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Case PresentationAn 85-year-old male presented to the emergency department after a motor vehicle collision and developed progressive neurological deficits.  CT imaging demonstrated epidural thickening from C2-C7, and MRI was notable for a cervicothoracic epidural hematoma.  The patient underwent emergent decompression with a favorable outcome.DiscussionCases of traumatic spinal epidural hematomas are rarely seen in the emergency department.  These are part of a small subset of operative neurological emergencies that benefit from urgent operative intervention.

Case Presentation: An 85-year-old male who had been prescribed prasurgel presented to the emergency department (ED) after a motor vehicle collision and developed progressive neurological deficits. Computed tomography imaging demonstrated epidural thickening from the second through seventh cervical vertebrae, and magnetic resonance imaging was notable for a cervicothoracic epidural hematoma. The patient underwent emergent decompression with a favorable outcome.Discussion: Cases of traumatic spinal epidural hematomas are rarely seen in the ED. These are part of a small subset of operative neurological emergencies that benefit from urgent surgical intervention.

Introduction: Point-of-care (POC) echocardiography (echo) is a useful adjunct in the management of cardiac arrest. However, the practice pattern of POC echo utilization during management of cardiac arrest cases among emergency physicians (EP) is unclear. In this pilot study we aimed to characterize the utilization of POC echo and the potential barriers to its use in the management of cardiac arrest among EPs. Methods: This was a cross-sectional survey of attending EPs who completed an electronic questionnaire composed of demographic variables (age, gender, year of residency graduation, practice setting, and ultrasound training) and POC echo utilization questions. The first question queried participants regarding frequency of POC echo use during the management of cardiac arrest. Branching logic then presented participants with a series of subsequent questions regarding utilization and barriers to use based on their responses.  Results: A total of 155 EPs participated in the survey, with a median age of 39 years (interquartile range 31-67). Regarding POC echo utilization, participants responded that they always (66%), sometimes (30%), or never (4.5%) use POC echo during cardiac arrest cases. Among participants who never use POC echo, 86% reported a lack of training, competency, or credentialing as a barrier to use. Among participants who either never or sometimes use POC echo, the leading barrier to use (58%) reported was a need for improved competency. Utilization was not different among participants of different age groups (P = 0.229) or different residency graduation dates (P = 0.229). POC echo utilization was higher among participants who received ultrasound training during residency (P = 0.006) or had completed ultrasound fellowship training (P

Introduction: Tricuspid annular plane systolic excursion (TAPSE) is an established echocardiographic marker of right ventricular (RV) systolic function. The objective of this study was to evaluate whether emergency clinicians can visually estimate RV function using TAPSE in a set of video clips compared to a reference standard M-mode measurement.Methods: Emergency clinicians were shown a five-minute educational video on TAPSE. Participants then viewed 20 apical four-chamber point-of-care ultrasound (POCUS) echocardiography clips and recorded their estimate of TAPSE distance in centimeters (cm), as well as whether TAPSE was normal (>1.9 cm), borderline (1.5-1.9 cm), or abnormal (1.9 cm was 91.4% (95% CI, 88.4-94.3%) and 90.8% (95% CI, 87.7-93.9%), respectively. There was no significant difference in sensitivity (p = 0.27) or specificity (p = 0.55) between resident and attending physicians or between physicians and PAs (p = 0.17 and p = 0.81). Median self-reported comfort with TAPSE assessment increased from 1 (interquartile range [IQR] 1-2) to 3 (IQR 3-4) points after participation in the study.Conclusion: A wide range of emergency clinicians demonstrated fair accuracy for visual estimation of TAPSE on previously recorded POCUS echocardiography video clips. These findings should be considered hypothesis generating and warrant validation in larger, prospective studies.

Objectives: Point‐of‐care ultrasound (POCUS) detects the pulmonary manifestations of COVID‐19 and may predict patient outcomes. Methods: We conducted a prospective cohort study at four hospitals from March 2020 to January 2021 to evaluate lung POCUS and clinical outcomes of COVID‐19. Inclusion criteria included adult patients hospitalized for COVID‐19 who received lung POCUS with a 12‐zone protocol. Each image was interpreted by two reviewers blinded to clinical outcomes. Our primary outcome was the need for intensive care unit (ICU) admission versus no ICU admission. Secondary outcomes included intubation and supplemental oxygen usage. Results: N = 160 patients were included. Among critically ill patients, B‐lines (94 vs 76%; P <.01) and consolidations (70 vs 46%; P <.01) were more common. For scans collected within 24 hours of admission (N = 101 patients), early B‐lines (odds ratio [OR] 4.41 [95% confidence interval, CI: 1.71–14.30]; P <.01) or consolidations (OR 2.49 [95% CI: 1.35–4.86]; P <.01) were predictive of ICU admission. Early consolidations were associated with oxygen usage after discharge (OR 2.16 [95% CI: 1.01–4.70]; P =.047). Patients with a normal scan within 24 hours of admission were less likely to require ICU admission (OR 0.28 [95% CI: 0.09–0.75]; P <.01) or supplemental oxygen (OR 0.26 [95% CI: 0.11–0.61]; P <.01). Ultrasound findings did not dynamically change over a 28‐day scanning window after symptom onset. Conclusions: Lung POCUS findings detected within 24 hours of admission may provide expedient risk stratification for important COVID‐19 clinical outcomes, including future ICU admission or need for supplemental oxygen. Conversely, a normal scan within 24 hours of admission appears protective. POCUS findings appeared stable over a 28‐day scanning window, suggesting that these findings, regardless of their timing, may have clinical implications. [ABSTRACT FROM AUTHOR]

Objectives: Lung ultrasound (LUS) can accurately diagnose several pulmonary diseases, including pneumothorax, effusion, and pneumonia. LUS may be useful in the diagnosis and management of COVID‐19. Methods: This study was conducted at two United States hospitals from 3/21/2020 to 6/01/2020. Our inclusion criteria included hospitalized adults with COVID‐19 (based on symptomatology and a confirmatory RT‐PCR for SARS‐CoV‐2) who received a LUS. Providers used a 12‐zone LUS scanning protocol. The images were interpreted by the researchers based on a pre‐developed consensus document. Patients were stratified by clinical deterioration (defined as either ICU admission, invasive mechanical ventilation, or death within 28 days from the initial symptom onset) and time from symptom onset to their scan. Results: N = 22 patients (N = 36 scans) were included. Eleven (50%) patients experienced clinical deterioration. Among N = 36 scans, only 3 (8%) were classified as normal. The remaining scans demonstrated B‐lines (89%), consolidations (56%), pleural thickening (47%), and pleural effusion (11%). Scans from patients with clinical deterioration demonstrated higher percentages of bilateral consolidations (50 versus 15%; P =.033), anterior consolidations (47 versus 11%; P =.047), lateral consolidations (71 versus 29%; P =.030), pleural thickening (69 versus 30%; P =.045), but not B‐lines (100 versus 80%; P =.11). Abnormal findings had similar prevalences between scans collected 0–6 days and 14–28 days from symptom onset. Discussion: Certain LUS findings may be common in hospitalized COVID‐19 patients, especially for those that experience clinical deterioration. These findings may occur anytime throughout the first 28 days of illness. Future efforts should investigate the predictive utility of these findings on clinical outcomes. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to evaluate the accuracy and timeliness of resident‐performed point‐of‐care lung ultrasound (LUS) examinations for the follow‐up of pneumothorax (PTX) after tube thoracostomy. Methods: After brief training, Rwandan surgical residents blinded to chest radiography (CXR) performed and interpreted LUS examinations for PTX in participants undergoing CXR for PTX follow‐up. Treating clinicians interpreted CXR for the presence of PTX for therapeutic decisions. Lung ultrasound was later reviewed by ultrasound experts, and CXR was reviewed by a radiologist. We defined expert LUS interpretation as the reference standard. The sensitivity and specificity of resident‐performed LUS examinations for diagnosing PTX were calculated. We assessed agreement between trained resident versus expert LUS and clinician versus radiology CXR using the Cohen κ coefficient. We compared the time to results between LUS and CXR. Results: Over an 8‐month period, 51 participants were enrolled. Compared to expert LUS interpretation, the sensitivity and specificity (95% confidence intervals) of resident LUS were 100% (85%–100%) and 96% (82%–100%), respectively, whereas the sensitivity and specificity of clinician‐interpreted CXR were 48% (27%–69%) and 100% (88%–100%). The agreement between resident and expert LUS was excellent (κ = 0.96), whereas the agreement between clinician and radiologist CXR was only moderate (κ = 0.60). The time to results was significantly longer for CXR than LUS (mean, 1335 versus 396 minutes; P =.0001). Conclusions: A resident‐performed LUS examination was a quicker imaging modality with superior sensitivity compared to clinician‐interpreted CXR for PTX follow‐up after tube thoracostomy in this Rwandan study. Lung ultrasound can be a valuable imaging tool for PTX follow‐up, especially in resource‐limited settings. [ABSTRACT FROM AUTHOR]

The adoption of point-of-care ultrasound (POCUS) has greatly improved the ability to rapidly evaluate unstable emergency department (ED) patients at the bedside. One major use of POCUS is to obtain echocardiograms to assess cardiac function. We developed EchoNet-POCUS, a novel deep learning system, to aid emergency physicians (EPs) in interpreting POCUS echocardiograms and to reduce operator-to-operator variability. We collected a new dataset of POCUS echocardiogram videos obtained in the ED by EPs and annotated the cardiac function and quality of each video. Using this dataset, we train EchoNet-POCUS to evaluate both cardiac function and video quality in POCUS echocardiograms. EchoNet-POCUS achieves an area under the receiver operating characteristic curve (AUROC) of 0.92 (0.89–0.94) for predicting whether cardiac function is abnormal and an AUROC of 0.81 (0.78–0.85) for predicting video quality. EchoNet-POCUS can be applied to bedside echocardiogram videos in real time using commodity hardware, as we demonstrate in a prospective pilot study. [ABSTRACT FROM AUTHOR]

Background: Rib fractures are common injuries associated with considerable morbidity, long-term disability, and mortality. Early, adequate analgesia is important to mitigate complications such as pneumonia and respiratory failure. Regional anesthesia has been proposed for rib fracture pain control due to its superior side effect profile compared with systemic analgesia. Our objective was to evaluate the effect of emergency physician-performed, ultrasound-guided serratus anterior plane block (SAPB) on pain and respiratory function in emergency department patients with multiple acute rib fractures., Methods: This was a prospective observational cohort study of adult patients at a level 1 trauma center who had two or more acute unilateral rib fractures. Eligible patients received a SAPB if an emergency physician trained in the procedure was available at the time of diagnosis. Primary outcomes were the absolute change in pain scores and percent change in expected incentive spirometry volumes from baseline to 3 hours after rib fracture diagnosis., Results: 38 patients met eligibility criteria, 15 received the SAPB and 23 did not. The SAPB group had a greater decrease in pain scores at 3 hours (-3.7 vs. -0.9; p=0.003) compared with the non-SAPB group. The SAPB group also had an 11% (CI 1.5% to 17%) increase in percent expected spirometry volumes at 3 hours which was significantly better than the non-SAPB group, which had a -3% (CI -9.1% to 2.7%) decrease (p=0.008)., Conclusion: Patients with rib fractures who received SAPB as part of a multimodal pain control strategy had a greater improvement in pain and respiratory function compared with those who did not. Larger trials are indicated to assess the generalizability of these initial findings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Hyperkalaemia is common, life-threatening and often requires emergency department (ED) management; however, no standardised ED treatment protocol exists. Common treatments transiently reducing serum potassium (K + ) (including albuterol, glucose and insulin) may cause hypoglycaemia. We outline the design and rationale of the Patiromer Utility as an Adjunct Treatment in Patients Needing Urgent Hyperkalaemia Management (PLATINUM) study, which will be the largest ED randomised controlled hyperkalaemia trial ever performed, enabling assessment of a standardised approach to hyperkalaemia management, as well as establishing a new evaluation parameter (net clinical benefit) for acute hyperkalaemia treatment investigations., Methods and Analysis: PLATINUM is a Phase 4, multicentre, randomised, double-blind, placebo-controlled study in participants who present to the ED at approximately 30 US sites. Approximately 300 adult participants with hyperkalaemia (K + ≥5.8 mEq/L) will be enrolled. Participants will be randomised 1:1 to receive glucose (25 g intravenously <15 min before insulin), insulin (5 units intravenous bolus) and aerosolised albuterol (10 mg over 30 min), followed by a single oral dose of either 25.2 g patiromer or placebo, with a second dose of patiromer (8.4 g) or placebo after 24 hours. The primary endpoint is net clinical benefit, defined as the mean change in the number of additional interventions less the mean change in serum K + , at hour 6. Secondary endpoints are net clinical benefit at hour 4, proportion of participants without additional K + -related medical interventions, number of additional K + -related interventions and proportion of participants with sustained K + reduction (K + ≤5.5 mEq/L). Safety endpoints are the incidence of adverse events, and severity of changes in serum K + and magnesium., Ethics and Dissemination: A central Institutional Review Board (IRB) and Ethics Committee provided protocol approval (#20201569), with subsequent approval by local IRBs at each site, and participants will provide written consent. Primary results will be published in peer-reviewed manuscripts promptly following study completion., Trial Registration Number: NCT04443608., Competing Interests: Competing interests: ZR: Advisory board memberships (Cardiorenal disease) for AstraZeneca and CSL Vifor. JB: Employee and shareholder of CSL Vifor. CMQ: Employee and shareholder of CSL Vifor. YD: No relevant conflicts of interest to disclose. BS: NHLBI, CDC, Comprehensive Research Associates (institutional grants). JJB: No relevant conflicts of interest to disclose. BED: No relevant conflicts of interest to disclose. CAH: Personal fees (consultant) from AstraZeneca, Bayer, Diamedica, FibroGen, Merck, NxStage, Pfizer, Relypsa, University of Oxford, Bristol Myers Squibb; Grants from the University of British Columbia and Bristol Myers Squibb and the National Institutes of Health (NIDDK and NHLBI), and author royalties from UpToDate. Stock ownership in Johnson & Johnson, Merck, and Pfizer. Employee of Hennepin Healthcare. MRW: Consulting fees: CSL Vifor and AstraZeneca. Honoraria: CSL Vifor. AJS: Research grants: Comprehensive Research Associates. Consulting fees: AstraZeneca. SB: No relevant conflicts of interest to disclose. KMS-R: No relevant conflicts of interest to disclose. WFP: Research Grants: Brainbox, Instrument Labs, Salix. Consultant: Abbott, Brainbox, Instrument Labs, Janssen, Osler, Roche, Siemens, CSL Vifor. Stock/Ownership Interests: AseptiScope Inc, Brainbox Inc, Braincheck Inc, Coagulo Inc, Comprehensive Research Associates LLC, Comprehensive Research Management Inc, Emergencies in Medicine LLC, Fast Inc, Forrest Devices, Ischemia DX LLC, Lucia Inc, Prevencio Inc, RCE Technologies, ROMTech, ScPharma, Trivirum Inc, Upstream Inc., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)