Publications

BACKGROUND: The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri-intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation.

METHODS: We analyzed ED intubation data for patients aged >14 years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100 mm Hg) or cardiac arrest prior to intubation. The primary outcome was peri-intubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality.

RESULTS: There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference = 8.8%, 95% confidence interval [CI] = 5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI = 4.4% to 12.0%). Peri-intubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference = 5.9%, 95% CI = 2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri-intubation hypotension (effect size difference = 6.5%, 95% CI = 3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri-intubation hypotension (aOR = 1.4, 95% CI = 1.2 to 1.7) and treatment for hypotension (aOR = 1.8, 95% CI = 1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0 mg/kg versus >1.0 mg/kg or patients receiving etomidate at doses ≤0.3 mg/kg versus >0.3 mg/kg.

CONCLUSIONS: Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation.

BACKGROUND: Data are limited regarding current practice and outcomes for emergency department airway management in status asthmaticus. This paper describes the foremost methods and outcomes of airway management in patients in the emergency department who required intubation for status asthmaticus.

METHODS: We analyzed all intubations with a primary indication of asthma over a 3-y period (January 1, 2016 to December 31, 2018) using the National Emergency Airway Registry (NEAR), a 25-center, prospective, observational registry of emergency department intubations. We report the incidence of intubations for asthma, methods and medications used, devices used, peri-intubation adverse events, and intubation success and failures using univariate descriptive statistics and cluster-adjusted incidence with 95% CI.

RESULTS: A total of 19,071 encounters were recorded during the study period, with 14,517 patients intubated for medical indications. Of those, 173 (1.2%, 95% CI 0.9-1.6) were intubated for asthma. The first-attempt success rate was 90.8% (95% CI 81.9-95.5), and overall intubation success was 100%. Compared to the medical registry as a whole, patients with asthma were more likely to undergo rapid-sequence intubation (96.5% [95% CI 92.9-98.3] vs 80.8% [95% CI 75.1-82.5]), preoxygenation with bi-level positive airway pressure (BPAP) (62.9% [95% CI 49.6-74.6] vs 13.5% (95% CI 10.4-16.9]), and induction with ketamine (51.8% [95% CI 30.6-71.4] vs 11.6% [95% CI 7.6-16.8]). The adverse event rate in the patients with asthma was 12.14% (95% CI 8.1-17.9) compared to 11.93% (95% CI 9.79-14.12) in the medical registry.

CONCLUSIONS: Status asthmaticus accounted for about 1% of emergent medical intubations. The majority of patients were intubated using rapid-sequence intubation after preoxygenation with BPAP and induction with ketamine, with the latter 2 practices being much more common for emergent intubations for status asthmaticus than for other medical indications.

Point-of-care ultrasound (POCUS) equipment management is critical in optimizing daily clinical operations in emergency departments (EDs). Traditional consultative ultrasound laboratories are well practiced at operations management, but this is not the case for POCUS programs, because machine upgrade and replacement metrics have not been developed or tested. We present a data-driven method for assessment of POCUS equipment maintenance and replacement named the ULTrA (a data-driven approach to point-of-care ultrasound upgrade) score. This novel model of assessing each ultrasound machine by quantitative scoring in each of four mostly objective categories: use (U), likeability (L), trustworthiness (Tr), and age (A). We propose the ULTrA model as a method to identify underperforming devices which could be upgraded or eliminated, and to compare relative performance amongst a group of departmental ultrasound machines. This composite score may be a useful objective tool that could replace individual proxies for clinical effectiveness, such as age, use, or individual provider preference. Additional research in multiple centers would be needed to refine and validate the ULTrA score. Once fully developed, the ULTrA score could be deployed in EDs and other clinical settings where POCUS is used to help streamline resources to maintain a functional and state-of-the-art fleet of ultrasound machines over time.

INTRODUCTION: First detected in December 2019, the severe acute respiratory syndrome coronavirus 2 pandemic upended the global community in a few short months. Diagnostic testing is currently limited in availability, accuracy, and efficiency. Imaging modalities such as chest radiograph (CXR), computed tomography, and lung ultrasound each demonstrate characteristic findings of coronavirus disease 2019 (COVID-19). Lung ultrasound offers benefits over other imaging modalities including portability, cost, reduced exposure of healthcare workers as well as decreased contamination of equipment such as computed tomography scanners.

CASE SERIES: Here we present a case series describing consistent lung ultrasound findings in patients with confirmed COVID-19 despite variable clinical presentations and CXR findings. We discuss a triage algorithm for clinical applicability and utility of lung point-of-care ultrasound in the setting of COVID-19 and advocate for judicious and targeted use of this tool.

CONCLUSION: Lung point-of-care ultrasound can provide valuable data supporting diagnostic and triage decisions surrounding suspected cases of COVID-19. Prospective studies validating our proposed triage algorithm are warranted.

BACKGROUND: Lung point-of-care ultrasound (POCUS) is a critical tool for evaluating patients with dyspnea in the emergency department (ED), including patients with suspected coronavirus disease (COVID)-19. However, given the threat of nosocomial disease spread, the use of ultrasound is no longer risk free.

OBJECTIVE: Here, we review the lung POCUS findings in patients with COVID-19. In doing so we present a scanning protocol for lung POCUS in COVID-19 that maximizes clinical utility and provider safety.

DISCUSSION: In COVID-19 lung, POCUS findings are predominantly located in the posterior and lateral lung zones bilaterally. A six-zone scanning protocol that prioritizes obtaining images in these locations optimizes provider positioning, and minimizes time spent scanning, which can reduce risk to health care workers performing POCUS.

CONCLUSIONS: Lung POCUS can offer valuable clinical data when evaluating patients with COVID-19. Scanning protocols such as that presented here, which target clinical utility and decreased nosocomial disease spread, must be prioritized.

INTRODUCTION: Tricuspid annular plane systolic excursion (TAPSE) is an established echocardiographic marker of right ventricular (RV) systolic function. The objective of this study was to evaluate whether emergency clinicians can visually estimate RV function using TAPSE in a set of video clips compared to a reference standard M-mode measurement.

METHODS: Emergency clinicians were shown a five-minute educational video on TAPSE. Participants then viewed 20 apical four-chamber point-of-care ultrasound (POCUS) echocardiography clips and recorded their estimate of TAPSE distance in centimeters (cm), as well as whether TAPSE was normal (>1.9 cm), borderline (1.5-1.9 cm), or abnormal (<1.5 cm). We calculated sensitivity, specificity, and overall accuracy of visual TAPSE categorization using M-mode measurement as the criterion standard. Participants also reported their comfort with assessing TAPSE on a five-point Likert scale before and after participation in the study.

RESULTS: Among 70 emergency clinicians, including 20 postgraduate year 1-4 residents, 22 attending physicians, and 28 physician assistants (PA), the pooled sensitivity and specificity for visual assessment of TAPSE was 88.6% (95% confidence interval, 85.4-91.7%) and 81.6% (95% CI, 78.2-84.4%), respectively. The sensitivity and specificity for the clips in which the measured TAPSE was <1.5 cm or >1.9 cm was 91.4% (95% CI, 88.4-94.3%) and 90.8% (95% CI, 87.7-93.9%), respectively. There was no significant difference in sensitivity (p = 0.27) or specificity (p = 0.55) between resident and attending physicians or between physicians and PAs (p = 0.17 and p = 0.81). Median self-reported comfort with TAPSE assessment increased from 1 (interquartile range [IQR] 1-2) to 3 (IQR 3-4) points after participation in the study.

CONCLUSION: A wide range of emergency clinicians demonstrated fair accuracy for visual estimation of TAPSE on previously recorded POCUS echocardiography video clips. These findings should be considered hypothesis generating and warrant validation in larger, prospective studies.

INTRODUCTION: Point-of-care ultrasound (POCUS) is an essential tool in the timely evaluation of an undifferentiated patient in the emergency department (ED). Our primary objective in this study was to determine the perceived impact of POCUS in high-risk cases presented at emergency medicine (EM) morbidity and mortality (M&M) conferences. Additionally, we sought to identify in which types of patients POCUS might be most useful, and which POCUS applications were considered to be highest yield.

METHODS: This was a retrospective survey of cases submitted to M&M at an EM residency program that spans two academic EDs, over one academic year. Postgraduate year 4 (PGY) residents who presented M&M cases at departmental sessions were surveyed on perceived impacts of POCUS on individual patient outcomes. We evaluated POCUS use and indications while the POCUS was used.

RESULTS: Over the 12-month period, we reviewed 667 cases from 18 M&M sessions by 15 PGY-4 residents and a supervising EM attending physician who chairs the M&M committee. Of these cases, 75 were selected by the M&M committee for review and presentation. POCUS was used in 27% (20/75) of the cases and not used in 73% (55/75). In cases where POCUS was not used, retrospective review determined that if POCUS had been used it would have "likely prevented the M&M" in 45% (25/55). Of these 25 cases, the majority of POCUS applications that could have helped were cardiac (32%, 8/25) and lung (32%, 8/25) ultrasound. POCUS was felt to have greatest potential in identifying missed diagnoses (92%, 23/25), and decreasing the time to diagnosis (92%, 23/25). Patients with cardiopulmonary chief complaints and abnormal vital signs were most likely to benefit. There were seven cases (35%, 7/20, 95% CI 15-59%) in which POCUS was performed and thought to have possibly adversely affected the outcome of the M&M.

CONCLUSION: POCUS was felt to have the potential to reduce or prevent M&M in 45% of cases in which it was not used. Cardiac and lung POCUS were among the most useful applications, especially in patients with cardiopulmonary complaints and in those with abnormal vital signs.

Sciatic radicular back pain is a painful condition resulting in approximately 2% of emergency department (ED) visits a year. Typically, the ED treatment has been limited to various analgesic regimens with limited success sometimes resulting in hospital admissions for pain control. Regional anesthesia has become increasing popular for lower-limb analgesia, but has not universally permeated the ED setting. The transgluteal sciatic nerve block (TGSNB) is a procedure that can provide effective analgesia for lower extremity pain. Herein, we present the first technical description and clinical response to ultrasound-guided TGSNB performed by emergency physicians for acute pain control of sciatic back pain through a series of cases.

The outbreak of a novel coronavirus disease (COVID-19) has been of concern to health care workers (HCW's) in the emergency department (ED) due to potential exposure and transmission. This case report describes a man who was referred to the ED for abdominal and testicular pain who was subsequently found to test positive for COVID-19. Due to the lack of respiratory symptoms, proper protective equipment (PPE) was not donned, and it led to several patients and health care workers being exposed. Given recent new descriptions of patients who present atypically, full PPE for all patients may be considered as community spread increases.