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Performance and interpretation of pelvic ultrasound by emergency physicians in patients with suspected ectopic pregnancy: A prospective study
The Journal of Emergency
Medicine,
ABSTRACTS
Vol. 8, pp. 551452,
1990
Printed in the USA
OF PAPERS PRESENTED
The Illinois Chapter of the American College of Emergency Physicians has submitted the following abstracts presented at their annual meeting, March 22,199O. The Scientific Papers were presented as a project of the Illinois ACEP Research Committee. “A Comparison of Prehospital Estimated Time of Arrival and Actual Time of Arrival to an Emergency Department” by Douglas A. Propp, MD, FACEP, was selected as the best paper and awarded a cash prize generously donated by Emergency Management Systems, the emergency medicine group at St.Francis Hospital, Evanston, Illinois.
. Copyright
0 1990 Pergamon Press plc
AT ILLINOIS ACEP CONFERENCE value with a 90% confidence level to an accuracy of ? 3%, a sample size of approximately 270 cases was necessary. Results: The average ETA was 7.39 ? 3.72 minutes (mean 2 SD), and the average actual time until arrival (ATA) was 10.29 * 3.95 minutes. There were 24 cases (8.57%) in which the actual time of arrival would have changed the patient’s management. Two hundred and twenty-seven patients (8 1.1%) arrived later than their ETA and 33 patients (11.8%) arrived earlier than their ETA. Twenty-one cases (7.1%) had an actual time of arrival equal to or within the interval given by the paramedics. The mean age of the study population was 65.2 -+ 21.5 years. Conclusion: The estimated time until arrival is not always accurate in the suburban setting. ETA’s tend to be understated rather than overstated. Greater accuracy in ETA would frequently result in a change in patient field care.
0 A COMPARISON OF PREHOSPITAL ESTIMATED TIME OF ARRIVAL AND ACTUAL TIME OF ARRIVAL TO AN EMERGENCY DEPARTMENT. Douglas
0 PERFORMANCE AND INTERPRETATION OF PELVIC ULTRASOUND BY EMERGENCY PI-IYSICIANS IN PATIENTS WITH SUSPECTED ECTOPIC PREGNANCY: A PROSPECTIVE STUDY. Gino Alberto,
A. Propp, MD, FACEP, and Craig A. Rosenberg, MD. Study Hypothesis: The estimated time until arrival (ETA) of an emergency department patient will influence the treatment in the field, and this ETA is often inaccurate with clinical implications. Study Population: Three hundred seventeen consecutive patients about whom telemetry communication with the receiving hospital took place were enrolled. Of these 317 cases, 280 runs were correctly completed and used in the data analysis. The vast majority of the study population was drawn from a suburban setting. Methods: In a prospective manner over a 3-month period, consecutive telemetry transports of patients to a suburban university-affiliated hospital emergency department were analyzed. The emergency physician directing the medical management of the patient who was discussed over telemetry started a stopwatch at the conclusion of the communication. The timing ceased as the paramedics entered the emergency department. A data collection sheet included the date, time, telemetry log number, patient age, patient’s chief complaint, and paramedic ETA as well as the actual time of arrival. The physicians were also asked to record the number of minutes, both shorter and longer than the ETA that would cause them to alter their patient management. The paramedics were unaware that the study was being performed. In the absence of any previous literature on the subject, the authors estimated that 10% of all telemetry ETAs are sufficiently inaccurate that the physician would have altered the patient management plan had more accurate data been available. In order for the study to estimate the population
DO; Leon Gussow, MD, Department of Emergency Medicine, Cook County Hospital, Chicago. Study Hypothesis: Emergency physicians can use ultrasound imaging reliably to establish the presence of intrauterine pregnancy (IUP) in patients with suspected actopic pregnancy. Study Population: Emergency department patients with suspected actopic pregnancy. All had been scheduled for formal emergency pelvic ultrasound in the radiology or obstetrics department. Methods: Two emergency physicians received a maximum of 6 hours training in pelvic ultasound, supplemented by individual reading. Patients entered in the study had their bladders filled by the technique indicated for the formal test. In a blinded manner, one of the two authors performed a transabdominal pelvic scan on each patient, using the ScanMate II portable ultrasound scanner (Damon Corp.) fitted with a 3.5 MHz probe. The scan was interpreted immediately, with definite IUP being established by the visualization of a yolk sac, fetal pole, fetal heart movement, or double decidual sign. This reading was compared to the formal scan by Radiology or Obstetrics. Results: 17 patients were studied. The average patient age was 23.4 years; the average gestational age was 8.1 menstrual weeks. 7 scans were read by the emergency physician as demonstrating IUP; all of these were confirmed by the formal scan (P < 0.01). 10 scans were read by the emergency physician as not demonstrating a definite IUP; all of these
551
0736-4679190
$3.00
+ .OO
The Journal of Emergency
552
readings agreed with the formal scan (P < 0.001). Conclusions: Emergency physicians can reliably perform pelvic ultrasound in patients with suspected ectopic pregnancy, and interpret the results as to the presence or absence of definite intrauterine pregnancy.
CHANGES IN URBAN TRAUMA TRIAGE WITH SPECIFIED ANATOMIC AND PHYSIOLOGIC CRITERIA. Mark Gordon, MD; Edward Sloan, MD; John Barrett, MD.
0
Department of Emergency Medicine, and Division of Trauma Surgery, Cook County Hospital, Chicago. Study Hypothesis: Revised specific anatomic and physiologic trauma triage criteria, developed to incorporate prior broad criteria (life-threat, limb-threat, Trauma Score (TS) 5 12) and prior causes of judgement bypass, will not increase trauma center (TC) volume. Study population: Included in the study were 332 consecutive adult trauma patients triaged via telemetry to the closest hospital or Trauma Center (TC). Methods: The trauma mechanism, injury, and triage destination using old triage criteria were obtained from telemetry run sheets. The more specific revised triage criteria were then applied to these same runs in order to determine changes in TC volume. Chi-square analysis compared proportions. Results: Using the old criteria, 228 patients (69%) were treated in a TC, either because they were closest to a TC, met the criteria, or were triaged based on paramedic judgment. Use of the revised criteria would have resulted in trauma center treatment of 176 patients (53%). Another 51 patients (15%) would have gone to a TC using the new criteria, either because of TC proximity or persistent judgment to bypass to a TC. The total TC volume would equal 227 patients (68%; P = NS).
Conclusion: Revised specific trauma triage criteria will not increase TC volume.
? ?METABOLIC
ACIDOSIS ASSOCIATED WITH HYPERTONIC SALINE RESUSCITATION IN AN INTRACRANIAL MASS, HEMORRHAGIC SHOCK MODEL: IS PLASMA LACTATE ELEVATION THE CAUSE? J.
Soyka, K. Nagy, D. Batesky, M. Martin, W. Gunnar, and J. Barrett, Division of Trauma, Department of Surgery, and Department of Emergency Medicine, Cook County Hospital, Chicago, Illinois.
Medicine
Using a splenectomized, intracranial mass, hemorrhagic shock Beagle model, our research laboratory has shown that hypertonic saline (HTS) fluid resuscitation of hemorrhagic shock induced by a rapid, 40% blood shed, is associated with a significant metabolic acidosis when compared to .9% saline (NS) and 10% dextran solutions. In an attempt to explain this phenomenon, this double-blinded study compared the effects of NS, 3% saline (3NS), and 10% dextran-70 (D70) on arterial lactate levels in this same model (n = 4 for each fluid). ICP was measured using subarachnoid bolt. An intracranial mass was produced by inflating a contralateral epidural balloon to 10 mmHg above baseline (BL) ICP levels. After a l-h shock state (ES) each dog was resuscitated with blood equal to 112the total blood shed followed by an unknown resuscitation fluid equal to the amount of blood shed. Hemodynamic data, tissue oxygenation data (V02, DO,, and Pulmonary Shunt), blood gases, and arterial lactate levels were measured at BL, ES, 20 minutes post-resuscitation (ER) and 60 minutes postresuscitation (LR). The mean hemodynamic, tissue oxygenation, and pC0, values did not differ between the 3 solution groups during any period (P > 0.05). The ER and LR mean ( f SD) arterial pH, lactate and chloride levels are shown in the table below:
Fluid NS HTS D70
ER-Lactatet 2.9 2.5 2.1
(.40) (.65) (1.1)
ERpH* NS HTS D70
NS HTS D70
7.30 7.20 7.32
(.06) (.05) (.05)
LR-Lactatet 2.1 2.0 1.5
(55) (.36) (.14)
LRpH* 7.35 7.22 7.32
(.06) (.05) (.05)
ER-CL
LR-CL
Ill (2.9) 120 (2.1) 114 (3.6)
111 (2.0) 119 (1.4) 114 (4.1)
tNot Significant;‘P < 0.05 (Kruskal-WallisANOVA).
We conclude that the metabolic acidosis that occurs during HTS resuscitation in this hemorrhagic shock head injury model is not caused by plasma lactate elevations alone. Hyperchloremia or some unidentified phenomenon occurring at the cellular or microcirculatory level may be the cause.
Medicine,
ABSTRACTS
Vol. 8, pp. 551452,
1990
Printed in the USA
OF PAPERS PRESENTED
The Illinois Chapter of the American College of Emergency Physicians has submitted the following abstracts presented at their annual meeting, March 22,199O. The Scientific Papers were presented as a project of the Illinois ACEP Research Committee. “A Comparison of Prehospital Estimated Time of Arrival and Actual Time of Arrival to an Emergency Department” by Douglas A. Propp, MD, FACEP, was selected as the best paper and awarded a cash prize generously donated by Emergency Management Systems, the emergency medicine group at St.Francis Hospital, Evanston, Illinois.
. Copyright
0 1990 Pergamon Press plc
AT ILLINOIS ACEP CONFERENCE value with a 90% confidence level to an accuracy of ? 3%, a sample size of approximately 270 cases was necessary. Results: The average ETA was 7.39 ? 3.72 minutes (mean 2 SD), and the average actual time until arrival (ATA) was 10.29 * 3.95 minutes. There were 24 cases (8.57%) in which the actual time of arrival would have changed the patient’s management. Two hundred and twenty-seven patients (8 1.1%) arrived later than their ETA and 33 patients (11.8%) arrived earlier than their ETA. Twenty-one cases (7.1%) had an actual time of arrival equal to or within the interval given by the paramedics. The mean age of the study population was 65.2 -+ 21.5 years. Conclusion: The estimated time until arrival is not always accurate in the suburban setting. ETA’s tend to be understated rather than overstated. Greater accuracy in ETA would frequently result in a change in patient field care.
0 A COMPARISON OF PREHOSPITAL ESTIMATED TIME OF ARRIVAL AND ACTUAL TIME OF ARRIVAL TO AN EMERGENCY DEPARTMENT. Douglas
0 PERFORMANCE AND INTERPRETATION OF PELVIC ULTRASOUND BY EMERGENCY PI-IYSICIANS IN PATIENTS WITH SUSPECTED ECTOPIC PREGNANCY: A PROSPECTIVE STUDY. Gino Alberto,
A. Propp, MD, FACEP, and Craig A. Rosenberg, MD. Study Hypothesis: The estimated time until arrival (ETA) of an emergency department patient will influence the treatment in the field, and this ETA is often inaccurate with clinical implications. Study Population: Three hundred seventeen consecutive patients about whom telemetry communication with the receiving hospital took place were enrolled. Of these 317 cases, 280 runs were correctly completed and used in the data analysis. The vast majority of the study population was drawn from a suburban setting. Methods: In a prospective manner over a 3-month period, consecutive telemetry transports of patients to a suburban university-affiliated hospital emergency department were analyzed. The emergency physician directing the medical management of the patient who was discussed over telemetry started a stopwatch at the conclusion of the communication. The timing ceased as the paramedics entered the emergency department. A data collection sheet included the date, time, telemetry log number, patient age, patient’s chief complaint, and paramedic ETA as well as the actual time of arrival. The physicians were also asked to record the number of minutes, both shorter and longer than the ETA that would cause them to alter their patient management. The paramedics were unaware that the study was being performed. In the absence of any previous literature on the subject, the authors estimated that 10% of all telemetry ETAs are sufficiently inaccurate that the physician would have altered the patient management plan had more accurate data been available. In order for the study to estimate the population
DO; Leon Gussow, MD, Department of Emergency Medicine, Cook County Hospital, Chicago. Study Hypothesis: Emergency physicians can use ultrasound imaging reliably to establish the presence of intrauterine pregnancy (IUP) in patients with suspected actopic pregnancy. Study Population: Emergency department patients with suspected actopic pregnancy. All had been scheduled for formal emergency pelvic ultrasound in the radiology or obstetrics department. Methods: Two emergency physicians received a maximum of 6 hours training in pelvic ultasound, supplemented by individual reading. Patients entered in the study had their bladders filled by the technique indicated for the formal test. In a blinded manner, one of the two authors performed a transabdominal pelvic scan on each patient, using the ScanMate II portable ultrasound scanner (Damon Corp.) fitted with a 3.5 MHz probe. The scan was interpreted immediately, with definite IUP being established by the visualization of a yolk sac, fetal pole, fetal heart movement, or double decidual sign. This reading was compared to the formal scan by Radiology or Obstetrics. Results: 17 patients were studied. The average patient age was 23.4 years; the average gestational age was 8.1 menstrual weeks. 7 scans were read by the emergency physician as demonstrating IUP; all of these were confirmed by the formal scan (P < 0.01). 10 scans were read by the emergency physician as not demonstrating a definite IUP; all of these
551
0736-4679190
$3.00
+ .OO
The Journal of Emergency
552
readings agreed with the formal scan (P < 0.001). Conclusions: Emergency physicians can reliably perform pelvic ultrasound in patients with suspected ectopic pregnancy, and interpret the results as to the presence or absence of definite intrauterine pregnancy.
CHANGES IN URBAN TRAUMA TRIAGE WITH SPECIFIED ANATOMIC AND PHYSIOLOGIC CRITERIA. Mark Gordon, MD; Edward Sloan, MD; John Barrett, MD.
0
Department of Emergency Medicine, and Division of Trauma Surgery, Cook County Hospital, Chicago. Study Hypothesis: Revised specific anatomic and physiologic trauma triage criteria, developed to incorporate prior broad criteria (life-threat, limb-threat, Trauma Score (TS) 5 12) and prior causes of judgement bypass, will not increase trauma center (TC) volume. Study population: Included in the study were 332 consecutive adult trauma patients triaged via telemetry to the closest hospital or Trauma Center (TC). Methods: The trauma mechanism, injury, and triage destination using old triage criteria were obtained from telemetry run sheets. The more specific revised triage criteria were then applied to these same runs in order to determine changes in TC volume. Chi-square analysis compared proportions. Results: Using the old criteria, 228 patients (69%) were treated in a TC, either because they were closest to a TC, met the criteria, or were triaged based on paramedic judgment. Use of the revised criteria would have resulted in trauma center treatment of 176 patients (53%). Another 51 patients (15%) would have gone to a TC using the new criteria, either because of TC proximity or persistent judgment to bypass to a TC. The total TC volume would equal 227 patients (68%; P = NS).
Conclusion: Revised specific trauma triage criteria will not increase TC volume.
? ?METABOLIC
ACIDOSIS ASSOCIATED WITH HYPERTONIC SALINE RESUSCITATION IN AN INTRACRANIAL MASS, HEMORRHAGIC SHOCK MODEL: IS PLASMA LACTATE ELEVATION THE CAUSE? J.
Soyka, K. Nagy, D. Batesky, M. Martin, W. Gunnar, and J. Barrett, Division of Trauma, Department of Surgery, and Department of Emergency Medicine, Cook County Hospital, Chicago, Illinois.
Medicine
Using a splenectomized, intracranial mass, hemorrhagic shock Beagle model, our research laboratory has shown that hypertonic saline (HTS) fluid resuscitation of hemorrhagic shock induced by a rapid, 40% blood shed, is associated with a significant metabolic acidosis when compared to .9% saline (NS) and 10% dextran solutions. In an attempt to explain this phenomenon, this double-blinded study compared the effects of NS, 3% saline (3NS), and 10% dextran-70 (D70) on arterial lactate levels in this same model (n = 4 for each fluid). ICP was measured using subarachnoid bolt. An intracranial mass was produced by inflating a contralateral epidural balloon to 10 mmHg above baseline (BL) ICP levels. After a l-h shock state (ES) each dog was resuscitated with blood equal to 112the total blood shed followed by an unknown resuscitation fluid equal to the amount of blood shed. Hemodynamic data, tissue oxygenation data (V02, DO,, and Pulmonary Shunt), blood gases, and arterial lactate levels were measured at BL, ES, 20 minutes post-resuscitation (ER) and 60 minutes postresuscitation (LR). The mean hemodynamic, tissue oxygenation, and pC0, values did not differ between the 3 solution groups during any period (P > 0.05). The ER and LR mean ( f SD) arterial pH, lactate and chloride levels are shown in the table below:
Fluid NS HTS D70
ER-Lactatet 2.9 2.5 2.1
(.40) (.65) (1.1)
ERpH* NS HTS D70
NS HTS D70
7.30 7.20 7.32
(.06) (.05) (.05)
LR-Lactatet 2.1 2.0 1.5
(55) (.36) (.14)
LRpH* 7.35 7.22 7.32
(.06) (.05) (.05)
ER-CL
LR-CL
Ill (2.9) 120 (2.1) 114 (3.6)
111 (2.0) 119 (1.4) 114 (4.1)
tNot Significant;‘P < 0.05 (Kruskal-WallisANOVA).
We conclude that the metabolic acidosis that occurs during HTS resuscitation in this hemorrhagic shock head injury model is not caused by plasma lactate elevations alone. Hyperchloremia or some unidentified phenomenon occurring at the cellular or microcirculatory level may be the cause.