RESUMEN
OBJECTIVE: The objectives of this study are to determine the efficacy of a roster of clinical factors in identifying risk for renal insufficiency in emergency department (ED) patients requiring intravenous contrast-enhanced CT scan (IVCE-CT) and to help mitigate potential for developing contrast-induced nephropathy (CIN). METHODS: A review was conducted of consecutive ED patients who received IVCE-CT during a 4-month period in our urban ED. The values of ED serum creatinine (SCr) performed were tabulated. The medical records of all patients with an elevated SCr (> 1.4 mg/dL) were reviewed to determine and correlate the presence of clinical risk factors for underlying renal insufficiency. RESULTS: During the 4-month study period, there were 2260 consecutive cases who received IVCE-CT; of these, 2250 (99.6%) had concomitant measurement of SCr. Elevated SCr occurred in 141 patients (6.2%); of these, 75 had a SCr > 2 mg/dL. In all, 139/141 (98.6%) with an elevated SCr had an underlying chronic or acute medical condition identified by medical record review which potentially compromised renal function, including chronic renal disease, diabetes mellitus, HIV infection, cancer, hypertension, congestive heart failure, sepsis/septic shock, chronic alcoholism, and sickle cell disease. Two patients with no identified risk factor each had (mildly) elevated SCr; both had a normal SCr measured post-CT scan. The total cost of performing serum basic metabolic panel to measure SCr in all patients during the 4-month study period was $94,500. CONCLUSIONS: Elevated SCr is rarely present in ED patients without recognized risk factors who receive IVCE-CT scan. The vast majority with underlying renal insufficiency are readily identified by a review of the patient's medical history and/or clinical findings. Routine SCr measurement on all ED patients regardless of risk stratification prior to IVCE imaging is neither time nor cost-effective.
Asunto(s)
Infecciones por VIH , Medios de Contraste , Creatinina , Servicio de Urgencia en Hospital , Humanos , Riñón/fisiología , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: In our academic emergency department, our senior residents lead their own patient care team, known as the red team (RT). Attending physicians are responsible for managing their own team (AT) and precepting the senior resident's cases. OBJECTIVE: We hypothesized that the RT would have the same number of morbidity and mortality (M&M) cases and similar numbers of adverse outcomes as the AT. We also hypothesized that there would be no increase in M&M cases during the first quarter of every academic year. METHODS: We obtained data from M&M cases from 2009-2013, including month and year of patient visit, standard of care code (SoCC), and whether the patient was seen by the RT or an AT. Data were analyzed using a χ(2) test comparing expected outcomes with observed outcomes. RESULTS: There was a total of 117 M&M cases during the study period with a SoCC ≥ 3; 76 cases were AT and 41 cases were RT. There was no statistically significant difference between expected and observed number of cases. Mean RT and AT SoCCs were 4.03 and 4.23, respectively. There was no statistically significant difference between the two groups for SoCC. Mean SoCC was not significantly different for the first quarter of the year. CONCLUSIONS: We found that our patient care model did not lead to an increased number of M&M cases and RT cases were not associated with worse outcomes overall. Additionally, there was no increased rate of M&M cases in the beginning of the academic year.
Asunto(s)
Educación de Postgrado en Medicina , Medicina de Emergencia/educación , Mortalidad Hospitalaria , Internado y Residencia , Morbilidad , Grupo de Atención al Paciente/organización & administración , Seguridad del Paciente , Humanos , Calidad de la Atención de Salud , Estudios Retrospectivos , Recursos HumanosRESUMEN
We present the case of an 8-year-old girl with two emergency department visits for constipation and abdominal pain. Her medical history and physical examination noted by the emergency physician did not reveal a clear etiology of her symptoms until the second visit, when a point-of-care ultrasound was performed. The sonographic findings were consistent with a fecalith surrounded by fluid concerning for appendiceal rupture. A computerized tomographic scan of the abdomen confirmed these findings in addition to two large abscesses in the lower pelvis, which subsequently required percutaneous drainage. This case illustrates the utility of point-of-care ultrasound in the evaluation of the pediatric patient with abdominal pain when appendicitis is a concern, as well as the ability of the emergency physician to use this technology to guide treatment and care of pediatric patients.
Asunto(s)
Dolor Abdominal/etiología , Apendicitis/diagnóstico por imagen , Apéndice/diagnóstico por imagen , Sistemas de Atención de Punto , Absceso Abdominal/diagnóstico por imagen , Absceso Abdominal/etiología , Apendicitis/complicaciones , Niño , Estreñimiento/etiología , Diagnóstico Tardío , Femenino , Humanos , Rotura Espontánea/diagnóstico por imagen , UltrasonografíaRESUMEN
Cardiac amyloidosis is a disease process of abnormal amyloid fibril deposition in cardiac muscle that can be diagnosed by specific electrocardiographic and echocardiographic findings. We present the case of a patient with a history of cardiac amyloidosis who presented to the emergency department (ED) with shortness of breath, and was diagnosed with a large pericardial effusion by ultrasonography. The patient's myocardium exhibited a granular, "sparkling" appearance with increased echogenicity, typical for cardiac amyloidosis. We discuss the bedside ultrasound findings found in this infiltrative cardiomyopathy, and how they influenced the ED management and treatment plan for this patient.
Asunto(s)
Amiloidosis/diagnóstico por imagen , Cardiomiopatías/diagnóstico por imagen , Servicios Médicos de Urgencia/métodos , Sistemas de Atención de Punto , Ultrasonografía/métodos , Anciano , Femenino , HumanosRESUMEN
BACKGROUND: Disorders of the salivary glands can be evaluated by bedside ultrasonography and should be considered in patients presenting with undifferentiated neck swelling. OBJECTIVE: Our aim was to describe the sonographic findings present in sialolithiasis and sialadenitis. CASE REPORT: A 61-year-old man presented to the emergency department with 2 days of neck swelling. Initial evaluation included a bedside ultrasound that demonstrated sialolithiasis, which was later confirmed by computed tomography. CONCLUSIONS: Bedside ultrasound can be a useful imaging modality in the evaluation of the patient with neck swelling.