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Kegel F, Chenkin J. Resuscitative transesophageal echocardiography in the emergency department: a single-centre case series. Scand J Trauma Resusc Emerg Med 2023; 31:24. [PMID: 37210538 DOI: 10.1186/s13049-023-01077-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/10/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is an emerging tool that can aid emergency physicians in treating patients in cardiac arrest and undifferentiated shock. TEE can aid in diagnosis, resuscitation, identify cardiac rhythms, guide chest compression vectors, and shorten sonographic pulse checks. This study evaluated the proportion of patients who underwent a change in their resuscitation management as a result of emergency department resuscitative TEE. METHODS This was a single-centre case series of 25 patients who underwent ED resuscitative TEE from 2015 to 2019. The objective of this study is to evaluate the feasibility and clinical impact of resuscitative TEE in critically ill patients in the emergency department. Data including changes in working diagnosis, complications, patient disposition, and survival to hospital discharge were also collected. RESULTS 25 patients (median age 71, 40% female) underwent ED resuscitative TEE. All patients were intubated prior to probe insertion and adequate TEE views were obtained for every patient. The most common indications for resuscitative TEE were cardiac arrest (64%) and undifferentiated shock (28%). Resuscitation management changed in 76% (N = 19) and working diagnosis changed in 76% (N = 19) of patients. Ten patients died in the ED, 15 were admitted to hospital, and eight survived to hospital discharge. There were no immediate complications (0/15) and two delayed complications (2/15), both of which were minor gastrointestinal bleeding. CONCLUSIONS The use of ED resuscitative TEE is a practical modality that provides useful diagnostic and therapeutic information for critically ill patients in the emergency department, with an excellent rate of adequate cardiac visualization, and a low complication rate.
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Affiliation(s)
- Fraser Kegel
- Department of Emergency Medicine, Faculty of Medicine, University of Toronto, C. David Naylor Building, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, M5S 3H2, Canada
| | - Jordan Chenkin
- Department of Emergency Medicine, Faculty of Medicine, University of Toronto, C. David Naylor Building, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, M5S 3H2, Canada.
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room AG 245, Toronto, ON, M4N 3M5, Canada.
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Kegel F, Chenkin J. 172 The Impact of Resuscitative Transesophageal Echocardiography Performed by Emergency Physicians on Diagnosis and Management of Critically Ill Patients. Ann Emerg Med 2022. [DOI: 10.1016/j.annemergmed.2022.08.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Aspler A, Kegel F, Beyene T, Zewdu T, Tesfaye B, McKnight A, Cheung E, Bryan J, Acton C. Establishing a Self-sustaining Emergency Medicine Point-of-Care Ultrasound Curriculum in an Academic Teaching Hospital in Ethiopia. Ethiop J Health Sci 2022; 32:533-538. [PMID: 35813690 PMCID: PMC9214745 DOI: 10.4314/ejhs.v32i3.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background Point-of-care ultrasound (POCUS) training has become a standard component of Canadian emergency medicine (EM) residency programs. In resource-limited contexts, including Ethiopia, there is a critical shortage of local clinicians who can perform and teach POCUS. Our aim was to establish an introductory POCUS rotation within the EM residency program at Addis Ababa University (AAU) through The Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM). Methods Through stakeholder engagement, the authors completed a quality improvement initiative and conducted a survey of AAU EM faculty and residents to understand which POCUS scans should be included in a core residency POCUS curriculum, "POCUS1". Results 17 residents completed the POCUS1 program and 16 residents completed the written survey. Focused assessment with sonography for trauma, inferior vena cava, and lung (pneumothorax, pleural effusions, and interstitial syndrome) were identified as core introductory topics. Seventeen residents completed the initial POCUS1 program. Three program graduates were supported to become "POCUS1 Master Instructors" to continue the program during the SARS-CoV-2 global pandemic. Conclusion The authors identified the highest yield POCUS scans through a written survey, successfully introduced a sustainable core POCUS curriculum at AAU for EM residents, and graduated three master instructors for curriculum continuation. We outline the structure and materials for implementation of POCUS programs for EM trainees and staff in similar low- and middle-income countries.
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Affiliation(s)
- Anne Aspler
- Division of Emergency Medicine, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada, Department of Emergency Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Fraser Kegel
- Division of Emergency Medicine, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Temesgen Beyene
- Department of Emergency Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia, Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM), Toronto, ON, Canada
| | - Tigist Zewdu
- Department of Emergency Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia, Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM), Toronto, ON, Canada
| | - Berhanu Tesfaye
- Department of Emergency Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia, Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM), Toronto, ON, Canada
| | - Alexandra McKnight
- Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM), Toronto, ON, Canada
| | - Eileen Cheung
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada, Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM), Toronto, ON, Canada
| | - Jennifer Bryan
- Division of Emergency Medicine, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada, Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM), Toronto, ON, Canada
| | - Claire Acton
- Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada, Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM), Toronto, ON, Canada
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Kegel F, Luo OD, Richer S. The Impact of Extreme Heat Events on Emergency Departments in Canadian Hospitals. Wilderness Environ Med 2021; 32:433-440. [PMID: 34364750 DOI: 10.1016/j.wem.2021.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Mean daily temperatures in Canada rose 1.7°C between 1948 and 2016, and the frequency, severity, and duration of extreme heat events has increased. These events can exacerbate underlying health conditions, bringing patients to emergency departments (EDs). This retrospective analysis assessed the impact of temperature and humidex on ED volume and length of stay (LOS). METHODS LOS is an indicator of ED overcrowding and system performance. Using daily maximum temperatures and humidex values, this study investigated the impact of mean 3-d temperatures and humidex preceding ED presentation on the median and maximum ED LOS and patient volume in 2 community hospitals in Montreal, Quebec, during the summer months of 2016 to 2018. Data were analyzed with 1-way analysis of variance with post hoc Fisher least significant difference tests and Spearman correlation tests. RESULTS The mean maximum temperature and humidex were 26.1°C and 30.4°C, respectively (n=276 d). Mean 3-d temperatures ≥30°C were associated with higher daily ED volumes in both hospitals (138 vs 121, P=0.002 and 132 vs 125, P=0.03) and with increased median LOS at 1 hospital (8.9 vs 7.6 h, P=0.03). Mean 3-d humidex ≥35 was associated with higher daily ED volumes at both hospitals as well (136 vs 123, P=0.01 and 133 vs 125, P=0.009) with an increased median LOS at 1 hospital (8.6 vs 6.9 h, P=0.0001) with humidex values of 25 to 29.9°C. CONCLUSIONS Heat events were associated with increased ED presentations and LOS. This study suggests that a warming climate can impede emergency service provision by increasing the demand for and delaying timely care.
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Affiliation(s)
- Fraser Kegel
- Department of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Owen D Luo
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Signe Richer
- Verdun Hospital, McGill University, Montreal, Quebec, Canada.
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Datar R, Gangatharan H, Kegel F. What affects medical students’ applications to five-year FRCPC emergency medicine programs? Mcgill J Med 2020. [DOI: 10.26443/mjm.v18i1.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose: To compare the impact of institutional and epidemiologic factors on differences in application trends of Canadian medical graduates (CMGs) from different medical schools to FRCPC emergency medicine (EM) residency programs.
Methods: This was a retrospective cohort study. Data from 2013-2018 were obtained from the Canadian Resident Matching Service (CaRMS) database and standardized questionnaires sent to Canadian medical schools.
Results: CaRMS data were available for all schools and survey data was available for 76% schools. Five schools yielded significantly higher rates of applications to FRCPC-EM programs (8.8-13.1%, p<0.05), and 5 schools had significantly lower rates compared to the national mean (2.9-5.1%, p<0.05). Increased exposure to EM (a core rotation and/or elective rotation in EM in the third year of medical school at home-school) yielded 28-55% higher application rates (p<0.001). The presence of an FRCPC-EM residency program at the applicant's home school, and a home school program with 5 or more CMG residency positions at a CMG’s increased the application rates by 39 and 17%, respectively (p<0.05).
Conclusion: These data demonstrate a significant difference in application rates of CMGs graduating from Canadian medical schools and certain factors may affect application rates. This information could be used by medical schools to modify curricula, increase exposure to EM, and contribute towards addressing the forecasted national shortage of EM physicians.
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Koziarz A, Sne N, Kegel F, Nath S, Badhiwala JH, Nassiri F, Mansouri A, Yang K, Zhou Q, Rice T, Faidi S, Passos E, Healey A, Banfield L, Mensour M, Kirkpatrick AW, Nassar A, Fehlings MG, Hawryluk GWJ, Almenawer SA. Bedside Optic Nerve Ultrasonography for Diagnosing Increased Intracranial Pressure: A Systematic Review and Meta-analysis. Ann Intern Med 2019; 171:896-905. [PMID: 31739316 DOI: 10.7326/m19-0812] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Optic nerve ultrasonography (optic nerve sheath diameter sonography) has been proposed as a noninvasive, quick method for diagnosing increased intracranial pressure. PURPOSE To examine the accuracy of optic nerve ultrasonography for diagnosing increased intracranial pressure in children and adults. DATA SOURCES 13 databases from inception through May 2019, reference lists, and meeting proceedings. STUDY SELECTION Prospective optic nerve ultrasonography diagnostic accuracy studies, published in any language, involving any age group or reference standard. DATA EXTRACTION 3 reviewers independently abstracted data and performed quality assessment. DATA SYNTHESIS Of 71 eligible studies involving 4551 patients, 61 included adults, and 35 were rated as having low risk of bias. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of optic nerve ultrasonography in patients with traumatic brain injury were 97% (95% CI, 92% to 99%), 86% (CI, 74% to 93%), 6.93 (CI, 3.55 to 13.54), and 0.04 (CI, 0.02 to 0.10), respectively. Respective estimates in patients with nontraumatic brain injury were 92% (CI, 86% to 96%), 86% (CI, 77% to 92%), 6.39 (CI, 3.77 to 10.84), and 0.09 (CI, 0.05 to 0.17). Accuracy estimates were similar among studies stratified by patient age, operator specialty and training level, reference standard, sonographer blinding status, and cutoff value. The optimal cutoff for optic nerve sheath dilatation on ultrasonography was 5.0 mm. LIMITATION Small studies, imprecise summary estimates, possible publication bias, and no evaluation of effect on clinical outcomes. CONCLUSION Optic nerve ultrasonography can help diagnose increased intracranial pressure. A normal sheath diameter measurement has high sensitivity and a low negative likelihood ratio that may rule out increased intracranial pressure, whereas an elevated measurement, characterized by a high specificity and positive likelihood ratio, may indicate increased intracranial pressure and the need for additional confirmatory tests. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42017055485).
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Affiliation(s)
- Alex Koziarz
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Niv Sne
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Fraser Kegel
- McGill University, Montreal, Quebec, Canada (F.K.)
| | - Siddharth Nath
- School of Medicine, McMaster University, Hamilton, Ontario, Canada (S.N.)
| | - Jetan H Badhiwala
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Farshad Nassiri
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Alireza Mansouri
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Kaiyun Yang
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Qi Zhou
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Timothy Rice
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Samir Faidi
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Edward Passos
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Andrew Healey
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Laura Banfield
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Mark Mensour
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada (M.M.)
| | | | | | - Michael G Fehlings
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | | | - Saleh A Almenawer
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
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Koziarz A, Sne N, Kegel F, Alhazzani W, Nath S, Badhiwala JH, Rice T, Engels P, Samir F, Healey A, Kahnamoui K, Banfield L, Sharma S, Reddy K, Hawryluk GWJ, Kirkpatrick AW, Almenawer SA. Optic nerve sheath diameter sonography for the diagnosis of increased intracranial pressure: a systematic review and meta-analysis protocol. BMJ Open 2017; 7:e016194. [PMID: 28801417 PMCID: PMC5629711 DOI: 10.1136/bmjopen-2017-016194] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Increased intracranial pressure (ICP) is a significant neurological issue that may lead to permanent neurological sequelae. When evaluating patients with traumatic brain injury, it is crucial to identify those with high ICP in order to expedite ICP lowering measures and maintain adequate cerebral perfusion. Several measures are used to recognise patients with increased ICP including CT scan, MRI, ICP monitor, and lumbar puncture (LP). However, these tests can be invasive, associated with radiation exposure, contraindicated, or not readily available. Ultrasonography measurement of the optic nerve sheath diameter (ONSD) is proposed as a non-invasive and quick measure to identify high ICP. The aim of this systematic review and meta-analysis will be to examine the accuracy of ONSD sonography for increased ICP diagnosis. METHODS AND ANALYSES We will include published and unpublished randomised controlled trials, observational studies, and abstracts, with no publication type or language restrictions. Search strategies will be designed to peruse the MEDLINE, Embase, Web of Science, WHO Clinical Trials, ClinicalTrials.gov, CINAHL, and the Cochrane Library databases. We will also implement strategies to search grey literature. Two reviewers will independently complete data abstraction and conduct quality assessment. Included studies will be assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We will construct the hierarchical summary receiver operating characteristic curve for included studies and pool sensitivity and specificity using the bivariate model. We also plan to conduct prespecified subgroup analyses to explore heterogeneity. The overall quality of evidence will be rated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). ETHICS AND DISSEMINATION Research ethics board approval is not required for this study as it draws from published data and raises no concerns related to patient privacy. This review will provide a comprehensive assessment of the evidence on ONSD sonography diagnostic accuracy and is directed to a wide audience. Results from the review will be disseminated extensively through conferences and submitted to a peer-reviewed journal for publication. PROSPERO REGISTRATION NUMBER CRD42017055485. CLINICAL TRIAL NUMBER Trial registration number is NCT00783809.
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Affiliation(s)
- Alex Koziarz
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Niv Sne
- Division of General Surgery and Trauma, McMaster University, Hamilton, Ontario, Canada
| | - Fraser Kegel
- Division of General Surgery and Trauma, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Siddharth Nath
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Timothy Rice
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Paul Engels
- Division of General Surgery, Trauma, and Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Faidi Samir
- Division of General Surgery and Trauma, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Healey
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kamyar Kahnamoui
- Division of General Surgery and Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Kesava Reddy
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Gregory W J Hawryluk
- Department of Neurosurgery and Neurology, University of Utah, Salt Lake City, Utah, USA
| | | | - Saleh A Almenawer
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
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