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Volume 12, Issue 1, 2011

Volume 12 Issue 1 2011

Clinical Practice

Randomized Controlled Trial of Ondansetron vs. Prochlorperazine in Adults in the Emergency Department

Objective: To compare the effectiveness of ondansetron and prochlorperazine to treat vomiting. Secondary objectives were the effectiveness of ondansetron and prochlorperazine to treat nausea and their tolerability.

Methods: This was a prospective, randomized, active controlled, double-blinded study. Using a convenience sample, patients were randomized to either intravenous ondansetron 4mg (n=32) or prochlorperazine 10mg (n=32). The primary outcome was the percentage of patients with vomiting at 0-30, 31-60, and 61-120 minutes after the administration of ondansetron or prochlorperazine. Secondary outcomes were nausea assessed by a visual analog scale (VAS) at baseline, 0-30, 31-60, and 61-120 minutes after the administration of ondansetron or prochlorperazine and the percentage of patients with adverse effects (sedation, headache, akathisia, dystonia) to either drug. We performed statistical analyses on the VAS scales at each time point and did a subgroup analysis to examine if nausea scores were affected if the patient had vomited at baseline.

Results: The primary identified cause for nausea and vomiting was flu-like illness or gastroenteritis (19%). The number of patients experiencing breakthrough vomiting at 0-30, 31-60, and 61-120 minutes was similar between groups for these time periods; however, more patients receiving ondansetron experienced vomiting overall (7 [22%] vs. 2[3.2%] patients, p=not significant). Nausea scores at baseline and 0-30 minutes were severe and similar between groups; however, at 31-60 and 61-120 minutes, patients receiving prochlorperazine had better control of nausea (24.9 vs. 43.7 mm, p=0.03; 16.8 vs. 34.3 mm, p=0.05). Sedation scores were similar between groups. There were no cases of extrapyramidal symptoms as assessed by the treating physician and there were four cases of akathisia (prochlorperazine=3 [9%], ondansetron=1[3%]).

Conclusion: Prochlorperazine and ondansetron appear to be equally effective at treating vomiting in the emergency department. [West J Emerg Med. 2011;12(1):1-5.]

Punch Injuries: Insights into Intentional Closed Fist Injuries

Objectives: This study sought to investigate the patterns of injury resulting from a punch mechanism and to investigate the associated psychopathology present in patients with these injuries.

Methods: Retrospective analysis of patients with hand radiographs ordered from the emergency department allowed for identification of patients with a punch mechanism. We recorded injury patterns and queried patients’ medical records for associated psychopathology.

Results: 1,292 patients underwent hand radiographs during a one-year time period; 172 patients (13%) were radiographed following an intentional punch injury, identifying 76 fractures in 70 patients. Males contributed a greater proportion of patients presenting with punch injury when compared to females (80% vs. 20%). Males were more likely to sustain fracture from a punch mechanism (48% vs. 11%, OR 7 [95% CI 2.3-20.9]), but were less likely to have preexisting documented psychiatric disease (23% vs. 49%, OR 3.1 [95% CI 1.4-6.7]). Of all fractures, 61% were to the fifth metacarpal, 21% were to the remainder of the metacarpals, and the remaining were fractures to phalanges and bones of the wrist.

Conclusion: Women are less likely to present with punch injury and are less likely to sustain a fracture when they do present but have more associated psychiatric disease. Both men and women presenting with punch injuries have a higher prevalence of psychiatric disease than the background incidence in the population as a whole. Although punch injuries result in a significant number of boxer fractures, a number of other injuries are associated with punch mechanisms. [West J Emerg Med. 2011;12(1):6-10.]

Genetics of Warfarin Sensitivity in an Emergency Department Population with Thromboembolism

Background: Emergency department (ED) patients with venous thromboembolism (VTE) are eventually treated with a standard dose of warfarin despite the fact that a number of patients are known to be sensitive to warfarin and may experience supra-therapeutic INRs and adverse bleeding events. Pharmacogenetics is an emerging field of medical practice that seeks to improve drug safety and efficacy in an individual patient by tailoring treatment to the patient’s known genetic makeup.

Objective: To identify patients with risk for warfarin sensitivity among an ED population with VTE and to assess if the warfarin sensitivity mutations were of significant enough prevalence to be of clinical significance in customizing treatment of VTE. We sought in a pilot study to identify if testing for common CYP2C9 and VKORC1 single nucleotide polymorphisms (SNPs) in patients who were likely to begin warfarin treatment was feasible in an ED setting.

Methods: A prospective study that identified and enrolled patients presenting to our ED with high clinical suspicion of VTE. Those with high clinical suspicion of VTE were defined as those who had a Doppler ultrasound or computed tomography pulmonary angiography (CTPA) ordered by the primary emergency physician. Blood was taken and processed to ascertain the following SNPs: CYP2C9*2, CYP2C9*3, and VKORC1 3673.

Results: Of the 194 patients enrolled, 132 (68.0%) had at least one known warfarin sensitivity mutation and 114 (58.8%) had the most clinically significant VKORC1 3673 mutation.

Conclusion: A majority of our patients had at least one mutation associated with the atypical metabolism of warfarin. Over half of our population had the most clinically significant VKORC1 3673 mutation. They would likely benefit from individualized warfarin dosing if ever needing anticoagulation. Our initial pilot study shows that allele frequencies of target warfarin sensitivity SNPs in our patient population are frequent enough to make initiation of personalized warfarin dosing feasible. [West J Emerg Med. 2011;12(1):11-16.]

Plastic Bronchitis

Plastic bronchitis is not yet well understood. There have been less than 500 reported cases in adults worldwide. This patient presented with a one month history of productive sputum consisting of bronchial casts resulting in a diagnosis of plastic bronchitis. [West J Emerg Med. 2011;12(1):118-119.]

Symptomatic Morgagni Hernia Misdiagnosed As Chilaiditi Syndrome

Chilaiditi syndrome, symptomatic interposition of bowel beneath the right hemidiaphragm, is uncommon and usually managed without surgery. Morgagni hernia is an uncommon diaphragmatic hernia that generally requires surgery. In this case a patient with a longstanding diagnosis of bowel interposition (Chilaiditi sign) presented with presumed Chilaiditi syndrome. Abdominal computed tomography was performed and revealed no bowel interposition; instead, a Morgagni hernia was found and surgically repaired. Review of the literature did not reveal similar misdiagnosis or recommendations for advanced imaging in patients with Chilaiditi sign or syndrome to confirm the diagnosis or rule out other potential diagnoses. [West J Emerg Med. 2011;12(1):121-123.]

Lingual Ischemia from Prolonged Insertion of a Fastrach Laryngeal Mask Airway

We report a case of lingual ischemia and swelling in an elderly stroke patient from prolonged insertion of a FastrachTM Laryngeal Mask Airway ® following a failed Emergency Department intubation. Simple suggestions to mitigate such injury are provided. [West J Emerg Med. 2011;12(1):124-127.]

Diaster Medicine/ Emergency Medical Services

A Detailed Analysis of Prehospital Interventions in Common Medical Priority Dispatch System Determinants

Background: Medical Priority Dispatch System (MPDS) is a type of Emergency Medical Dispatch (EMD) system used to prioritize 9-1-1 calls and optimize resource allocation. Dispatchers use a series of scripted questions to assign determinants to calls based on chief complaint and acuity.

Objective: We analyzed the prehospital interventions performed on patients with MPDS determinants for breathing problems, chest pain, unknown problem (man down), seizures, fainting (unconscious) and falls for transport status and interventions.

Methods: We matched all prehospital patients in complaint-based categories for breathing problems, chest pain, unknown problem (man down), seizures, fainting (unconscious) and falls from January 1, 2004, to December 31, 2006, with their prehospital record. Calls were queried for the following prehospital interventions: Basic Life Support care only, intravenous line placement only, medication given, procedures or non-transport. We defined Advanced Life Support (ALS) interventions as the administration of a medication or a procedure.

Results: Of the 77,394 MPDS calls during this period, 31,318 (40%) patients met inclusion criteria. Breathing problems made up 12.2%, chest pain 6%, unknown problem 1.4%, seizures 3%, falls 9% and unconscious/fainting 9% of the total number of MPDS calls. Patients with breathing problem had a low rate of procedures (0.7%) and cardiac arrest medications (1.6%) with 38% receiving some medication. Chest pain patients had a similar distribution; procedures (0.5%), cardiac arrest medication (1.5%) and any medication (64%). Unknown problem: procedures (1%), cardiac arrest medication (1.3%), any medication (18%). Patients with Seizures had a low rate of procedures (1.1%) and cardiac arrest medications (0.6%) with 20% receiving some medication. Fall patients had a lower rate of severe illness with more medication, mostly morphine: procedures (0.2%), cardiac arrest medication (0.2%), all medications (28%). Unconscious/fainting patients received the following interventions: procedures (0.3%), cardiac arrest medication (1.9%), all medications (32%). Few stepwise increases in the rate of procedures or medications were seen as determinants increased in acuity.

Conclusion: Among these common MPDS complaint-based categories, the rates of advanced procedures and cardiac arrest medications were low. ALS medications were common in all categories and most determinants. Multiple determinants were rarely used and did not show higher rates of interventions with increasing acuity. Many MPDS determinants are of modest use to predict ALS intervention. [West J Emerg Med. 2011;12(1):19-29.]

Characteristics of Patients with an Abnormal Glasgow Coma Scale in the Prehospital Setting

Objective: This cross-sectional study describes the characteristics of patients with an abnormal Glasgow Coma Scale (GCS) in the prehospital setting.

Methods: We reviewed existing prehospital care reports (PCRs) in the San Mateo County, California, emergency medical services (EMS) database from January 1 to December 31, 2007. Adults age 18 or greater with a documented GCS fit inclusion criteria. We excluded single and multisystem trauma patients, as well as patients in cardiac arrest, respiratory arrest, or listed as deceased from the study. We classified the remaining patients as a normal GCS of 15 or abnormal (defined as less than 15 at any time during paramedic contact), and then further sub-classified into mild (GCS 13-14), moderate (GCS 9-12) or severe (GCS 3-8).

Results: Of the 12,235 unique prehospital care record in the database, 9,044 (73.9%) met inclusion criteria, comprised of 2,404 (26.6%) abnormal GCS patients and 6,640 (73.4%) normal GCS patients. In the abnormal GCS category, we classified 1,361 (56.6%) patients as mild, 628 (26.1%) as moderate, and 415 (17.3%) as severe. Where sex was recorded, we identified 1,214 (50.5%) abnormal GCS patients and 2,904 (43.7%) normal GCS patients as male. Mean age was 65.6 years in the abnormal GCS group and 61.4 in the normal GCS group (p<0.0001). Abnormal GCS patients were more likely to have a history of conditions known to be associated, such as alcohol abuse (odds ratio [OR] 2.3, 95% confidence interval [CI]=2.75-3.00), diabetes (OR 1.34, 95% CI=1.17-1.54), substance abuse (OR 1.6, CI=1.09-2.3), stroke/transient ischemic attack (OR 2.0, CI=1.64-2.5), and seizures (OR 3.0, CI=1.64-2.5). Paramedics established intravenous (IV) access on 1,821 (75.7%, OR 1.94, CI=1.74-2.2) abnormal GCS patients and administered medications to 777 (32.3%, OR 1.01, CI=0.92-1.12). Compared to patients with normal GCS, patients with a mildly abnormal GCS were less likely to receive medications (OR 0.61, CI=0.53-0.70) while those with a moderately or severely abnormal GCS were more likely (OR 1.27, CI=1.07-1.50 and OR 2.86, CI=2.34-3.49, respectively). Of the normal GCS patients, 4,097 (61.7%) received an IV and 2,125 (32.0%) received medications by any route.

Conclusion: Twenty-seven percent of all prehospital patients in our study presented with an abnormal GCS. Prehospital patients with an abnormal GCS are more likely to be male, slightly older, and have higher rates of history of alcohol use or seizure. This group of patients had a higher rate of IV placement. Patients with a mildly abnormal GCS were less likely to receive medications while those with a moderately or severely abnormal GCS were more likely. [West J Emerg Med. 2011;12(1):30-36.]

Mass Casualty Incident Response and Aeromedical Evacuation in Antarctica

Antarctica is one of the most remote regions on Earth. Mass casualty incident (MCI) responses in Antarctica are prone to complications from multiple environmental and operational challenges. This review of the current status of MCI risks and response strategies for Antarctica focuses on aeromedical evacuation, a critical component of many possible MCI scenarios. Extreme cold and weather, a lack of medical resources and a multitude of disparate international bases all exert unique demands on MCI response planning. Increasing cruise ship traffic is also escalating the risk of MCI occurrence. To be successful, MCI response must be well coordinated and undertaken by trained rescuers, especially in the setting of Antarctica. Helicopter rescue or aeromedical evacuation of victims to off-continent facilities may be necessary. Currently, military forces have the greatest capacity for mass air evacuation. Specific risks that are likely to occur include structure collapses, vehicle incapacitations, vehicle crashes and fires. All of these events pose concomitant risks of hypothermia among both victims and rescuers. Antarctica’s unique environment requires flexible yet robust MCI response planning among the many entities in operation on the continent. [West J Emerg Med. 2011;12(1):37-42.]

Geriatrics

Analgesia for Older Adults with Abdominal or Back Pain in the Emergency Department

Objective: To determine the association between age and analgesia for emergency department (ED) patients with abdominal or back pain.

Methods: Using a fully electronic medical record, we performed a retrospective cohort study of adults presenting with abdominal or back pain to two urban EDs. To assess differences in analgesia administration and time to analgesia between age groups, we used chi-square and Kruskal-Wallis test respectively. To adjust for potential confounders, we used a generalized linear model with log link and Gaussian error.

Results: Of 24,752 subjects (mean age 42 years, 65% female, 69% black, mean triage pain score 7.5), the majority (76%) had abdominal pain and 61% received analgesia. The ≥80 years group (n=722; 3%), compared to the 65-79 years group (n=2,080; 8%) and to the (n=21,950; 89%), was more often female (71 vs. 61 vs. 65%), black (72 vs. 65 vs. 69%), and had a lower mean pain score (6.6 vs. 7.1 vs. 7.6). Both older groups were less likely to receive any analgesia (48 vs. 59 vs. 62%, p<0.0001) and the oldest group less likely to receive opiates (35 vs. 47 vs. 44%, p<0.0001). Of those who received analgesia, both older groups waited longer for their medication (123 vs. 113 vs. 94 minutes; p<0.0001). After controlling for potential confounders, patients ≥80 years were 17% less likely than the <65 years group to receive analgesia (95% CI 14-20%).

Conclusion: Older adults who present to the ED for abdominal or back pain are less likely to receive analgesia and wait significantly longer for pain medication compared to younger adults. [West J Emerg Med. 2011;12(1);43-50.]

Older Emergency Department Drivers: Patterns, Behaviors, and Willingness to Enroll in a Safe Driver Program

Objective: Our objective was to assess the reported driving patterns of older emergency department (ED) drivers and the factors that might lead them to enroll in a safe driving program.

Methods: We conducted a prospective, cross-sectional survey of a convenience sample of ED patients 65-years-old and up regarding their driving patterns, behaviors and willingness to enroll in a safe driving program.

Results: We surveyed 138 patients. Most (73%) reported driving within the last year, and 88% of these believe they could not manage without driving. Eleven percent of ED older drivers have been in a motor vehicle crash (MVC) in the past year (95% CI 6-20%), compared to 2.5% of all seniors. Our survey findings suggest that 88% of older ED drivers avoid at least some high-risk driving situations and 65% are unwilling to enroll in a safe driver program unless it lowers their automobile insurance rates. At the same time, most older ED drivers underestimate their risk of being involved in (75%) or dying from (74%) a MVC.

Conclusion: Overall, there are a significant number of older people for whom driving remains a vital yet risky daily function. Most of these drivers have little interest in information regarding safe driving programs while in the ED. Those willing to learn about such programs would prefer to take home the information regarding the program rather than have any staff member discuss it while in the ED. [West J Emerg Med. 2011;12(1):51-55.]

Cognitive Impairment among Older Adults in the Emergency Department

Background: Within the next 30 years, the number of visits older adults will make to emergency departments (EDs) is expected to double from 16 million, or 14% of all visits, to 34 million and comprise nearly a quarter of all visits.

Objective: The objectives of this study were to determine prevalence rates of cognitive impairment among older adults in the ED and to identify associations, if any, between environmental factors unique to the ED and rates of cognitive impairment.

Methods: A cross-sectional observational study of adults 65 and older admitted to the ED of a large, urban, tertiary academic health center was conducted between September 2007 and May 2008. Patients were screened for cognitive impairment in orientation, recall and executive function using the Six-Item Screen (SIS) and the CLOX1, clock drawing task. Cognitive impairment among this ED population was assessed and both patient demographics and ED characteristics (crowding, triage time, location of assessment, triage class) were compared through adjusted generalized linear models.

Results: Forty-two percent (350/829) of elderly patients presented with deficits in orientation and recall as assessed by the SIS. An additional 36% of elderly patients with no impairment in orientation or recall had deficits in executive function as assessed by the CLOX1. In full model adjusted analyses patients were more likely to screen deficits in orientation and recall (SIS) if they were 85 years or older (Relative Risk [RR]=1.63, 95% Confidence Interval [95% CI]=1.3-2.07), black (RR=1.85, 95% CI=1.5-2.4) and male (RR=1.42, 95% CI=1.2-1.7). Only age was significantly associated with executive functioning deficits in the ED screened using the clock drawing task (CLOX1) (75-84 years: RR=1.35, 95% CI= 1.2-1.6; 85+ years: RR=1.69, 95% CI= 1.5-2.0).

Conclusion: These findings have several implications for patients seen in the ED. The SIS coupled with a clock drawing task (CLOX1) provide a rapid and simple method for assessing and documenting cognition when lengthier assessment tools are not feasible and add to the literature on the use of these tools in the ED. Further research on provider use of these tools and potential implication for quality improvement is needed. [West J Emerg Med. 2011; 12(1):56-62.]

Neuroscience

Urine Test Strips to Exclude Cerebral Spinal Fluid Blood

Introduction: Determining the presence or absence of red blood cells (RBC) or their breakdown products in cerebrospinal fluid (CSF) is essential for the evaluation of subarachnoid hemorrhage (SAH) in headache patients. Current methodology for finding blood in the CSF is either spectrophotometric detection of pigment, which is time consuming and labor intensive, or visual assesment of samples for color change (xanthochromia), which is inaccurate. Bayer Multistix® urine test strips are designed to test urine for RBC by detecting the presence of hemoglobin. The aim of this pilot study was to evaluate the perfomance of urine reagent test strips for ruling out the presence of RBC in CSF.

Methods: We compared color changes on Multistix® urine test strips to the standard of spectrophotometric absorbtion at 415nm and initial RBC counts in 138 visually clear CSF samples.

Results: We performed Pearson Chi-Square and likelihood ratios on the results and found a correlation between a negative result on the urine test strip and less than 5 RBC per high power field and a spectrophotometric absorbance of less than 0.02% at 415nm in a CSF sample.

Conclusion: These results warrant further investigation in the form of a prospective clinical validation as it may alter the emergency department evaluation for SAH. [West J Emerg Med. 2011;12(1):63-66.]

Imaging in Acute Stroke

Imaging in the acute setting of suspected stroke is an important topic to all emergency physicians, neurologists, neurosurgeons and neuroradiologist. When it comes to imaging, the American College of Radiology (ACR) continually updates its guidelines for imaging pathways through the ACR Appropriateness Criteria. 1,2 This article is a general review of the imaging modalities currently used to assess and help guide the treatment of strokes. [West J Emerg Med. 2011;12(1):67-76.]

Excited Delirium

Excited (or agitated) delirium is characterized by agitation, aggression, acute distress and sudden death, often in the pre-hospital care setting. It is typically associated with the use of drugs that alter dopamine processing, hyperthermia, and, most notably, sometimes with death of the affected person in the custody of law enforcement. Subjects typically die from cardiopulmonary arrest, although the cause is debated. Unfortunately an adequate treatment plan has yet to be established, in part due to the fact that most patients die before hospital arrival. While there is still much to be discovered about the pathophysiology and treatment, it is hoped that this extensive review will provide both police and medical personnel with the information necessary to recognize and respond appropriately to excited delirium. [West J Emerg Med. 2011;12(1):77-83.]

Primary Cardiac Tumor Identified as the Cause of Seizure

A 65-year-old woman presented to the emergency department after a seizure. An unexplained bradycardia and heart murmur were detected and an emergency bedside echocardiography was performed. This revealed a mass in the left atrium. The provisional diagnosis of left atrial tumor was later confirmed by formal echocardiography and ultimately by histology. The first presentation of primary cardiac tumors can be misleading and sometimes presents with neurological manifestations. An early echocardiography can be diagnostic and could lead to early surgical intervention with better prognosis. [West J Emerg Med 2011;12(1):84-86.]

Contagious Weakness in an Elderly Couple with Neurologic Emergencies

We present an unusual neurologic emergency in an elderly male patient. Given his presentation and risk factors, we presumed the initial symptoms to be secondary to a cerebrovascular accident. As the case evolved, however, it became apparent that a more unusual pathology was present. This case report showcases a rare condition masquerading as a common neurologic emergency. [West J Emerg Med. 2011;12(1):87-89.]

Ultrasound

Differential Use of Diagnostic Ultrasound in U.S. Emergency Departments by Time of Day

Background: Survey data over the last several decades suggests that emergency department (ED) access to diagnostic ultrasound performed by the radiology department is unreliable, particularly outside of regular business hours.

Objective: To evaluate the association between the time of day of patient presentation and the use of diagnostic ultrasound services in United States (U.S.) EDs.

Methods: This was a cross-sectional study of ED patient visits using the National Hospital Ambulatory Medical Care Survey for the years 2003 to 2005. Our main outcome measure was the use of diagnostic ultrasound during the ED patient visit as abstracted from the medical record. We performed multivariate analyses to identify any association between ultrasound use and time of presentation for all patients, as well as for two subgroups who are more likely to need ultrasound as part of their routine workup: patients at risk of deep venous thrombosis, and patients at risk for ectopic pregnancy.

Results: During the three-year period, we analyzed 110,447 patient encounters, representing 39 million national visits. Of all ED visits, 2.6% received diagnostic ultrasound. Presenting to the ED “off hours” (defined as Monday through Friday 7pm to 7am and weekends) was associated with a lower rate of ultrasound use independent of potential confounders (odds ratio [OR] 0.73, 95% confidence interval [CI]: 0.65 - 0.82). Patients at increased risk of deep venous thrombosis who presented to the ED during “off hours” were also less likely to undergo diagnostic ultrasound (OR 0.34, 95% CI: 0.15 - 0.79). Similarly, patients at increased risk of ectopic pregnancy received fewer diagnostic ultrasounds during “off hours” (OR 0.56, 95% CI 0.35 - 0.91).

Conclusion: In U.S. EDs, ultrasound use was lower during “off hours,” even among patient populations where its use would be strongly indicated. [West J Emerg Med. 2011;12(1):90-95.]

Variable Access to Immediate Bedside Ultrasound in the Emergency Department

Objective: Use of bedside emergency department (ED) ultrasound has become increasingly important for the clinical practice of emergency medicine (EM). We sought to evaluate differences in the availability of immediate bedside ultrasound based on basic ED characteristics and physician staffing.

Methods: We surveyed ED directors in all 351 EDs in Colorado, Georgia, Massachusetts, and Oregon between January and April 2009. We assessed access to bedside ED ultrasound by the question: “Is bedside ultrasound available immediately in the ED?” ED characteristics included location, visit volume, admission rate, percent uninsured, total emergency physician full-time equivalents and proportion of EM board-certified (BC) or EM board-eligible (BE) physicians. Data analysis used chi-square tests and multivariable logistical regression to compare differences in access to bedside ED ultrasound by ED characteristics and staffing.

Results: We received complete responses from 298 (85%) EDs. Immediate access to bedside ultrasound was available in 175 (59%) EDs. ED characteristics associated with access to bedside ultrasound were: location (39% for rural vs. 71% for urban, P20%] rates, P<0.001); and EM BC/BE physicians (26% for EDs with a low percentage [0-20%] vs.74% for EDs with a high percentage [≥80%], P<0.001).

Conclusion: U.S. EDs differ significantly in their access to immediate bedside ultrasound. Smaller, rural EDs and those staffed by fewer EM BC/BE physicians more frequently lacked access to immediate bedside ultrasound in the ED. [West J Emerg Med. 2011;12(1):96-99.]

Accidental Carotid Artery Cannulation Detected by Bedside Ultrasound

This report highlights the importance of using bedside ultrasound in the emergency department to confirm guide-wire placement when performing central venous catheter placement prior to dilating and cannulating the vessel. [West J Emerg Med. 2011;12(1):100-101.]

Identification of Sonographic B-Lines with Linear Transducer Predicts Elevated B-Type Natriuretic Peptide Level

Objective: This study sought to correlate the presence of pleural-based B-lines seen by emergency department ultrasound performed with the linear transducer with B-type natriuretic peptide (BNP) level in patients with suspected congestive heart failure.

Methods: The study was a prospective convenience sample on adult patients in an academic, urban emergency department with over 100,000 annual patient visits. Adult patients with a BNP level ordered by the treating physician were prospectively enrolled by one of four physicians, blinded to the BNP level. The enrolling physicians included an emergency ultrasound director, two emergency ultrasound fellows, and a senior emergency medicine resident. Bedside ultrasound was performed using a 3-12 MHz linear broadband transducer in four lung fields. The serum BNP level was correlated with bilateral B-lines, defined as three or more comet-tail artifacts arising from the pleural line extending to the far field without a decrease in intensity on the right and left thorax.

Results: Sixty three patients were consented and enrolled during a four-month period. Fifteen patients had the presence of bilateral B-lines. The median BNP in patients with bilateral B-lines was 1560 pg/mL (95% confidence interval (CI) 1141-3706 pg/mL), compared with 538 pg/mL (95% confidence interval 310-1917 pg/mL) in patients without B-lines. The distributions in the two groups differed significantly (p=0.0006). Based on the threshold level of BNP 500 pg/mL, the sensitivity of finding bilateral B-lines on ultrasound was 33.3% (95% CI: 0.19-0.50), and the specificity was 91.7% (95% CI: 0.73-0.99). In addition, bilateral B-lines were absent in all patients with a BNP<100 pg/mL.

Conclusion: The presence of bilateral B-lines identified with the linear probe is associated with significantly higher BNP levels than patients without B-lines. In our patient population, the presence of B-lines was specific but not sensitive for BNP>500. Further research may show that it can be applied to quickly assess patients with undifferentiated dyspnea. [West J Emerg Med. 2011;12(1):102-106.]

Legal Medicine

The Standard of Care: Legal History and Definitions: The Bad and Good News

The true meaning of the term “the standard of care” is a frequent topic of discussion among emergency physicians as they evaluate and perform care on patients. This article, using legal cases and dictums, reviews the legal history and definitions of the standard of care. The goal is to provide the working physician with a practical and useful model of the standard of care to help guide daily practice. [West J Emerg Med. 2011;12(1):109-112.]

Trauma

Delayed Duodenal Hematoma and Pancreatitis from a Seatbelt Injury

Traumatic duodenal hematoma is a rare condition that is encountered in the paediatric age group following blunt abdominal trauma. It poses both a diagnostic and therapeutic challenge. The main concern is increased morbidity secondary to delayed diagnosis and associated occult injuries to the adjacent structures. Most of these hematomas resolve spontaneously with conservative management, and the prognosis is good. We present a case of a 15-year-old boy who had a delayed presentation of duodenal hematoma and acute pancreatitis, which was treated conservatively with complete resolution. [West J Emerg Med. 2011;12(1):128-130.]

Fracture Blisters

Fracture blisters are a relatively uncommon complication of fractures in locations of the body, such as the ankle, wrist elbow and foot, where skin adheres tightly to bone with little subcutaneous fat cushioning. The blister that results resembles that of a second degree burn.

These blisters significantly alter treatment, making it difficult to splint or cast and often overlying ideal surgical incision sites. Review of the literature reveals no consensus on management; however, most authors agree on early treatment prior to blister formation or delay until blister resolution before attempting surgical correction or stabilization. [West J Emerg Med. 2011;12(1);131-133.]

Spontaneous Thigh Compartment Syndrome

A young man presented with a painful and swollen thigh, without any history of trauma, illness, coagulopathic medication or recent exertional exercise. Preliminary imaging delineated a haematoma in the anterior thigh, without any fractures or muscle trauma. Emergent fasciotomies were performed. No pathology could be identified intra-operatively, or on follow-up imaging. A review of thigh compartment syndromes described in literature is presented in a table. Emergency physicians and traumatologists should be cognisant of spontaneous atraumatic presentations of thigh compartment syndrome, to ensure prompt referral and definitive management of this limb-threatening condition. [West J Emerg Med. 2011;12(1):134-138].

Patellar Tendonitis

[West J Emerg Med. 2011;12(1):139-140.]

Residency Abstract Competition