Association of biliary distention with a diagnosis of acute cholecystitis

BACKGROUND

Gallbladder distention has been described in radiology literature but its value on point-of-care ultrasound (PoCUS) performed by emergency physicians is unclear. We sought to determine the test characteristics of gallbladder distention on PoCUS for cholecystitis (acute or chronic), and secondarily whether distention was associated with an obstructing stone-in-neck (SIN), acute cholecystitis on subsequent pathology report, and longer cholecystectomy operative times.

METHODS

This was a dual-site retrospective cohort study of all Emergency Department (ED) patients that underwent diagnostic biliary PoCUS and were subsequently admitted from 11/1/2020 to 10/31/2022. Patients with pregnancy, liver failure, ascites, hepatobiliary cancer, prior cholecystectomy, or known cholecystitis were excluded. Gallbladder distention was defined as a width ≥4 cm or a length ≥10 cm. Saved ultrasound images were reviewed by three independent reviewers who obtained measurements during the review. Test characteristics, Cohen's kappa (κ), and strength of association between distention and our variables (acute cholecystitis on pathology report and SIN on PoCUS) were calculated using a Chi Square analysis, where intervention (cholecystectomy, percutaneous cholecystostomy, or intravenous antibiotics) was used as the reference standard for AC. A one-tail two sample t-test was calculated for mean operative times.

RESULTS

Of 280 admitted patients who underwent ED biliary PoCUS, 53 were excluded, and 227 were analyzed. Of the 227 patients, 113 (49.8%) had cholecystitis according to our reference standard, and 68 (30.0%) had distention on PoCUS: 32 distended by both width and length, 16 distended by width alone, and 20 distended by length alone. Agreement between investigators was substantial for width (κ 0.630) and length (κ 0.676). Distention was 85.09% (95% CI 77.20-91.07%) specific and 45.1% (95% CI 35.8-54.8%) sensitive for cholecystitis. There was an association between distention and SIN; odds ratio (OR) 2.76 (95% CI 1.54-4.97). Distention of both length and width was associated with acute over chronic cholecystitis; OR 4.32 (95% CI 1.42-13.14). Among patients with acute cholecystitis, mean operative times were 114 min in patients with distention and 89 min in patients without distention (p = 0.03).

CONCLUSION

Gallbladder distention on PoCUS was specific for cholecystitis (acute or chronic), and associated with SIN, acute cholecystitis on subsequent pathology report, and longer cholecystectomy operative times. Measurement of gallbladder dimensions as part of the assessment of cholecystitis may be advantageous.

Radiology Imaging Adds Time and Diagnostic Uncertainty when Point of Care Ultrasound Demonstrates Cholecystitis

BACKGROUND

Point of care ultrasound (POCUS) is specific for acute cholecystitis (AC), but surgeons request radiology imaging (RI) prior to admitting patients with POCUS-diagnosed AC.

OBJECTIVES

We sought to determine the test characteristics of POCUS for AC when performed and billed by credentialed emergency physicians (EPs), the accuracy rate of RI when performed after POCUS, and the time added when RI is requested after POCUS demonstrates AC.

METHODS

We performed a dual-site retrospective cohort study of admitted adult ED patients who had received biliary POCUS from November 1, 2020 to April 30, 2022. Patients with previously diagnosed AC, liver failure, ascites, hepatobiliary cancer, or cholecystectomy were excluded. Descriptive statistics and 95% confidence intervals for point estimates were calculated. Medians were compared using a Wilcoxon signed-rank test. Test characteristics of POCUS for AC were calculated using inpatient intervention for AC as the reference standard.

RESULTS

Of 473 screened patients, 143 were included for analysis: 80 (56%) had AC according to our reference standard. POCUS was positive for AC in 46 patients: 44 true positives and two false positives, yielding a positive likelihood ratio of 17.3 (95%CI 4.4-69.0) for AC. The accuracy rate of RI after positive POCUS for AC was 39.0%. Median time from ED arrival to POCUS and ED arrival to RI were 115 (IQR 64, 207) and 313.5 (IQR 224, 541) minutes, respectively; p < 0.01.

CONCLUSION

RI after positive POCUS performed by credentialed EPs takes additional time and may increase diagnostic uncertainty.

Now You See It, Now You Don't: Point-of-Care Ultrasound Identification of Left Ventricular Thrombus-in-Transit

BACKGROUND

Left-sided intracardiac thrombi are most commonly seen in conditions with decreased cardiac flow, such as myocardial infarction or atrial fibrillation. They can be propagated into the systemic circulation, leading to a cerebrovascular accident. Identification of thrombus-in-transit via point-of-care ultrasound (POCUS) has the potential to change patient management given its association with high patient morbidity and mortality.

CASE REPORT

An intubated 60-year-old man was transferred to our emergency department for management of altered mental status and seizure-like activity. The patient was markedly hypotensive on arrival, and cardiac POCUS was performed to identify potential causes of hypotension. A left ventricular thrombus-in-transit was identified. The thrombus was notably absent on a repeat POCUS examination < 10 min later, which led to concern for thrombus propagation. Furthermore, the patient's vasopressor requirements had significantly increased in that time period. Subsequent emergent neuroimaging revealed a large ischemic stroke in the left internal carotid and middle cerebral artery distribution. The patient was, unfortunately, deemed to not be a candidate for either thrombectomy or thrombolysis and ultimately expired in the hospital. Why Should an Emergency Physician Be Aware of This? Serial POCUS examinations identified the propagation of this patient's thrombus-in-transit, leading the physician to change the initial presumptive diagnosis and treatment course, and pursue further imaging and workup for ischemic stroke. Identification of a thrombus-in-transit is a clue to potentially underlying critical pathology and should be followed with serial POCUS examinations to assess for treatment efficacy and thrombus propagation.

Prevalence of Phantom Scanning in Cardiac Arrest and Trauma Resuscitations: The Scary Truth

Background: The prevalence of phantom scanning, or point of care ultrasound (POCUS) performed without saving images, has not been well studied. Phantom scanning can negatively affect patient care, reduce billed revenue, and can increase medicolegal liability. We sought to quantify and compare the prevalence of phantom scanning among emergency department (ED) cardiac arrests and trauma resuscitations. Methods: This was a single center, retrospective cohort study from July 1, 2019, to July 1, 2021, of all occurrences of POCUS examination documented on the resuscitation run sheet during cardiac arrest and trauma resuscitations. Two investigators reviewed the run sheets to screen for POCUS documentation. Instances where documentation was present were matched with saved images in the picture archiving and communication system. Instances where documentation was present but no images could be located were considered phantom scans. A two-tailed student's t test was utilized to compare the phantom scanning rate between cardiac arrest and trauma resuscitations. Results: A total of 1,862 patients were included in the study period, with 329 cardiac arrests and 401 trauma resuscitations having run sheet documentation of POCUS performance. The phantom scanning rate in cardiac arrests and trauma resuscitations was 70.5% (232/329) and 86.5% (347/401), respectively (p < 0.001). Conclusion: Phantom scanning is common in both cardiac arrests and trauma resuscitations in the ED at our institution, but is significantly higher in trauma resuscitations. Further research is needed to assess causes and develop potential solutions to reduce the high prevalence of phantom scanning.

Role of POCUS in Assessing an Acute Aortic Thrombus

A 67-year-old female patient presented with abdominal pain with a recent diagnosis of paroxysmal atrial fibrillation. Computed tomography (CT) of the abdomen demonstrated a filling defect concerning for an aortic thrombus. Point of care ultrasound (POCUS) confirmed a mobile thrombus in the proximal abdominal aorta in close proximity to several major arterial branches, leading to urgent surgical consultation due to a concern for mesenteric and end-organ ischemia. POCUS played a role in determining patient management in this novel case, and the patient was anticoagulated and ultimately discharged from the hospital.

Epinephrine in Cardiac Arrest: Identifying a Potential Limit for Resuscitation

Introduction

Epinephrine continues to be a fundamental part of the Advanced Cardiac Life Support algorithm despite a lack of evidence that it improves neurologically intact survival. Our aim was both to identify a potential upper limit of epinephrine use in resuscitations and to demonstrate real-world epinephrine use in different patient subgroups.

Methods

This was a single-center, retrospective cohort study, conducted between August 1, 2016-July 1, 2021, of patients with medical cardiac arrest who were administered a known number of epinephrine doses. The primary outcome was neurologically intact discharge defined by a modified Rankin scale ≤3, with secondary outcomes of comparing epinephrine doses by age, rhythm, and emergency medical services vs emergency department administration of epinephrine.

Results

The study included 1,330 patients, with 184 patients (13.8%) surviving to neurologically intact discharge. The primary outcome of neurologically intact discharge was found in 89 (65.4%) patients in the zero epinephrine dose group, 75 (20.0%) in the 1-3 dose group, 15 (4.3%) in the 4-6 dose group, and one (0.002%) in the ≥7 dose group (P < 0.001). Patients received similar amounts of epinephrine when stratified by age, while patients with shockable rhythms received more epinephrine than patients with non-shockable rhythms.

Conclusion

There was a significant decrease in neurologically intact discharge with increasing number of epinephrine doses, and our data suggests that seven or more doses of epinephrine is almost always futile. While further prospective studies are needed, clinicians should consider epinephrine doses when weighing the futility or benefit of continued resuscitation efforts.

Whirlpool No More: A Case of Misdiagnosed Malrotation with Midgut Volvulus

INTRODUCTION

Adult intestinal malrotation with midgut volvulus is rare and most often diagnosed on abdominal imaging. Once the diagnosis is made, prompt surgical intervention is necessary. A finding suggestive of malrotation with midgut volvulus on abdominal imaging is the "whirlpool" sign where the superior mesenteric vein and superior mesenteric artery twist at the root of the abdominal mesentery. This sign was once thought to be pathognomonic, but recent studies have shown that it can be seen in asymptomatic patients.

CASE REPORT

A 20-year-old female presented to our emergency department with diffuse abdominal pain. Computed tomography demonstrated the "whirlpool" sign with a concern for malrotation with midgut volvulus. Surgical consultation was obtained and the patient was rushed to the operating room for an exploratory laparotomy. Normal mesenteric attachments were seen and no significant pathology was identified during the laparotomy. The patient was eventually diagnosed with gastritis and discharged in stable condition.

CONCLUSION

Emergency physicians and surgeons alike should be cautious in confirming malrotation with midgut volvulus solely due to the "whirlpool" sign on abdominal imaging. Premature diagnostic closure can lead to unnecessary procedures and interventions for patients as in the case we report here.

Point-of-care ultrasound assessment of the abdominal aorta by physician assistant students: a pilot study

OBJECTIVE

Point-of-care ultrasound (POCUS) decreases time to diagnosis and improves mortality of those diagnosed with abdominal aortic aneurysms and dissections. While medical students have demonstrated an ability to obtain adequate POCUS images of the abdominal aorta (AA), physician assistant (PA) student studies are lacking. This pilot study aims to evaluate the ability of PA students to acquire AA POCUS images.

METHODS

PA students, instructors, and models voluntarily participated. Student participants received online material to review several weeks before the study. During the study, students performed 4 precepted practice scans of the AA, and their fifth scan was recorded for review by three ultrasound fellowship trained Emergency Medicine physicians. Images were graded on proper identification and measurement of the AA, as well as interpretability of images.

RESULTS

A total of 20 PA students participated. Ninety-five percent were able to obtain interpretable transverse images of the distal aorta and longitudinal views of the aorta, and 65% were able to obtain interpretable transverse images of the proximal and mid aorta.

CONCLUSIONS

In the most rigorous evaluation of student-obtained AA POCUS images to date, we found that PA students were able to obtain adequate AA images. PA students were able to image the distal and longitudinal aorta in the transverse plane where the majority of AAAs are found to a very high degree. Results demonstrate PA students' ability to learn POCUS and encourage PA education to take steps to incorporate POCUS education and development of competency standards for PA graduates.

Discharge in Pandemic: Suspected Covid-19 patients returning to the Emergency Department within 72 hours for admission

INTRODUCTION

Coronavirus disease 2019 (Covid-19) has led to unprecedented healthcare demand. This study seeks to characterize Emergency Department (ED) discharges suspected of Covid-19 that are admitted within 72 h.

METHODS

We abstracted all adult discharges with suspected Covid-19 from five New York City EDs between March 2nd and April 15th. Those admitted within 72 h were then compared against those who were not using descriptive and regression analysis of background and clinical characteristics.

RESULTS

Discharged ED patients returning within 72 h were more often admitted if suspected of Covid-19 (32.9% vs 12.1%, p < .0001). Of 7433 suspected Covid-19 discharges, the 139 (1.9%) admitted within 72 h were older (55.4 vs. 45.6 years, OR 1.03) and more often male (1.32) or with a history of obstructive lung disease (2.77) or diabetes (1.58) than those who were not admitted (p < .05). Additional associations included non-English preference, cancer, heart failure, hypertension, renal disease, ambulance arrival, higher triage acuity, longer ED stay or time from symptom onset, fever, tachycardia, dyspnea, gastrointestinal symptoms, x-ray abnormalities, and decreased platelets and lymphocytes (p < .05 for all). On 72-h return, 91 (65.5%) subjects required oxygen, and 7 (5.0%) required mechanical ventilation in the ED. Twenty-two (15.8%) of the study group have since died.

CONCLUSION

Several factors emerge as associated with 72-h ED return admission in subjects suspected of Covid-19. These should be considered when assessing discharge risk in clinical practice.

Creating an Asynchronous Curriculum for Your Emergency Medicine Residency

This article was migrated. The article was marked as recommended. Background An asynchronous curriculum is one in which residents complete structured learning assignments outside of the traditional Emergency Medicine conference day. As educators are challenged with filling the time in the traditional didactic classroom setting with appropriate content while maintaining the interest of learners, asynchronous learning is becoming an essential component of Emergency Medicine resident curricula. While many residencies are investigating best practices to design and implement asynchronous education, relatively little guidance exists on the creation of such a curriculum. Methods Our goal was to create an asynchronous curriculum using only a chief resident and a core faculty member. Our module-based asynchronous curriculum was formulated based on recommendations from the Council of Emergency Medicine Residency Directors (CORD) ( Sadosty et al. 2009). We focused on using free open access medical education (FOAMEd) as primary content. Results Our residency program has successfully implemented an asynchronous curriculum for two years, and it is still ongoing. We achieved an assignment completion rate of 77.0% in the first year of implementation and 88.6% in our second year. Conclusions The creation and implementation of an asynchronous curriculum is manageable and well-received by Emergency Medicine residents.