- Email: [email protected]
Noncontrasted abdominal computerized tomography compared to intravenous pyelography for the evaluation of suspected renal colic
RESEARCH FORUM ABSTRACTS
iii Conclusion: In afebrile ED patients evaluated for headache, a CSF cell count is a safe initial screening test and other laboratory tests are unnecessary.
171 Evaluation ore ComputerizedEsophageal Detector Device(CED*) in Patients With Morbid Obesity and Severe Pulmonary Disease Wolfe TR, Kimball EJ, Hartsell SC/Universityof Utah Schoolof Medicine. Salt LakeCity. LIT Undetected esophageal intubation can result in permanent injury or death. Clinical confirmation is operator dependent and may be misleading. Therefore, alternate methods of intubauon confirmation exist. End-tidal CO 2 and esophageal detector devices (EDDs) both identify esophageal intubations with extreme accuracy but may misidentiff properly placed tracheal tubes. Study objective: To create a computerized esophageal detector device (CEDD) that is accurate in all clinical situations. Methods: Forty elective surgacal patients underwent tracheal and esophageal intubation. CEDD data were collected from all tubes and were used to create a decmion algorithm. Intubated patients at high risk for EDD failure (severe pulmonary disease or morbid obesity) were eligible for study entry. All ETTs were confirmed to be tracheal by waveform capnography and clinical judgment before study entry. All ET tubes were then tested with the CEDD. Results: Twenty-eight patients with pulmonary disease and 11 morbidly obese patients were entered. The CEDD properly identified 100% of the ETTs as tracheal in location. A log normal distribution provided the best fit of the data. Using this distribution, the probability of misidentifying a tracheal intubation in this high-risk population was 0 to 2%. Conclusion: The CEDD can reliably identify tracheal intubations in situations where standard EDDs may fail. Future studies will determine the reliability of this device in less controlled settings.
172 IsFeasible? a Clinical Rule for Predicting the Need for Shoulder X-rays Silver BE, SextonJD. McGinn MA, Heller MB/St, Luke's Hospital. Bethlehem. PA Study objective: To determine what history and physical examination factors might be useful in establishing a decision rule for ordering shoulder radiographs Methods: This was a prospective, convenience sample of 105 patients presenting to a community hospital emergency department with a chief complaint of shoulder pain. Historical, demographic, and physical examination findings were recorded before obtaining 2-view shoulder films. The presence or absence of abnormality was analyzed by univariate and multivariate analysis; correlation coefficients were calculated for all associations identified by logistic regression. Results: Two physical examination findings (humeral neck tenderness, sensitivity 5 0 % specificity 88%; and visible deformity, sensitivity 43%, specificity 96%) were associated with a positive radiographic result (P<.001 and phi>3.1, <4. I, a moderately strong association). One historical finding, a history of blunt trauma was also a predictor of X-ray positivity (P<.001, phi=0.33). No other single predictor of injury was significant, but no patient who denied blunt trauma and also had a full range of motion had a positive radiograph. Conclusion: There appears to be no frequent and simple combination of history and physical examination factors that has sufficient sensitivity to exclude a fracture with a very high degree of certainty. The combination of no history of blunt trauma and a normal range of motion does merit further evaluation in a validation study
1 7 3 .onco.= AbdominalComputerizedTomographyComparedto IntravenousPyelographyfor the Evaluationof SuspectedRenal Colic O'Brien JF, Schulman BN, Plotkin MS, Davis DA, Mahan SM/Orlando Regional Healthcare System, Orlando,FL Study objectives: Intravenous pyelography (IVP) has been the standard radiologic evaluation technique for suspected ureteral stones. Recently, abdominal computed tomography (CT) with no contrast agent (NCCT) has been proposed as an effective and safer imaging alternative. This study was conducted to compare the utility of IVP with NCCT for radiographic diagnosis of suspected renal colic. Methods: This observational study was conducted over a 7-month period from April to November 1998, at an emergency department with an annual census of about 80,000 Adult patients with a clinical evaluation suggestive of renal colic were eligible if an imaging technique was felt necessary for diagnostic confirmation and no
OCTOBER 1999, PART 2 34:4 ANNALSOF EMERGENCYMEDICINE
contraindications to iodinated contrast existed. Pregnant patients were excluded. Eligible patients, after informed consent, underwent abdominal CT without contrast agent followed immediately by IVP. At a later date, 2 radiologists and 3 emergency physicians reviewed each IVP and NCCT without knowledge of the ED clinical course. Every IVP and NCCT was read independently by each physician in a blinded fashion without knowledge of the result of the other imaging test. Sensitivity and specificity of each test were compared with a final ED radiologic diagnosis, which included information from both the patient's IVP and NCCT along with other relevant clinical information. Results: A total of 109 patients were analyzed who completed both 1VP and NCCT during the study period. Sensitivity using 1VP to diagnose renal colic averaged 80% (range 75% to 86%) among emergency physicians and 91% (range 90% to 92%) for radiologists. Sensitivity using NCCT to diagnose renal colic averaged 82% (range 77% to 88%) among emergency physicians and 90% (range 86% to 93%) for radiologasts. Specificity using 1VP was 86% (range 81% to 89%) for emergency physicians and 83% (range 83% to 83%) for radiologists, and using NCCT was 79% (range 75% to 86%) for emergency physicians and 81% (range 78% to 83%) for radiologrsts. In 3 cases, clinically significant ahemative diagnoses were recognized only by NCCT. Conclusion: Noncontrasted abdominal CT appears equally sensitive compared with IVP in evaluating renal colic, with similar specificines. Radiologasts may interpret both tests slightly more effectively than emergency physicians. As noncontrasted CT avoids complications related to iodinated dye and allows more specific diagnosis of other intraabdominal pathology, it may appropriately become the imaging modality of choice in the evaluation of suspected renal colic.
174 Arterial-Central Venous Carbon Dioxide Difference in the Emergency Depaament: An Indicator of Cardiac Index Nguyen HB, Mullen MT. Sud P. Rivers E. CuschieriJ. UrrunagaJ, TomlanovichMC/Nenry Ford
Hospital.Detroit,MI Cardiac output (CO) and cardiac index (CI) are integral in the hemodynamic management of cntically ill patients. The ability to obtain CO and CI in the emergency department is limited by the feasibility of pulmonary artery cathetenaation Study objecuves: The purpose of this study was to compare CO and CI obtained by arterial-central venous Pco 2 differences or (a-v)Pco2 with Doppler CO and C1, respectively. Methods: This was a prospective cohort of critically ill ED patients who required intubation, mechanical ventilation, vasopressors, arterial, and central venous catheterization for hemodynamic optimization over a 4-month period. CO was measured in all patients from aortic Doppler flow, using esophageal Doppler monitoring (EDM). CI (EDM) was calculated by dividing the CO (EDM) by body surface area. Simultaneous blood gas samples were obtained for calculating CO (a-v)Pco 2 and CI (a-v)Pco 2 Results: Twenty-seven patients were enrolled with mean age of 68+16 years. The CO (EDM) and CO (a-v)Pco2 were 6.735:3.08 L/min and 6.14:1:2.64 L/rain, respectively, with a Pearson's correlation coefficient of 0.71. CI (EDM) and CI (a-v)Pco2 were 3.585:1.61 lJmin/m 2 and 3.41_1.37 L/min/m 2, respectively, with a Pearson's correlation coefficient of 0.70. Conclusion: CO and CI obtained by arterial-central venous Pr 2 differences closely approximate CO and CI obtained by EDM This method provides a practical means of assessing cardiac function in the ED when treating critically ill patients.
175
Prospective Evaluation of 8 Protocol for Selective Thoracolumbar Radiography
Terregino CA. Nyce A. Killian AJ. Lipinski MF. RossSE/CooperHospital. University Medical Center, Camden,NJ Thoracolumbar (TL) radiography may be unnecessary in clinically evaluable patients without signs or symptoms of injury. Study objective: To prospectively evaluate a protocol of selective indications for TL radiographs in blunt trauma patients. Methods: This oservational, cross-sectional study was conducted at a Level 1 trautna center. The protocol implemented required TL spine radiographs in all patient if any of the following criteria were met: Glasgow Coma Scale score <13, intoxication, intubation, cervical fracture, or cervical, thoracic, or lumbar neurodeficit (group l); or in the absence of the above cntena m those with a major distracting injury (group 2). Otherwise radiographs were based on the presence of clinical signs and/or symptoms (group 3) or their absence (group 4). Data were collected by trained observers. Subjects were reexamined for signs of missed fractures. Test performance characteristics for positive or negative criteria were determined.
S 45
iii Conclusion: In afebrile ED patients evaluated for headache, a CSF cell count is a safe initial screening test and other laboratory tests are unnecessary.
171 Evaluation ore ComputerizedEsophageal Detector Device(CED*) in Patients With Morbid Obesity and Severe Pulmonary Disease Wolfe TR, Kimball EJ, Hartsell SC/Universityof Utah Schoolof Medicine. Salt LakeCity. LIT Undetected esophageal intubation can result in permanent injury or death. Clinical confirmation is operator dependent and may be misleading. Therefore, alternate methods of intubauon confirmation exist. End-tidal CO 2 and esophageal detector devices (EDDs) both identify esophageal intubations with extreme accuracy but may misidentiff properly placed tracheal tubes. Study objective: To create a computerized esophageal detector device (CEDD) that is accurate in all clinical situations. Methods: Forty elective surgacal patients underwent tracheal and esophageal intubation. CEDD data were collected from all tubes and were used to create a decmion algorithm. Intubated patients at high risk for EDD failure (severe pulmonary disease or morbid obesity) were eligible for study entry. All ETTs were confirmed to be tracheal by waveform capnography and clinical judgment before study entry. All ET tubes were then tested with the CEDD. Results: Twenty-eight patients with pulmonary disease and 11 morbidly obese patients were entered. The CEDD properly identified 100% of the ETTs as tracheal in location. A log normal distribution provided the best fit of the data. Using this distribution, the probability of misidentifying a tracheal intubation in this high-risk population was 0 to 2%. Conclusion: The CEDD can reliably identify tracheal intubations in situations where standard EDDs may fail. Future studies will determine the reliability of this device in less controlled settings.
172 IsFeasible? a Clinical Rule for Predicting the Need for Shoulder X-rays Silver BE, SextonJD. McGinn MA, Heller MB/St, Luke's Hospital. Bethlehem. PA Study objective: To determine what history and physical examination factors might be useful in establishing a decision rule for ordering shoulder radiographs Methods: This was a prospective, convenience sample of 105 patients presenting to a community hospital emergency department with a chief complaint of shoulder pain. Historical, demographic, and physical examination findings were recorded before obtaining 2-view shoulder films. The presence or absence of abnormality was analyzed by univariate and multivariate analysis; correlation coefficients were calculated for all associations identified by logistic regression. Results: Two physical examination findings (humeral neck tenderness, sensitivity 5 0 % specificity 88%; and visible deformity, sensitivity 43%, specificity 96%) were associated with a positive radiographic result (P<.001 and phi>3.1, <4. I, a moderately strong association). One historical finding, a history of blunt trauma was also a predictor of X-ray positivity (P<.001, phi=0.33). No other single predictor of injury was significant, but no patient who denied blunt trauma and also had a full range of motion had a positive radiograph. Conclusion: There appears to be no frequent and simple combination of history and physical examination factors that has sufficient sensitivity to exclude a fracture with a very high degree of certainty. The combination of no history of blunt trauma and a normal range of motion does merit further evaluation in a validation study
1 7 3 .onco.= AbdominalComputerizedTomographyComparedto IntravenousPyelographyfor the Evaluationof SuspectedRenal Colic O'Brien JF, Schulman BN, Plotkin MS, Davis DA, Mahan SM/Orlando Regional Healthcare System, Orlando,FL Study objectives: Intravenous pyelography (IVP) has been the standard radiologic evaluation technique for suspected ureteral stones. Recently, abdominal computed tomography (CT) with no contrast agent (NCCT) has been proposed as an effective and safer imaging alternative. This study was conducted to compare the utility of IVP with NCCT for radiographic diagnosis of suspected renal colic. Methods: This observational study was conducted over a 7-month period from April to November 1998, at an emergency department with an annual census of about 80,000 Adult patients with a clinical evaluation suggestive of renal colic were eligible if an imaging technique was felt necessary for diagnostic confirmation and no
OCTOBER 1999, PART 2 34:4 ANNALSOF EMERGENCYMEDICINE
contraindications to iodinated contrast existed. Pregnant patients were excluded. Eligible patients, after informed consent, underwent abdominal CT without contrast agent followed immediately by IVP. At a later date, 2 radiologists and 3 emergency physicians reviewed each IVP and NCCT without knowledge of the ED clinical course. Every IVP and NCCT was read independently by each physician in a blinded fashion without knowledge of the result of the other imaging test. Sensitivity and specificity of each test were compared with a final ED radiologic diagnosis, which included information from both the patient's IVP and NCCT along with other relevant clinical information. Results: A total of 109 patients were analyzed who completed both 1VP and NCCT during the study period. Sensitivity using 1VP to diagnose renal colic averaged 80% (range 75% to 86%) among emergency physicians and 91% (range 90% to 92%) for radiologists. Sensitivity using NCCT to diagnose renal colic averaged 82% (range 77% to 88%) among emergency physicians and 90% (range 86% to 93%) for radiologasts. Specificity using 1VP was 86% (range 81% to 89%) for emergency physicians and 83% (range 83% to 83%) for radiologists, and using NCCT was 79% (range 75% to 86%) for emergency physicians and 81% (range 78% to 83%) for radiologrsts. In 3 cases, clinically significant ahemative diagnoses were recognized only by NCCT. Conclusion: Noncontrasted abdominal CT appears equally sensitive compared with IVP in evaluating renal colic, with similar specificines. Radiologasts may interpret both tests slightly more effectively than emergency physicians. As noncontrasted CT avoids complications related to iodinated dye and allows more specific diagnosis of other intraabdominal pathology, it may appropriately become the imaging modality of choice in the evaluation of suspected renal colic.
174 Arterial-Central Venous Carbon Dioxide Difference in the Emergency Depaament: An Indicator of Cardiac Index Nguyen HB, Mullen MT. Sud P. Rivers E. CuschieriJ. UrrunagaJ, TomlanovichMC/Nenry Ford
Hospital.Detroit,MI Cardiac output (CO) and cardiac index (CI) are integral in the hemodynamic management of cntically ill patients. The ability to obtain CO and CI in the emergency department is limited by the feasibility of pulmonary artery cathetenaation Study objecuves: The purpose of this study was to compare CO and CI obtained by arterial-central venous Pco 2 differences or (a-v)Pco2 with Doppler CO and C1, respectively. Methods: This was a prospective cohort of critically ill ED patients who required intubation, mechanical ventilation, vasopressors, arterial, and central venous catheterization for hemodynamic optimization over a 4-month period. CO was measured in all patients from aortic Doppler flow, using esophageal Doppler monitoring (EDM). CI (EDM) was calculated by dividing the CO (EDM) by body surface area. Simultaneous blood gas samples were obtained for calculating CO (a-v)Pco 2 and CI (a-v)Pco 2 Results: Twenty-seven patients were enrolled with mean age of 68+16 years. The CO (EDM) and CO (a-v)Pco2 were 6.735:3.08 L/min and 6.14:1:2.64 L/rain, respectively, with a Pearson's correlation coefficient of 0.71. CI (EDM) and CI (a-v)Pco2 were 3.585:1.61 lJmin/m 2 and 3.41_1.37 L/min/m 2, respectively, with a Pearson's correlation coefficient of 0.70. Conclusion: CO and CI obtained by arterial-central venous Pr 2 differences closely approximate CO and CI obtained by EDM This method provides a practical means of assessing cardiac function in the ED when treating critically ill patients.
175
Prospective Evaluation of 8 Protocol for Selective Thoracolumbar Radiography
Terregino CA. Nyce A. Killian AJ. Lipinski MF. RossSE/CooperHospital. University Medical Center, Camden,NJ Thoracolumbar (TL) radiography may be unnecessary in clinically evaluable patients without signs or symptoms of injury. Study objective: To prospectively evaluate a protocol of selective indications for TL radiographs in blunt trauma patients. Methods: This oservational, cross-sectional study was conducted at a Level 1 trautna center. The protocol implemented required TL spine radiographs in all patient if any of the following criteria were met: Glasgow Coma Scale score <13, intoxication, intubation, cervical fracture, or cervical, thoracic, or lumbar neurodeficit (group l); or in the absence of the above cntena m those with a major distracting injury (group 2). Otherwise radiographs were based on the presence of clinical signs and/or symptoms (group 3) or their absence (group 4). Data were collected by trained observers. Subjects were reexamined for signs of missed fractures. Test performance characteristics for positive or negative criteria were determined.
S 45