Faculty Bibliography

OBJECTIVES: To compare major adverse cardiac event (MACE), downstream resource utilization, and direct cost of care for low-risk chest pain patients observed in the clinical decision unit (CDU) with exercise treadmill testing (ETT) and with stress-only myocardial perfusion imaging (sMPI). BACKGROUND: CDUs are poised to increase efficiency and resource utilization. However, the optimal testing strategy that would assure favorable outcomes while decreasing cost is not defined. METHODS: 1016 subjects from 2 locations were propensity score-matched (PSM) by age, gender, pre-test likelihood, Duke treadmill score, and test results. Outcomes were length of stay >24 hours, MACE (acute coronary syndrome, revascularization, cardiac death), downstream resource use (admission for chest pain, repeat testing, angiography), and mean direct cost per patient. RESULTS: PSM yielded 680 patients (340 matches). 98% of all tests were normal. 96.6% of patients were discharged from the CDU within 24 hours but twice as many exceeded 24 hours in the sMPI group. There were no cardiac deaths. MACE rate was 1.47% at 72 hours and 1% at 1 year. Downstream resource use was 4.82% at 72 hours, and 7.69% at 1 year. The sMPI group was event-free longer than the ETT group reflecting less repeat testing. The mean direct cost was 30% higher for sMPI ($3168.70) vs. ETT ($2226.96). CONCLUSION: Low-risk chest pain patients in the observation unit had low MACE rate, not different for ETT vs. sMPI. The majority of ETT and sMPI tests were normal. The sMPI reduced additional testing, but resulted in greater expense and longer stay.

OBJECTIVE: Our objective was to determine whether organized or disorganized cardiac activity is associated with increased survival in patients who present in pulseless electrical activity (PEA) treated with either 1) standard advanced cardiac life support (ACLS) medications or 2) other interventions. METHODS: This was a secondary analysis of a prospective, multi-center observational study utilizing ultrasound in out-of-hospital or inemergency department PEA arrest. Bedside ultrasound was performed as ACLS protocol started and during pulse checks. Only cases with visible cardiac activity on ultrasound were included in the present analysis. Cardiac activity was categorized as disorganized (agonal twitching) or organized (contractions with changes in ventricular dimensions). Patients were categorized as receiving either standard bolus ACLS medications or alternative medications during the resuscitation (continuous adrenergic agents, thrombolytics, others). The primary outcome was survival to hospital admission. The secondary outcome was return of spontaneous circulation (ROSC). Multivariate modeling was performed to assess association between survival to hospital admission in patients with intravenous adrenergic agents and cardiac activity. RESULTS: In our cohort of 225 patients in PEA cardiac arrest with cardiac activity on ultrasound, the overall survival rate was higher in patients with organized cardiac activity than with disorganized cardiac activity. PEA cardiac arrest patients with organized cardiac activity treated with standard ACLS interventions demonstrated improved survival to hospital admission compared to those with disorganized activity (37.7% (95%CI 24.8-50.2%) versus 17.9% (95%CI 10.9-28%). PEA cardiac arrest patients with organized cardiac activity who received continuous adrenergic agents during the resuscitation and prior to ROSC demonstrated higher survival to hospital admission 45.5% (95%CI 26.9-65.4%) and ROSC 90.9% (95%CI 71.0-98.7%) compared to those with disorganized cardiac activity who received continuous adrenergic agents during the resuscitation 0% (95%CI 0-23.0%) and 47.1% (95%CI 26-69%). Regression analysis demonstrates an association between increased survival in patients receiving intravenous adrenergic agents and organized cardiac activity. CONCLUSION: Survival in patients following PEA arrest is higher in patients with organized cardiac activity. The initiation of continuous adrenergic agents during PEA was associated with improved survival to hospital admission in patients with organized cardiac activity on bedside ultrasound, but this improvement was not seen in patients in PEA with disorganized cardiac activity. Bedside ultrasound may identify a subset of patients that respond differently to ACLS interventions.

BACKGROUND: Point-of-care ultrasound has been suggested to improve outcomes from advanced cardiac life support (ACLS), but no large studies have explored how it should be incorporated into ACLS. Our aim was to determine whether cardiac activity on ultrasound during ACLS is associated with improved survival. METHODS: We conducted a non-randomized, prospective, protocol-driven observational study at 20 hospitals across United States and Canada. Patients presenting with out-of-hospital arrest or in-ED arrest with pulseless electrical activity or asystole were included. An ultrasound was performed at the beginning and end of ACLS. The primary outcome was survival to hospital admission. Secondary outcomes included survival to hospital discharge and return of spontaneous circulation. FINDINGS: 793 patients were enrolled, 208 (26.2%) survived the initial resuscitation, 114 (14.4%) survived to hospital admission, and 13 (1.6%) survived to hospital discharge. Cardiac activity on US was the variable most associated with survival at all time points. On multivariate regression modeling, cardiac activity was associated with increased survival to hospital admission (OR 3.6, 2.2-5.9) and hospital discharge (OR 5.7, 1.5-21.9). No cardiac activity on US was associated with non-survival, but 0.6% (95% CI 0.3-2.3) survived to discharge. Ultrasound identified findings that responded to non-ACLS interventions. Patients with pericardial effusion and pericardiocentesis demonstrated higher survival rates (15.4%) compared to all others (1.3%). CONCLUSION: Cardiac activity on ultrasound was the variable most associated with survival following cardiac arrest. Ultrasound during cardiac arrest identifies interventions outside of the standard ACLS algorithm.

In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 (PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision.

Background: Nephrolithiasis is a common pathology presenting to emergency departments. Studies have focused on evaluating the diagnostic process that emergency physicians use in order to identify and treat such patients. Ultrasound is safe and effective, and should be the initial imaging modality for patients with suspected nephrolithiasis. Objectives: To determine how level of training of Emergency Physicians(EP) affect the diagnostic accuracy of identifying and grading hydronephrosis. In this study we assessed how accurately medical students(MS), emergency residents and ultrasound fellows from one academic medical center could identify different grades of hydronephrosis. Methods: Subjects were given a brief presentation on hydronephrosis. Subjects then reviewed 42 independent renal ultrasound video clips and were given 30 seconds each to identify the grade of hydronephrosis visualized. Answers were recorded with only the subjects training level as an identifier. The grading of hydronephrosis of each level of medical training was compared to a gold standard (100% agreement between senior EP Ultrasound faculty). Accuracy as well as inter-relater reliability was evaluated. Results: A total of 56 subjects, 24 students, 10 PGY-1, 9 PGY-2, 9 PGY-3 and 4 fellows participated. The average total number of correctly identified clips for MS, PGY-1, PGY-2, PGY-3 and fellows was 21.8 (52.1%), 24.8 (59%), 26 (61.9%), 23.5 (56.1%), and 30 (71.4%) respectively. There was a significant association between the overall score and level of training (P < 0.0107). Among residents and fellows, normal had the highest level of accuracy and there was a trend toward increasing accuracy for severe hydronephrosis. Inter-rater reliability was lowest among students and highest among participants with a training level at or above PGY-2. Conclusion: The accuracy of identifying various grades of hydronephrosis increased with level of training. Participants were very good at recognizing both normal and severe hydronephrosis. While differentiating mild from moderate proved to be more difficult, this distinction is less important in the clinical arena. Using ultrasound to identify patients with suspected nephrolithiasis requires continued training of EP's to be proficient at grading hydronephrosis

OBJECTIVES: Resuscitation often requires rapid vascular access via central venous catheters. Chest radiography is the reference standard to confirm central venous catheter placement and exclude complications. However, radiographs are often untimely. The purpose of this study was to determine whether dynamic sonographic visualization of a saline flush in the right side of the heart after central venous catheter placement could serve as a more rapid confirmatory study for above-the-diaphragm catheter placement. METHODS: A consecutive prospective enrollment study was conducted in the emergency departments of 2 major tertiary care centers. Adult patients of the study investigators who required an above-the-diaphragm central venous catheter were enrolled during the study period. Patients had a catheter placed with sonographic guidance. After placement of the catheter, thoracic sonography was performed. The times for visualization of the saline flush in the right ventricle and sonographic exclusion of ipsilateral pneumothorax were recorded. Chest radiography was performed per standard practice. RESULTS: Eighty-one patients were enrolled; 13 were excluded. The mean catheter confirmation time by sonography was 8.80 minutes (95% confidence interval, 7.46-10.14 minutes). The mean catheter confirmation time by chest radiograph availability for viewing was 45.78 minutes (95% confidence interval, 37.03-54.54 minutes). Mean sonographic confirmation occurred 36.98 minutes sooner than radiography (P< .001). No discrepancy existed between sonographic and radiographic confirmation. CONCLUSIONS: Confirmation of central venous catheter placement by dynamic sonographic visualization of a saline flush with exclusion of pneumothorax is an accurate, safe, and more efficient method than confirmation by chest radiography. It allows the central line to be used immediately, expediting patient care.

Background: Previous studies suggest that no cardiac activity visualized by U/S during Advanced Cardiac Life Support (ACLS) predicts death. However, the evidence supporting this arises from small, single center retrospective studies. Objectives: The purpose of this study was to examine whether cardiac activity during ACLS is a associated with improved outcomes in a prospective multi-center study. Methods: Eighteen sites across North America collected prospective cardiac US data on patients with pulseless electrical activity (PEA) or asystole during resuscitation following ACLS protocols. An initial US was performed as ACLS started and again at the conclusion of the resuscitation efforts. US images were interpreted unblinded as demonstrating cardiac activity or not. The primary outcome was survival to hospital admission. The secondary outcome was return of spontaneous circulation (ROSC). All data were uploaded into a central electronic database (REDCap). Based on prior studies, our initial power calculation determined 761 patients were required assuming 20% ROSC and a misclassification rate of 1%. Comparisons were performed using Mann-Whitney U test and Fisher's exact test. Results: A total of 1103 patients presenting from May 2011 to November 2014 were included. Of these, 288 were excluded due to (Figure presented) missing data or breach in protocol, leaving 815 patients. The initial presenting cardiac rhythm was PEA (49%) and asystole (48%). Figure 78 depicts median times (IQR) of resuscitation events in all patients. Patients without cardiac activity at initial ED US had longer downtimes in the field prior to EMS arrival (7 min vs 4 min, p <0.0001). Patients with cardiac activity on the initial US underwent more resuscitation time in the ED (22 vs 16min, p<0.001). The presence of cardiac activity on initial US was associated with greater incidence of ROSC (49.4 vs 14.0%, p<0.001) and survival to admission (30.3 vs 8.8%, p<0.001). Asystolic patients demonstrated no statistical difference in ROSC relative to the presence or absence of cardiac activity on US (9.8 vs 18.4%, p=0.15), but patients with PEA did (21.2 vs 53.3%, p<0.001). Conclusion: Patients in PEA and asystole with no cardiac activity on initial US during CPR can survive to hospital admission, but the survival rate is more than three times greater in patients with detectable cardiac activity on initial US