This clinical policy from the American College of Emergency Physicians is a revision of the 2010 "Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: 1) in ED patients with possible acute appendicitis, can a clinical prediction rule be used to identify patients for whom no advanced imaging is required? 2) in ED patients with suspected acute appendicitis, is the diagnostic accuracy of ultrasound comparable with computed tomography or magnetic resonance imaging for the diagnosis of acute appendicitis? 3) in ED patients who are undergoing computed tomography of the abdomen and pelvis for suspected acute appendicitis, does the addition of contrast improve diagnostic accuracy? Evidence was graded, and recommendations were made based on the strength of the available data.

Objective: Emergency Department Observation Units (Obs Units) provide a setting and a mechanism for further care of Emergency Department (ED) patients. Our hospital has a protocol-driven, type 1, complex 20 bed Obs Unit with 36 different protocols. We wanted to understand how the different protocols performed and what types of care were provided. Methods: This was an IRB-approved, retrospective chart review study. A random 10% of ED patient charts with a "transfer to observation" order were selected monthly from October 2015 through June 2017. This database was designed to identify high and low functioning protocols based on length of stays (LOS) and admission rates. Results: Over 20 months, a total of 984 patients qualified for the study. The average age was 49.5 +/- 17.2 years, 57.3% were women, and 32.3% were non-Caucasian. The admission rate was 23.5% with an average LOS in observation of 13.7 h [95% CI 13.3-14.1]. Thirty day return rate was 16.8% with 5.3% of the patients returning to the ED within the first 72 h. Thirty six different protocols were used, with the most common being chest pain (13.9%) and general (13.2%). Almost 70% received a consultation from another service, and 7.2% required a procedure while in observation. Procedures included fluoroscopic-guided lumbar punctures, endoscopies, dental extractions, and catheter replacements (nephrostomy, gastrostomy, and biliary tubes). Conclusions: An Obs Unit can care for a wide variety of patients who require multiple consultations, procedures, and care coordination while maintaining an acceptable length of stay and admission rate. (C) 2019 Elsevier Inc. All rights reserved.

Emergency departments (EDs) have seen rising numbers of patients in psychiatric crises, patient boarding, and throughput delays. This study describes and evaluates the impact of a Crisis Assessment Linkage and Management (CALM) service designed to manage behavioral health crises. A year-to-year comparison was performed before (n = 2211 ED visits) and after implementation of CALM (n = 2387). CALM was associated with reductions in median ED and hospital length of stay (LOS) from 9.5 to 7.3 hours and 46.2 to 31.4 hours, respectively. Mean transformed ED LOS decreased by 32.4% ( P < .001). The CALM model improved patient care and throughput metrics by proactively managing behavioral health crises.

We describe a case of a middle-aged male with end-stage renal disease who presented with dyspnea after a recent mycoplasma infection. The following core competencies are addressed in this article: Medical knowledge, Patient care. Republished with permission from: Wallace LA, Adkins EJ, Bahner DP. Bedside sonography primer: diagnosis of pleural effusion with ultrasound. OPUS 12 Scientist 2012;6(1):12-13.

Background Accurate and timely review of microbiological test results is a core component of antimicrobial stewardship. There is documented success of these programs in the inpatient setting; however, emergency department (ED) patients are typically not included in these initiatives. Objectives To assess the impact of an emergency medicine pharmacist (EMP)–facilitated review process of positive microbiological test results from patients discharged from the ED as measured by time to positive result review and number of indicated interventions completed. Methods This was a retrospective study that compared EMP-facilitated to ED charge nurse (CN)–facilitated physician review of randomly selected positive microbiological test results. Groups were compared concurrently within the time frame of July 1, 2012 through December 31, 2012. Results One hundred seventy-eight positive microbiological test results were included (EMP, n = 91; CN, n = 87). The median (IQR) time to initial review was 3 (1.0–6.3) hours for the EMP and 2 (0.3–5.5) hours for the CN group ( p = .35). Four percent (1/25) of indicated interventions were not completed in the EMP group versus 47% (14/30) in the CN group ( p = .0004). Conclusion An EMP was significantly less likely to miss an intervention when indicated with no difference in time to review of positive microbiological results. These findings support the role of the EMP in antimicrobial stewardship in the ED.

Ambulance diversion presents a dilemma pitting the ethical principles of patient autonomy and beneficence against the principles of justice and nonmaleficence. The guiding priority in requesting ambulance diversion is to maintain the safety of all patients in the emergency department as well as those waiting to be seen. Policies and procedures can be developed that maintain the best possible outcome for patients transported by ambulance during periods of diversion. More importantly, the discussion must focus on addressing the operational inefficiencies within our health systems that lead to conditions such as patient boarding, high waiting room congestion, and ambulance diversion. Addressing these inefficiencies has a greater potential impact on ambulance diversion than simply banning or restricting the practice for practical or ethical considerations.

The Ultrasound Challenge was developed at The Ohio State University College of Medicine to introduce focused ultrasound to medical students. The goal was to develop experience in ultrasound through practice and competition. Initially this competition was held between Ohio State University College of Medicine students from years 1 through 4. The Ultrasound Challenge 2.0 was held in 2013. The event expanded on the previous structure by including students from the Wayne State University College of Medicine. The goal of this article is to describe our experiences with expansion of our interinstitutional ultrasound event. The challenge consisted of 6 stations: focused assessment with sonography for trauma, aortic ultrasound, cardiac ultrasound, pelvic ultrasound, musculoskeletal ultrasound, and vascular access. The participants were given a handbook outlining the expectations for each station ahead of time. Vascular access was graded in real time using the Brightness Mode Quality Ultrasound Imaging Examination Technique (B‐QUIET) method. The remainder were timed, saved, and graded after the event by 3 independent faculty members using the B‐QUIET method. The highest score with the fastest time was the winner. The Ultrasound Challenge 2.0 included 40 participants: 31 from The Ohio State University College of Medicine and 9 from the Wayne State University College of Medicine. The makeup of the winners in all categories consisted of 1 first‐year medical student, 7 second‐year medical students, 3 third‐year medical students, and 10 fourth‐year medical students. The Ultrasound Challenge 2.0 was a success for those who participated. It provided the first known interinstitutional medical student ultrasound competition. Students from both institutions were able to practice their image acquisition skills, demonstrate abilities in a competitive environment, and develop collegiality and teamwork.

BACKGROUND In search of a standardized noninvasive assessment of intravascular volume status, we prospectively compared the sonographic inferior vena cava collapsibility index (IVC-CI) and central venous pressures (CVPs). Our goals included the determination of CVP behavior across clinically relevant IVC-CI ranges, examination of unitary behavior of IVC-CI with changes in CVP, and estimation of the effect of positive end-expiratory pressure (PEEP) on the IVC-CI/CVP relationship.METHODS Prospective, observational study was performed in surgical/medical intensive care unit patients between October 2009 and July 2013. Patients underwent repeated sonographic evaluations of IVC-CI. Demographics, illness severity, ventilatory support, CVP, and patient positioning were recorded. Correlations were made between CVP groupings (< 7, 7-12, 12-18, 19+) and IVC-CI ranges (< 25, 25-49, 50-74, 75+). Comparison of CVP (2-unit quanta) and IVC-CI (5-unit quanta) was performed, followed by assessment of per-unit IVC-CI/CVP behavior as well as examination of the effect of PEEP on the IVC-CI/CVP relationship.RESULTS We analyzed 320 IVC-CI/CVP measurement pairs from 79 patients (mean [SD] age, 55.8 [16.8] years; 64.6% male; mean [SD] Acute Physiology and Chronic Health Evaluation II, 11.7 [6.21]). Continuous data for IVC-CI/CVP correlated poorly (R-2 = 0.177, p < 0.01) and were inversely proportional, with CVP less than 7 noted in approximately 10% of the patients for IVC-CIs less than 25% and CVP less than 7 observed in approximately 85% of patients for IVC-CIs greater than or equal to 75%. Median IVC-CI per unit CVP was 3.25%. Most measurements (361 of 320) were collected in mechanically ventilated patients (mean [SD] PEEP, 7.76 [4.11] cm H2O). PEEP-related CVP increase was approximately 2 mm Hg to 2.5 mm Hg for IVC-CIs greater than 60% and approximately 3 mm Hg to 3.5 mm Hg for IVC-CIs less than 30%. PEEP also resulted in lower IVC-CIs at low CVPs, which reversed with increasing CVPs. When IVC-CI was examined across increasing PEEP ranges, we noted an inverse relationship between the two variables, but this failed to reach statistical significance.CONCLUSION IVC-CI and CVP correlate inversely, with each 1 mm Hg of CVP corresponding to 3.3% median IVC-CI. Low IVC-CI (< 25%) is consistent with euvolemia/hypervolemia, while IVC-CI greater than 75% suggests intravascular volume depletion. The presence of PEEP results in 2 mm Hg to 3.5 mm Hg of CVP increase across the IVC-CI spectrum and lower collapsibility at low CVPs. Although IVC-CI decreased with increasing degrees of PEEP, this failed to reach statistical significance. While this study represents a step forward in the area of intravascular volume estimation using IVC-CI, our findings must be applied with caution owing to some methodologic limitations.LEVEL OF EVIDENCE Diagnostic study, level III. Prognostic study, level III.

OBJECTIVES:Medical educators must develop ultrasound education programs to ensure that future physicians are prepared to face the changing demands of clinical practice. It can be challenging to find human models for hands-on scanning sessions. This article outlines an educational model from a large university medical center that uses medical students to fulfill the need for human models. METHODS:During the 2011-2012 academic year, medical students from The Ohio State University College of Medicine served as trained simulated ultrasound patients (TSUP) for hands-on scanning sessions held by the college and many residency programs. The extracurricular program is voluntary and coordinated by medical students with faculty supervision. Students receive a longitudinal didactic and hands-on ultrasound education program as an incentive for serving as a TSUP. RESULTS:The College of Medicine and 7 residency programs used the program, which included 47 second-year and 7 first-year student volunteers. Participation has increased annually because of the program's ease, reliability, and cost savings in providing normal anatomic models for ultrasound education programs. A key success of this program is its inherent reproducibility, as a new class of eager students constitutes the volunteer pool each year. CONCLUSIONS:The TSUP program is a feasible and sustainable method of fulfilling the need for normal anatomic ultrasound models while serving as a valuable extracurricular ultrasound education program for medical students. The program facilitates the coordination of ultrasound education programs by educators at the undergraduate and graduate levels.

The Ultrasound Challenge was developed at The Ohio State University College of Medicine to introduce focused ultrasound to medical students. The goal was to develop experience in ultrasound through practice and competition. Initially this competition was held between Ohio State University College of Medicine students from years 1 through 4. The Ultrasound Challenge 2.0 was held in 2013. The event expanded on the previous structure by including students from the Wayne State University College of Medicine. The goal of this article is to describe our experiences with expansion of our interinstitutional ultrasound event. The challenge consisted of 6 stations: focused assessment with sonography for trauma, aortic ultrasound, cardiac ultrasound, pelvic ultrasound, musculoskeletal ultrasound, and vascular access. The participants were given a handbook outlining the expectations for each station ahead of time. Vascular access was graded in real time using the Brightness Mode Quality Ultrasound Imaging Examination Technique (B-QUIET) method. The remainder were timed, saved, and graded after the event by 3 independent faculty members using the B-QUIET method. The highest score with the fastest time was the winner. The Ultrasound Challenge 2.0 included 40 participants: 31 from The Ohio State University College of Medicine and 9 from the Wayne State University College of Medicine. The makeup of the winners in all categories consisted of 1 first-year medical student, 7 second-year medical students, 3 third-year medical students, and 10 fourth-year medical students. The Ultrasound Challenge 2.0 was a success for those who participated. It provided the first known interinstitutional medical student ultrasound competition. Students from both institutions were able to practice their image acquisition skills, demonstrate abilities in a competitive environment, and develop collegiality and teamwork.

Background: Recently, high-dose insulin (HDI) and intravenous lipid emulsion (ILE) have emerged as treatment options for severe toxicity from calcium-channel blocker (CCB) and beta blocker (BB). Objective: Our aim was to describe the use and effectiveness of HDI and ILE for the treatment of CCB and BB overdose. Case Reports: We describe 2 patients presenting to the emergency department after intentional ingestions of CCBs and BBs. A 35-year-oldman presented in pulseless electrical activity after ingesting amlodopine, verapamil, and metoprolol. A 59-year-old man presented with cardiogenic shock (CS) after ingesting amlodopine, simvastatin, lisinopril, and metformin. Both patients were initially treated with glucagon, calcium, and vasopressors. Shortly after arrival, HDI (1 unit/kg x 1; 1 unit/kg/h infusion) and ILE 20% (1.5 mL/kg x 1; 0.25 mL/kg/min x 60 min) were initiated. This led to hemodynamic improvement and resolution of shock. At the time of hospital discharge, both patients had achieved full neurologic recovery. Conclusions: HDI effectively reverses CS induced by CCBs and BBs due to its inotropic effects, uptake of glucose into cardiac muscle, and peripheral vasodilatation. ILE is theorized to sequester agents dependent on lipid solubility from the plasma, preventing further toxicity. To our knowledge, these are the first two successful cases reported using the combination of HDI and ILE for reversing CS induced by intentional ingestions of CCBs and BBs. (C) 2014 Elsevier Inc.

BACKGROUND In search of a standardized noninvasive assessment of intravascular volume status, we prospectively compared the sonographic inferior vena cava collapsibility index (IVC-CI) and central venous pressures (CVPs). Our goals included the determination of CVP behavior across clinically relevant IVC-CI ranges, examination of unitary behavior of IVC-CI with changes in CVP, and estimation of the effect of positive end-expiratory pressure (PEEP) on the IVC-CI/CVP relationship. METHODS Prospective, observational study was performed in surgical/medical intensive care unit patients between October 2009 and July 2013. Patients underwent repeated sonographic evaluations of IVC-CI. Demographics, illness severity, ventilatory support, CVP, and patient positioning were recorded. Correlations were made between CVP groupings (<7, 7–12, 12–18, 19+) and IVC-CI ranges (<25, 25–49, 50–74, 75+). Comparison of CVP (2-unit quanta) and IVC-CI (5-unit quanta) was performed, followed by assessment of per-unit ΔIVC-CI/ΔCVP behavior as well as examination of the effect of PEEP on the IVC-CI/CVP relationship. RESULTS We analyzed 320 IVC-CI/CVP measurement pairs from 79 patients (mean [SD] age, 55.8 [16.8] years; 64.6% male; mean [SD] Acute Physiology and Chronic Health Evaluation II, 11.7 [6.21]). Continuous data for IVC-CI/CVP correlated poorly (R2 = 0.177, p < 0.01) and were inversely proportional, with CVP less than 7 noted in approximately 10% of the patients for IVC-CIs less than 25% and CVP less than 7 observed in approximately 85% of patients for IVC-CIs greater than or equal to 75%. Median ΔIVC-CI per unit CVP was 3.25%. Most measurements (361 of 320) were collected in mechanically ventilated patients (mean [SD] PEEP, 7.76 [4.11] cm H2O). PEEP-related CVP increase was approximately 2 mm Hg to 2.5 mm Hg for IVC-CIs greater than 60% and approximately 3 mm Hg to 3.5 mm Hg for IVC-CIs less than 30%. PEEP also resulted in lower IVC-CIs at low CVPs, which reversed with increasing CVPs. When IVC-CI was examined across increasing PEEP ranges, we noted an inverse relationship between the two variables, but this failed to reach statistical significance. CONCLUSION IVC-CI and CVP correlate inversely, with each 1 mm Hg of CVP corresponding to 3.3% median ΔIVC-CI. Low IVC-CI (<25%) is consistent with euvolemia/hypervolemia, while IVC-CI greater than 75% suggests intravascular volume depletion. The presence of PEEP results in 2 mm Hg to 3.5 mm Hg of CVP increase across the IVC-CI spectrum and lower collapsibility at low CVPs. Although IVC-CI decreased with increasing degrees of PEEP, this failed to reach statistical significance. While this study represents a step forward in the area of intravascular volume estimation using IVC-CI, our findings must be applied with caution owing to some methodologic limitations. LEVEL OF EVIDENCE Diagnostic study, level III. Prognostic study, level III.

Dear Editor Ultrasound use in cardiac arrest (CA) has been associated with poor outcome when cardiac activity is unable to be visualized.[1] The focused echocardiographic evaluation in life support (FEEL) protocol evolved as a systematic approach to using focused echo in CA.[2] Use in the United States is sporadic and relies on having trained personnel in the use of ultrasound available at the site of the CA. Ultrasound is not yet a standard part of advanced cardiac life support (ACLS). This case illustrates; how use of point-of-care (POC) ultrasound can be utilized for decision making in the CA patient. A 55-year-old male was admitted for abdominal pain, nausea, vomiting, and weight loss. CT scan of the abdomen revealed a cirrhotic liver with mass and intravascular thrombus. Liver biopsy confirmed hepatocellular carcinoma. Post procedure the patient became anemic and received blood products following the biopsy. The abdominal exam remained soft and non-tender. On hospital day (HD) #6 the patient developed altered mental status requiring intubation. A multidisciplinary team led by emergency physicians that conducts weekly intensive care unit (ICU) ultrasound rounds arrived in the medical ICU (MICU). The patient was suggested for the educational ultrasound rounds. While preparing the ultrasound machine, the patient became hypotensive. A focused cardiac echo was done showing a severely hypokinetic heart without pericardial effusion. The ratio of the right and left ventricles were normal. The arterial waveform showed narrowed pulse pressure. Within seconds, the patient had a pulseless electrical activity (PEA) CA. ACLS was initiated. During the pulse check, cardiac activity was assessed as described in the FEEL protocol[2] [Video 1]. The echo showed cardiac activity with severe hypokinesis [Video 2]. During cardiopulmonary resuscitation (CPR), a focused assessment with sonography in trauma (FAST) scan demonstrated free fluid within Morrison's pouch. Return of spontaneous circulation (ROSC) occurred after intravenous (IV) epinephrine and aggressive volume resuscitation. The cause of the pulseless electrical activity (PEA) arrest was felt to be hypovolemia and anemia. The heart was reexamined and showed improved contractility with a relatively hypokinetic state [Video 3]. Surgery was consulted and exploratory laparotomy was performed. Large amounts of blood and blood clots were removed and the liver was packed at the biopsy site. This case highlights the benefits of POC ultrasound in the ICU setting. Initial images obtained at the onset of this patient's instability led to the early recognition and mobilization of the CA response teams. The use of ultrasound in CA can provide information to help guide resuscitation and identify reversible causes.[3] The FEEL protocol demonstrated the feasibility of applying ultrasound during CPR. Physicians were able to detect reversible conditions as causes of PEA (hypovolemia, tamponade, etc.) and alter the management of the arresting patient.[2] In our patient, the ultrasound provided value during CPR by demonstrating hypokinetic cardiac activity, excluded pericardial tamponade, and showed free fluid in the abdomen associated with the hemorrhagic shock. The use of ultrasound during CA is feasible by nonexpert sonographers.[4] Image acquisition during the pulse check should not exceed the 10-s allotment in a pulseless patient to avoid interference with CPR. Real time scanning during CPR can occur as well. Imaging during CPR is best performed using the subcostal window to prevent any obstruction of the provider giving chest compressions.[5] Our case shows how real-time POC ultrasound technology in critically ill patients can assist in recognition of reversible causes of CA. Identifying ways to increase use of ultrasound during CA may result in improved outcomes for critically ill patients.

Hemodynamic assessment utilizing intensivist-performed bedside sonography is an actively evolving clinical area. Inferior vena cava collapsibility index (IVC-CI) has been shown to correlate with both clinical assessment and invasive monitoring of intravascular volume status. Major limitations of IVC-CI include the requirement for advanced sonographic skills, steep learning curve, frequently difficult visualization of vena cava, and interference by surgical dressings. In search of viable alternative for IVC-CI, we performed a direct comparison of the subclavian vein collapsibility index (SCV-CI) and IVC-CI.

Introduction: High dose insulin (HDI) and intravenous lipid emulsion (ILE) have emerged as treatment options for severe calcium channel blocker (CCB) and beta-blocker (BB) toxicity. Insulin causes increased glucose uptake into cardiac myocytes and affects various intra-cellular pathways resulting in

Background Physician-performed focused ultrasonography is a rapidly growing field with numerous clinical applications. Focused ultrasound is a clinically useful tool with relevant applications across most specialties. Ultrasound technology has outpaced the education, necessitating an early introduction to the technology within the medical education system. There are many challenges to integrating ultrasound into medical education including identifying appropriately trained faculty, access to adequate resources, and appropriate integration into existing medical education curricula. As focused ultrasonography increasingly penetrates academic and community practices, access to ultrasound equipment and trained faculty is improving. However, there has remained the major challenge of determining at which level is integrating ultrasound training within the medical training paradigm most appropriate. Methods The Ohio State University College of Medicine has developed a novel vertical curriculum for focused ultrasonography which is concordant with the 4-year medical school curriculum. Given current evidenced-based practices, a curriculum was developed which provides medical students an exposure in focused ultrasonography. The curriculum utilizes focused ultrasonography as a teaching aid for students to gain a more thorough understanding of basic and clinical science within the medical school curriculum. The objectives of the course are to develop student understanding in indications for use, acquisition of images, interpretation of an ultrasound examination, and appropriate decision-making of ultrasound findings. Results Preliminary data indicate that a vertical ultrasound curriculum is a feasible and effective means of teaching focused ultrasonography. The foreseeable limitations include faculty skill level and training, initial cost of equipment, and incorporating additional information into an already saturated medical school curriculum. Conclusions Focused ultrasonography is an evolving concept in medicine. It has been shown to improve education and patient care. The indications for and implementation of focused ultrasound is rapidly expanding in all levels of medicine. The ideal method for teaching ultrasound has yet to be established. The vertical curriculum in ultrasound at The Ohio State University College of Medicine is a novel evidenced-based training regimen at the medical school level which integrates ultrasound training into medical education and serves as a model for future integrated ultrasound curricula.

BACKGROUND:Traditional methods for intravascular volume status assessment are invasive and are associated significant complications. While focused bedside sonography of the inferior vena cava (IVC) has been shown to be useful in estimating intravascular volume status, it may be technically difficult and limited by patient factors such as obesity, bowel gas, or postoperative surgical dressings. The goal of this investigation is to determine the feasibility of subclavian vein (SCV) collapsibility as an adjunct to IVC collapsibility in intravascular volume status assessment. METHODS:A prospective study was conducted on a convenience sample of surgical intensive care unit patients to evaluate interchangeability of IVC collapsibility index (IVC-CI) and SCV-CI. After demographic and acuity of illness information was collected, all patients underwent serial, paired assessments of IVC-CI and SCV-CI using portable ultrasound device (M-Turbo; Sonosite, Bothell, WA). Vein collapsibility was calculated using the formula [collapsibility (%) = (max diameter - min diameter)/max diameter × 100%]. Paired measurements from each method were compared using correlation coefficient and Bland-Altman measurement bias analysis. RESULTS:Thirty-four patients (mean age 56 y, 38% female) underwent a total of 94 paired SCV-CI and IVC-CI sonographic measurements. Mean acute physiology and chronic health evaluation II score was 12. Paired SCV- and IVC-CI showed acceptable correlation (R(2) = 0.61, P < 0.01) with acceptable overall measurement bias [Bland-Altman mean collapsibility difference (IVC-CI minus SCV-CI) of -3.2%]. In addition, time needed to acquire and measure venous diameters was shorter for the SCV-CI (70 s) when compared to IVC-CI (99 s, P < 0.02). CONCLUSIONS:SCV collapsibility assessment appears to be a reasonable adjunct to IVC-CI in the surgical intensive care unit patient population. The correlation between the two techniques is acceptable and the overall measurement bias is low. In addition, SCV-CI measurements took less time to acquire than IVC-CI measurements, although the clinical relevance of the measured time difference is unclear.