Pulmonary congestion is a common and important finding in heart failure (HF). While clinical examination and chest radiography are insensitive, lung ultrasound (LUS) is a novel technique that may ...detect and quantify subclinical pulmonary congestion. We sought to independently relate LUS and clinical findings to 6-month HF hospitalizations and all-cause mortality (composite primary outcome).
We used LUS to examine 195 NYHA class II-IV HF patients (median age 66, 61% men, 74% white, ejection fraction 34%) during routine cardiology outpatient visits. Lung ultrasound was performed in eight chest zones with a pocket ultrasound device (median exam duration 2 min) and analysed offline.
In 185 patients with adequate LUS images in all zones, the sum of B-lines (vertical lines on LUS) ranged from 0 to 13. B-lines, analysed by tertiles, were associated with clinical and laboratory markers of congestion. Thirty-two per cent of patients demonstrated ≥3 B-lines on LUS, yet 81% of these patients had no findings on auscultation. During the follow-up period, 50 patients (27%) were hospitalized for HF or died. Patients in the third tertile (≥3 B-lines) had a four-fold higher risk of the primary outcome (adjusted HR 4.08, 95% confidence interval, CI 1.95, 8.54; P < 0.001) compared with those in the first tertile and spent a significantly lower number of days alive and out of the hospital (125 days vs. 165 days; adjusted P < 0.001).
Pulmonary congestion assessed by ultrasound is prevalent in ambulatory patients with chronic HF, is associated with other features of clinical congestion, and identifies those who have worse prognosis.
Young Man With Syncope Lange, Joel; Frasure, Sarah E.; Dearing, Elizabeth
Annals of emergency medicine,
October 2022, 2022-10-00, 20221001, Letnik:
80, Številka:
4
Journal Article
Pacemaker lead related myocardial perforation Kumar, Prianka; Skrabal, Joseph; Frasure, Sarah E. ...
The American journal of emergency medicine,
March 2022, 2022-Mar, 2022-03-00, 20220301, Letnik:
53
Journal Article
Recenzirano
Permanent pacemaker (PPM) insertion is widely used to treat cardiac rhythm disorders; approximately 600,000 pacemakers are implanted annually in the US. Almost 9% of patients who receive a permanent ...pacemaker, however, experience a variety of medical complications such as infections, battery problems, programming issues, lead migration, or lead fracture. Moreover 1–2% of these patients will encounter severe lead-related problems within 30 days of their pacemaker insertion. In this report, we focus on an uncommon but serious complication of PPM insertion: right ventricular lead perforation leading to a pericardial effusion. Although lead perforation is a relatively rare occurrence, this event can be life-threatening, and should be considered in the differential diagnosis when patients present to the emergency department (ED) with relevant symptoms and recent PPM insertion. Specifically, patients who experience complications from pacemaker insertion may present to the ED with a variety of symptoms such as chest pain, syncope, dyspnea, or even dizziness. Pacemaker complications include pneumothorax, pleural and/or pericardial effusions, and infection, placing the patient at serious risk for significant harm. The evaluation of a lead-related issue typically involves chest radiography to visualize abnormal lead placement and check for a pneumothorax or pleural effusion, and a 12‑lead electrocardiogram (ECG) to detect pacing errors. We present the case of a patient who presented to the ED three days after his pacemaker insertion with chest pain and dyspnea; he was subsequently diagnosed with a lead perforation into the pericardial space resulting in a pericardial effusion.
Extended Focused Assessment with Sonography for Trauma (eFAST) ultrasound exams are central to the care of the unstable trauma patient. We examined six years of eFAST quality assurance data to ...identify the most common reasons for false positive and false negative eFAST exams.
This was an observational, retrospective cohort study of trauma activation patients evaluated in an urban, academic Level 1 trauma center. All eFAST exams that were identified as false positive or false negative exams compared with computed tomography (CT) imaging were included.
4860 eFAST exams were performed on trauma patients. 1450 (29.8%) were undocumented, technically limited, or incomplete (missing images). Of the 3410 remaining exams, 180 (5.27%) were true positive and 3128 (91.7%) were true negative. 27 (0.79%) exams were identified as false positive and 75 (2.19%) were identified as false negative. Of the false positive scans, 7 had no CT scan and 8 had correct real-time trauma paper documentation of eFAST exam results when compared to CT and were excluded, leaving 12 false positive scans. Of the false negative scans, 11 were excluded for concordant documentation in real-time trauma room paper documentation, 20 were excluded for no CT scan, and 2 were excluded as incomplete, leaving 42 false negative scans. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam were the most common source of errors.
The eFAST exams in trauma activation patients are highly accurate. Unfortunately poor documentation and technically limited/incomplete studies represent 29.8% of our eFAST exams.
Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam are the most common source of errors.
Background
Syncope is a common problem encountered in the emergency department (ED) and a significant source of ED resource utilisation, including advanced imaging modalities. Current guidelines do ...not recommend routine Computed Tomography (CT) imaging of the head for patients seen in the ED due to syncope.
Objective
In this study, we investigate resource allocation in the ED for syncope‐related visits, including advanced imaging modalities using a large national database.
Outcomes analysis
Data from the CDC's National Hospital Ambulatory Medical Care Survey (NHAMCS) for years 2008‐2017 were compiled and analysed. Intrinsic survey and constructed variables were utilised to identify and investigate all syncope‐related ED visits in the United States during the study period that met study criteria. Appropriate bivariate and multivariate statistical analyses were applied in order to identify and compare the resource utilisation, demographics, and ED visit dynamics of syncope and non‐syncope‐related ED visits.
Results
During the study period, there were over 15 million ED visits for syncope. A high percentage of syncope visits received head CT compared with non‐syncope visits (34% vs. 4.5%, P > .001). When investigated by age‐grouping utilisation of head CT ranged from 26.5 (95% CI 18.9‐27.5) for ages 18‐40 to as high as 40.2% (95% CI 33.8‐47.1) for ages 80 and higher. Compared with non‐syncope ED visits, syncope‐related ED visits were older and more likely to have Medicare or private insurance.
Conclusion
Syncope continues to be a large and growing share of visits to US EDs. Despite well‐supported, evidence‐based recommendations that do not recommend routine utilisation of head CT in syncope‐related ED visits, these data suggest that emergency physicians routinely over‐utilise this modality. More specific guidelines may be required to help reduce the use of imaging studies for patients who present to the ED with syncope.
Specifically, the benefits of breastfeeding on infant health are well-documented and include reduced hospitalization rates for lower respiratory tract infections as well as a decreased incidence of ...otitis media, gastroenteritis, necrotizing enterocolitis (among preterm infants), celiac disease, obesity, type 1 diabetes mellitus, and childhood inflammatory bowel disease 8,9. ...there is a decreased risk of breast cancer and ovarian cancer among women who breastfeed 10,11 (Table 2). Interviews conducted with eighty female physicians revealed that those who actively encouraged breastfeeding with their patients had a longer personal breastfeeding history than those who did not 6. Since work-related barriers cause many women to cease this practice, it is imperative that medical centers address ways in which to help female physicians pump breast milk while at work. Infant outcomes: breastfeedingwas associated with risk reduction for otitis media, gastroenteritis, necrotizing enterocolitis, severe lower respiratory tract infections, atopic dermatitis, asthma, obesity, diabetes mellitus type 1 and 2, leukemia, and sudden infant death syndrome.
Point‐of‐care ultrasound (POCUS) can help the clinician diagnose different ocular pathologies including retinal detachment, vitreous detachment, lens dislocation, and intraocular foreign bodies. ...Ocular pathologies such as blurry vision, double vision, loss of vision, and eye trauma are common chief complaints and require a comprehensive evaluation in order to determine the etiology and choose the correct treatment. Specifically ultrasound can help the clinician decide whether an urgent ophthalmology consult is appropriate. We present a case in which a lens dislocation was diagnosed using POCUS and review the available literature.
Valproic acid (VPA) is a common antiepileptic drug that is also used routinely for various psychiatric disorders. VPA toxicity typically manifests as central nervous system depression, while ...hyperammonemic encephalopathy and hepatotoxicity are potentially life-threatening complications.
We describe the case of a 56-year-old man who presented to the emergency department after an intentional VPA overdose, was found to have hyperammonemia, and was treated with L-carnitine exclusively. He was subsequently admitted to the hospital for monitoring and serial laboratory testing. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although VPA toxicity has conventionally been managed by gastric decontamination, L-carnitine, and, in severe and refractory cases, extracorporeal removal, recent literature supports the use of carbapenem antibiotics, particularly meropenem. Thus, we report the details of current treatment modalities for VPA toxicity by reviewing current literature.
Adult Female With Abdominal Pain Abboud, Michael E., MD; Frasure, Sarah E., MD
Annals of emergency medicine,
01/2017, Letnik:
69, Številka:
1
Journal Article
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