Mythbusting

Peds, POCUS, & SSTI.

Generally, most pediatric patients I’ve seen despise “needles.” Fortunately, they general love ipads and various other forms of technology. This particular study combines the two. Looking at 151 skin & soft tissue infections among 148 patients, the initial treating physician recorded their initial assessment as to whether or not there was a drainable collection, which was followed by a second physician who was blinded to the first assessment, doing an ultrasound.

In the above referenced study, POCUS for an abscess had a sensitivity of 95% and specificity of 87%. Physical exam sensitivity was 84% with 60% specificity. Add in this lit review – which also shows a higher sensitivity for US, and – especially for peds who run and scream at the suggestion of an I&D – there is no reason to not be doing more POCUS in these situations.

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Improving Outcomes, Improving Throughput

Dont hang your CAP on that Xray!

What is your threshold for sensitivity of a test? If head CT missed 30% of bleeds, would we even do them? If UA’s missed 30% of UTI’s, would we even send them for anything other than culture? Would you feel comfortable making a decision based off a test that misses 30% of an infectious process that is common in your ED?

Here, 319 prospectively enrolled patients with suspected community acquired pneumonia were subjected to plain films and followed by Chest CT. CT revealed an infiltrate in a third of patients who did not have an infiltrate on chest film and excluded CAP in 29.8% of patients with an infiltrate on chest film. 6.9% of patients were hospitalized (rather than discharged), and 7.2% were discharged rather than admitted based off CT findings (22 vs 23 patients).

The authors suggest that changing the disposition on 14% of patients is worth the “just scan ’em” mentality, while I would argue that a better question would be, why waste everyone’s time when you could just pull out the ultrasound? (Not to mention you would have an answer faster, at ~95% sensitivity?)

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Improving Outcomes, Improving Throughput, Pediatrics, Pediatrics

Increased sono, decreased negative peds appy rate.

Academia and community ED settings are very different, and sometimes one community to the next is often times very different as well. This study– which included 35 pediatric ED’s and 52,000+ cases of appendicitis demonstrates this. Essentially, the authors took all their appendicitis data from 2010-2013, and looked at what imaging, if any, the patient received, negative appendectomy rates, length of stay, frequency of perforation, and 3 day bounceback rates from initial ED visit (ie, did ultrasound or CT “miss” an eventual appendicitis?)

Ultrasound use increased from 24% in 2010 to 35.3% in 2013 for the sole diagnostic modality in what eventually was diagnosed as appendicitis. CT rate decreased 21.4% in 2010 to 11.6% in 2013. Almost 50% of the patients (25,254 out of 52,153) had neither CT or US (!). The negative appendectomy rate in 2010 was 4.7%, while in 2013, it was 3.6%. There was no difference in length of stay, frequency of perforation, or 3 day bounce back rates from 2010 to 2013.

Ok. If you work in a community ED, raise your hand if 50% of your potential appendicitis cases get seen by surgery without any imaging. Only 11.6 % CT use? I think most community surgeons would be less than thrilled to be called at 2am for a “rule out” appendicitis evaluation without imaging.

While I think the authors live in an alternate universe, I think this paper makes a great argument to do the right thing. It would be great if non-academic settings could utilize US and surgical consultations for a “hot belly” without shipping them off to radiology. Or better yet, have surgery perform POCUS with you to confirm findings.

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Critical Care, Improving Outcomes, Mythbusting

POCUS in codes: Is that PEA really PEA?

So a few weeks ago, I asked the Twittersphere whether or not ultrasound should be readily available (if not outright used) in all codes.  The answer was a resounding yes, and today’s article helps support that claim.

49 ICU patients with cardiopulmonary arrest (asystole or PEA) underwent intra-arrest bedside TTE.  Based on Echo findings, these patients were classified as either asystole, PEA without cardiac contractility, or PEA with cardiac contractility.  ROSC and survival to discharge, and survival to 180 days were evaluated. Of these 49 patients, 17 (35%) were in asystole based on Echo, 5 (10%) were in PEA without cardiac contractility, and 27 (55%) were in PEA with cardiac contractility.  Rates of ROSC were 23.5% for those in asystole, 20% for PEA without cardiac contractility, and 70.4% for those in PEA with cardiac contractility.  Survival to discharge (22%) and after 180 days (15%) only occurred in the PEA group with cardiac contractility.  (Full disclosure- no word on CPC neurologic outcomes for survivors).

Now, this study looks at ICU arrests – clearly a bit different from OHCA cases we see in the ED, and perhaps intrigues me to suggest using cardiac POCUS in OHCA to stratify the futility of the resuscitation (This review found significant bias and large heterogeneity for prehospital sono usage for arrests).  Nevertheless, with 15% 6-month survival in a group that without bedside sono you would call the code – its time to seriously consider the use of ultrasound (at least for) cardiac evaluation in all codes.  For all of the things we do that fall into the “can’t hurt, might help” category, ultrasound in an arrest has to be high on the list.

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Improving Throughput, Mythbusting, Radiology, Radiology

Hocus POCUS, legal mumbo jumbo.

First, there was “Failure to Perform”, then the next hot legal topic, “Failure to Perform in A Timely Manner,” took stage.  We are in an age where there is a “Golden Hour” for everything – time to antibiotics, time to lysis, time to cath lab – and if you have been lucky enough to attend the ACEP Scientific Assembly over the last few years, you’ve likely heard that the legal landscape is changing to reflect this.  Legal teams are now privy to the fact that ultrasound training is now mandatory in EM residencies, and we are beginning to see legal outcomes in which POCUS has played a role – though its legal role probably is not what you think.

Like many community ED docs, you are probably uncomfortable doing POCUS.  Perhaps you don’t have the fancy machine you did in residency.  Perhaps you are concerned it increases your liability, and you wonder why you would do it when radiology has a better machine and your institute has radiologists to share the wealth (and the lawsuits!).

First, one previous paper exists examining the liability of point of care ultrasound (POCUS).  Admittedly, this was a 2012 paper looking at 1987-2007, and I would think POCUS has grown exponentially since that time.  Regardless, of the 659 available POCUS cases examined, none were related to misinterpretation- but there was one was for failure to perform POCUS! Now a second study looks at the Westlaw database reviewing cases from January 2008 to December 2012 involving EPs and POCUS.  Here they are:

study

 

Five cases in four years when POCUS is starting to take off.  Without playing armchair quarterback too much, I’ll simply state that one of the central issues was that POCUS was *not* performed in all of the above cases.  There were two other cases in which POCUS was not performed (intra-ocular foreign body after multiple beestings; dyspnea in a patient ultimately found to have acute mitral valve insufficiency on ECHO), but the counterargument was that these indications (intra-ocular FB, valvular evaluation) were not part of ACEP core applications & thus outside of the EPs scope.  So what are ACEP’s Core Applications for Ultrasound? Trauma, IUP, AAA, cardiac, biliary, urinary tract, DVT, soft tissue/musculoskeletal, thoracic, ocular, and procedural guidance.  That’s quite the range, and for a more detailed explanation, ACEP’s clinical policy on sono can be found here (opens pdf, specifics start around page 20)

There you have it.  The precedent has been set. The failure to do POCUS for one of ACEP’s Core Applications in a timely fashion actually puts you at more risk then if you had performed POCUS.  There has yet to be a case on public record to dispute this.  POCUS.  Learn it.  Use it.

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Improving Outcomes, Improving Throughput, Twelve Trials of Christmas!

Day 9 of Christmas: Midlevel EM Sono Training

Welcome to the Twelve Trials of Christmas series on EMinFocus! This is the ninth of twelve posts in a series where I ramble on various topics for which I would love to see an EM study done. I’ve taken morsels of prior studies (case series, small trials, etc) and highlight reasons on why I believe this study would benefit EM. Some may pan out, some may not. All of them I would be highly interested in assisting with in any way possible to continue to advance our fine specialty.

Simply put, for traumatic injuries, nerve blocks are the best source of pain control. If your only option of providing pain control for a femur fracture is to make the patient limp from your favorite opiate or giving tylenol, you have failed as a provider to keep up with current trends and literature. EM is all about having options in your toolbox.

Why are we not using nerve blocks? Can we train mid-levels to do these safely to provide a higher level of care and provide more job satisfaction?

I have seen patients with rib fractures go to observation for pain control and have been stonewalled in attempts to perform a block, either by myself or in consultation with anesthesia. This is despite evidence showing that nerve blocks work wonderfully during the EDs attempt at initial pain control, and with even better when a catheter is placed for continuous infusion. Nerve blocks for rib fractures also decrease mortality.  In case you were wondering, lidoderm patches wont work.

So, can we perform an ED based study showing mid-levels can safely use ED ultrasound for blocks? We can already safely do sono guided liver biopsies, soft tissue foreign bodies, hip injections, transrectal prostate biopsies, and we can even be remotely guided for lung sono. Its time for an ED study demonstrating we can safely do this in the ED.

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Improving Outcomes, Improving Throughput, Mythbusting

Why Are You Not Doing Femoral Blocks?

     I’ve been on a bit of a rant lately about how the ED sets the course for the remainder of the inpatient stay. The most recent eye-catching paper to come across my QxMD feed reinforces this.

     326 patients with an acute hip fracture who received a fascia iliaca compartment block in the ED were compared to 100 patients who had received “standard of care” – IV, IM, or oral meds at the teams discretion. Not surprisingly, there was a reduction in pain score and opiate requirement with the iliaca block. Most surprisingly was the 9.9 to 15 day difference in length of stay, as well as inpatient mortality of 5.5% vs 15% in the iliaca nerve block vs standard treatment, respectively. The authors admit there may be confounding factors at play, however, these are striking numbers and the largest study of a nerve block I have seen in the acute setting, and these are hard to argue with. For those of you wondering, this study then retrospectively looked at 1586 patients that were given an iliac block at their participating institutes, and noted only 2 (TWO) incidences of systemic anesthetic toxicity.

     Now, given the above, lets compare iliaca to femoral nerve blocks. A previous study of 110 patients showed a statistically significant pain improvement with the femoral nerve block vs the iliaca block, and that the femoral block arm required less parenteral narcotics.

     If you have not yet done a sono guided femoral nerve block – try it out! (https://www.youtube.com/watch?v=5ht_N8j2KL8) Its pretty easy, and takes about five minutes to do the procedure, plus a few more for set up.  If admin gives you grief, its hard to argue with improved pain control, LOS & mortality.

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PMID: 23789738

PMID: 24949565

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