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Accuracy of sonography performed by emergency medicine residents for the diagnosis of acute appendicitis
RESEARCH FORUM ABSTRACTS
192
Metoclopramide Versus Hydromorphone for the Emergency Department Treatment of Migraine Headaches
Griffith JD, Mycyk MB, Kyriacou DN/Northwestern University, Chicago, IL Study objectives: The recent unavailability of prochlorperazine and droperidol has prompted the use of alternative medications for the emergency department (ED) treatment of migraine headaches. We evaluate the effectiveness of metoclopramide versus hydromorphone for the initial ED treatment of migraine headaches. Methods: We conducted a retrospective cohort study of patients with migraine headache treated at a large urban ED. Information about medications and potential confounders was abstracted from medical records. Pain scores were determined from patient-reported measures (0 to 10) before and after medication interventions. A reduction of 3 or more points after medication was considered effective. Crude and adjusted (using Cox proportional hazards regression) relative risks (RR) were estimated to compare the effects of the medications. Results: A total of 183 subjects were included. Ages ranged from 18 to 79 years (mean 40 years), and 85.8% were women. Patients initially received metoclopramide intravenously (n=89), and hydromorphone intravenously or intramuscularly (n=48: 45 intravenous, 3 intramuscular), or one of several other medications (n=46). There were no significant age, sex, race, or initial pain score differences among these 3 groups. Mean reductions in pain scores after initial medication were 3.9 points for metoclopramide, 2.2 points for hydromorphone, and 2.6 points for all others combined (P=.0009). When metoclopramide versus hydromorphone was compared, the crude RR for effective pain reduction was 1.70 (95% confidence interval [CI] 1.15 to 2.53, P=.003), and the adjusted RR was 1.87 (95% CI 0.95 to 3.69, P=.072). There was no difference in pain reduction between 10-mg and 20-mg doses of metoclopramide (P=.937) or between 0.5-mg, 1-mg, 2-mg, and 4-mg doses of hydromorphone (P=.103). Conclusion: Metoclopramide appears to be more effective than hydromorphone as an initial ED treatment of migraine headaches. Increasing doses of metoclopramide and hydromorphone demonstrated no significant pain reduction.
193
Prevalence of Abdominal Aortic Aneurysm in Emergency Department Patients With High-Risk Symptoms
Phelan MP, Emerman CL/Cleveland Clinic Foundation, Cleveland, OH Study objectives: The prevalence of abdominal aortic aneurysm (AAA) has been measured in a number of populations, suggesting that the prevalence is anywhere from 3% to 11% of those populations studied. Men between the ages of 65 and 74 years have a prevalence rate of 5.4%, men and women between the ages of 65 and 80 years have a prevalence rate of 4.3%, and hypertensive patients with peripheral vascular disease have a prevalence rate of 9.6%. Although the classic triad of hypotension, pulsatile abdominal mass, and abdominal pain occurs infrequently, there is a lack of reliable information on the prevalence of this disease in an emergency department (ED) population with symptoms that could relate to aortic aneurysms. The purpose of this pilot study is to gather prevalence data on AAA dilatation in patients at risk for disease in an ED setting. Methods: This was a convenience sample of patients presenting during times when an emergency physician trained in ultrasonography was available. Any patient 50 years or older who had 1 of the 6 symptoms (abdominal pain, back pain, flank pain, groin pain, syncope, or hypotension) was considered for the study. Abdominal aortas were measured in the longitudinal plane and transverse plane using a Hitachi EUB 405 Ultrasound machine with a 3.5-MHz curvilinear probe. Informed consent was obtained from the patient. Images were obtained above the level of the bifurcation but below the level of the superior mesenteric artery. Because adequate previous studies have demonstrated the accuracy of trained emergency physicians in interpreting these studies, confirmatory examinations were not required as part of this study. Diameters greater than 3 cm were considered aneurysmal. Images were saved and reviewed by one of the investigators blinded to outcome. Data were analyzed using simple descriptive statistics. Results: Ninety-seven patients were entered in the study, of whom 57% were male patients, 66% had a history of hypertension, and 38% used tobacco. The mean age was 67.4610.8 years. The most common symptom was abdominal pain (40.6%), followed by back pain and hypotension, each at 21.9%. The mean maximal aortic diameter was 2.060.7 cm. There were 5 patients with a maximal aortic diameter of 3 cm or more, resulting in a prevalence of 5.15% (95% confidence interval [CI] 0.8%
S 6 0
to 9.6%). Two patients had a maximal diameter of greater than 5 cm (2.1%; 95% CI 0.4% to 8%). The outcome of the 2 patients with a maximal diameter greater than 5 cm was satisfactory. One patient had a known history of AAA status postrepair was admitted to vascular surgery and discharged 2 days later without intervention. The other patient had a newly diagnosed AAA, which vascular surgery evaluated and discharged from the ED for outpatient follow-up. No patient with aneurysmal dilation of the aorta was found to be ruptured. Conclusion: The prevalence of AAA in an ED population at risk with symptoms that could be referable to the aorta is in the range of that which has been described in other populations. Although the incidence of symptomatic aortic aneurysms is lower, the utility of screening of patients at risk warrants further study.
194
Accuracy of Sonography Performed by Emergency Medicine Residents for the Diagnosis of Acute Appendicitis
Min YG, Lee CC, Bae YS, Jung YS/Ajou University Hospital, Suwon, Korea; Flushing Hospital Medical Center, Flushing, NY Study objectives: We evaluate the accuracy of sonography performed by emergency medicine residents for the diagnosis of acute appendicitis with equivocal physical findings. Methods: In this prospective study, 40 consecutive patients with equivocal physical findings of acute appendicitis were examined with graded compression sonography by emergency medicine residents after a 1-hour lecture and 20 observations. The primary sonographic criterion for diagnosing acute appendicitis was an incompressible appendix with a outer diameter of 6 mm or larger with periappendicular inflamed fat with or without an appendicolith. The sonographic findings were correlated with surgical and pathologic findings. Results: Among 40 patients studied, 29 patients were confirmed to have acute appendicitis, and 11 patients were confirmed to have other pathology during operation. Among 29 patients who had an acute appendicitis, 24 patients were diagnosed by sonography, and 5 patients did not have sonographic diagnosis of acute appendicitis. The 11 patients who did not have acute appendicitis during operation also did not have sonographic criteria for acute appendicitis. Those 5 patients who did not have sonographic criteria for acute appendicitis all had positive computed tomographic scan results for acute appendicitis. The sensitivity of emergency medicine residents diagnosing acute appendicitis by sonography was 83%, and specificity was 100%. The positive predictive value was 100% and negative predictive value was 69%. Conclusion: The sonography performed by emergency medicine residents is useful for diagnosing acute appendicitis among patients with equivocal physical findings.
195
The Use of Cardiac Ultrasonography by Emergency Physicians to Assess Hydration Status in Healthy Volunteers
Davies S, Furman AC, Constantino TG, Satz WA/Drexel University College of Medicine, Philadelphia, PA; Temple University Medical School, Philadelphia, PA Study objectives: Some studies have shown the value of ultrasonography in patients presenting in pulseless electrical activity in the detection of pericardial effusion. There has been some suggestion that hypovolemia could also be detected in these patients by ultrasonography to suggest alternate treatment to correct the cause of pulseless electrical activity. This study attempts to determine which objective measurements on cardiac ultrasonography best correlate with hydration status as measured by urine specific gravity in healthy volunteers. Methods: Volunteer medical students and residents were evaluated after a normal overnight fast by a single subxiphoid-view cardiac ultrasonographic examination performed by emergency physicians who all had ultrasonographic training that met or exceeded national guidelines put forth by the American College of Emergency Physicians and the Society for Academic Emergency Medicine. Measurements were taken of the right ventricle in systole and diastole, as well as the inferior vena cava. A subjective ‘‘fullness’’ score was also assigned by the emergency physician performing the cardiac ultrasonography. These were compared to urine specific gravity obtained after completion of the cardiac ultrasonography. Results: Forty-eight subjects were enrolled in the study. Urine specific gravity ranged from 1.00 to 1.03 in the volunteers. There was no correlation found between
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004
192
Metoclopramide Versus Hydromorphone for the Emergency Department Treatment of Migraine Headaches
Griffith JD, Mycyk MB, Kyriacou DN/Northwestern University, Chicago, IL Study objectives: The recent unavailability of prochlorperazine and droperidol has prompted the use of alternative medications for the emergency department (ED) treatment of migraine headaches. We evaluate the effectiveness of metoclopramide versus hydromorphone for the initial ED treatment of migraine headaches. Methods: We conducted a retrospective cohort study of patients with migraine headache treated at a large urban ED. Information about medications and potential confounders was abstracted from medical records. Pain scores were determined from patient-reported measures (0 to 10) before and after medication interventions. A reduction of 3 or more points after medication was considered effective. Crude and adjusted (using Cox proportional hazards regression) relative risks (RR) were estimated to compare the effects of the medications. Results: A total of 183 subjects were included. Ages ranged from 18 to 79 years (mean 40 years), and 85.8% were women. Patients initially received metoclopramide intravenously (n=89), and hydromorphone intravenously or intramuscularly (n=48: 45 intravenous, 3 intramuscular), or one of several other medications (n=46). There were no significant age, sex, race, or initial pain score differences among these 3 groups. Mean reductions in pain scores after initial medication were 3.9 points for metoclopramide, 2.2 points for hydromorphone, and 2.6 points for all others combined (P=.0009). When metoclopramide versus hydromorphone was compared, the crude RR for effective pain reduction was 1.70 (95% confidence interval [CI] 1.15 to 2.53, P=.003), and the adjusted RR was 1.87 (95% CI 0.95 to 3.69, P=.072). There was no difference in pain reduction between 10-mg and 20-mg doses of metoclopramide (P=.937) or between 0.5-mg, 1-mg, 2-mg, and 4-mg doses of hydromorphone (P=.103). Conclusion: Metoclopramide appears to be more effective than hydromorphone as an initial ED treatment of migraine headaches. Increasing doses of metoclopramide and hydromorphone demonstrated no significant pain reduction.
193
Prevalence of Abdominal Aortic Aneurysm in Emergency Department Patients With High-Risk Symptoms
Phelan MP, Emerman CL/Cleveland Clinic Foundation, Cleveland, OH Study objectives: The prevalence of abdominal aortic aneurysm (AAA) has been measured in a number of populations, suggesting that the prevalence is anywhere from 3% to 11% of those populations studied. Men between the ages of 65 and 74 years have a prevalence rate of 5.4%, men and women between the ages of 65 and 80 years have a prevalence rate of 4.3%, and hypertensive patients with peripheral vascular disease have a prevalence rate of 9.6%. Although the classic triad of hypotension, pulsatile abdominal mass, and abdominal pain occurs infrequently, there is a lack of reliable information on the prevalence of this disease in an emergency department (ED) population with symptoms that could relate to aortic aneurysms. The purpose of this pilot study is to gather prevalence data on AAA dilatation in patients at risk for disease in an ED setting. Methods: This was a convenience sample of patients presenting during times when an emergency physician trained in ultrasonography was available. Any patient 50 years or older who had 1 of the 6 symptoms (abdominal pain, back pain, flank pain, groin pain, syncope, or hypotension) was considered for the study. Abdominal aortas were measured in the longitudinal plane and transverse plane using a Hitachi EUB 405 Ultrasound machine with a 3.5-MHz curvilinear probe. Informed consent was obtained from the patient. Images were obtained above the level of the bifurcation but below the level of the superior mesenteric artery. Because adequate previous studies have demonstrated the accuracy of trained emergency physicians in interpreting these studies, confirmatory examinations were not required as part of this study. Diameters greater than 3 cm were considered aneurysmal. Images were saved and reviewed by one of the investigators blinded to outcome. Data were analyzed using simple descriptive statistics. Results: Ninety-seven patients were entered in the study, of whom 57% were male patients, 66% had a history of hypertension, and 38% used tobacco. The mean age was 67.4610.8 years. The most common symptom was abdominal pain (40.6%), followed by back pain and hypotension, each at 21.9%. The mean maximal aortic diameter was 2.060.7 cm. There were 5 patients with a maximal aortic diameter of 3 cm or more, resulting in a prevalence of 5.15% (95% confidence interval [CI] 0.8%
S 6 0
to 9.6%). Two patients had a maximal diameter of greater than 5 cm (2.1%; 95% CI 0.4% to 8%). The outcome of the 2 patients with a maximal diameter greater than 5 cm was satisfactory. One patient had a known history of AAA status postrepair was admitted to vascular surgery and discharged 2 days later without intervention. The other patient had a newly diagnosed AAA, which vascular surgery evaluated and discharged from the ED for outpatient follow-up. No patient with aneurysmal dilation of the aorta was found to be ruptured. Conclusion: The prevalence of AAA in an ED population at risk with symptoms that could be referable to the aorta is in the range of that which has been described in other populations. Although the incidence of symptomatic aortic aneurysms is lower, the utility of screening of patients at risk warrants further study.
194
Accuracy of Sonography Performed by Emergency Medicine Residents for the Diagnosis of Acute Appendicitis
Min YG, Lee CC, Bae YS, Jung YS/Ajou University Hospital, Suwon, Korea; Flushing Hospital Medical Center, Flushing, NY Study objectives: We evaluate the accuracy of sonography performed by emergency medicine residents for the diagnosis of acute appendicitis with equivocal physical findings. Methods: In this prospective study, 40 consecutive patients with equivocal physical findings of acute appendicitis were examined with graded compression sonography by emergency medicine residents after a 1-hour lecture and 20 observations. The primary sonographic criterion for diagnosing acute appendicitis was an incompressible appendix with a outer diameter of 6 mm or larger with periappendicular inflamed fat with or without an appendicolith. The sonographic findings were correlated with surgical and pathologic findings. Results: Among 40 patients studied, 29 patients were confirmed to have acute appendicitis, and 11 patients were confirmed to have other pathology during operation. Among 29 patients who had an acute appendicitis, 24 patients were diagnosed by sonography, and 5 patients did not have sonographic diagnosis of acute appendicitis. The 11 patients who did not have acute appendicitis during operation also did not have sonographic criteria for acute appendicitis. Those 5 patients who did not have sonographic criteria for acute appendicitis all had positive computed tomographic scan results for acute appendicitis. The sensitivity of emergency medicine residents diagnosing acute appendicitis by sonography was 83%, and specificity was 100%. The positive predictive value was 100% and negative predictive value was 69%. Conclusion: The sonography performed by emergency medicine residents is useful for diagnosing acute appendicitis among patients with equivocal physical findings.
195
The Use of Cardiac Ultrasonography by Emergency Physicians to Assess Hydration Status in Healthy Volunteers
Davies S, Furman AC, Constantino TG, Satz WA/Drexel University College of Medicine, Philadelphia, PA; Temple University Medical School, Philadelphia, PA Study objectives: Some studies have shown the value of ultrasonography in patients presenting in pulseless electrical activity in the detection of pericardial effusion. There has been some suggestion that hypovolemia could also be detected in these patients by ultrasonography to suggest alternate treatment to correct the cause of pulseless electrical activity. This study attempts to determine which objective measurements on cardiac ultrasonography best correlate with hydration status as measured by urine specific gravity in healthy volunteers. Methods: Volunteer medical students and residents were evaluated after a normal overnight fast by a single subxiphoid-view cardiac ultrasonographic examination performed by emergency physicians who all had ultrasonographic training that met or exceeded national guidelines put forth by the American College of Emergency Physicians and the Society for Academic Emergency Medicine. Measurements were taken of the right ventricle in systole and diastole, as well as the inferior vena cava. A subjective ‘‘fullness’’ score was also assigned by the emergency physician performing the cardiac ultrasonography. These were compared to urine specific gravity obtained after completion of the cardiac ultrasonography. Results: Forty-eight subjects were enrolled in the study. Urine specific gravity ranged from 1.00 to 1.03 in the volunteers. There was no correlation found between
ANNALS OF EMERGENCY MEDICINE
44:4
OCTOBER 2004