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354 Emergency Medicine Bedside Ultrasound Utilization in the Diagnostic and Therapeutic Approach to Peritonsillar Abscesses
Research Forum Abstracts or autopsy). Studies were excluded if they examined only specific comorbidities (eg, cancer, liver disease, etc); were on pediatric or pregnant patients; used healthy volunteers as controls; did not have a calculable sensitivity (Sn) and specificity (Sp) from the data presented; or were reviews, commentaries, or editorials. All articles were screened for inclusion by two independent reviewers, with 97% agreement; k ¼ 0.77, P < .001. Both reviewers decided a priori to err on the side of inclusion, and if either reviewer selected an article, it was ordered for full text review. A single reviewer then determined if the full text articles met the inclusion criteria, and any questions were discussed with the team to reach a final decision on inclusion. Sn and Sp were combined using equal weighting methods and calculated using Microsoft Excel. Results: Our search strategy yielded 4,472 articles without duplicates. Of these, 389 were ordered for full text review, and 22 were included in the final analysis. The most commonly cited use of echo to detect PE was through a combination of findings suggestive of PE. These findings were termed and defined variably across 16 studies. Terms for combined measures included: right ventricular (RV) dysfunction, RV strain, and acute cor pulmonale. These combined measures had a Sn of 57% and a Sp of 78%, and those only in point of care studies had a Sn of 60% and an Sp of 87%. The most common (n¼7) stand-alone signs used were an increased RV:LV ratio (Sn¼64%, Sp ¼85%), abnormal septal motion (Sn¼29%, Sp¼ 96%), and tricuspid insufficiency (Sn¼49%, Sp¼80%). The most specific test was visualizing a RV thrombus, with a Sp of 100% in 2 studies. However, 3 other markers showed a Sp greater than 95%: RV hypokinesis (98%, n¼4), McConnell’s sign (98%, n¼3), and abnormal septal motion (96%, n¼7). The most sensitive test was an increased RV end diastolic diameter, with a Sn of 78% in 3 studies. The test with the highest diagnostic odds ratio (DOR) was RV wall hypokinesis, with a DOR of 34.7, a Sn of 39% and a Sp of 98% in 3 studies. Conclusion: Studies have consistently shown a high specificity for echo in the diagnosis of PE, making it potentially adequate as a rule-in test at the bedside in the emergency department for patients unable to get other confirmatory studies. Future research should examine if combining echo with other modalities, such as lung and deep venous thrombosis ultrasound improves accuracy.
354
Emergency Medicine Bedside Ultrasound Utilization in the Diagnostic and Therapeutic Approach to Peritonsillar Abscesses
Gibbons R, Costantino T, Satz W, Mulflur M, Goett H/Temple University Hospital, Philadelphia, PA
Study Objectives: Our previous retrospective, case control study from January 2007 through December 2008 suggested that emergency medicine bedside ultrasound (EMBU) improved successful needle aspiration of peritonsillar abscesses. During that time period, EMBU was utilized in only 20% of cases. This study aims to assess the more contemporary use and impact of EMBU since our initial review. Methods: This was a retrospective, case-control study of all adult patients with a final diagnosis of peritonsillar abscess, who presented to the emergency department (ED) from January 2013 through December 2014 at an urban academic hospital. Chart review and abstraction were performed. The data were separated into those with emergency medicine bedside ultrasound (US) versus those without ultrasound (NUS). The primary endpoint was successful aspiration with EMBU. Secondary endpoints were frequency of specialty consultation, need for computed tomography (CT) imaging, unscheduled return visits within 1 week, and length of stay. The Fisher Exact method analyzed the frequency data, and the T test was applied to length of stay. Results: There were 114 patients enrolled, 89 of whom had emergency medicine bedside ultrasound performed (78%). The median age was 32 with a range of 18 to 62. The results are: Successful aspiration by an emergency physician: US 89% vs NUS 4% P ¼ .001, (OR 189.6; 95% CI 23, 1157). Overall Success (including ENT consultant): US 98% vs NUS 88% P ¼ .30, (OR 2.5; 95% CI 0.39, 15.8). ENT consultation rate: US 15% vs NUS 64% P ¼ .002, (OR 154; 95% CI 19, 1246). Additional Imaging (CT scans only): US 27% vs NUS 65% P ¼ .002, (OR 4.8; 95% CI 1.9, 12.3). Return visit rate: US 4% vs NUS 12% P ¼ .18, (OR 0.34; 95% CI 0.72, 1.66). Length of stay (minutes): US 166 vs NUS 267 P ¼ .0002, (95% CI 146, 309.5) Conclusion: The increased availability and utilization of emergency medicine ultrasound has impacted our diagnostic and treatment approach to peritonsillar abscesses. Nearly 80% of cases employed EMBU in comparison to 20% in the past. As suggested previously, ultrasound use by emergency physicians seems to improve the rate of successful aspiration of peritonsillar abscesses. Additionally, it appears to decrease specialty consultation rates, CT imaging, and length of stay.
S128 Annals of Emergency Medicine
355
B-Lines on Lung Ultrasound in End Stage Renal Disease Patients Post Hemodialysis: Accuracy and PrecisionInterim Analysis
Saad M, Mansour W, Kamal J, Ross H, Kapoor M, Brown C, El-Sayegh S, Das D/Staten Island University Hospital, Staten Island, NY
Background: Studies have shown that B-lines on lung ultrasound are an objective method for the evaluation of extravascular fluid and volume overload. The availability, feasibility and sensitivity of ultrasound renders it an important tool for initial bedside evaluation in the emergency department. Training residents to take advantage of this exam can lead to a more precise and rapid assessment of a patient’s volume status. Study Objective: To evaluate the precision and reliability of measuring volume overload through quantitating B-lines on lung ultrasound by residents following a short training course. Secondary objective was to evaluate the correlation between the B-line scores obtained and the NYHA CHF scores in end stage renal disease (ESRD) patients post hemodialysis (HD). Methods: Internal medicine and emergency medicine residents were trained by ultrasound-fellowship trained emergency physicians to use ultrasound (Sonosite Edge) to identify B-lines on lung ultrasound in a 3-hour course. This course included a didactics and simulation training portion. All resident investigators had to pass an objective structured clinical examination (OSCE) and 10 question multiple choice exam for eligibility in enrolling patients in the study. Residents then performed lung ultrasound looking specifically for B-lines in patients post HD to assess for volume overload. Patients on HD have a high prevalence of moderate to severe pulmonary congestion, even after achieving dry weight. As validated in a study by Zoccali et al, a total of 28 lung windows were scanned: 16 in the right hemithorax (parasternal, midclavicular, anterior axillary and mid-axillary in the 2nd through 5th intercostal space (ICS)) and 12 in the left hemithorax in the 2nd through the 4th ICS at the same positions. For each scanned window, a 6-second video clip was recorded. A B-line score was calculated and categorized as minimal (0-5 B-lines present), mild (6-13), moderate (14-30) and severe (>30 B) for pulmonary congestion. This score was recorded in real time by the study investigators who were blinded to the patients’ clinical data. Each video clip was reviewed at a later time by two emergency physician, who were also blinded to the patients’ clinical data. The B-line scores obtained by the emergency physician were compared with the results obtained by the study investigators. Results: A total of 41 ESRD patients on HD were scanned. Sixty-eight percent were males; mean age 60.83 16.175, mean BMI 28.17 5.347; mean test duration was 15 minutes. The mean number of B-lines found by the study investigators and EPs was 18.24 and 19.33, respectively. The mean and standard deviation for difference was 5.13 and 11.98, respectively. When categorized, there was no significant difference in classification between the study investigators and emergency physicians (significance 0.982). NYHA score correlated with B-lines (P ¼ .003) even after adjusting for other variables. Conclusion: B-lines on bedside lung ultrasound can provide a reliable indicator for a patient’s volume status assessment in comparison to other validated measures, including the NYHA CHF score. Our study also shows that a short training course can render novice users of ultrasound capable of performing this quick evaluation, This can aid in objectively assessing volume overload in patients presenting to the ED, especially in HD patients who present a unique clinical challenge.
356
Emergency Physician-Performed Echocardiography as a Predictor of Cardiac Events in Patients Presenting With Symptoms of Acute Coronary Syndrome
Chandra A, Blackstock U, Kurkowski E, Menlove S, Vermeulen M, Carmody K/New York University, New York, NY
Study Objective: Echocardiography (echo) has gained wide acceptance for its utility at the bedside in emergency department (ED) patients presenting with chest pain. Cardiology literature has demonstrated that both resting and stress echo are reliable in detecting myocardial ischemia and that bedside echo accurately identifies patients who present to the ED with a myocardial infarction. Echo has also been found to be more sensitive than ECG in detecting cardiac events in patients who present with chest pain or acute coronary syndrome (ACS) like symptoms. Regional wall motion abnormalities (RWMA) may precede ECG changes in patients with active myocardial ischemia. The objective of this study is to determine if emergency physician-performed bedside echo can predict cardiac events in patients presenting to the ED with ACS. Methods: This is a preliminary prospective observational study of ED patients at two academic urban medical centers beginning December 2014. Patients presenting
Volume 66, no. 4s : October 2015
354
Emergency Medicine Bedside Ultrasound Utilization in the Diagnostic and Therapeutic Approach to Peritonsillar Abscesses
Gibbons R, Costantino T, Satz W, Mulflur M, Goett H/Temple University Hospital, Philadelphia, PA
Study Objectives: Our previous retrospective, case control study from January 2007 through December 2008 suggested that emergency medicine bedside ultrasound (EMBU) improved successful needle aspiration of peritonsillar abscesses. During that time period, EMBU was utilized in only 20% of cases. This study aims to assess the more contemporary use and impact of EMBU since our initial review. Methods: This was a retrospective, case-control study of all adult patients with a final diagnosis of peritonsillar abscess, who presented to the emergency department (ED) from January 2013 through December 2014 at an urban academic hospital. Chart review and abstraction were performed. The data were separated into those with emergency medicine bedside ultrasound (US) versus those without ultrasound (NUS). The primary endpoint was successful aspiration with EMBU. Secondary endpoints were frequency of specialty consultation, need for computed tomography (CT) imaging, unscheduled return visits within 1 week, and length of stay. The Fisher Exact method analyzed the frequency data, and the T test was applied to length of stay. Results: There were 114 patients enrolled, 89 of whom had emergency medicine bedside ultrasound performed (78%). The median age was 32 with a range of 18 to 62. The results are: Successful aspiration by an emergency physician: US 89% vs NUS 4% P ¼ .001, (OR 189.6; 95% CI 23, 1157). Overall Success (including ENT consultant): US 98% vs NUS 88% P ¼ .30, (OR 2.5; 95% CI 0.39, 15.8). ENT consultation rate: US 15% vs NUS 64% P ¼ .002, (OR 154; 95% CI 19, 1246). Additional Imaging (CT scans only): US 27% vs NUS 65% P ¼ .002, (OR 4.8; 95% CI 1.9, 12.3). Return visit rate: US 4% vs NUS 12% P ¼ .18, (OR 0.34; 95% CI 0.72, 1.66). Length of stay (minutes): US 166 vs NUS 267 P ¼ .0002, (95% CI 146, 309.5) Conclusion: The increased availability and utilization of emergency medicine ultrasound has impacted our diagnostic and treatment approach to peritonsillar abscesses. Nearly 80% of cases employed EMBU in comparison to 20% in the past. As suggested previously, ultrasound use by emergency physicians seems to improve the rate of successful aspiration of peritonsillar abscesses. Additionally, it appears to decrease specialty consultation rates, CT imaging, and length of stay.
S128 Annals of Emergency Medicine
355
B-Lines on Lung Ultrasound in End Stage Renal Disease Patients Post Hemodialysis: Accuracy and PrecisionInterim Analysis
Saad M, Mansour W, Kamal J, Ross H, Kapoor M, Brown C, El-Sayegh S, Das D/Staten Island University Hospital, Staten Island, NY
Background: Studies have shown that B-lines on lung ultrasound are an objective method for the evaluation of extravascular fluid and volume overload. The availability, feasibility and sensitivity of ultrasound renders it an important tool for initial bedside evaluation in the emergency department. Training residents to take advantage of this exam can lead to a more precise and rapid assessment of a patient’s volume status. Study Objective: To evaluate the precision and reliability of measuring volume overload through quantitating B-lines on lung ultrasound by residents following a short training course. Secondary objective was to evaluate the correlation between the B-line scores obtained and the NYHA CHF scores in end stage renal disease (ESRD) patients post hemodialysis (HD). Methods: Internal medicine and emergency medicine residents were trained by ultrasound-fellowship trained emergency physicians to use ultrasound (Sonosite Edge) to identify B-lines on lung ultrasound in a 3-hour course. This course included a didactics and simulation training portion. All resident investigators had to pass an objective structured clinical examination (OSCE) and 10 question multiple choice exam for eligibility in enrolling patients in the study. Residents then performed lung ultrasound looking specifically for B-lines in patients post HD to assess for volume overload. Patients on HD have a high prevalence of moderate to severe pulmonary congestion, even after achieving dry weight. As validated in a study by Zoccali et al, a total of 28 lung windows were scanned: 16 in the right hemithorax (parasternal, midclavicular, anterior axillary and mid-axillary in the 2nd through 5th intercostal space (ICS)) and 12 in the left hemithorax in the 2nd through the 4th ICS at the same positions. For each scanned window, a 6-second video clip was recorded. A B-line score was calculated and categorized as minimal (0-5 B-lines present), mild (6-13), moderate (14-30) and severe (>30 B) for pulmonary congestion. This score was recorded in real time by the study investigators who were blinded to the patients’ clinical data. Each video clip was reviewed at a later time by two emergency physician, who were also blinded to the patients’ clinical data. The B-line scores obtained by the emergency physician were compared with the results obtained by the study investigators. Results: A total of 41 ESRD patients on HD were scanned. Sixty-eight percent were males; mean age 60.83 16.175, mean BMI 28.17 5.347; mean test duration was 15 minutes. The mean number of B-lines found by the study investigators and EPs was 18.24 and 19.33, respectively. The mean and standard deviation for difference was 5.13 and 11.98, respectively. When categorized, there was no significant difference in classification between the study investigators and emergency physicians (significance 0.982). NYHA score correlated with B-lines (P ¼ .003) even after adjusting for other variables. Conclusion: B-lines on bedside lung ultrasound can provide a reliable indicator for a patient’s volume status assessment in comparison to other validated measures, including the NYHA CHF score. Our study also shows that a short training course can render novice users of ultrasound capable of performing this quick evaluation, This can aid in objectively assessing volume overload in patients presenting to the ED, especially in HD patients who present a unique clinical challenge.
356
Emergency Physician-Performed Echocardiography as a Predictor of Cardiac Events in Patients Presenting With Symptoms of Acute Coronary Syndrome
Chandra A, Blackstock U, Kurkowski E, Menlove S, Vermeulen M, Carmody K/New York University, New York, NY
Study Objective: Echocardiography (echo) has gained wide acceptance for its utility at the bedside in emergency department (ED) patients presenting with chest pain. Cardiology literature has demonstrated that both resting and stress echo are reliable in detecting myocardial ischemia and that bedside echo accurately identifies patients who present to the ED with a myocardial infarction. Echo has also been found to be more sensitive than ECG in detecting cardiac events in patients who present with chest pain or acute coronary syndrome (ACS) like symptoms. Regional wall motion abnormalities (RWMA) may precede ECG changes in patients with active myocardial ischemia. The objective of this study is to determine if emergency physician-performed bedside echo can predict cardiac events in patients presenting to the ED with ACS. Methods: This is a preliminary prospective observational study of ED patients at two academic urban medical centers beginning December 2014. Patients presenting
Volume 66, no. 4s : October 2015