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Weekes AJ, Trautmann A, Hambright PL, Ali S, Pikus AM, Wellinsky N, Goonan KL, Bradford S, O'Connell NS. Comparison of Treatment Approaches and Subsequent Outcomes within a Pulmonary Embolism Response Team Registry. Crit Care Res Pract 2024; 2024:5590805. [PMID: 38560480 PMCID: PMC10980543 DOI: 10.1155/2024/5590805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 02/19/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024] Open
Abstract
Objectives To characterize the association between pulmonary embolism (PE) severity and bleeding risk with treatment approaches, outcomes, and complications. Methods Secondary analysis of an 11-hospital registry of adult ED patients treated by a PE response team (August 2016-November 2022). Predictors were PE severity and bleeding risk. The primary outcome was treatment approach: anticoagulation monotherapy vs. advanced intervention (categorized as "immediate" or "delayed" based on whether the intervention was received within 12 hours of PE diagnosis or not). Secondary outcomes were death, clinical deterioration, and major bleeding. Results Of the 1832 patients, 139 (7.6%), 977 (53.3%), and 9 (0.5%) were classified as high-risk, intermediate-high, intermediate-low, and low-risk severity, respectively. There were 94 deaths (5.1%) and 218 patients (11.9%) had one or more clinical deterioration events. Advanced interventions were administered to 86 (61.9%), 195 (27.6%), and 109 (11.2%) patients with high-risk, intermediate-high, and intermediate-low severity, respectively.Major bleeding occurred in 61/1440 (4.2%) on ACm versus 169/392 (7.6%) with advanced interventions (p <0.001): bleeding withcatheter-directed thrombolysiswas 19/145 (13.1%) versus 33/154(21.4%) with systemic thrombolysis,p= 0.07. High risk was twice as strong as intermediate-high risk for association with advanced intervention (OR: 5.3 (4.2 and 6.9) vs. 1.9 (1.6 and 2.2)). High risk (OR: 56.3 (32.0 and 99.2) and intermediate-high risk (OR: 2.6 (1.7 and 4.0)) were strong predictors of clinical deterioration. Major bleeding was significantly associated with advanced interventions (OR: 5.2 (3.5 and 7.8) for immediate, 3.3 (1.8 and 6.2)) for delayed, and high-risk PE severity (OR: 3.4 (1.9 and 5.8)). Conclusions Advanced intervention use was associated with high-acuity patients experiencing death, clinical deterioration, and major bleeding with a trend towards less bleeding with catheter-directed interventions versus systemic thrombolysis.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Ariana Trautmann
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Parker L. Hambright
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Shane Ali
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Angela M. Pikus
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Nicole Wellinsky
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kelly L. Goonan
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Sarah Bradford
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Weekes AJ, Davison J, Lupez K, Raper JD, Thomas AM, Cox CA, Esener D, Boyd JS, Nomura JT, Murphy K, Ockerse PM, Leech S, Johnson J, Abrams E, Kelly C, O'Connell NS. Quality of life 1 month after acute pulmonary embolism in emergency department patients. Acad Emerg Med 2023; 30:819-831. [PMID: 36786661 DOI: 10.1111/acem.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/30/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE The Pulmonary Embolism Quality-of-Life (PEmb-QoL) questionnaire assesses quality of life (QoL) after pulmonary embolism (PE). We aimed to determine whether any clinical or pathophysiologic features of PE were associated with worse PEmb-QoL scores 1 month after PE. METHODS In this prospective multicenter registry, we conducted PEmb-QoL questionnaires. We determined differences in QoL domain scores for four primary variables: clinical deterioration (death, cardiac arrest, respiratory failure, hypotension requiring fluid bolus, catecholamine support, or new dysrhythmia), right ventricular dysfunction (RVD), PE risk stratification, and subsequent rehospitalization. For overall QoL score, we fit a multivariable regression model that included these four primary variables as independent variables. RESULTS Of 788 PE patients participating in QoL assessments, 156 (19.8%) had a clinical deterioration event, 236 (30.7%) had RVD of which 38 (16.1%) had escalated interventions. For those without and with clinical deterioration, social limitations had mean (±SD) scores of 2.07 (±1.27) and 2.36 (±1.47), respectively (p = 0.027). For intensity of complaints, mean (±SD) scores for patients without RVD (4.32 ± 2.69) were significantly higher than for those with RVD with or without reperfusion interventions (3.82 ± 1.81 and 3.83 ± 2.11, respectively; p = 0.043). There were no domain score differences between PE risk stratification groups. All domain scores were worse for patients with rehospitalization versus without. By multivariable analysis, worse total PEmb-QoL scores with effect sizes were subsequent rehospitalization 11.29 (6.68-15.89), chronic obstructive pulmonary disease (COPD) 8.17 (3.91-12.43), and longer index hospital length of stay 0.06 (0.03-0.08). CONCLUSIONS Acute clinical deterioration, RVD, and PE severity were not predictors of QoL at 1 month post-PE. Independent predictors of worsened QoL were rehospitalization, COPD, and index hospital length of stay.
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Affiliation(s)
- Anthony J Weekes
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Health, Orlando, Florida, USA
| | - Kathryn Lupez
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Department of Emergency Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jaron D Raper
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alyssa M Thomas
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Emergency Department, Houston Methodist Baytown Hospital, Houston, Texas, USA
| | - Carly A Cox
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Emergency Medicine of Idaho, Meridian, Idaho, USA
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente, San Diego, California, USA
| | - Jeremy S Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jason T Nomura
- Department of Emergency Medicine, Christiana Care, Newark, Delaware, USA
| | - Kathleen Murphy
- Department of Emergency Medicine, Christiana Care, Newark, Delaware, USA
| | - Patrick M Ockerse
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Health, Orlando, Florida, USA
| | - Jakea Johnson
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric Abrams
- Department of Emergency Medicine, Kaiser Permanente, San Diego, California, USA
| | - Christopher Kelly
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Weekes AJ, Raper JD, Esener D, Davison J, Boyd JS, Kelly C, Nomura JT, Thomas AM, Lupez K, Cox CA, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, O'Connell NS. Comparing predictive performance of pulmonary embolism risk stratification tools for acute clinical deterioration. J Am Coll Emerg Physicians Open 2023; 4:e12983. [PMID: 37251351 PMCID: PMC10214857 DOI: 10.1002/emp2.12983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives Existing pulmonary embolism (PE) risk scores were developed to predict death within weeks, but not more proximate adverse events. We determined the ability of 3 PE risk stratification tools (simplified pulmonary embolism severity index [sPESI], 2019 European Society of Cardiology guidelines [ESC], and PE short-term clinical outcomes risk estimation [PE-SCORE]) to predict 5-day clinical deterioration after emergency department (ED) diagnosis of PE. Methods We analyzed data from six EDs on ED patients with confirmed PE. Clinical deterioration was defined as death, respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension requiring vasopressors or volume resuscitation, or escalated intervention within 5 days of PE diagnosis. We determined sensitivity and specificity of sPESI, ESC, and PE-SCORE for predicting clinical deterioration. Results Of 1569 patients, 24.5% had clinical deterioration within 5 days. sPESI, ESC, and PE-SCORE classifications were low-risk in 558 (35.6%), 167 (10.6%), and 309 (19.6%), respectively. Sensitivities of sPESI, ESC, and PE-SCORE for clinical deterioration were 81.8 (78, 85.7), 98.7 (97.6, 99.8), and 96.1 (94.2, 98), respectively. Specificities of sPESI, ESC, and PE-SCORE for clinical deterioration were 41.2 (38.4, 44), 13.7 (11.7, 15.6), and 24.8 (22.4, 27.3). Areas under the curve were 61.5 (59.1, 63.9), 56.2 (55.1, 57.3), and 60.5 (58.9, 62.0). Negative predictive values were 87.5 (84.7, 90.2), 97 (94.4, 99.6), and 95.1 (92.7, 97.5). Conclusions ESC and PE-SCORE were better than sPESI for detecting clinical deterioration within 5 days after PE diagnosis.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
| | - Jaron D. Raper
- Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
- Present address:
Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabama
| | - Dasia Esener
- Department of Emergency MedicineKaiser PermanenteSan DiegoCaliforniaUSA
| | - Jillian Davison
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Jeremy S. Boyd
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Christopher Kelly
- Department of Emergency MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Jason T. Nomura
- Department of Emergency MedicineChristiana CareNewarkDelawareUSA
| | - Alyssa M. Thomas
- Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
- Present address:
Emergency DepartmentHouston Methodist Baytown HospitalHoustonTexas
| | - Kathryn Lupez
- Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
- Present address:
Department of Emergency MedicineTufts Medical CenterBostonMassachusetts
| | - Carly A. Cox
- Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
- Present address:
Emergency Medicine of IdahoMeridianIdaho
| | - Patrick M. Ockerse
- Department of Emergency MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Stephen Leech
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Jakea Johnson
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Eric Abrams
- Department of Emergency MedicineKaiser PermanenteSan DiegoCaliforniaUSA
| | - Kathleen Murphy
- Department of Emergency MedicineChristiana CareNewarkDelawareUSA
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data ScienceWake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
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Weekes AJ, Raper JD, Thomas AM, Lupez K, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Abrams E, Kelly C, O'Connell NS. Electrocardiographic findings associated with early clinical deterioration in acute pulmonary embolism. Acad Emerg Med 2022; 29:1185-1196. [PMID: 35748352 PMCID: PMC9796434 DOI: 10.1111/acem.14554] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES We sought to determine associations of early electrocardiogram (ECG) patterns with clinical deterioration (CD) within 5 days and with RV abnormality (abnlRV) by echocardiography in pulmonary embolism (PE). METHODS In this prospective, multicenter study of newly confirmed PE patients, early echocardiography and initial ECG were examined. Initial ECG patterns included lead-specific ST-segment elevation (STE) or depression (STD), T-wave inversion (TWI), supraventricular tachycardia (SVT), sinus tachycardia, and right bundle branch block as complete (cRBBB) or incomplete (iRBBB). We defined CD as respiratory failure, hypotension, dysrhythmia, cardiac arrest, escalated PE intervention, or death within 5 days. We calculated odds ratios (ORs) for CD and abnlRV with univariate and full multivariate models in the presence of other variables. RESULTS Of 1676 patients, 1629 (97.2%) had both ECG and GDE; 415/1676 (24.7%) had CD, and 529/1629 (32.4%) had abnlRV. AbnlRV had an OR for CD of 4.25 (3.35, 5.38). By univariable analysis, the absence of abnormal ECG patterns had OR for CD and abnlRV of 0.34 (0.26, 0.44; p < 0.001) and 0.24 (0.18, 0.31; p < 0.001), respectively. By multivariable analyses, one ECG pattern had a significant OR for CD: SVT 2.87 (1.66, 5.00). Significant ORS for abnlRV were: TWI V2-4 4.0 (2.64, 6.12), iRBBB 2.63 (1.59, 4.38), STE aVR 2.42 (1.58, 3.74), S1-Q3-T3 2.42 (1.70, 3.47), and sinus tachycardia 1.68 (1.14, 2.49). CONCLUSIONS SVT was an independent predictor of CD. TWI V2-4 , iRBBB, STE aVR, sinus tachycardia, and S1-Q3-T3 were independent predictors of abnlRV. Finding one or more of these ECG patterns may increase considerations for performance of echocardiography to look for RV abnormalities and, if present, inform concerns for early clinical deterioration.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency MedicineAtrium Health's Carolinas Medical Center (Carolinas Medical Center is the Central Site of the Pulmonary Embolism Short‐term Outcomes Registry (PESCOR) consortium)CharlotteNorth CarolinaUSA
| | - Jaron D. Raper
- Department of Emergency MedicineAtrium Health's Carolinas Medical Center (Carolinas Medical Center is the Central Site of the Pulmonary Embolism Short‐term Outcomes Registry (PESCOR) consortium)CharlotteNorth CarolinaUSA,Jaron D. Raper, Department of Emergency MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Alyssa M. Thomas
- Department of Emergency MedicineAtrium Health's Carolinas Medical Center (Carolinas Medical Center is the Central Site of the Pulmonary Embolism Short‐term Outcomes Registry (PESCOR) consortium)CharlotteNorth CarolinaUSA,Alyssa M. Thomas, Emergency DepartmentHouston Methodist Baytown HospitalHoustonTexasUSA
| | - Kathryn Lupez
- Department of Emergency MedicineAtrium Health's Carolinas Medical Center (Carolinas Medical Center is the Central Site of the Pulmonary Embolism Short‐term Outcomes Registry (PESCOR) consortium)CharlotteNorth CarolinaUSA,Kathryn Lupez, Department of Emergency MedicineTufts Medical CenterBostonMassachusettsUSA
| | - Carly A. Cox
- Department of Emergency MedicineAtrium Health's Carolinas Medical Center (Carolinas Medical Center is the Central Site of the Pulmonary Embolism Short‐term Outcomes Registry (PESCOR) consortium)CharlotteNorth CarolinaUSA,Carly A. Cox, Emergency Medicine of IdahoMeridianIdahoUSA
| | - Dasia Esener
- Department of Emergency Medicine Kaiser PermanenteSan DiegoCaliforniaUSA
| | - Jeremy S. Boyd
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jason T. Nomura
- Department of Emergency MedicineChristiana CareNewarkDelawareUSA
| | - Jillian Davison
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Patrick M. Ockerse
- Division of Emergency MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Stephen Leech
- Department of Emergency MedicineOrlando HealthOrlandoFloridaUSA
| | - Eric Abrams
- Department of Emergency Medicine Kaiser PermanenteSan DiegoCaliforniaUSA
| | - Christopher Kelly
- Division of Emergency MedicineUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
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Weekes AJ, Fraga DN, Belyshev V, Bost W, Gardner CA, O’Connell NS. Intermediate-risk pulmonary embolism: echocardiography predictors of clinical deterioration. Crit Care 2022; 26:160. [PMID: 35659340 PMCID: PMC9166499 DOI: 10.1186/s13054-022-04030-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/23/2022] [Indexed: 12/26/2022] Open
Abstract
Background We determine the predictive value of transthoracic echocardiographic (TTE) metrics for clinical deterioration within 5 days in adults with intermediate-risk pulmonary embolism (PE). Methods This was a prospective observational study of intermediate-risk PE patients. To determine associations of TTE and clinical predictors with clinical deterioration, we used univariable analysis, Youden’s index for optimal thresholds, and multivariable analyses to report odds ratios (ORs) or area under the curve (AUC). Results Of 306 intermediate-risk PE patients, 115 (37.6%) experienced clinical deterioration. PE patients who had clinical deterioration within 5 days had greater baseline right ventricle (RV) dilatation and worse systolic function than the group without clinical deterioration as indicated by the following: RV basal diameter 4.46 ± 0.77 versus 4.20 ± 0.77 cm; RV/LV basal width ratio 1.14 ± 0.29 versus 1.02 ± 0.24; tricuspid annular plane systolic excursion (TAPSE) 1.56 ± 0.55 versus 1.80 ± 0.52 cm; and RV systolic excursion velocity 10.40 ± 3.58 versus 12.1 ± 12.5 cm/s, respectively. Optimal thresholds for predicting clinical deterioration were: RV basal width 3.9 cm (OR 2.85 [1.64, 4.97]), RV-to-left ventricle (RV/LV) ratio 1.08 (OR 3.32 [2.07, 5.33]), TAPSE 1.98 cm (OR 3.3 [2.06, 5.3]), systolic excursion velocity 10.10 cm/s (OR 2.85 [1.75, 4.63]), and natriuretic peptide 190 pg/mL (OR 2.89 [1.81, 4.62]). Significant independent predictors were: transient hypotension 6.1 (2.2, 18.9), highest heart rate 1.02 (1.00, 1.03), highest respiratory rate 1.02 (1.00, 1.04), and RV/LV ratio 1.29 (1.14, 1.47). By logistic regression and random forest analyses, AUCs were 0.80 (0.73, 0.87) and 0.78 (0.70, 0.85), respectively. Conclusions Basal RV, RV/LV ratio, and RV systolic function measurements were significantly different between intermediate-risk PE patients grouped by subsequent clinical deterioration. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04030-z.
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Raper JD, Thomas AM, Lupez K, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, Kelly C, O'Connell NS, Weekes AJ. Can right ventricular assessments improve triaging of low risk pulmonary embolism? Acad Emerg Med 2022; 29:835-850. [PMID: 35289978 DOI: 10.1111/acem.14484] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/21/2022] [Accepted: 02/21/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Identifying right ventricle (RV) abnormalities is important to stratifying pulmonary embolism (PE) severity. Disposition decisions are influenced by concerns about early deterioration. Triaging strategies, like the Simplified Pulmonary Embolism Severity Index (sPESI), do not include RV assessments as predictors or early deterioration as outcome(s). We aimed to (1) determine if RV assessment variables add prognostic accuracy for 5-day clinical deterioration in patients classified low risk by sPESI, and (2) determine the prognostic importance of RV assessments compared to other variables and to each other. METHODS We identified low risk sPESI patients (sPESI = 0) from a prospective PE registry. From a large field of candidate variables, we developed, and compared prognostic accuracy of, full and reduced random forest models (with and without RV assessment variables, respectively) on a validation database. We reported variable importance plots from full random forest and provided odds ratios for statistical inference of importance from multivariable logistic regression. Outcomes were death, cardiac arrest, hypotension, dysrhythmia, or respiratory failure within 5 days of PE. RESULTS Of 1736 patients, 610 (35.1%) were low risk by sPESI and 72 (11.8%) experienced early deterioration. Of the 610, RV abnormality was present in 157 (25.7%) by CT, 121 (19.8%) by echocardiography, 132 (21.6%) by natriuretic peptide, and 107 (17.5%) by troponin. For deterioration, the receiver operating characteristics for full and reduced random forest prognostic models were 0.80 (0.77-0.82) and 0.71 (0.68-0.73), respectively. RV assessments were the top four in the variable importance plot for the random forest model. Echocardiography and CT significantly increased predicted probability of 5-day clinical deterioration by the multivariable logistic regression. CONCLUSIONS A PE triaging strategy with RV imaging assessments had superior prognostic performance at classifying low risk for 5-day clinical deterioration versus one without.
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Affiliation(s)
- Jaron D. Raper
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Jaron D. RaperDepartment of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama USA
| | - Alyssa M. Thomas
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Alyssa M. Thomas, Emergency Department Houston Methodist Baytown Hospital Houston Texas USA
| | - Kathryn Lupez
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Kathryn Lupez, Department of Emergency Medicine Tufts Medical Center Boston Massachusetts USA
| | - Carly A. Cox
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
- Carly A. Cox, Emergency Medicine of Idaho Meridian Idaho USA
| | - Dasia Esener
- Department of Emergency Medicine Kaiser Permanente San Diego California USA
| | - Jeremy S. Boyd
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Jason T. Nomura
- Department of Emergency Medicine Christiana Care Newark Delaware USA
| | - Jillian Davison
- Department of Emergency Medicine Orlando Health Orlando Florida USA
| | - Patrick M. Ockerse
- Division of Emergency Medicine University of Utah Health Salt Lake City Utah USA
| | - Stephen Leech
- Department of Emergency Medicine Orlando Health Orlando Florida USA
| | - Jakea Johnson
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Eric Abrams
- Department of Emergency Medicine Kaiser Permanente San Diego California USA
| | - Kathleen Murphy
- Department of Emergency Medicine Christiana Care Newark Delaware USA
| | - Christopher Kelly
- Division of Emergency Medicine University of Utah Health Salt Lake City Utah USA
| | - Nathaniel S. O'Connell
- Department of Biostatistics and Data Science Wake Forest School of Medicine Winston‐Salem North Carolina USA
| | - Anthony J. Weekes
- Department of Emergency Medicine Atrium Health's Carolinas Medical Center Charlotte North Carolina USA
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Rosario J, Lewiss RE, Stolz LA, Del Rios M, Acuña J, Adhikari S, Amponsah D, Dessie AS, Gottlieb M, Huang RD, Jones J, Landry A, Liu RB, Ng L, Panebianco NL, Weekes AJ, Knight S. Creating a more racial-ethnic inclusive clinical ultrasound community. Am J Emerg Med 2022; 54:208-211. [PMID: 35176660 PMCID: PMC8824357 DOI: 10.1016/j.ajem.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Javier Rosario
- University of Central Florida, Department of Emergency Medicine, Orlando, FL, United States of America.
| | - Resa E Lewiss
- Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, PA, United States of America
| | - Lori A Stolz
- University of Cincinnati, Department of Emergency Medicine, Cincinnati, OH, United States of America
| | - Marina Del Rios
- University of Iowa, Department of Emergency Medicine, Iowa City, IA, United States of America
| | - Josie Acuña
- University of Arizona, Department of Emergency Medicine, Tucson, AZ, United States of America
| | - Srikar Adhikari
- University of Arizona, Department of Emergency Medicine, Tucson, AZ, United States of America
| | - David Amponsah
- Henry Ford Hospital, Department of Emergency Medicine, Detroit, MI, United States of America
| | - Almaz S Dessie
- Columbia University Vagelos College of Physicians & Surgeons, Department of Emergency Medicine, New York, NY, United States of America
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, IL, United States of America
| | - Robert D Huang
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, MI, United States of America
| | - Jodi Jones
- UT Southwestern Medical Center, Department of Emergency Medicine, Dallas, TX, United States of America
| | - Adaira Landry
- Harvard Medical School, Brigam and Women's Hospital, Department of Emergency Medicine, Boston, MA, United States of America
| | - Rachel B Liu
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT, United States of America
| | - Lorraine Ng
- Columbia University Vagelos College of Physicians & Surgeons, Department of Emergency Medicine, New York, NY, United States of America
| | - Nova L Panebianco
- University of Pennsylvania, Department of Emergency Medicine, Philadelphia, PA, United States of America
| | - Anthony J Weekes
- Carolinas Medical Center at Atrium Health, Department of Emergency Medicine, Charlotte, NC, United States of America
| | - Starr Knight
- University of California San Francisco, Department of Emergency Medicine, San Francisco, CA
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Weekes AJ, Raper JD, Lupez K, Thomas AM, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, Kelly C, Norton HJ. Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE). PLoS One 2021; 16:e0260036. [PMID: 34793539 PMCID: PMC8601564 DOI: 10.1371/journal.pone.0260036] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria. METHODS We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801). RESULTS Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome. CONCLUSIONS PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Jaron D. Raper
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Kathryn Lupez
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Alyssa M. Thomas
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Carly A. Cox
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente, San Diego, CA, United States of America
| | - Jeremy S. Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Jason T. Nomura
- Department of Emergency Medicine, Christiana Care, Newark, DE, United States of America
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Patrick M. Ockerse
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Jakea Johnson
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Eric Abrams
- Department of Emergency Medicine, Kaiser Permanente, San Diego, CA, United States of America
| | - Kathleen Murphy
- Department of Emergency Medicine, Christiana Care, Newark, DE, United States of America
| | - Christopher Kelly
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America
| | - H. James Norton
- Professor Emeritus of Biostatistics, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
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Dessie AS, Lewiss RE, Stolz LA, Acuña J, Adhikari S, Amponsah D, Del Rios M, Huang RD, Knight RS, Landry A, Liu RB, Gottlieb M, Ng L, Panebianco NL, Rosario J, Weekes AJ, Jones JD. The state of gender inclusion in the point-of-care ultrasound community. Am J Emerg Med 2021; 56:283-285. [PMID: 34334282 DOI: 10.1016/j.ajem.2021.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Almaz S Dessie
- Columbia University Vagelos College of Physicians & Surgeons, Department of Emergency Medicine, 630 W 168th St, New York, NY 10032, United States of America.
| | - Resa E Lewiss
- Thomas Jefferson University, Department of Emergency Medicine, 130 South 9th Street, Philadelphia, PA 19107, United States of America
| | - Lori A Stolz
- University of Cincinnati, Department of Emergency Medicine, 3230 Eden Ave, Cincinnati, OH 45267, United States of America
| | - Josie Acuña
- University of Arizona, Department of Emergency Medicine, 1501 N Campbell Ave, Tucson, AZ 85724, United States of America
| | - Srikar Adhikari
- University of Arizona, Department of Emergency Medicine, 1501 N Campbell Ave, Tucson, AZ 85724, United States of America
| | - David Amponsah
- Henry Ford Hospital, Department of Emergency Medicine, 2799 W Grand Blvd, Detroit, MI 48202, United States of America
| | - Marina Del Rios
- University of Illinois Chicago, Department of Emergency Medicine, 1853 W Polk St, Chicago, IL 60612, United States of America
| | - Rob D Huang
- University of Michigan Medical School, Department of Emergency Medicine, 1301 Catherine St, Ann Arbor, MI 48109, United States of America
| | - R Starr Knight
- University of California-San Francisco, Department of Emergency Medicine, 513 Parnassus Ave, San Francisco, CA 94143, United States of America
| | - Adaira Landry
- Brigham and Women's Hospital, Emergency Medicine, 75 Francis St, Boston, MA 02115, United States of America
| | - Rachel B Liu
- Yale School of Medicine, Department of Emergency Medicine, 333 Cedar St, New Haven, CT 06510, United States of America
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, 1620 W Harrison St, Chicago, IL 60612, United States of America
| | - Lorraine Ng
- Columbia University Vagelos College of Physicians & Surgeons, Department of Emergency Medicine, 630 W 168th St, New York, NY 10032, United States of America
| | - Nova L Panebianco
- University of Pennsylvania, Department of Emergency Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States of America
| | - Javier Rosario
- University of Central Florida, Department of Emergency Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, United States of America
| | - Anthony J Weekes
- Carolinas Medical Center at Atrium Health, Department of Emergency Medicine, 1000 Blythe Blvd, Charlotte, NC 28203, United States of America
| | - Jodi D Jones
- UT Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Blvd, Dallas, TX 75390, United States of America
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10
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Becattini C, Maraziti G, Vinson DR, Ng ACC, den Exter PL, Côté B, Vanni S, Doukky R, Khemasuwan D, Weekes AJ, Soares TH, Ozsu S, Polo Friz H, Erol S, Agnelli G, Jiménez D. Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis. Eur Heart J 2021; 42:3190-3199. [PMID: 34179965 DOI: 10.1093/eurheartj/ehab329] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 01/01/2023] Open
Abstract
AIMS Patients with acute pulmonary embolism (PE) at low risk for short-term death are candidates for home treatment or short-hospital stay. We aimed at determining whether the assessment of right ventricle dysfunction (RVD) or elevated troponin improves identification of low-risk patients over clinical models alone. METHODS AND RESULTS Individual patient data meta-analysis of studies assessing the relationship between RVD or elevated troponin and short-term mortality in patients with acute PE at low risk for death based on clinical models (Pulmonary Embolism Severity Index, simplified Pulmonary Embolism Severity Index or Hestia). The primary study outcome was short-term death defined as death occurring in hospital or within 30 days. Individual data of 5010 low-risk patients from 18 studies were pooled. Short-term mortality was 0.7% [95% confidence interval (CI) 0.4-1.3]. RVD at echocardiography, computed tomography or B-type natriuretic peptide (BNP)/N-terminal pro BNP (NT-proBNP) was associated with increased risk for short-term death (1.5 vs. 0.3%; OR 4.81, 95% CI 1.98-11.68), death within 3 months (1.6 vs. 0.4%; OR 4.03, 95% CI 2.01-8.08), and PE-related death (1.1 vs. 0.04%; OR 22.9, 95% CI 2.89-181). Elevated troponin was associated with short-term death (OR 2.78, 95% CI 1.06-7.26) and death within 3 months (OR 3.68, 95% CI 1.75-7.74). CONCLUSION RVD assessed by echocardiography, computed tomography, or elevated BNP/NT-proBNP levels and increased troponin are associated with short-term death in patients with acute PE at low risk based on clinical models. RVD assessment, mainly by BNP/NT-proBNP or echocardiography, should be considered to improve identification of low-risk patients that may be candidates for outpatient management or short hospital stay.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Ospedale Santa Maria della Misericordia, Via G. Dottori 1, 06129 Perugia, Italy
| | - Giorgio Maraziti
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Ospedale Santa Maria della Misericordia, Via G. Dottori 1, 06129 Perugia, Italy
| | - David R Vinson
- Department of Emergency Medicine, The Permanente Medical Group and the Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Austin C C Ng
- Cardiology Department, Concord Hospital, The University of Sydney, Concord, NSW, Australia
| | - Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Benoit Côté
- Département de Médecine Interne, Hôpital de l'Enfant-Jésus du CHU de Québec, Université Laval, Québec, Canada
| | - Simone Vanni
- Emergency Medicine Unit, Empoli, Azienda Usl Toscana Centro, Italy
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA
| | - Danai Khemasuwan
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Anthony J Weekes
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Thiago Horta Soares
- Internal Medicine Division, Rede Mater Dei de Saúde, Belo Horizonte, Minas Gerais, Brazil
| | - Savas Ozsu
- Department of Pulmonary Medicine, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Hernan Polo Friz
- Internal Medicine Division, Medical Department, Vimercate Hospital, Vimercate, Italy
| | - Serhat Erol
- University of Ankara School of Medicine, Pulmonary Diseases Department, Ankara, Turkey
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Ospedale Santa Maria della Misericordia, Via G. Dottori 1, 06129 Perugia, Italy
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá (IRYCIS), Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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11
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Kline JA, Camargo CA, Courtney DM, Kabrhel C, Nordenholz KE, Aufderheide T, Baugh JJ, Beiser DG, Bennett CL, Bledsoe J, Castillo E, Chisolm-Straker M, Goldberg EM, House H, House S, Jang T, Lim SC, Madsen TE, McCarthy DM, Meltzer A, Moore S, Newgard C, Pagenhardt J, Pettit KL, Pulia MS, Puskarich MA, Southerland LT, Sparks S, Turner-Lawrence D, Vrablik M, Wang A, Weekes AJ, Westafer L, Wilburn J. Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021. PLoS One 2021; 16:e0248438. [PMID: 33690722 PMCID: PMC7946184 DOI: 10.1371/journal.pone.0248438] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/25/2021] [Indexed: 12/11/2022] Open
Abstract
Objectives Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care. Methods Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables. Results Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79–0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8–96.3%), specificity of 20.0% (19.0–21.0%), negative likelihood ratio of 0.22 (0.19–0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points). Conclusion Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.
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Affiliation(s)
- Jeffrey A. Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
- * E-mail:
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - D. Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, United States of America
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kristen E. Nordenholz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Thomas Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Joshua J. Baugh
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - David G. Beiser
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Christopher L. Bennett
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Joseph Bledsoe
- Department of Emergency Medicine, Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah, United States of America
| | - Edward Castillo
- Department of Emergency Medicine, University of California, San Diego, California, United States of America
| | - Makini Chisolm-Straker
- Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, New York, United States of America
| | - Elizabeth M. Goldberg
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Hans House
- Department of Emergency Medicine, University of Iowa School of Medicine, Iowa City, Iowa, United States of America
| | - Stacey House
- Department of Emergency Medicine, Washington University School of Medicine, St. Louise, Missouri, United States of America
| | - Timothy Jang
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Stephen C. Lim
- University Medical Center New Orleans, Louisiana State University School of Medicine, New Orleans, Louisiana, United States of America
| | - Troy E. Madsen
- Division of Emergency Medicine, Department Surgery, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Danielle M. McCarthy
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Andrew Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine, Washington D.C., DC, United States of America
| | - Stephen Moore
- Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Craig Newgard
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Justine Pagenhardt
- Department of Emergency Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, United States of America
| | - Katherine L. Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Michael S. Pulia
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center and the University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Lauren T. Southerland
- Department of Emergency Medicine, Ohio State University Medical Center, Columbus, Ohio, United States of America
| | - Scott Sparks
- Department of Emergency Medicine, Riverside Regional Medical Center, Newport News, Virginia, United States of America
| | - Danielle Turner-Lawrence
- Department of Emergency Medicine, Beaumont Health, Royal Oak, Michigan, United States of America
| | - Marie Vrablik
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Alfred Wang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Anthony J. Weekes
- Department of Emergency Medicine, Carolinas Medical Center at Atrium Health, Charlotte, North Carolina, United States of America
| | - Lauren Westafer
- Department of Emergency Medicine, Baystate Health, Springfield, Massachusetts, United States of America
| | - John Wilburn
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
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12
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Bullard MJ, Weekes AJ, Cordle RJ, Fox SM, Wares CM, Heffner AC, Howley LD, Navedo D. A Mixed-methods Comparison of Participant and Observer Learner Roles in Simulation Education. AEM Educ Train 2019; 3:20-32. [PMID: 30680344 PMCID: PMC6339532 DOI: 10.1002/aet2.10310] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/15/2018] [Accepted: 10/22/2018] [Indexed: 05/23/2023]
Abstract
BACKGROUND Traditional simulation-based education prioritizes participation in simulated scenarios. The educational impact of observation in simulation-based education compared with participation remains uncertain. Our objective was to compare the performances of observers and participants in a standardized simulation scenario. METHODS We assessed learning differences between simulation-based scenario participation and observation using a convergent, parallel, quasi-experimental, mixed-methods study of 15 participants and 15 observers (N = 30). Fifteen first-year residents from six medical specialties were evaluated during a simulated scenario (cardiac arrest due to critical hyperkalemia). Evaluation included predefined critical actions and performance assessments. In the first exposure to the simulation scenario, participants and observers underwent a shared postevent debriefing with predetermined learning objectives. Three months later, a follow-up assessment using the same case scenario evaluated all 30 learners as participants. Wilcoxon signed rank and Wilcoxon rank sum tests were used to compare participants and observers at 3-month follow-up. In addition, we used case study methodology to explore the nature of learning for participants and observers. Data were triangulated using direct observations, reflective field notes, and a focus group. RESULTS Quantitative data analysis comparing the learners' first and second exposure to the investigation scenario demonstrated participants' time to calcium administration as the only statistically significant difference between participant and observer roles (316 seconds vs. 200 seconds, p = 0.0004). Qualitative analysis revealed that both participation and observation improved learning, debriefing was an important component to learning, and debriefing closed the learning gap between observers and participants. CONCLUSIONS Participants and observers had similar performances in simulation-based learning in an isolated scenario of cardiac arrest due to hyperkalemia. Findings support current limited literature that observation should not be underestimated as an important opportunity to enhance simulation-based education. When paired with postevent debriefing, scenario observers and participants may reap similar educational benefits.
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Affiliation(s)
- Mark J. Bullard
- Department of Emergency MedicineCarolinas Medical CenterCarolinas HealthCare SystemCharlotteNC
| | - Anthony J. Weekes
- Department of Emergency MedicineCarolinas Medical CenterCarolinas HealthCare SystemCharlotteNC
| | - Randolph J. Cordle
- Department of Emergency MedicineCarolinas Medical CenterCarolinas HealthCare SystemCharlotteNC
| | - Sean M. Fox
- Department of Emergency MedicineCarolinas Medical CenterCarolinas HealthCare SystemCharlotteNC
| | - Catherine M. Wares
- Department of Emergency MedicineCarolinas Medical CenterCarolinas HealthCare SystemCharlotteNC
| | - Alan C. Heffner
- Department of Emergency MedicineCarolinas Medical CenterCarolinas HealthCare SystemCharlotteNC
- Department of Internal MedicineDivision of Critical CareCarolinas Medical CenterCarolinas HealthCare SystemCharlotteNC
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13
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Stolz LA, Stolz U, Fields JM, Saul T, Secko M, Flannigan MJ, Sheele JM, Rifenburg RP, Weekes AJ, Josephson EB, Bedolla J, Resop DM, dela Cruz J, Boysen‐Osborn M, Caffery T, Derr C, Bengiamin R, Chiricolo G, Backlund B, Heer J, Hyde RJ, Adhikari S. Emergency Medicine Resident Assessment of the Emergency Ultrasound Milestones and Current Training Recommendations. Acad Emerg Med 2017; 24:353-361. [PMID: 27739636 DOI: 10.1111/acem.13113] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 08/22/2016] [Accepted: 09/27/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Emergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment. METHODS This study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents. RESULTS There were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM. CONCLUSIONS EM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.
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Affiliation(s)
- Lori A. Stolz
- Department of Emergency Medicine University of Arizona Tucson AZ
- Banner University Medical Center University of Arizona Tucson AZ
| | - Uwe Stolz
- Department of Emergency Medicine University of Arizona Tucson AZ
| | - J. Matthew Fields
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA
| | - Turandot Saul
- Icahn School of Medicine at Mount Sinai Department of Emergency Medicine Mount Sinai St. Luke's Mount Sinai Roosevelt New York NY
| | - Michael Secko
- Department of Emergency Medicine SUNY Downstate Medical Center/Kings County Hospital Brooklyn NY
| | | | - Johnathan M. Sheele
- Department of Emergency Medicine University Hospitals Case Medical Center Cleveland OH
| | | | - Anthony J. Weekes
- University of North Carolina School of Medicine Department of Emergency Medicine Carolinas Medical Center Charlotte NC
| | - Elaine B. Josephson
- Weill Cornell Medical College of Cornell University Department of Emergency Medicine Lincoln Medical and Mental Health Center Bronx NY
| | - John Bedolla
- Department of Emergency Medicine University of Texas–Austin Austin TX
| | - Dana M. Resop
- Berbee Walsh Department of Emergency Medicine University of Wisconsin School of Medicine and Public Health Madison WI
| | - Jonathan dela Cruz
- Division of Emergency Medicine Southern Illinois University School of Medicine Springfield IL
| | - Megan Boysen‐Osborn
- Department of Emergency Medicine University of California at Irvine Irvine CA
| | - Terrell Caffery
- Emergency Medicine Residency Program Louisiana State University at Baton‐Rouge Baton‐Rouge LA
| | - Charlotte Derr
- Department of Internal Medicine Division of Emergency Medicine University of South Florida Tampa FL
| | - Rimon Bengiamin
- Department of Emergency Medicine University of California San Francisco Fresno CA
| | - Gerardo Chiricolo
- Department of Emergency Medicine New York Methodist Hospital New York NY
| | - Brandon Backlund
- Division of Emergency Medicine University of Washington Seattle WA
| | - Jagdipak Heer
- Department of Emergency Medicine Kern Medical Center Bakersfield CA
| | - Robert J. Hyde
- Geisel School of Medicine Department of Emergency Medicine Dartmouth‐Hitchcock Medical Center Concord NH
| | - Srikar Adhikari
- Department of Emergency Medicine University of Arizona Tucson AZ
- Banner University Medical Center University of Arizona Tucson AZ
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14
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Weekes AJ, Johnson AK, Troha D, Thacker G, Chanler-Berat J, Runyon M. Prognostic Value of Right Ventricular Dysfunction Markers for Serious Adverse Events in Acute Normotensive Pulmonary Embolism. J Emerg Med 2016; 52:137-150. [PMID: 27751702 DOI: 10.1016/j.jemermed.2016.09.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/27/2016] [Accepted: 09/05/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Right ventricular dysfunction (RVD) in pulmonary embolism (PE) has been associated with increased morbidity. Tools for RVD identification are not well defined. The prognostic value of RVD markers to predict serious adverse events (SAE) during hospitalization is unclear. OBJECTIVE Prospectively compare the incidence of SAE in normotensive emergency department patients with PE based upon RVD by goal-directed echocardiography (GDE), cardiac biomarkers, and right-to-left ventricle ratio by computed tomography (CT). Simplified Pulmonary Embolism Severity Index (sPESI) was calculated. Deaths and readmissions within 30 days were recorded. METHODS Consecutive normotensive PE patients underwent GDE focused on RVD (RV enlargement, hypokinesis, or septal bowing), serum troponin, and brain natriuretic peptide (BNP), and evaluation of the CT ventricle ratio. In-hospital SAE and complications within 30 days were recorded. RESULTS We enrolled 123 normotensive PE patients (median age 59 years, 49% female). Twenty-six of 123 (26%) patients had one or more SAE. RVD was detected in 26% by GDE, in 39% by biomarkers, and in 38% with CT. In-hospital SAE included one death, six respiratory interventions, six dysrhythmias, three major bleeding episodes, and 21 hypotension episodes. Forty-one percent of patients RVD positive by GDE had SAE, compared to the 18% RVD negative by GDE. Odds ratios for GDE, CT, BNP, troponin, and sPESI for SAE were 3.2 (95% confidence interval [CI] 1.2-8.5), 2.0 (95% CI 0.8-5.1), 3.3 (95% CI 1.3-8.6), 4.2 (95% CI 1.4-13.5), and 2.9 (95% CI 1.1-8.3), respectively. Five patients had non-PE-related deaths within 30 days. CONCLUSION The incidence of SAE within days of PE was significant in our cohort. Those with RVD had an increased risk of nonmortality SAE.
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Affiliation(s)
| | | | - Daniel Troha
- Carolinas Medical Center, Charlotte, North Carolina
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Weekes AJ, Oh L, Thacker G, Johnson AK, Runyon M, Rose G, Johnson T, Templin M, Norton HJ. Interobserver and Intraobserver Agreement on Qualitative Assessments of Right Ventricular Dysfunction With Echocardiography in Patients With Pulmonary Embolism. J Ultrasound Med 2016; 35:2113-2120. [PMID: 27503757 DOI: 10.7863/ultra.15.11007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 12/29/2015] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To evaluate observer agreement using qualitative goal-directed echocardiographic criteria for right ventricular (RV) dysfunction prognostication in submassive pulmonary embolism (PE). METHODS Two emergency physicians and 2 cardiologists independently reviewed 31 packets of goal-directed echocardiographic video clips consisting of at least 3 windows obtained by emergency physicians from normotensive patients with PE. Nine packets were repeated to assess for intraobserver agreement. Right ventricular dysfunction criteria on goal-directed echocardiography were as follows: RV enlargement was present, with a right-to-left ventricular basal diameter ratio of 1.0 or higher and blunting of the apex of the RV in 2 or more different windows; RV systolic dysfunction was present if the tricuspid annulus moved toward the apex 10 mm or less and there was RV free wall hypokinesis; and septal deviation was present with any flattening or deviation of the ventricular septum toward the left ventricle. RESULTS Among the 4 participants, there was 83.9% agreement on the presence or absence of RV enlargement (κ = 0.84), 74.2% agreement on the presence or absence of RV systolic dysfunction (κ = 0.69), and 71.0% agreement on the presence or absence of septal deviation (κ = 0.59). Intraobserver agreement was 100% for each RV dysfunction variable for each observer (κ = 1.0). CONCLUSIONS Agreement was substantial for both severe RV enlargement and RV systolic dysfunction and moderate for septal deviation. Right ventricular dysfunction assessment with qualitative goal-directed echocardiographic criteria is reproducible for PE risk stratification.
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Affiliation(s)
- Anthony J Weekes
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina USA
| | - Laura Oh
- Emory University, Atlanta, Georgia USA
| | - Gregory Thacker
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina USA
| | - Angela K Johnson
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina USA
| | - Michael Runyon
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina USA
| | - Geoffrey Rose
- Sanger Cardiology, Carolinas Medical Center, Charlotte, North Carolina USA
| | - Thomas Johnson
- Sanger Cardiology, Carolinas Medical Center, Charlotte, North Carolina USA
| | - Megan Templin
- Biostatistics Facility, Carolinas Medical Center, Charlotte, North Carolina USA
| | - H James Norton
- Biostatistics Facility, Carolinas Medical Center, Charlotte, North Carolina USA
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Weekes AJ, Thacker G, Troha D, Johnson AK, Chanler-Berat J, Norton HJ, Runyon M. Diagnostic Accuracy of Right Ventricular Dysfunction Markers in Normotensive Emergency Department Patients With Acute Pulmonary Embolism. Ann Emerg Med 2016; 68:277-91. [DOI: 10.1016/j.annemergmed.2016.01.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/29/2015] [Accepted: 01/21/2016] [Indexed: 02/06/2023]
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Weekes AJ, Keller SM, Efune B, Ghali S, Runyon M. Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement. Emerg Med J 2015; 33:176-80. [PMID: 26446313 DOI: 10.1136/emermed-2015-205000] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 09/17/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To prospectively compare ultrasound (US) versus CXR for confirmation of central vascular catheter (CVC) placement. Secondary objective was to determine the incidence of pneumothorax (PTX) and compare US with CXR completion times. METHODS Investigators performed the US saline flush echo test, and evaluated each anterior hemithorax for pleural sliding with US after subclavian or internal jugular CVC placement. MEASUREMENTS AND MAIN RESULTS 151 total (135 in the emergency department, 16 in the intensive care unit) patients after CVC placement, mean age 62.1±15.6 years and 83 (55%) female patients. The rapid atrial swirl sign ( RASS) was ultrasound finding of an immediate appearance of turbulence entering the right atrium via superior vena cava after a rapid saline flush of the distal CVC port. RASS was considered 'negative' for CVC malposition. US identified all correct CVC placements. Four suboptimal CVC tip placements were detected by CXR. US identified three of these misplacements (McNemar exact p value >0.99). There were no cases of PTX or abnormal pleural sliding by either CXR or US. Median times for US and CXR completion were 1.1 (IQR 0.7) minutes and 20 (IQR: 30) minutes, respectively, median difference 23.8 (95% CI 19.6 to 29.3) minutes, p<0.0001. CONCLUSIONS PTX and CVC tip malposition were rare after US-guided CVC placement. There was no significant difference between saline flush echo and CXR for the identification of catheter tip malposition. Benefits of US assessment for complications include reduced radiation exposure and time delays associated with CXR.
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Affiliation(s)
- Anthony J Weekes
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Stephen M Keller
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Bradley Efune
- Department of Emergency Medicine, Good Shepherd Medical Center, Longview, Texas, USA
| | - Sama Ghali
- Department of Emergency Medicine, Chandler Medical Center, Lexington, Kentucky, USA
| | - Michael Runyon
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
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Weekes AJ, Johnson DA, Keller SM, Efune B, Carey C, Rozario NL, James Norton H. Central vascular catheter placement evaluation using saline flush and bedside echocardiography. Acad Emerg Med 2014; 21:65-72. [PMID: 24552526 DOI: 10.1111/acem.12283] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Central venous catheter (CVC) placement is a common procedure in critical care management. The authors set out to determine echocardiographic features during a saline flush of any type of CVC. The hypothesis was that the presence of a rapid saline swirl in the right atrium on bedside echocardiography would confirm correct placement of the CVC tip, similar to the accuracy of the postplacement chest radiograph (CXR). METHODS This was a prospective convenience sample of emergency department (ED) and intensive care unit (ICU) patients who had CVCs placed. Investigators used subcostal or apical four-chamber echocardiography windows to evaluate the onset and appearance of turbulent flow in the right atrium when the distal port of the CVC was flushed with 10 mL of saline. Onset was rated as "immediate" (within 2 seconds), "delayed" (2 to 6 seconds), or "absent" (did not appear within 6 seconds). Appearance was rated as "prominent," "speckling," or "absent." Digital video review was used later to objectively determine precise timing of turbulence onset. The rapid atrial swirl sign (RASS) was defined as the echo appearance of turbulence entering the right atrium immediately (within 2 seconds) after the saline flush of the CVC distal port. The observance of RASS ("positive") was considered "negative" for CVC malposition. Echocardiographic results were compared to CVC tip locations within predetermined zones on the CXR. Superior vena cava (SVC) region was considered the optimal CVC tip position for subclavian and internal jugular CVC. Left CVC tips within the mid left innominate vein were also considered appropriately placed. RESULTS A total of 142 patients enrolled, yielding 152 CVCs. Two CVCs were excluded from analysis due to incomplete data. Both CXR and echocardiographic images for 107 internal jugular CVCs and 28 subclavian CVCs were available for analysis. Saline flush echo evaluations were also performed on 15 femoral CVCs. Either 16-cm triple-lumen or 20-cm PreSep CVCs were used. CVC malposition was discovered on CXR in four of 135 (3.0%) of the subclavian and internal jugular CVCs. RASS for subclavian and internal jugular CVC evaluations versus CXR results for CVC tip malposition yielded 75% sensitivity, 100% specificity, positive predictive value (PPV) 100% (95% confidence interval [CI] = 29.24% to 100%), and negative predictive value (NPV) 99.24% (95% CI = 95.85% to 99.98%). Mean (±SD) time for onset of saline flush turbulence was 1.1 (±0.3) seconds for subclavian and internal jugular CVC tips within the target CXR zone. CONCLUSIONS The rapid appearance of prominent turbulence in the right atrium on echocardiography after CVC saline flush serves as a precise bedside screening test of optimal CVC tip position.
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Affiliation(s)
- Anthony J. Weekes
- The Department of Emergency Medicine; Carolinas Medical Center; Charlotte NC
| | - David A. Johnson
- The Department of Emergency Medicine; Carolinas Medical Center; Charlotte NC
| | - Stephen M. Keller
- The Department of Emergency Medicine; Carolinas Medical Center; Charlotte NC
| | - Bradley Efune
- The Department of Emergency Medicine; Carolinas Medical Center; Charlotte NC
| | - Christopher Carey
- The Department of Emergency Medicine; Carolinas Medical Center; Charlotte NC
| | | | - H. James Norton
- Biostatistics Facility; Carolinas Medical Center; Charlotte NC
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Weekes AJ, Lewis MR, Kahler ZP, Stader DE, Quirke DP, Norton HJ, Almond C, Middleton D, Tayal VS. The effect of weight-based volume loading on the inferior vena cava in fasting subjects: a prospective randomized double-blinded trial. Acad Emerg Med 2012; 19:901-7. [PMID: 22849308 DOI: 10.1111/j.1553-2712.2012.01416.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Inferior vena cava ultrasound (IVC-US) assessment has been proposed as a noninvasive method of assessing volume status. Current literature is divided on its ability to do so. The primary objective was to compare IVC-US changes in healthy fasting subjects randomized to either 10 or 30 mL/kg of intravenous (IV) fluid administration versus a control group that received only 2 mL/kg. METHODS This was a prospective randomized double-blinded trial set in emergency department (ED) clinical care rooms. Volunteer subjects with no history of cardiac disease or hypertension fasted for 12 hours. Subjects were randomly assigned to receive IV 0.9% saline bolus of 2 (control group), 10, or 30 mL/kg over 30 minutes. IVC-US was performed before and 15 minutes after each fluid bolus. RESULTS Forty-two fasting subjects were enrolled. Analysis of variance (ANOVA) comparison showed that IVC-US was unable to detect any significant difference between the control group and those given either 10 or 30 mL/kg fluid, whether using maximum or minimum IVC diameter or caval index (IVC-CI). The groups receiving 10 and 30 mL/kg each had a statistically significant change in IVC-CI; however, the 30 mL/kg group had no significant change in either of the mean IVC diameters. CONCLUSIONS Overall, there were statistically significant differences in mean IVC-US measurements before and after fluid loading, but not between groups. Fasting asymptomatic subjects had a wide intersubject variation in both baseline IVC-US measurements and fluid-related changes. The degree of IVC-US change in association with graded acute volume loading was not predictably proportional between our subjects.
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Affiliation(s)
- Anthony J Weekes
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA.
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Weekes AJ, Tassone HM, Babcock A, Quirke DP, Norton HJ, Jayarama K, Tayal VS. Comparison of serial qualitative and quantitative assessments of caval index and left ventricular systolic function during early fluid resuscitation of hypotensive emergency department patients. Acad Emerg Med 2011; 18:912-21. [PMID: 21906201 DOI: 10.1111/j.1553-2712.2011.01157.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The objective was to determine whether serial bedside visual estimates of left ventricular systolic function (LVF) and respiratory variation of the inferior vena cava (IVC) diameter would agree with quantitative measurements of LVF and caval index in hypotensive emergency department (ED) patients during fluid challenges. The authors hypothesized that there would be moderate inter-rater agreement on the visual estimates. METHODS This prospective observational study was performed at an urban, regional ED. Patients were eligible for enrollment if they were hypotensive in the ED as defined by a systolic blood pressure (sBP) of <100 mm Hg or mean arterial pressure of ≤65 mm Hg, exhibited signs or symptoms of shock, and the treating physician intended to administer intravenous (IV) fluid boluses for resuscitation. Sonologists performed a sequence of echocardiographic assessments at the beginning, during, and toward the end of fluid challenge. Both caval index and LVF were determined by the sonologist in qualitative then quantitative manners. Deidentified digital video clips of two-dimensional IVC and LVF assessments were later presented, in random order, to an ultrasound (US) fellowship-trained emergency physician using a standardized rating system for review. Statistical analysis included both descriptive statistics and correlation analysis. RESULTS Twenty-four patients were enrolled and yielded 72 caval index and LVF videos that were scored at the bedside prior to any measurements and then reviewed later. Visual estimates of caval index compared to measured caval index yielded a correlation of 0.81 (p < 0.0001). Visual estimates of LVF compared to fractional shortening yielded a correlation of 0.84 (p < 0.0001). Inter-rater agreement of respiratory variation of IVC diameter and LVF scores had simple kappa values of 0.70 (95% confidence interval [CI] = 0.56 to 0.85) and 0.46 (95% CI = 0.29 to 0.63), respectively. Significant differences in mean values between time 0 and time 2 were found for caval index measurements, the visual scores of IVC diameter variation, and both maximum and minimum IVC diameters. CONCLUSIONS This study showed that serial visual estimations of the respiratory variation of IVC diameter and LVF agreed with bedside measurements of caval index and LVF during early fluid challenges to symptomatic hypotensive ED patients. There was moderate inter-rater agreement in both visual estimates. In addition, acute volume loading was associated with detectable acute changes in IVC measurements.
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Affiliation(s)
- Anthony J Weekes
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA.
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Novik J, Weekes AJ. An unusual cause of severe dyspnea: diastolic dysfunction due to calcific constrictive pericarditis. J Emerg Med 2009; 38:208-13. [PMID: 19232873 DOI: 10.1016/j.jemermed.2008.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 07/29/2008] [Accepted: 09/04/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Constrictive pericarditis is a rare cause of dyspnea. This disease shares many signs and symptoms with other causes of cardiac failure as well as gastrointestinal and renal diseases, making it difficult to diagnose. CASE REPORT We present a case of a 73-year-old woman who presented to our Emergency Department (ED) in respiratory failure after a recent history of worsening dyspnea. Constrictive pericarditis was strongly suspected on bedside ultrasonography. Computed tomography scan showed extensive pericardial calcifications and large pleural effusions, supporting the diagnoses. The patient was admitted for treatment and evaluation of constrictive pericarditis, but died of complications during cardiac catheterization. CONCLUSIONS The etiology and physiology of constrictive pericarditis are reviewed and an ultrasound-centered approach to undifferentiated dyspnea in the ED is discussed.
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Affiliation(s)
- Joseph Novik
- Department of Emergency Medicine, Jacobi Medical Center, Bronx, New York, USA
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Highet AS, Warren RE, Weekes AJ. Bacteriology and antibiotic treatment of perineal suppurative hidradenitis. Arch Dermatol 1988; 124:1047-51. [PMID: 3291777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A plausible bacterial pathogen (Streptococcus milleri, Staphylococcus aureus, anaerobic streptococcus, or Bacteroides species) was isolated at least once in 26 of 32 patients with active perineal suppurative hidradenitis. The main pathogen was S milleri, whose presence was significantly associated with disease activity and whose disappearance significantly correlated with clinical improvement; S aureus nd anaerobic streptococci were also implicated.
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Affiliation(s)
- A S Highet
- Department of Dermatology, York (England) District Hospital
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