Point-of-care ultrasound in cardiorespiratory arrest (POCUS-CA): narrative review article

The POCUS-CA (Point-of-care ultrasound in cardiac arrest) is a diagnostic tool in the Intensive Care Unit and Emergency Department setting. The literature indicates that in the patient in a cardiorespiratory arrest it can provide information of the etiology of the arrest in patients with non-defibrillable rhythms, assess the quality of compressions during cardiopulmonary resuscitation (CPR), and define prognosis of survival according to specific findings and, thus, assist the clinician in decision-making during resuscitation. This narrative review of the literature aims to expose the usefulness of ultrasound in the setting of cardiorespiratory arrest as a tool that allows making a rapid diagnosis and making decisions about reversible causes of this entity. More studies are needed to support the evidence to make ultrasound part of the resuscitation algorithms. Teamwork during cardiopulmonary resuscitation and the inclusion of ultrasound in a multidisciplinary approach is important to achieve a favorable clinical outcome.

Use of Ophthalmic Sonography to Evaluate for Intraocular Foreign Body in Both Outpatient and Emergency Department/Urgent Care Patients

Intraocular foreign bodies (IOFB) present differently depending on the type of material (wood, glass, metal) for the IOFB, extent of the injury, and location of the injury. IOFB and the injury can cause a perforation or penetration of the globe which can require more extensive treatment including surgery. Proper evaluation of the IOFB and injury can help to determine extent of the injury, the prognosis of the vision, and health of the eye before and after treatment but may be difficult for the physician depending on the view of the posterior chamber being compromised by media or simply by patient sensitivity. The extent of the injury may also prevent proper evaluation due to swelling, lacerations on the lids, or pain. Proper ophthalmic sonography can provide a quick evaluation of the globe for any IOFB in both the outpatient setting as well as emergency department setting. Evaluation via sonography may allow the physician to accurately diagnose and properly treat the patient to help restore and prevent further loss of vision.

Treatment of Pyogenic Flexor Tenosynovitis in the Emergency Department Setting With WALANT Technique

Background The standard of care for treatment of pyogenic flexor tenosynovitis (PFT) involves antibiotic therapy and prompt irrigation of the flexor tendon sheath, traditionally performed in the operating room. With the acceptance of wide-awake local anesthesia no tourniquet (WALANT) hand surgery and its potential ability to minimize time to flexor tendon sheath irrigation, we sought to determine whether closed irrigation of the flexor tendon sheath could be safely and effectively performed in the emergency department setting with WALANT technique. Methods A retrospective review was conducted of the senior author’s hand surgery consultations over a 12-month period. Six patients were identified who were diagnosed with PFT and subsequently underwent irrigation of the flexor tendon sheath using WALANT technique. Patient outcomes such as length of hospital stay, need for reoperation, infectious etiology, perioperative complications, and postprocedure range of motion (ROM) were identified. Results Six patients with diagnosis of PFT underwent irrigation of the flexor tendon sheath in the emergency department with local anesthesia only. The irrigation procedures were all well-tolerated. One patient required reoperation due to lack of appropriate clinical improvement following initial irrigation. Four of 6 patients regained their preinjury ROM while the remaining 2 patients had mild proximal interphalangeal joint extension lag. There were no complications associated with the procedures. Conclusions Surgical treatment of PFT with closed irrigation of the flexor tendon sheath in the emergency department utilizing WALANT technique was safe, effective, and well-tolerated. Local anesthesia alone can be used effectively for irrigation procedures of the flexor tendon sheath.

Defining a Clinical Prediction Rule to Diagnose Bacterial Gastroenteritis Requiring Empirical Antibiotics in an Emergency Department Setting: a Retrosepctive Review

BACKGROUNDGastroenteritis (GE) is a nonspecific term for various pathologic states of the gastrointestinal tract. Infectious agents usually cause acute gastroenteritis. At present, there are no robust decision-making rules that predict bacterial GE and hence dictate when to start antibiotics in patients presenting with acute GE to the ED. We aim to define a clinical prediction rule to diagnose bacterial gastroenteritis requiring empirical antibiotics in an emergency department setting. METHODSA 2-year retrospective case review was performed on all cases from July 2015 to June 2017 that presented acutely with infectious GE symptoms to the Emergency Department and then had stool cultures performed. The clinical parameters analysed included patient co-morbid conditions, physical examination findings, historical markers, point of care tests and other laboratory work. We then used multivariate logistic regression analysis on each group (Bacterial culture-positive GE and Bacterial culture-negative GE) to elucidate clinical criteria with the highest yield for predicting BGE. RESULTS756 patients with a mean age of 52 years, 52% of whom were female, and 48% male, were recruited into the study. Based on the data from these patients, we suggest using a scoring system to delineate the need for empirical antibiotics in patients with suspected bacterial GE based on six clinical and laboratory variables. A score 0-3 points on the suggests low risk (5.8%) of bacterial GE. A score of 4-5 points confers an intermediate risk of 28.5% and a score of 6-8 points confers a high risk of 66.7%. A cut-off of >5 points may be used to predict culture positive BGE with a 75% sensitivity and 75% specificity. The AUROC for the scoring system (range 0-8) is 0.812+0.016 (95% CI: 0.780-0.843) p-value <0.001. CONCLUSIONWhile this is a pilot study which will require further validation with a larger sample size, our proposed decision-making rule will potentially serve to improve diagnosis of BGE, reduce unnecessary prescribing of antibiotics which will in turn reduce antibiotic associated adverse events and save costs worldwide.