1
|
Alexander-Savino CV, Mirowski GW, Culton DA. Mucocutaneous Manifestations of Recreational Drug Use. Am J Clin Dermatol 2024; 25:281-297. [PMID: 38217568 DOI: 10.1007/s40257-023-00835-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/15/2024]
Abstract
Recreational drug use is increasingly common in the dermatology patient population and is often associated with both general and specific mucocutaneous manifestations. Signs of substance use disorder may include changes to general appearance, skin, and mucosal findings associated with particular routes of drug administration (injection, insufflation, or inhalation) or findings specific to a particular drug. In this review article, we provide an overview of the mucocutaneous manifestations of illicit drug use including cocaine, methamphetamine, heroin, hallucinogens, marijuana, and common adulterants to facilitate the identification and improved care of these patients with the goal being to connect this patient population with appropriate resources for treatment.
Collapse
Affiliation(s)
- Carolina V Alexander-Savino
- State University of New York Upstate Medical University, Syracuse, NY, USA
- Department of Dermatology, University of North Carolina at Chapel Hill, 410 Market Street, Suite 400, Chapel Hill, NC, 27516, USA
| | - Ginat W Mirowski
- Department of Dermatology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Oral Pathology, Medicine, Radiology, Indiana University School of Dentistry, Indianapolis, IN, USA
| | - Donna A Culton
- Department of Dermatology, University of North Carolina at Chapel Hill, 410 Market Street, Suite 400, Chapel Hill, NC, 27516, USA.
| |
Collapse
|
2
|
Popat A, Harikrishnan S, Seby N, Sen U, Patel SK, Mittal L, Patel M, Vundi C, Patel Y, Babita, Kumar A, Nakrani AA, Patel M, Yadav S. Utilization of Point-of-Care Ultrasound as an Imaging Modality in the Emergency Department: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e52371. [PMID: 38694948 PMCID: PMC11062642 DOI: 10.7759/cureus.52371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 05/04/2024] Open
Abstract
Point-of-care ultrasound (POCUS) is an imaging modality that has become a fundamental part of clinical care provided in the emergency department (ED). The applications of this tool in the ED have ranged from resuscitation, diagnosis, and therapeutic to procedure guidance. This review aims to summarize the evidence on the use of POCUS for diagnosis and procedure guidance. To achieve this, CrossRef, PubMed, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched for studies published between January 2000 and November 2023. Additionally, the risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 (for studies on the diagnostic role of POCUS) and Cochrane Risk of Bias tool (for studies on the use of POCUS for procedure guidance). Furthermore, diagnostic accuracy outcomes were pooled using STATA 16 software (StatCorp., College Station, TX, USA), while outcomes related to procedure guidance were pooled using the Review Manager software. The study included 81 articles (74 evaluating the diagnostic application of POCUS and seven evaluating the use of POCUS in guiding clinical procedures). In our findings sensitivities and specificities for various conditions were as follows: appendicitis, 65% and 89%; hydronephrosis, 82% and 74%; small bowel obstruction, 93% and 82%; cholecystitis, 75% and 96%; retinal detachment, 94% and 91%; abscess, 95% and 85%; foreign bodies, 67% and 97%; clavicle fractures, 93% and 94%; distal forearm fractures, 97% and 94%; metacarpal fractures, 94% and 92%; skull fractures, 91% and 97%; and pleural effusion, 91% and 97%. A subgroup analysis of data from 11 studies also showed that the two-point POCUS has a sensitivity and specificity of 89% and 96%, while the three-point POCUS is 87% sensitive and 92% specific in the diagnosis of deep vein thrombosis. In addition, the analyses showed that ultrasound guidance significantly increases the overall success rate of peripheral venous access (p = 0.02) and significantly reduces the number of skin punctures (p = 0.01) compared to conventional methods. In conclusion, POCUS can be used in the ED to diagnose a wide range of clinical conditions accurately. Furthermore, it can be used to guide peripheral venous access and central venous catheter insertion.
Collapse
Affiliation(s)
- Apurva Popat
- Internal Medicine, Marshfield Clinic Health System, Marshfield, USA
| | | | - Niran Seby
- Internal Medicine, Tbilisi State Medical University, Tbilisi, GEO
| | - Udvas Sen
- Internal Medicine, Agartala Government Medical College, Agartala, IND
| | - Sagar K Patel
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Bhuj, IND
| | - Lakshay Mittal
- Internal Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Mitkumar Patel
- Internal Medicine, Mahatma Gandhi Mission (MGM) Medical College, Navi Mumbai, IND
| | - Charitha Vundi
- Internal Medicine, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, IND
| | - Yashasvi Patel
- Internal Medicine, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Babita
- Internal Medicine, Uzhhorod National University, Uzhhorod, UKR
| | - Ashish Kumar
- General Practice, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Ahmedabad, IND
| | - Akash A Nakrani
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Surat, IND
| | - Mahir Patel
- Medical School, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Sweta Yadav
- Internal Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Ahmedabad, IND
| |
Collapse
|
3
|
Jerome D, Stacey M, Newbigging J. Twinkle Artifact Observed During POCUS of a Human Myiasis Caused by the Dermatobia hominisBotfly. POCUS JOURNAL 2023; 8:142-145. [PMID: 38099171 PMCID: PMC10721296 DOI: 10.24908/pocus.v8i2.16712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
An 81-year-old man presented to urgent care for assessment of an area of erythema and tenderness on his right thigh after recent travel to Belize. Point of care ultrasound (POCUS) revealed a hyperechoic structure with acoustic shadowing in the subcutaneous tissue. Colour Doppler assessment of the structure produced a twinkle artifact. The structure was removed and pathology identified the object as a Dermatobia hominis larva (human botfly). The use of POCUS helped identify and localize the subcutaneous foreign body. The use of colour Doppler produced the twinkle artifact, which has not been previously reported as a finding produced during ultrasonographic assessment of botfly larvae.
Collapse
Affiliation(s)
- David Jerome
- Northern Ontario School of Medicine UniversityThunder Bay, ONCanada
- Department of Medicine, Queen's UniversityKingston, ONCanada
| | - Matthew Stacey
- Department of Medicine, Queen's UniversityKingston, ONCanada
| | | |
Collapse
|
4
|
Barton MF, Al Jalbout N, Barton BL, Alnuaimi M, Shokoohi H. Novel techniques in performing extraoral ultrasound in diagnosing dental abscesses. Am J Emerg Med 2023; 70:57-60. [PMID: 37201451 DOI: 10.1016/j.ajem.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/30/2023] [Accepted: 05/02/2023] [Indexed: 05/20/2023] Open
Abstract
INTRODUCTION Dental abscesses are a common reason patients present to the emergency department (ED). Facial and dental imaging are sometimes necessary to support the clinical diagnosis. While radiographs and computed tomography scans are frequently used, point-of-care ultrasound (US) offers several advantages, including decreased radiation exposure, reduced costs, and shorter patient length of stay. This report outlines the use of US in evaluating patients with suspected dental abscesses in the ED. DISCUSSION The typical orofacial US techniques include examining the affected area for cobblestoning or fluid collections. To improve the accuracy of diagnoses, novel techniques such as the Oral Hydroscan (OHS) and the Tongue Pointing Techniques (TPT) may be employed in specific cases. The OHS utilizes a water-filled oral cavity to enhance the spatial resolution of ultrasound images, providing improved visualization of near-field structures and preventing air accumulation between the gingiva and the buccal mucosa. The TPT involves asking the patient to extend their tongue towards the affected area, pointing to the painful location, and serving as a visual reference for an extraoral US. CONCLUSION US presents several advantages as an alternative imaging method for patients with suspected dental abscesses in the ED. Using innovative techniques such as the OHS and the TPT can further increase the visibility of tissue planes and help define the area of interest in these cases.
Collapse
Affiliation(s)
| | - Nour Al Jalbout
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | | | - Maryam Alnuaimi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
5
|
Ladowski JM, Kang L, Triplett L, Fogler B, Migaly J, Zani S, Jackson L, Vatsaas CJ. A novel low-cost model of superficial abscess for trainee education in incision and drainage. Surg Open Sci 2023; 14:124-127. [PMID: 37593672 PMCID: PMC10428102 DOI: 10.1016/j.sopen.2023.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 08/19/2023] Open
Abstract
Background Proficiency in ultrasound usage is quickly becoming an expectation in multiple residency programs: emergency medicine, obstetrics-gynecology, surgery, and internal medicine. There is a lack of affordable training devices for ultrasound training and identification of superficial fluid collections. We sought to develop a model for trainee education in ultrasound usage, identification of superficial fluid collection, aspiration, and incision & drainage (I&D). Materials & methods Commercially available products were used to develop a novel, low-cost model for ultrasound-guided aspiration and I&D of an abscess. A latex balloon embedded in silicone gel construct simulated a superficial fluid collection when examined with an ultrasound probe and monitor. A 18-gauge needle on a 10-cc syringe were used for aspiration, and a 15-blade disposal scalpel with 0.25″ packing strip used for I&D. Results Approximately six hours are required to generate 24 individual models of a superficial abscess. Following an initial investment, each model costs less than $1 USD to produce. Compared to commercially available models, this represents a significant savings. This model was utilized during the medical school academic year as a teaching aid for medical students to simulate ultrasound-guided identification, aspiration, and incision and drainage of a superficial abscess. Conclusions We successfully produced an affordable, low-cost model of a superficial fluid collection for training in ultrasound usage, aspiration, and I&D. The model represents significant savings over commercially available alternatives and can be easily replicated for trainee education.
Collapse
Affiliation(s)
- Joseph M. Ladowski
- Duke University, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Lillian Kang
- Duke University, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Layla Triplett
- Duke University, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Brian Fogler
- Duke University, Department of Radiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - John Migaly
- Duke University, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Sabino Zani
- Duke University, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Louise Jackson
- Duke University, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Cory J. Vatsaas
- Duke University, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| |
Collapse
|
6
|
Adhikari S, Leo M, Liu R, Johnston M, Keehbauch J, Barton M, Kendall J. The 2023 Core Content of advanced emergency medicine ultrasonography. J Am Coll Emerg Physicians Open 2023; 4:e13015. [PMID: 37564703 PMCID: PMC10411060 DOI: 10.1002/emp2.13015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
In February 2023, the American Board of Emergency Medicine (ABEM) approved modifications to the Advanced Emergency Medicine Ultrasonography (AEMUS) Core Content, which defines the areas of knowledge considered essential for the practice of AEMUS. This manuscript serves as a revision of the AEMUS Core Content originally published in 2014. The revision of the Core Content for AEMUS training aims to establish standardized education and qualifications necessary for AEMUS fellowship program leadership, clinical application, administration, quality improvement, and research. The Core Content provides the organizational framework and serves as the basis for the development of content for the Focused Practice Examination (FPE) administered by ABEM. AEMUS fellowship directors may reference the Core Content when designing AEMUS fellowship curricula to help prepare graduates for the autonomous practice of AEMUS and the FPE. In this article, an updated revision of the previously published AEMUS Core Content is detailed, and the entire development of the Core Content is presented.
Collapse
Affiliation(s)
- Srikar Adhikari
- Department of Emergency MedicineUniversity of ArizonaTucsonArizonaUSA
| | - Megan Leo
- Department of Emergency MedicineBoston Medical CenterBostonMassachussetsUSA
| | - Rachel Liu
- Department of Emergency MedicineYale UniversityNew HavenConnecticutUSA
| | - Mary Johnston
- American Board of Emergency MedicineEast LansingMichiganUSA
| | | | - Melissa Barton
- American Board of Emergency MedicineEast LansingMichiganUSA
| | - John Kendall
- Department of Emergency MedicineDenver Health Medical CenterDenverColoradoUSA
| |
Collapse
|
7
|
Delantoni A, Sarafopoulos A, Giannouli N, Rafailidis V. Maxillofacial inflammations visualized with ultrasonography. Description of the imaging features and literature review based on a characteristic case series. J Ultrason 2023; 23:e80-e89. [PMID: 37520752 PMCID: PMC10379848 DOI: 10.15557/jou.2023.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/12/2023] [Indexed: 08/01/2023] Open
Abstract
Objectives Inflammations of the maxillofacial regions are a frequent occurrence. They areusually of odontogenic origin, but maxillofacial swelling could also have non-odontogenic causes. Their clinical presentation is worrisome for the patient, presenting as swellings of the region with rapid and significant expansion to adjacent areas due to the thin and delicate nature of the regional soft tissues. Materials and methods The characteristic features are discussed upon the presentation of a case series of the most common types of inflammation seen in the region. Results In most hospital emergency departments, ultrasound scanning is readily accessible, and typically constitutes the first-line imaging modality for this entity. Nevertheless, the role of ultrasound imaging is limited in cases with deep extension of the inflammation, where cross-sectional imaging with CT or MRI will be the modality of choice. This manuscript aims to present the characteristic features of various inflammatory conditions of the maxillofacial area seen on ultrasonography. Conclusions Even though maxillofacial inflammations are often treated without imaging in their initial phase, ultrasound can provide aninexpensive, easy-to-use, and readily available alternative that best visualizes the characteristics and expansion patterns of the lesions, based on their origin and area of initial presentation.
Collapse
Affiliation(s)
- Antigoni Delantoni
- Oral Surgery, Implant Surgery and Radiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Sarafopoulos
- Department of Clinical Radiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Natalia Giannouli
- Department of Clinical Radiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios Rafailidis
- Department of Clinical Radiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
8
|
Brooks SC, Sivilotti MLA, Hétu MF, Norman PA, Day AG, O'Callaghan N, Latiu V, Newbigging J, Hill B, Johri AM. Focused carotid ultrasound to predict major adverse cardiac events among emergency department patients with chest pain. CAN J EMERG MED 2023; 25:81-89. [PMID: 36315347 DOI: 10.1007/s43678-022-00395-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/04/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Point-of-care focused vascular ultrasound (FOVUS), an assessment of carotid artery plaque, predicts coronary artery disease in outpatients referred for coronary angiography. Our primary objective was to determine the diagnostic accuracy of sonographer-performed FOVUS to predict major adverse cardiac events (MACE) within 30 days among patients with suspected cardiac ischemia in the emergency department (ED). METHODS We conducted a prospective cohort study of patients with chest pain presenting to a tertiary care ED who had an electrocardiogram and cardiac troponin testing. The primary outcome was a composite of death, acute myocardial infarction, or re-vascularization at 30 days. A sonographer performed FOVUS scans in consenting eligible subjects. Emergency physicians, blinded to the sonographer FOVUS result, performed a second FOVUS on some subjects. RESULTS We recruited 326 subjects (age 62.1 ± 13.5 years; 166 (52%) men), 319 of whom completed an FOVUS scan by the sonographer. Of these, 198 (62%) had a positive FOVUS scan and 41 (13%) had a 30-day MACE. The sensitivity was 83% (95% CI 71-94%), specificity 41% (95% CI 36-47%), positive-likelihood ratio 1.41 (95% CI 1.19-1.68), and negative-likelihood ratio 0.41 (95% CI 0.23-0.75). Among 71 subjects also scanned by an emergency physician, the Kappa was 0.50 (95% CI 0.31-0.70), suggesting moderate agreement between sonographer and emergency physician on the determination of significant carotid plaque. CONCLUSIONS The presence of carotid plaque on sonographer-performed FOVUS is associated with 30-day MACE in ED patients presenting with chest pain. The prognostic performance of FOVUS is not sufficient to support its use as a stand-alone risk stratification tool in the ED. Future work should investigate FOVUS in conjunction with validated clinical decision rules for chest pain and the impact of enhanced training and quality improvement in the conduct of FOVUS by emergency physicians. REGISTRATION This study was registered at clinicaltrials.gov (NCT02947360).
Collapse
Affiliation(s)
- Steven C Brooks
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada. .,Department of Public Health Sciences, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada. .,Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada.
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada.,Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada
| | - Marie-France Hétu
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's University, Kingston, ON, Canada
| | - Patrick A Norman
- Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada
| | - Andrew G Day
- Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada
| | - Nicole O'Callaghan
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada
| | - Vlad Latiu
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada
| | - Joseph Newbigging
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada
| | - Braeden Hill
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's University, Kingston, ON, Canada
| | - Amer M Johri
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's University, Kingston, ON, Canada.,Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| |
Collapse
|
9
|
Shah N, Patel S, Rupawala T, Makwana S, Mansuri S, Bhimani K. Evaluation of Efficacy of Ultrasonography as an Additional Diagnostic Tool for Deciding Management Protocol of Odontogenic Superficial Fascial Space Infections: A Prospective Clinical Study. J Maxillofac Oral Surg 2022; 21:1148-1154. [PMID: 36896083 PMCID: PMC9989102 DOI: 10.1007/s12663-021-01560-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/27/2021] [Indexed: 10/21/2022] Open
Abstract
Objective To explore the efficacy of ultrasonography as an additional diagnostic tool in superficial odontogenic fascial space infections of maxillofacial region and modifying the treatment plan when needed. Materials and Methods Forty patients with superficial fascial space infections underwent a detailed clinical, plain radiological and ultrasonographic examination. Based on the ultrasonographic findings, final diagnosis was made and compared with clinical findings. Patients diagnosed with cellulitis were given medical line of treatment, and those with abscess were subjected to incision and drainage along with standard general supportive care and removal of etiologic agent. Results In this study, out of 40 patients (male = 22, female = 18), clinical diagnosis of cellulitis was made in 26 cases (65%) and abscess in 14 (35.0%). On USG examination, cellulitis was present in 21 cases (52.5%), while abscess in 19 (47.5%). Final diagnosis of cellulitis was made in 13 (59.1%) males and 12(66.7%) females, while abscess was confirmed in 9 (40.9%) male and 6 (33.3%) female patients. The results showed that sensitivity of the clinical examination alone was 64% with 33% specificity, and for USG, sensitivity was 84% with specificity of 100%. Conclusion The adjuvant role of ultrasonography in the diagnosis and timely management of superficial fascial space infections is promising owing to its accessibility, relative safety, repeatability and cost-effectiveness.
Collapse
Affiliation(s)
- Naiya Shah
- Department of Oral and Maxillofacial Surgery, Ahmedabad Municipal Corporation Dental College, Bhalakia Mill compound, Opp. Anupam cinema, Khokhra, Ahmedabad, 380008 India
| | - Shital Patel
- Department of Oral and Maxillofacial Surgery, Ahmedabad Municipal Corporation Dental College, Bhalakia Mill compound, Opp. Anupam cinema, Khokhra, Ahmedabad, 380008 India
| | - Taher Rupawala
- Department of Oral and Maxillofacial Surgery, Ahmedabad Municipal Corporation Dental College, Bhalakia Mill compound, Opp. Anupam cinema, Khokhra, Ahmedabad, 380008 India
| | - Sanjay Makwana
- Department of Oral and Maxillofacial Surgery, Ahmedabad Municipal Corporation Dental College, Bhalakia Mill compound, Opp. Anupam cinema, Khokhra, Ahmedabad, 380008 India
| | - Saloni Mansuri
- Department of Oral and Maxillofacial Surgery, Ahmedabad Municipal Corporation Dental College, Bhalakia Mill compound, Opp. Anupam cinema, Khokhra, Ahmedabad, 380008 India
| | - Kruna Bhimani
- Department of Oral and Maxillofacial Surgery, Ahmedabad Municipal Corporation Dental College, Bhalakia Mill compound, Opp. Anupam cinema, Khokhra, Ahmedabad, 380008 India
| |
Collapse
|
10
|
Nti BK, Phillips W, Sarmiento E, Russell F. Effect of a point-of-care ultrasound (POCUS) curriculum on emergency department soft tissue management. Ultrasound J 2022; 14:41. [PMID: 36269462 PMCID: PMC9587168 DOI: 10.1186/s13089-022-00292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 10/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background Pediatric emergency department (ED) visits for superficial skin and soft tissue infections (SSTI) have steadily been increasing and point-of-care ultrasound (POCUS) continues to be an effective modality to improve management and shorter ED length of stays (LOS). Objective We sought to determine the impact of a soft tissue POCUS curriculum on POCUS utilization, ED LOS, and cost-effectiveness. Methods This was a retrospective pre- and post-interventional study of pediatric patients aged 0 to 17 years. Patients presenting to ED with international classification of disease 9 or 10 code for abscess or cellulitis were included. Data were collected a year before and after curriculum implementation with a 1-year washout training period. Training included continuing medical education, greater than 25 quality assured examinations, and a post-test. We compared diagnostic imaging type, ED LOS, and mean charges in patients with SSTI. Results We analyzed data on 119 total patients, 38 pre- and 81 post-intervention. We found a significant increase in the total number of POCUS examinations performed pre- to post-curriculum intervention, 26 vs. 59 (p = 0.0017). Mean total charges were significantly decreased from $3,762 (± 270) to $2,622 (± 158; p = 0.0009). There was a significant trend towards a decrease in average ED LOS 282 (standard error of mean [SEM] ± 19) vs 185 (± 13) minutes (p = 0.0001). Conclusions Implementation of a soft tissue POCUS curriculum in a pediatric ED was associated with increased POCUS use, decreased LOS, and lower cost. These findings highlight the importance of POCUS education and implementation in the management of pediatric SSTI.
Collapse
Affiliation(s)
- Benjamin K Nti
- Division of Pediatric Emergency Medicine Division of Clinical Ultrasound Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, FT 3, Indianapolis, IN 46202, US.
| | - Whitney Phillips
- Department of Pediatrics Riley, Hospital for Children at Indiana University Health, Indiana University School of Medicine, 705 Riley Hospital Drive, Indianapolis, IN 46202, US
| | - Elisa Sarmiento
- Division of Pediatric Emergency Medicine Division of Clinical Ultrasound Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, FT 3, Indianapolis, IN 46202, US
| | - Frances Russell
- Division of Pediatric Emergency Medicine Division of Clinical Ultrasound Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, FT 3, Indianapolis, IN 46202, US
| |
Collapse
|
11
|
Patel K, Khan Z, Costumbrado J. To Drain or not to Drain? Point-of-care Ultrasound to Investigate an Axillary Mass: Case Report. Clin Pract Cases Emerg Med 2022. [DOI: 10.5811//cpcem.2022.2.53357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Point-of-care ultrasound (POCUS) has great sensitivity in the diagnosis of abscesses and swollen lymph nodes. Many studies outline the characteristics that distinguish abscesses from lymph nodes on POCUS.
Case Report: We present a case from the emergency department in which a patient presented with a potential abscess but was found to have a malignant lymph node on imaging.
Conclusion: Point-of-care ultrasound can be used to differentiate an abscess from a swollen lymph node. Abscesses are generally anechoic or hypoechoic with septae, sediment or gas contents, and they lack internal vascularity. Benign lymph nodes are echogenic with hypoechoic cortex with hilar vascularity.
Collapse
Affiliation(s)
- Kishan Patel
- University of California, Riverside School of Medicine, Riverside, California
| | - Zara Khan
- Riverside Community Hospital/University of California, Riverside, Department of Emergency Medicine, Riverside, California
| | - John Costumbrado
- Riverside Community Hospital/University of California, Riverside, Department of Emergency Medicine, Riverside, California
| |
Collapse
|
12
|
Tay ET, Ngai KM, Tsung JW, Sanders JE. Point-of-Care Ultrasound on Management of Cellulitis Versus Local Angioedema in the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e674-e677. [PMID: 34398861 DOI: 10.1097/pec.0000000000002416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate whether ultrasound can differentiate between cellulitis and angioedema from insect bites in pediatric patients. METHODS A prospective, pre-post study in an urban pediatric emergency department of patients younger than 21 years with soft tissue swelling from insect bites without abscesses were enrolled. Treating physician's pretest opinions regarding the diagnosis and need for antibiotics were determined. Ultrasound of the affected areas was performed, and effects on management were recorded. Further imaging, medications, and disposition were at the discretion of the enrolling physician. Phone call follow-ups were made within a week of presentation. RESULTS Among 103 patients enrolled with soft tissue swelling secondary to insect bites, ultrasound changed the management in 27 (26%) patients (95% confidence interval [CI], 18-35%). Of the patients who were indeterminate or believed to require antibiotics, ultrasound changed management in 6 (23%) of 26 patients (95% CI, 6%-40%). In those patients who were believed not to require antibiotics, ultrasound changed management in 12 (16%) 77 patients (95% CI, 7%-24%). Patients with diagnosis of local angioedema achieved symptom resolution 1.4 days sooner than patients diagnosed with cellulitis (mean, -1.389; 95% CI, -2.087 to -0.690; P < 0.001). No patient who was initially diagnosed as local angioedema received antibiotics upon patient follow-up. CONCLUSIONS Point-of-care ultrasound changed physician management in 1 of 4 patients in the pediatric emergency department with soft tissue swelling secondary to insect bites. Ultrasound may guide the management in these patients and lead to improved antibiotic stewardship in conjunction with history and physical examination.
Collapse
Affiliation(s)
- Ee Tein Tay
- From the Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine
| | | | - James W Tsung
- Department of Pediatric Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jennifer E Sanders
- Department of Pediatric Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
13
|
Goulding M, Haran J, Sanseverino A, Zeoli T, Gaspari R. Clinical failure in abscess treatment: the role of ultrasound and incision and drainage. CAN J EMERG MED 2022; 24:39-43. [PMID: 34591283 DOI: 10.1007/s43678-021-00179-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 07/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Skin and soft tissue abscesses are commonly treated in emergency departments (ED). The use of bedside ultrasound may improve patient outcomes. The primary objective of this study was to examine the relationship between ultrasound use and risk of treatment failure in ED patients treated for abscesses. METHODS In this multi-center observational study, we reviewed medical records of adult patients evaluated for abscesses. Demographics, infection characteristics, treatments rendered, use of ultrasound (for diagnosis and/or treatment) and follow-up data were collected from electronic medical record review. Treatment failure, the primary outcome, was defined as any surgical intervention after the initial ED visit. Multivariable logistic regression tested whether incision and drainage utilizing ultrasound was associated with reduced treatment failure. RESULTS We identified 609 patients diagnosed with abscesses over a 22-month period. Of them 75% were treated with incision and drainage, 55% had an ultrasound and 15% failed treatment. Multi-variable analysis demonstrated an 8% probability of failure with ultrasound plus incision and drainage, 14% with blind incision and drainage and 25% without incision and drainage. Individuals with incision and drainage performed were 50% less likely to fail treatment (RR 0.53, 95%CI 0.35-0.81) and 70% less likely to fail treatment (RR 0.30, 95%CI 0.18-0.51) with ultrasound and incision and drainage. CONCLUSIONS The use of ultrasound in diagnosing and or/treating patients with abscesses in the ED is associated with decreased treatment failure risk when utilized with incision and drainage. Consideration of ultrasound use in other studies which assess treatment methods in relation to patient outcomes may be warranted.
Collapse
Affiliation(s)
- Melissa Goulding
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA, 01655, USA.
| | - John Haran
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Alexandra Sanseverino
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Tyler Zeoli
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Romolo Gaspari
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| |
Collapse
|
14
|
Stoianovskyi IV, Khimich SD, Chemerys OM. POINT-OF-CARE ULTRASOUND IN THE EARLY DIAGNOSIS OF NECROTIZING FASCIITIS. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:2471-2475. [PMID: 36472282 DOI: 10.36740/wlek202210129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE The aim: To detect the ultrasonographic signs of necrotizing fasciitis (NF) suitable for its early diagnosis. PATIENTS AND METHODS Materials and methods: Eigty two patients with soft tissue infection, including 14 with necrotizing faciitis, were examined by ultrasonography at the admission. Ultrasonografic features were compared to intraoperative findings by the same surgeon. RESULTS Results: The thickening of subcutaneous tissue had high sensitivity (100%), but low specificity (5.8%). The hypoechoic and hyperechoic zones had the shape of "cobblestone" with sensitivity - 78.5%, specificity - 33.8%. Higher specificity (69.1%) had sign of "cobblestone separation" on two layers. The presence of fluid above the fascia (sensitivity - 71.4%; specificity - 69.1%), thickening of the fascia (sensitivity - 85.7%; specificity - 58.8%), indistinctness of the fascia edges (sensitivity - 85.7%; specificity - 66.1%) and loss of fascial homogeneity (sensitivity - 71.4%, specificity - 66.1%) were noted in early stages of NF. Advanced cases of NF were accompanied by the dissection of thick¬ened fascia with a strip of fluid (sensitivity - 57.1%, specificity - 92.6%) and accumulation of a fluid under the fascia (sensitivity - 28.5%, specificity - 95.5%). The muscles thickening (sensitivity - 28.5%; specificity - 67.6%), skin thickening (sensitivity - 57.1%; specificity - 58.8%), and loss of the skin's lower edge clarity (sensitivity - 57.1%; specificity - 63.2%) don't have diagnostic value without other signs of NF. CONCLUSION Conclusions: Point-of-care ultrasonography allows visualization of soft tissue changes that may be hidden in the initial stages of necrotizing fasciitis and should be recommended for implementation as mandatory method of examination in patients with suspected surgical soft tissue infection.
Collapse
Affiliation(s)
| | - Sergii D Khimich
- NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSIA, UKRAINE
| | | |
Collapse
|
15
|
Nelson CE, Kaplan S, Bellah RD, Chen AE. Sonographically Occult Abscesses of the Buttock and Perineum in Children. Pediatr Emerg Care 2021; 37:e910-e914. [PMID: 28953103 DOI: 10.1097/pec.0000000000001294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ultrasound (US) is used to differentiate abscess from cellulitis. At our institution, we observed children who had purulent fluid obtained after a negative abscess US. We sought to determine the incidence of sonographically occult abscess (SOA) of the buttock and perineum, and identify associated clinical and demographic characteristics. METHODS Retrospective chart review including children younger than 18 years old presenting to pediatric emergency department with soft tissue infection of the buttock or perineum and diagnostic radiology US read as negative for abscess. We defined SOA as wound culture growing pathogenic organism obtained within 48 hours of the US. Clinical and demographic characteristics included age, sex, race, ethnicity, fever, history of spontaneous drainage, duration of symptoms, previous methicillin resistant Staphylococcus aureus (MRSA) infection, or previous abscess. We used univariate and multivariate logistic regression to assess correlation between these characteristics and SOA. RESULTS A total of 217 children were included. Sixty-one (28%) children had SOA; 33 of 61 (54%) had incision and drainage within 4 hours of the US. Of children with SOA, 49 (80%) grew MRSA and 12 (20%) grew methicillin-sensitive S. aureus. In univariate analysis, a history of MRSA, symptom duration 4 days or less, age of younger than 4 years, and Hispanic ethnicity increased the odds of having SOA. In multivariate analysis, history of MRSA and duration of 4 days or less were associated with SOA. CONCLUSIONS Twenty-eight percent of children in our institution with US of the buttock and perineum negative for abscess had clinical abscess within 48 hours, most within 4 hours. History of MRSA and shorter symptom duration increased the odds of SOA.
Collapse
Affiliation(s)
- Courtney E Nelson
- From the Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | | | | | - Aaron E Chen
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|
16
|
Abo AM, Alade KH, Rempell RG, Kessler D, Fischer JW, Lewiss RE, Raio CC, Marin JR. Credentialing Pediatric Emergency Medicine Faculty in Point-of-Care Ultrasound: Expert Guidelines. Pediatr Emerg Care 2021; 37:e1687-e1694. [PMID: 30624416 DOI: 10.1097/pec.0000000000001677] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT As point-of-care ultrasound (POCUS) becomes standard practice in pediatric emergency medicine (PEM), it is important to have benchmarks in place for credentialing PEM faculty in POCUS. Faculty must be systematically trained and assessed for competency in order to be credentialed in POCUS and granted privileges by an individual institution. Recommendations on credentialing PEM faculty are needed to ensure appropriate, consistent, and responsible use of this diagnostic and procedural tool. It is our intention that these guidelines will serve as a framework for credentialing faculty in PEM POCUS.
Collapse
Affiliation(s)
- Alyssa M Abo
- From the Departments of Pediatrics and Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Kiyetta H Alade
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Rachel G Rempell
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - David Kessler
- Departments of Pediatrics and Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Jason W Fischer
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Resa E Lewiss
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Christopher C Raio
- Department of Emergency Medicine, Good Samaritan Hospital Medical Center, West Islip, NY
| | - Jennifer R Marin
- Departments of Pediatrics and Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
17
|
Bionat ED, Ongchuan MA. The Utility of Musculoskeletal Ultrasonography in Diagnosing Pyomyositis: A Comparison With Surgically and Conservatively Treated Cases. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2021. [DOI: 10.1177/8756479320982911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: The study aimed to determine the accuracy of sonography in diagnosing pyomyositis. Methods: A retrospective review of pyomyositis cases in a government hospital between January 1, 2016 and June 30, 2019 was done. All cases underwent a sonogram for the indication of pyomyositis. Positive purulence for surgical cases and improved laboratory parameters for conservative cases were confirmatory for pyomyositis. Comparison with sonographic results using a 2 × 2 contingency table was done to determine sensitivity and specificity. Results: A total of 122 cases were included. The sonographic results corresponded with 95% of surgical cases and 89% of conservative cases. A lack of false and true negatives for surgical cases resulted in a sensitivity of 100% (95% confidence interval [CI] = 93%–100%) and a specificity of 0% (95% CI = 0%–71%). In conservative cases, sonography had a sensitivity of 92% (95% CI = 82%–97%) and a specificity of 0% (95% CI = 0%–84%) due to a lack of true negatives. Conclusion: Sonography is not limited to primarily as a screening tool but a capable diagnostic imaging choice for pyomyositis, particularly in low-resource settings. The results show the strength of sonography, particularly in the suppurative stage of pyomyositis. [Box: see text]
Collapse
Affiliation(s)
- Edgar David Bionat
- Department of Physical and Rehabilitation Medicine, Philippine Orthopedic Center, Quezon City, Philippines
| | - Mae Angeleine Ongchuan
- Department of Physical and Rehabilitation Medicine, Philippine Orthopedic Center, Quezon City, Philippines
| |
Collapse
|
18
|
Nielsen OL, Mellergaard M, Frees D, Larsen MN, Skov S, Olsen LH, Reimann MJ. A porcine model of subcutaneous Staphylococcus aureus infection: a pilot study. APMIS 2021; 130:359-370. [PMID: 33644910 DOI: 10.1111/apm.13101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/18/2020] [Indexed: 11/30/2022]
Abstract
In this descriptive pilot study, we aim to establish a porcine Staphylococcus aureus skin infection model by subcutaneous injection (s.c.) of the porcine S54F9 S. aureus strain in the groin area. Six pigs were used in the study: Five pigs were injected with S. aureus, inocula ranging from 7 × 103 to 5 × 107 colony-forming units per kg bodyweight; one pig was injected with saline exclusively. Lesions were recorded up to 6 days postinoculation using clinical evaluation, ultrasound evaluation, microbiology, flow cytometry, and pathology. Inoculation gave rise to lesions ranging from localized skin infection, that is, minute histological changes, intracellular infection, and macroscopic abscess formation with sequestration of soft tissue, to generalized infection and development of disseminated intravascular coagulation necessitating euthanasia only 10 h after inoculation. Ultrasound assessment of maximum width and characteristics was not able to disclose the progress of the local infection. Flow cytometry and immunohistochemistry revealed the participation of γδT cells in the immune response. In conclusion, we did see a graded inflammatory response associated with the dose of s.c. inoculated bacteria, which may be useful for studying, in particular, the interaction of bacteria and inflammatory mononuclear cell populations. It needs to be investigated if the model is discriminatory and robust.
Collapse
Affiliation(s)
- Ole Lerberg Nielsen
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Maiken Mellergaard
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Dorte Frees
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Maria Nygaard Larsen
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Søren Skov
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Lisbeth Høier Olsen
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Maria Josefine Reimann
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| |
Collapse
|
19
|
Abstract
Cellulitis is a common infection of the skin and subcutaneous tissue caused predominantly by gram-positive organisms. Risk factors include prior episodes of cellulitis, cutaneous lesions, tinea pedis, and chronic edema. Cellulitis is a clinical diagnosis and presents with localized skin erythema, edema, warmth, and tenderness. Uncomplicated cellulitis can be managed in the outpatient setting with oral antibiotics. Imaging often is not required but can be helpful. Recurrent cellulitis is common and predisposing conditions should be assessed for and treated at the time of initial diagnosis. For patients with frequent recurrences despite management of underlying conditions, antimicrobial prophylaxis can be effective.
Collapse
Affiliation(s)
- Rachel J Bystritsky
- Department of Medicine, Infectious Diseases, University of California-San Francisco, 350 Parnassus, Rm 808B, UCSF Box 0654, San Francisco, CA 94117, USA.
| |
Collapse
|
20
|
Alfageme F, Wortsman X, Catalano O, Roustan G, Crisan M, Crisan D, Gaitini DE, Cerezo E, Badea R. European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Position Statement on Dermatologic Ultrasound. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:39-47. [PMID: 32380567 DOI: 10.1055/a-1161-8872] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Dermatologic ultrasound is a recent application of ultrasound for the evaluation of healthy skin and appendages and their diseases. Although the scientific literature regarding this application is still not sufficient for evidence-based guidelines, general recommendations issued by scientific societies are necessary. The EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) steering committee for dermatologic ultrasound has developed a series of consensus position statements regarding the main fields of dermatologic ultrasound (technical requirement, normal skin and appendages, inflammatory skin diseases, tumoral skin diseases, aesthetic dermatology and practice-training requirements). This document is the foundation for future evidence-based recommendations and guidelines for dermatologic ultrasound practice.
Collapse
Affiliation(s)
- Fernando Alfageme
- Dermatology, Hospital Universitario Puerta De Hierro Majadahonda, Madrid, Spain
| | - Ximena Wortsman
- Department of Dermatology, Universidad de Chile, Santiago de Chile
| | | | - Gaston Roustan
- Dermatology, Hospital Universitario Puerta De Hierro Majadahonda, Madrid, Spain
| | - Maria Crisan
- Dermatology, University of Medicine and Pharmacy Iuliu Hatieganu, Cluj-Napoca, Romania
| | - Diana Crisan
- Dermatology, Universitätsklinikum Ulm Klinik für Dermatologie und Allergologie, Ulm, Germany
| | | | | | - Radu Badea
- Regional Institute of Gastroenterology and Hepatology, University of Medicine and Pharmacy, "Iuliu Hatieganu", Cluj-Napoca, Romania
| |
Collapse
|
21
|
Knaysi G, Ringelberg J, Stadlberger N, Soucy Z. Point of Care Ultrasound Use by Associate Providers for Differentiating Abscess Versus Cellulitis Skin and Soft Tissue Infection in the Emergency Department. J Emerg Med 2021; 60:e1-e7. [DOI: 10.1016/j.jemermed.2020.07.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/15/2020] [Accepted: 07/11/2020] [Indexed: 11/28/2022]
|
22
|
Point-of-Care Ultrasound Used to Distinguish Between Superficial Skin Abscess and Deep Mediastinal Abscess: A Case Report. J Emerg Med 2020; 60:e23-e25. [PMID: 33262009 DOI: 10.1016/j.jemermed.2020.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/25/2020] [Accepted: 10/04/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Skin and soft tissue infections (SSTIs) are an increasingly common complaint in the emergency department (ED), but physical examination does not reliably identify abscesses or accurately determine which skin lesions require incision and drainage. Point-of-care ultrasound (POCUS) improves management of soft tissue skin infections by detecting occult abscess, preventing unnecessary procedures, and identifying more complex disease requiring further imaging. CASE REPORT Here, we report a case in which POCUS drastically changed the management of what initially appeared to be an uncomplicated superficial skin abscess but was actually a much more serious mediastinal infection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case underscores the importance and utility of POCUS to enhance the physical examination in suspected SSTIs. Because POCUS is easy, accurate, low risk, and can change management, we recommend its consideration as a standard component of the ED work up for SSTIs.
Collapse
|
23
|
Proud KC, Beg M, Soni NJ. A 93-Year-Old Man With Submassive Pulmonary Embolism and Fall. Chest 2020; 158:e47-e50. [PMID: 32654739 DOI: 10.1016/j.chest.2019.08.2213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/01/2019] [Accepted: 08/31/2019] [Indexed: 10/23/2022] Open
Affiliation(s)
- Kevin C Proud
- Long School of Medicine at University of Texas Health San Antonio and South Texas Veterans Health Care System, San Antonio, TX.
| | - Moeezullah Beg
- Long School of Medicine at University of Texas Health San Antonio and South Texas Veterans Health Care System, San Antonio, TX
| | - Nilam J Soni
- Long School of Medicine at University of Texas Health San Antonio and South Texas Veterans Health Care System, San Antonio, TX
| |
Collapse
|
24
|
Gottlieb M, Avila J, Chottiner M, Peksa GD. Point-of-Care Ultrasonography for the Diagnosis of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-analysis. Ann Emerg Med 2020; 76:67-77. [DOI: 10.1016/j.annemergmed.2020.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 12/13/2019] [Accepted: 12/31/2019] [Indexed: 02/01/2023]
|
25
|
Long B, Koyfman A, Gottlieb M. Accuracy of Point-of-care Ultrasound for Diagnosing Soft Tissue Abscess. Acad Emerg Med 2020; 27:429-430. [PMID: 31675445 DOI: 10.1111/acem.13881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Brit Long
- From the Department of Emergency Medicine Brooke Army Medical Center Fort Sam Houston TX
| | - Alex Koyfman
- the Department of Emergency Medicine The University of Texas Southwestern Medical Center Dallas TX
| | - Michael Gottlieb
- and the Department of Emergency Medicine Rush University Medical Center Chicago IL
| |
Collapse
|
26
|
Russell FM, Rutz M, Rood LK, McGee J, Sarmiento EJ. Abscess Size and Depth on Ultrasound and Association with Treatment Failure without Drainage. West J Emerg Med 2020; 21:336-342. [PMID: 32191191 PMCID: PMC7081847 DOI: 10.5811/westjem.2019.12.41921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/03/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Skin and soft tissue infections (SSTI) occur along a continuum from cellulitis to abscess. Point-of-care ultrasound (POCUS) is effective in differentiating between these two diagnoses and guiding acute management decisions. Smaller and more superficial abscesses may not require a drainage procedure for cure. The goal of this study was to evaluate the optimal abscess size and depth cut-off for determining when a drainage procedure is necessary. Methods We conducted a retrospective study of adult patients with a SSTI who had POCUS performed. Patients were identified through an ultrasound database. We reviewed examinations for the presence, size, and depth of abscess. Medical records were reviewed to determine acute ED management and assess outcomes. The primary outcome evaluated the optimal abscess size and depth when a patient could be safely discharged without a drainage procedure. We defined a treatment failure as a return visit within seven days requiring admission, change in antibiotics, or drainage procedure. Results A total of 162 patients had an abscess confirmed on POCUS and were discharged from the ED without a drainage procedure. The optimal cut-off to predict treatment failure by receiver operating curve analysis was 1.3 centimeters (cm) in longest dimension with a sensitivity of 85% and specificity of 37% (area under the curve [AUC] 0.60, 95% confidence interval [CI], 0.44–0.76), and 0.4cm in depth with a sensitivity of 85% and specificity of 68% (AUC 0.83, 95% CI, 0.74–93). Conclusion This retrospective data suggests that abscesses greater than 0.4 cm in depth from the skin surface may require a drainage procedure. Those less than 0.4 cm in depth may not require a drainage procedure and may be safely treated with antibiotics alone. Further prospective data is needed to validate these findings and to assess for an optimal size cut-off when a patient with a skin abscess may be discharged without a drainage procedure.
Collapse
Affiliation(s)
- Frances M Russell
- Indiana University, Department of Emergency Medicine, Indianapolis, Indiana
| | - Matt Rutz
- Indiana University, Department of Emergency Medicine, Indianapolis, Indiana
| | - L Ken Rood
- Indiana University, Department of Emergency Medicine, Indianapolis, Indiana
| | - Justin McGee
- Indiana University, Department of Emergency Medicine, Indianapolis, Indiana
| | - Elisa J Sarmiento
- Indiana University, Department of Emergency Medicine, Indianapolis, Indiana
| |
Collapse
|
27
|
Rodríguez Bandera AI, Sebaratnam DF, Feito Rodríguez M, de Lucas Laguna R. Cutaneous ultrasound and its utility in pediatric dermatology. Part I: Lumps, bumps, and inflammatory conditions. Pediatr Dermatol 2020; 37:29-39. [PMID: 31743485 DOI: 10.1111/pde.14033] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
High-frequency ultrasonography represents a promising tool for pediatric dermatologists. It is a non-invasive diagnostic technique that is particularly appealing when working with children. It can be easily performed at the patient's bedside, avoiding diagnostic delays, sedation, or multiple visits. It represents a useful adjunct to clinical examination and can enhance our understanding of cutaneous diseases. Patient cooperation and limited training and experience are the main challenges for cutaneous ultrasonography in pediatric dermatology. This review describes cutaneous ultrasonography and the nuances of its use in the pediatric setting, followed by the ultrasonographic findings of cutaneous lumps, bumps, and inflammatory dermatoses commonly encountered in pediatric patients.
Collapse
Affiliation(s)
| | - Deshan Frank Sebaratnam
- Sydney Children's Hospitals' Network, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | | | | |
Collapse
|
28
|
Hopkins A, Doniger SJ. Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice. Hosp Pediatr 2019; 9:707-718. [PMID: 31405888 DOI: 10.1542/hpeds.2018-0118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.
Collapse
Affiliation(s)
- Akshata Hopkins
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida; and
| | | |
Collapse
|
29
|
|
30
|
Mower WR, Crisp JG, Krishnadasan A, Moran GJ, Abrahamian FM, Lovecchio F, Karras DJ, Steele MT, Rothman RE, Talan DA. Effect of Initial Bedside Ultrasonography on Emergency Department Skin and Soft Tissue Infection Management. Ann Emerg Med 2019; 74:372-380. [PMID: 30926187 DOI: 10.1016/j.annemergmed.2019.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/23/2019] [Accepted: 02/01/2019] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE We examine the utility of emergency department (ED) ultrasonography in treatment of skin and soft tissue infections. METHODS We enrolled ED patients with skin and soft tissue infections and surveyed clinicians in regard to their pre-ultrasonography certainty about the presence or absence of an abscess, their planned management, post-ultrasonography findings, and actual management. We determined sensitivity and specificity of ultrasonography and clinical evaluation, and assessed appropriateness of management changes based on initial clinical assessment and outcomes through 1-week follow-up. RESULTS Among 1,216 patients, clinicians were uncertain of abscess presence in 105 cases (8.6%) and certain for 1,111 cases (91.4%). Based on surgical exploration and follow-up through 1 week, sensitivity and specificity for abscess detection by clinical evaluation were 90.3% and 97.7%, and by ultrasonography were 94.0% and 94.1%, respectively. Among 1,111 cases for which the clinician was certain, sensitivity and specificity of clinical evaluation were 96.6% and 97.3% compared with ultrasonographic evaluation sensitivity and specificity of 95.7% and 96.2%, respectively. Of 105 uncertain cases, sensitivity and specificity of ultrasonography were 68.5% and 80.4%. Ultrasonography changed management in 13 of 1,111 certain cases (1.2%), appropriately in 10 of 13 (76.9%) and inappropriately in 3 of 13 (23.1%). Of 105 uncertain cases, ultrasonography changed management in 25 (23.8%), appropriately in 21 of 25 (84.0%) and inappropriately in 4 of 25 (16.0%). CONCLUSION Ultrasonography rarely changed management when clinicians were certain about the presence or absence of an abscess. When they were uncertain, ultrasonography changed drainage decisions in approximately one quarter of cases, of which most (84%) were appropriate.
Collapse
Affiliation(s)
- William R Mower
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA.
| | - Jonathan G Crisp
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA; Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA
| | - Anusha Krishnadasan
- Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA
| | - Gregory J Moran
- Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA
| | - Fredrick M Abrahamian
- Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA
| | - Frank Lovecchio
- Department of Emergency Medicine, Maricopa Medical Center, University of Arizona and Mayo Graduate School of Medicine, Phoenix, AZ
| | - David J Karras
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Mark T Steele
- Department of Emergency Medicine, Truman Medical Center, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - David A Talan
- Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA
| |
Collapse
|
31
|
Mathews BK, Miller PE, Olson APJ. Point-of-Care Ultrasound Improves Shared Diagnostic Understanding Between Patients and Providers. South Med J 2018; 111:395-400. [PMID: 29978223 DOI: 10.14423/smj.0000000000000833] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Point-of-care ultrasound (POCUS) has become an integral part of the physical examination. The effect on shared understanding of adding POCUS to the traditional examination is unknown, yet this is an often-described benefit of POCUS. The primary aim of this study was to determine whether the use of POCUS improves shared understanding between providers and patients about patients' diagnoses. METHODS This was a prospective controlled trial involving a convenience sample of hospitalized adults. Providers in the control arm performed usual care without POCUS, whereas providers in the study arm had the option to add POCUS. Surveys were administered to the subjects and their providers with questions on patient understanding of symptoms, diagnosis, and main contributors to their health problem. Two independent physicians rated the degree of shared understanding between patient and provider surveys. RESULTS Of the 64 patients enrolled in the study, 60 had complete data. There was increased shared understanding between providers and patients with respect to their diagnosis (POCUS 9.56 ± 0.63, non-POCUS 7.62 ± 1.63, P < 0.005) and main contributors (POCUS 9.65 ± 0.77, non-POCUS 8.30 ± 1.13, P < 0.005) in the POCUS arm compared with the non-POCUS arm. Patients also increased the self-rating of their understanding of their health problem in the POCUS arm. CONCLUSIONS These findings suggest that using POCUS improves patients' understanding of the diagnostic process. POCUS may be uniquely poised to enhance patients' understanding of and engagement in that process.
Collapse
Affiliation(s)
- Benji K Mathews
- From HealthPartners Hospital Medicine, St Paul, Critical Care Research Center, Regions Hospital, St Paul, Minnesota, and the Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis
| | - Paula E Miller
- From HealthPartners Hospital Medicine, St Paul, Critical Care Research Center, Regions Hospital, St Paul, Minnesota, and the Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis
| | - Andrew P J Olson
- From HealthPartners Hospital Medicine, St Paul, Critical Care Research Center, Regions Hospital, St Paul, Minnesota, and the Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis
| |
Collapse
|
32
|
Bonasso PC, Dassinger MS, Wyrick DL, Gurien LA, Burford JM, Smith SD. Review of bedside surgeon-performed ultrasound in pediatric patients. J Pediatr Surg 2018; 53:2279-2289. [PMID: 29807830 DOI: 10.1016/j.jpedsurg.2018.04.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 03/21/2018] [Accepted: 04/28/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Pediatric surgeon performed bedside ultrasound (PSPBUS) is a targeted examination that is diagnostic or therapeutic. The aim of this paper is to review literature involving PSPBUS. METHODS PSPBUS practices reviewed in this paper include central venous catheter placement, physiologic assessment (volume status and echocardiography), hypertrophic pyloric stenosis diagnosis, appendicitis diagnosis, the Focused Assessment with Sonography for Trauma (FAST), thoracic evaluation, and soft tissue infection evaluation. RESULTS There are no standards for the practice of PSPBUS. CONCLUSIONS As the role of the pediatric surgeon continues to evolve, PSPBUS will influence practice patterns, disease diagnosis, and patient management. TYPE OF STUDY Review Article. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Patrick C Bonasso
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202.
| | - Melvin S Dassinger
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Deidre L Wyrick
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Lori A Gurien
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Jeffrey M Burford
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| | - Samuel D Smith
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR 72202
| |
Collapse
|
33
|
Abstract
This article covers the diagnosis and treatment of skin and soft tissue infections commonly encountered in the emergency department: impetigo, cutaneous abscesses, purulent cellulitis, nonpurulent cellulitis, and necrotizing skin and soft tissue infections. Most purulent infections in the United States are caused by methicillin-resistant Staphylococcus aureus. For abscesses, we emphasize the importance of incision and drainage. Nonpurulent infections are usually caused by streptococcal species and initial empiric antibiotics need not cover methicillin-resistant Staphylococcus aureus. For uncommon but potentially lethal necrotizing skin and soft tissue infections, the challenge is rapid diagnosis in the emergency department and prompt surgical exploration and debridement.
Collapse
|
34
|
Lam SHF, Sivitz A, Alade K, Doniger SJ, Tessaro MO, Rabiner JE, Arroyo A, Castillo EM, Thompson CA, Yang M, Mistry RD. Comparison of Ultrasound Guidance vs. Clinical Assessment Alone for Management of Pediatric Skin and Soft Tissue Infections. J Emerg Med 2018; 55:693-701. [PMID: 30170835 DOI: 10.1016/j.jemermed.2018.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/15/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) can potentially help distinguish cellulitis from abscess, which can appear very similar on physical examination but necessitate different treatment approaches. OBJECTIVE To compare POCUS guidance vs. clinical assessment alone on the management of pediatric skin and soft tissue infections (SSTI) in the emergency department (ED) setting. METHODS Children ages 6 months to 18 years presenting to participating EDs with SSTIs ≥ 1 cm were eligible. All treatment decisions, including use of POCUS, were at the discretion of the treating clinicians. Patients were divided into those managed with POCUS guidance (POCUS group) and those managed using clinical assessment alone (non-POCUS group). Primary outcome was clinical treatment failure at 7-10 days (unscheduled ED return visit or admission, procedural intervention, change in antibiotics therapy). Secondary outcomes were ED length of stay, discharge rate, use of alternative imaging, and need for procedural sedation. POCUS utility and impact on management decisions were also assessed by treating clinicians. RESULTS In total, 321 subjects (327 lesions) were analyzed, of which 299 (93%) had completed follow-up. There was no significant difference between the POCUS and non-POCUS groups in any of the primary or secondary outcomes. Management plan was changed in the POCUS group in 22.9% of cases (13.8% from medical to surgical, 9.1% from surgical to medical). Clinicians reported increased benefit of POCUS in cases of higher clinical uncertainty. CONCLUSIONS Use of POCUS was not associated with decreased ED treatment failure rate or process outcomes in pediatric SSTI patients. However, POCUS changed the management plan in approximately one in four cases.
Collapse
Affiliation(s)
- Samuel H F Lam
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Adam Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Kiyetta Alade
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Stephanie J Doniger
- Department of Emergency Medicine, NYU Winthrop Hospital, Mineola, New York; St Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Mark O Tessaro
- Division of Paediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joni E Rabiner
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Alexander Arroyo
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Edward M Castillo
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Caroline A Thompson
- Department of Public Health, San Diego State University, San Diego, California
| | - Mingan Yang
- Department of Public Health, San Diego State University, San Diego, California
| | - Rakesh D Mistry
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado
| |
Collapse
|
35
|
Wagner M, Shen-Wagner J, Zhang KX, Flynn T, Bergman K. Point-of-Care Ultrasound Applications in the Outpatient Clinic. South Med J 2018; 111:404-410. [DOI: 10.14423/smj.0000000000000835] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
36
|
Peh WM, Kang ML. A pilot survey on an understanding of point of care bedside ultrasound (POCUS) among medical doctors in internal medicine: Exposure, perceptions, interest and barriers to training. PROCEEDINGS OF SINGAPORE HEALTHCARE 2018. [DOI: 10.1177/2010105817731412] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Clinical bedside point-of-care ultrasonography (POCUS) is an important adjunct to history and physical examination. The objective of this pilot survey is to assess the level of exposure, perceptions, interest levels and possible barriers toward training of POCUS in internal medicine. Methods: In October 2015, all medical doctors who were working in the Singapore General Hospital Internal Medicine Department were invited to complete a hard-copy printed 27-question Likert-scale survey. Results: A total of 124 medical doctors participated in the survey (response rate 82.1%). The proportions of participants who have heard, witnessed, and performed POCUS were 65.6% ( N = 82), 71.2% ( N = 89) and 41.6% ( N = 52), respectively. POCUS was rated highly on usefulness in the practice of internal medicine ( M = 8.74; SD = 1.34). The top three POCUS skills that doctors would like to acquire would be (1) procedural guidance POCUS (70.8%); (2) point-of-care cardiac ultrasound (69%) and (3) lung ultrasound 58.4% (based on percentage ranked first through third). The sample mean of interest in undergoing further training in POCUS is 8.91 (SD = 1.27) (0 = not interested, 10 = very interested). The top three barriers identified were (1) lack of an ultrasound machine ( M = 7.98 SD = 2.28); (2) cost of an ultrasound machine ( M = 7.79 SD = 2.19) and (3) lack of a formal training curriculum ( M = 7.25 SD = 2.08) (0 = not a barrier at all, 10 = severe barrier). Conclusions: There is a high level of exposure and interest in POCUS. Doctors perceived bedside POCUS as very useful in the practice of internal medicine. A lack of machine and formal curriculum impedes development of a training program. This pilot survey may serve as a basic needs assessment to an implementation of an internal medicine POCUS training curriculum.
Collapse
Affiliation(s)
- Wee Ming Peh
- Department of Internal Medicine, Division of Medicine, Singapore General Hospital, Singapore
| | - Mei Ling Kang
- Department of Internal Medicine, Division of Medicine, Singapore General Hospital, Singapore
| |
Collapse
|
37
|
Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: a systematic review of the literature. Eur J Emerg Med 2018; 24:162-169. [PMID: 26485694 DOI: 10.1097/mej.0000000000000340] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In patients presenting with skin and soft tissue infections (SSTI), the use of ultrasound may lead to a more accurate distinction between cellulitis and abscess compared with clinical assessment alone. OBJECTIVES This systematic review aims to determine the diagnostic accuracy of ultrasound for detecting skin abscesses. In addition, it aims to assess the impact of using ultrasound on management decisions in patients with SSTI. METHODS We searched relevant electronic databases for primary studies including MEDLINE, EMBASE, and CINAHL. We searched conference proceedings, checked references of retrieved articles, and contacted field experts. Two reviewers assessed the quality of each full-text publication using a modified QUADAS-2 tool. RESULTS Five studies (n=710) fulfilled our inclusion criteria. Four studies compared the diagnostic accuracy of ultrasound with clinical examination alone (n=584). Most studies reported an improvement in diagnostic accuracy. The sensitivity of ultrasound ranged from 89 to 98% and the specificity ranged from 64 to 88%. However, the sensitivity of clinical assessment ranged from 75 to 90% and the specificity ranged from 55 to 83%; most of these results did not reach statistical significance. Sensitivity was further improved in cases of indeterminate clinical assessment. Two studies (n=176) examined the impact of ultrasound on management decisions. Use of ultrasound has led to significant and appropriate changes in management decisions in 16 to 39% of patients. CONCLUSION The use of ultrasound could potentially improve diagnostic accuracy and lead to improved management decisions in patients with SSTI, especially in cases of indeterminate clinical assessment. Most of our findings did not achieve statistical significance. Further research is required to confirm these findings.
Collapse
|
38
|
Ultrasonography in Emergency Department; a Diagnostic Tool for Better Examination and Decision-Making. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2017; 2:e7. [PMID: 31172070 PMCID: PMC6548109 DOI: 10.22114/ajem.v0i0.40] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Context: The aim of this study is to evaluate the applications of ultrasonography (US) as a diagnostic tool in emergency settings. Evidence acquisition: In the present review article, search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane were searched for the applications of US in emergencies. Finally, related articles which were published between 2000 and 2017, were selected and by reviewing them an attempt was made to evaluate various applications of US for examining and facilitating decision-making in emergency department (ED). Results: As a diagnostic tool, US can be of diagnostic help in emergency settings for the specialists and the treatment team regarding trauma, measuring intracranial pressure (ICP), hemothorax pneumothorax, abscess and its drainage, deep vein thrombosis (DVT), dyspnea, acute abdomen, appendicitis and biliary problems, renal colic and renal stones, shock, foreign object, bone fracture, peripheral nerve block, establishing central and peripheral venous access, lumbar puncture (LP), and confirmation of nasogastric tube (NGT) and endotracheal tube (ETT) placement. Conclusion: The results of this review study showed that US can be of help to EMPs as a diagnostic tool in a wide range of diseases and clinical conditions, which in turn can result in a decrease in the time needed for diagnosis and treatment, and therefore improve both the quality and quantity of the service provided in ED.
Collapse
|
39
|
Abstract
Though the use of point-of-care ultrasound (POCUS) has increased over the last decade, formal hospital credentialing for POCUS may still be a challenge for hospitalists. This document details the Hospital Medicine Department Ultrasound Credentialing Policy from Regions Hospital, which is part of the HealthPartners organization in Saint Paul, Minnesota. National organizations from internal medicine and hospital medicine (HM) have not published recommended guidelines for POCUS credentialing. Revised guidelines for POCUS have been published by the American College of Emergency Physicians, though these are not likely intended to guide hospitalists when working with credentialing committees and medical boards. This document describes the scope of ultrasound in HM and our training, credentialing, and quality assurance program. This report is intended to be used as a guide for hospitalists as they work with their own credentialing committees and will require modification for each institution. However, the overall process described here should assist in the establishment of POCUS at various institutions.
Collapse
Affiliation(s)
- Benji K Mathews
- Department of Hospital Medicine, HealthPartners, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Michael Zwank
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Regions Hospital, St. Paul, Minnesota, USA
| |
Collapse
|
40
|
Barbic D, Chenkin J, Cho DD, Jelic T, Scheuermeyer FX. In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis. BMJ Open 2017; 7:e013688. [PMID: 28073795 PMCID: PMC5253602 DOI: 10.1136/bmjopen-2016-013688] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES The primary objective of this systematic review was to determine the accuracy of point-of-care ultrasonography (POCUS) in diagnosing abscess in emergency department (ED) patients with skin and soft tissue infections (SSTI). The secondary objective was the accuracy of POCUS in the paediatric population subgroup. SETTING Prospective studies set in emergency departments. PARTICIPANTS Emergency department patients (adult and paediatric) presenting with SSTI and suspected abscess. PRIMARY AND SECONDARY OUTCOME MEASURES This systematic review was conducted according to Cochrane Handbook guidelines, and the following databases were searched: PubMed, MEDLINE, EMBASE and the Cochrane database of systematic reviews (1946-2015). We included prospective cohort and case-control studies investigating ED patients with SSTI and abscess or cellulitis, a defined POCUS protocol, a clearly defined gold standard for abscess and a contingency table describing sensitivity and specificity. Two reviewers independently ascertained all potentially relevant citations for methodologic quality according to QUADAS-2 criteria. The primary outcome measure was the sensitivity and specificity of POCUS for abscess. A preplanned subgroup (secondary) analysis examined the effects in paediatric populations, and changes in management were explored post hoc. RESULTS Of 3028 articles, 8 were identified meeting inclusion criteria; all were rated as good to excellent according to QUADAS-2 criteria. Combined test characteristics of POCUS on the ED diagnosis of abscess for patients with SSTI were as follows: sensitivity 96.2% (95% CI 91.1% to 98.4%), specificity 82.9% (95% CI 60.4% to 93.9%), positive likelihood ratio 5.63 (95% CI 2.2 to 14.6) and negative likelihood ratio 0.05 (95% CI 0.01 to 0.11). CONCLUSIONS A total of 8 studies of good-to-excellent quality were included in this review. The use of POCUS helps differentiate abscess from cellulitis in ED patients with SSTI. TRIAL REGISTRATION NUMBER CRD42015017115.
Collapse
Affiliation(s)
- David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan Chenkin
- Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dennis D Cho
- Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tomislav Jelic
- Department of Emergency Medicine, University of South Florida, Tampa, Florida, USA
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
41
|
Amini R, Amini A, Hollinger P, Rhodes SM, Schmier C. Emergency department diagnosis of a concealed pleurocutaneous fistula in a 78-year-old man using point-of-care ultrasound. World J Emerg Med 2016; 7:307-309. [PMID: 27965727 DOI: 10.5847/wjem.j.1920-8642.2016.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Richard Amini
- Emergency Medicine, University of Arizona, Tucson, Arizona 85724, USA
| | - Albert Amini
- Arizona Premier Surgery, 640 W Yellowstone Way, Chandler, Arizona 85248, USA
| | - Patrick Hollinger
- Emergency Medicine, University of Arizona, Tucson, Arizona 85724, USA
| | | | - Charles Schmier
- Emergency Medicine, University of Arizona, Tucson, Arizona 85724, USA
| |
Collapse
|
42
|
Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.
Collapse
Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
| | | | | | | | | | | |
Collapse
|
43
|
Management of Post-Traumatic Complications by Interventional Ultrasound: a Review. CURRENT TRAUMA REPORTS 2016. [DOI: 10.1007/s40719-016-0057-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
44
|
Whitson MR, Mayo PH. Ultrasonography in the emergency department. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:227. [PMID: 27523885 PMCID: PMC4983783 DOI: 10.1186/s13054-016-1399-x] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Point-of-care ultrasonography (POCUS) is a useful imaging technique for the emergency medicine (EM) physician. Because of its growing use in EM, this article will summarize the historical development, the scope of practice, and some evidence supporting the current applications of POCUS in the adult emergency department. Bedside ultrasonography in the emergency department shares clinical applications with critical care ultrasonography, including goal-directed echocardiography, echocardiography during cardiac arrest, thoracic ultrasonography, evaluation for deep vein thrombosis and pulmonary embolism, screening abdominal ultrasonography, ultrasonography in trauma, and guidance of procedures with ultrasonography. Some applications of POCUS unique to the emergency department include abdominal ultrasonography of the right upper quadrant and appendix, obstetric, testicular, soft tissue/musculoskeletal, and ocular ultrasonography. Ultrasonography has become an integral part of EM over the past two decades, and it is an important skill which positively influences patient outcomes.
Collapse
Affiliation(s)
- Micah R Whitson
- Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA.
| | - Paul H Mayo
- Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA
| |
Collapse
|
45
|
Surgical wound assessment by sonography in the prediction of surgical wound infections. J Trauma Acute Care Surg 2016; 80:229-36. [PMID: 26502211 DOI: 10.1097/ta.0000000000000908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are important sources of morbidity, prolonged hospital stays, and readmissions, so they have become a major economic burden. We hypothesized that surgical wound assessment by sonography (SWATS) used at the bedside would detect wound fluid collections and that the presence of such collections would predict SSI better than standard clinical examination. If so, SWATS might be used to indicate early intervention that could prevent SSI morbidity. METHODS A prospective, single-institution observational study was conducted on adult inpatients following open abdominal surgery for trauma, gastrointestinal pathology, or biliary pathology at high risk (>5%) for SSI using traditional wound classifications. After informed consent was obtained, SWATS was performed using a smartphone-based ultrasound system on postoperative Day 2 to 4 and again before discharge or at postoperative Day 30, whichever came first. Primary treating physicians delivered standard wound care and were blinded to SWATS. SSI was diagnosed if treatment was implemented for suspected or documented wound infection by the treating physician. Results were analyzed by χ test and two-sample pooled variance t test where appropriate, with significance set at p < 0.05. RESULTS Forty-nine patients were studied. Nineteen patients had peri-incisional fluid collections found by SWATS. Eight of these patients went on to develop an SSI. SSI was significantly associated with the presence of fluid collections on SWATS (p = 0.009). SWATS had a sensitivity of 72.7% (0.43-0.92), a specificity of 71.1% (0.62-0.77), a positive predictive value of 42.1% (0.25-0.53), and a negative predictive value of 90.0% (0.79-0.97). CONCLUSION SWATS has a high negative predictive value that may allow it be an effective screening tool for developing SSI in high-risk surgical wounds. SWATS has the potential to be a useful and cost-effective adjunct to the clinician by objectively suggesting need for early therapy. Further study with larger sample sizes and randomized, SWATS-based interventions are required to validate this small study and determine its place in clinical care. LEVEL OF EVIDENCE Diagnostic study, level IV.
Collapse
|
46
|
Shah A, Ahmed I, Hassan S, Samoon A, Ali B. Evaluation of ultrasonography as a diagnostic tool in the management of head and neck facial space infections: A clinical study. Natl J Maxillofac Surg 2015; 6:55-61. [PMID: 26668454 PMCID: PMC4668734 DOI: 10.4103/0975-5950.168213] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Introduction: Superficial facial space infections represent a significant amount of the dental problems that present to hospital. Determining whether an odontogenic swelling is a cellulitis or abscess is difficult, but important as both may require different treatments. The use of an ultrasound may aid in differentiating cellulitis and abscess. This study was done to compare the accuracy of clinical examination alone versus ultrasonography (USG) in the diagnosis of cellulitis and abscess in symptomatic patients with a diagnosis of superficial facial space infection. Materials and Methods: Twenty patients (1870 years) diagnosed as superficial facial space infections by clinical and radiographic examinations were included in the study and patients with significant medical conditions were excluded. The provisional clinical diagnosis was made after a thorough history was taken and clinical examination was performed to determine if the swelling was a cellulitis or abscess. Swelling was then evaluated using the ultrasonic transducer which was placed over the swelling to aid the diagnosis which was again recorded. An incision and drainage procedure was performed after the administration of local anesthesia. The success of the ultrasound intervention versus clinical examination was based on whether frank exudation was detected during incision and drainage of such swellings. Results: The statistical analysis found that USG is a valuable diagnostic aid for detection of abscess or cellulitis in head and neck facial space infections. Interpretation and Conclusion: The findings of this prospective analysis indicate that there was statistical difference between clinical examination alone and USG in making the correct diagnosis. The sensitivity, specificity, positive predictive, negative predictive, and accuracy were not similar for all methods tested. From the results of this study, ultrasound is recommended as an adjunct to clinical examination in differentiating between cellulitis and abscess.
Collapse
Affiliation(s)
- Ajaz Shah
- Department of Oral and Maxillofacial Surgery, Government Dental College, Srinagar, Jammu and Kashmir, India
| | - Irshad Ahmed
- Department of Oral and Maxillofacial Surgery, Government Dental College, Srinagar, Jammu and Kashmir, India
| | - Shahid Hassan
- Department of Oral and Maxillofacial Surgery, Government Dental College, Srinagar, Jammu and Kashmir, India
| | - Amina Samoon
- Department of Oral and Maxillofacial Surgery, Government Dental College, Srinagar, Jammu and Kashmir, India
| | - Babar Ali
- Department of Oral and Maxillofacial Surgery, Government Dental College, Srinagar, Jammu and Kashmir, India
| |
Collapse
|
47
|
Abstract
BACKGROUND The purpose of this study was to determine the test characteristics of formal ultrasound when used to diagnose upper extremity soft tissue abscess in the setting of suspected infection. METHODS We completed a retrospective chart review of all patients who had formal ultrasounds at our institution for the indication of diagnosing upper extremity abscess between July 2010 and July 2013. Using presence of purulence as the gold standard for diagnosis of abscess, we calculated the test characteristics of ultrasound. We then performed a series of logistic regression models with ultrasound being the independent variable of interest. RESULTS Using search criteria consistent with upper extremity abscess, we identified 512 patients who underwent ultrasound examinations during our study period. Of these, 178 met the enrollment criteria. Ultrasound reports revealed 110 negative findings, 37 definitively positive findings, and 31 ambiguous findings. Forty-four patients had a final diagnosis of abscess, and 15 of these patients had negative or ambiguous ultrasounds. The sensitivity of definitively positive ultrasound was 65.9 %. The specificity was 94.0 %. Positive predictive value (PPV) of a definitively positive ultrasound result was 78.4 %, and negative predictive value (NPV) of a definitively negative result was 90 %. Logistic regression demonstrated a statistically significant association between definitively positive ultrasound and abscess, but no association between ambiguous ultrasound and abscess after adjustment for significant covariates. CONCLUSIONS Ultrasound is not a sensitive method to detect the presence of abscess in the setting of upper extremity infection. However, in this population of patients with suspected abscess, the negative predictive value was high with and without the inclusion of ambiguous results, suggesting reasonable utility of ultrasound as a rule-out test. LEVEL OF EVIDENCE Diagnostic study, Level II.
Collapse
Affiliation(s)
- Andrea Halim
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
| | - Yushane Shih
- Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Seth D. Dodds
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 800 Howard Avenue, New Haven, CT 06510 USA
| |
Collapse
|
48
|
Mistry RD, Shapiro DJ, Goyal MK, Zaoutis TE, Gerber JS, Liu C, Hersh AL. Clinical management of skin and soft tissue infections in the U.S. Emergency Departments. West J Emerg Med 2015; 15:491-8. [PMID: 25035757 PMCID: PMC4100857 DOI: 10.5811/westjem.2014.4.20583] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/27/2014] [Accepted: 04/16/2014] [Indexed: 11/25/2022] Open
Abstract
Introduction Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) has emerged as the most common cause of skin and soft-tissue infections (SSTI) in the United States. A nearly three-fold increase in SSTI visit rates had been documented in the nation’s emergency departments (ED). The objective of this study was to determine characteristics associated with ED performance of incision and drainage (I+D) and use of adjuvant antibiotics in the management of skin and soft tissue infections (SSTI). Methods Cross-sectional study of the National Hospital Ambulatory Medical Care Survey, a nationally representative database of ED visits from 2007–09. Demographics, rates of I+D, and adjuvant antibiotic therapy were described. We used multivariable regression to identify factors independently associated with use of I+D and adjuvant antibiotics. Results An estimated 6.8 million (95% CI: 5.9–7.8) ED visits for SSTI were derived from 1,806 sampled visits; 17% were for children <18 years of age and most visits were in the South (49%). I+D was performed in 27% (95% CI 24–31) of visits, and was less common in subjects <18 years compared to adults 19–49 years (p<0.001), and more common in the South. Antibiotics were prescribed for 85% of SSTI; there was no relationship to performance of I+D (p=0.72). MRSA-active agents were more frequently prescribed after I+D compared to non-drained lesions (70% versus 56%, p<0.001). After multivariable adjustment, I+D was associated with presentation in the South (OR 2.36; 95% CI 1.52–3.65 compared with Northeast), followed by West (OR 2.13; 1.31–3.45), and Midwest (OR 1.96; 1.96–3.22). Conclusion Clinical management of most SSTIs in the U.S. involves adjuvant antibiotics, regardless of I+D. Although not necessarily indicated, CA-MRSA effective therapy is being used for drained SSTI.
Collapse
Affiliation(s)
- Rakesh D Mistry
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Daniel J Shapiro
- University of California, San Francisco Medical Center, Department of Pediatrics, San Francisco, California
| | - Monika K Goyal
- George Washington University, Department of Emergency Medicine, Washington, District of Columbia
| | - Theoklis E Zaoutis
- Perelman School of Medicine at the University of Pennsylvania, Division of Infectious Diseases, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- Perelman School of Medicine at the University of Pennsylvania, Division of Infectious Diseases, Philadelphia, Pennsylvania
| | - Catherine Liu
- University of California, San Francisco School of Medicine, Division of Infectious Diseases, San Francisco, California
| | - Adam L Hersh
- University of Utah School of Medicine, Division of Infectious Diseases, Salt Lake City, Utah
| |
Collapse
|
49
|
Bedside ultrasound procedures: musculoskeletal and non-musculoskeletal. Eur J Trauma Emerg Surg 2015; 42:127-38. [PMID: 26059560 DOI: 10.1007/s00068-015-0539-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 05/11/2015] [Indexed: 01/13/2023]
Abstract
The widespread availability of ultrasound (US) technology has increased its use for point of care applications in many health care settings. Focused (point of care) US is defined as the act of bringing US evaluation to the bedside for real-time performance. These images are collected immediately by the practitioner, allowing for direct integration into the physician's medical decision-making process. The real-time bedside diagnostic ability of US becomes a key tool for the management of patients. The purpose of this review is to (1) provide a general description of the use of focused US for bedside procedures; (2) specify the indications and common techniques used in bedside US procedures; and (3) describe the techniques used for each bedside intervention.
Collapse
|
50
|
Abstract
Emergency physicians have used point-of-care ultrasonography since the 1990 s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.
Collapse
|