8). Patients with a history of end-stage renal disease (odds ratio [OR] = 3.54, 95% CI = 1.59 to 7.89), and central lines placed by operators with intermediate experience (OR = 2.26, 95% CI = 1.19 to 4.32), were most likely to encounter adverse events. Previously cited predictors such as body mass index (BMI), coagulopathy, and pulmonary hyperinflation were not significant in our final model. CONCLUSIONS: Acute adverse events occurred in approximately one-fifth of US-guided internal jugular central line attempts. The study identified both patient (history of end-stage renal disease) and physician (intermediate experience level) factors that are associated with acute adverse events.


Assuntos
Cateterismo Venoso Central/efeitos adversos , Competência Clínica , Serviço Hospitalar de Emergência , Veias Jugulares/diagnóstico por imagem , Ultrassonografia de Intervenção , Centros Médicos Acadêmicos , Idoso , Cateterismo Venoso Central/métodos , Estudos de Coortes , Estado Terminal , Tratamento de Emergência/métodos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Estatísticas não Paramétricas
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