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Table of Content

    15 December 2019, Volume 10 Issue 4
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    Original Articles
    Ascending aortic dilatation rate after transcatheter aortic valve replacement in patients with bicuspid and tricuspid aortic stenosis: A multidetector computed tomography follow-up study
    Yu-xin He, Jia-qi Fan, Qi-feng Zhu, Qi-jing Zhou, Ju-bo Jiang, Li-han Wang, Stella Ng, Xian-bao Liu, Jian-an Wang
    2019, 10(4):  197-204.  doi:10.5847/wjem.j.1920-8642.2019.04.001
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    BACKGROUND: Current data is lacking about the progression of ascending aortic dilatation after transcatheter aortic valve replacement (TAVR) in aortic stenosis (AS) patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV). This study aims to assess the ascending aortic dilatation rate (mm/year) after TAVR in patients with BAV versus TAV using a multidetector computed tomography (MDCT) follow-up and to determine the predictors of ascending aortic dilatation rate.
    METHODS: Severe AS patients undergoing TAVR from March 2013 to March 2018 at our center with MDCT follow-ups were included. BAV and TAV were identified using baseline MDCT. Baseline and follow-up MDCT images were analyzed, and the diameters of ascending aorta were measured. Study end point is ascending aortic dilatation rate (mm/year). Furthermore, factors predicting ascending aortic dilatation rate were also investigated.
    RESULTS: Two hundred and eight patients were included, comprised of 86 BAV and 122 TAV patients. Five, 4, 3, 2, and 1-year MDCT follow-ups were achieved in 7, 9, 30, 46, and 116 patients. The ascending aortic diameter was significantly increased after TAVR in both BAV group (43.7±4.4 mm vs. 44.0±4.5 mm; P<0.001) and TAV group (39.1±4.8 mm vs. 39.7±5.1 mm; P<0.001). However, no difference of ascending aortic dilatation rate was found between BAV and TAV groups (0.2±0.8 mm/year vs. 0.3±0.8 mm/year, P=0.592). Multivariate linear regression revealed paravalvular leakage (PVL) grade was independently associated with ascending aortic dilatation rate in the whole population and BAV group, but not TAV group. No aortic events occurred during follow-ups.
    CONCLUSION: Ascending aortic size continues to grow after TAVR in BAV patients, but the dilatation rate is mild and comparable to that of TAV patients. PVL grade is associated with ascending aortic dilatation rate in BAV patients post-TAVR.

    Can emergency physicians perform extended compression ultrasound for the diagnosis of lower extremity deep vein thrombosis?
    Elaine Situ-LaCasse, Helpees Guirguis, Lucas Friedman, Asad E. Patanwala, Seth E. Cohen, Srikar Adhikari
    2019, 10(4):  205-209.  doi:10.5847/wjem.j.1920-8642.2019.04.002
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    BACKGROUND: Current point-of-care ultrasound protocols in the evaluation of lower extremity deep vein thrombosis (DVT) can miss isolated femoral vein clots. Extended compression ultrasound (ECUS) includes evaluation of the femoral vein from the femoral vein/deep femoral vein bifurcation to the adductor canal. Our objective is to determine if emergency physicians (EPs) can learn ECUS for lower extremity DVT evaluation after a focused training session.
    METHODS: Prospective study at an urban academic center. Participants with varied ultrasound experience received instruction in ECUS prior to evaluation. Two live models with varied levels of difficult sonographic anatomy were intentionally chosen for the evaluation. Each participant scanned both models. Pre- and post-study surveys were completed.
    RESULTS: A total of 96 ultrasound examinations were performed by 48 participants (11 attendings and 37 residents). Participants’ assessment scores averaged 95.8% (95% CI 93.3%-98.3%) on the easier anatomy live model and averaged 92.3% (95% CI 88.4%-96.2%) on the difficult anatomy model. There were no statistically significant differences between attendings and residents. On the model with easier anatomy, all but 1 participant identified and compressed the proximal femoral vein successfully, and all participants identified and compressed the mid and distal femoral vein. With the difficult anatomy, 97.9% (95% CI 93.8%-102%) identified and compressed the proximal femoral vein, whereas 93.8% (95% CI 86.9%-100.6%) identified and compressed the mid femoral vein, and 91.7% (95% CI 83.9%-99.5%) identified and compressed the distal femoral vein.
    CONCLUSION: EPs at our institution were able to perform ECUS with good reproducibility after a focused training session.

    Confirmation of endotracheal tube placement using disposable fiberoptic bronchoscopy in the emergent setting
    Avir Mitra, Asaf Gave, Kelsey Coolahan, Thomas Nguyen
    2019, 10(4):  210-214.  doi:10.5847/wjem.j.1920-8642.2019.04.003
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    BACKGROUND: Patients intubated in the prehospital setting require quick and definitive confirmation of endotracheal (ET) tube placement upon arrival to the emergency department (ED). Direct and adjunct strategies exist, but each has limitations and there is no definitive gold standard. The utility of bronchoscopy in ED intubation has been studied, but scant literature exists on its use for ET tube confirmation. This study aims to assess effectiveness, ease and speed with which ET tube placement can be confirmed with disposable fiberoptic bronchoscopy.
    METHODS: Emergency medicine residents recruited from a 3-year urban residency program received 5 minutes of active learning on a simulation mannequin using a disposable, flexible Ambu aScope interfaced with a monitor. With residents blinded, the researcher randomly placed the ET tube in the trachea, esophagus or right mainstem. Residents identified ET tube position by threading the bronchoscope through the tube and viewing distal anatomy. Each resident underwent 4 trials. Accuracy, speed and perceptions of difficulty were measured.
    RESULTS: Residents accurately identified the location of the ET tube in 88 out of 92 trials (95.7%). The median time-to-guess was 7.0 seconds, IQR (5.0-10.0). Average perceived difficulty was 1.6 on a scale from 1-5 (1 being very easy and 5 being very difficult). No tubes were damaged or dislodged.
    CONCLUSION: While simulation cannot completely replicate the live experience, fiberoptic bronchoscopy appears to be a quick and accurate method for ET tube confirmation. Further studies directly comparing this novel approach to established practices on actual patients are warranted.

    Comparison between Emergency Severity Index and Heart Failure Triage Scale in heart failure patients: A randomized clinical trial
    Ahmad Pouyamehr, Amir Mirhaghi, Mohammad Davood Sharifi, Ali Eshraghi
    2019, 10(4):  215-221.  doi:10.5847/wjem.j.1920-8642.2019.04.004
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    BACKGROUND: It is not clear whether Emergency Severity Index (ESI) is valid to triage heart failure (HF) patients and if HF patients benefit more from a customized triage scale or not. The aim of study is to compare the effect of Heart Failure Triage Scale (HFTS) and ESI on mistriage among patients with HF who present to the emergency department (ED).
    METHODS: A randomized clinical trial was conducted from April to June 2017. HF patients with dyspnea were randomly assigned to HFTS or ESI groups. Triage level, used resources and time to electrocardiogram (ECG) were compared between both groups among HF patients who were admitted to coronary care unit (CCU), cardiac unit (CU) and discharged patients from the ED. Content validity was examined using Kappa designating agreement on relevance (K*). Reliability of both scale was evaluated using inter-observer agreement (Kappa).
    RESULTS: Seventy-three and 74 HF patients were assigned to HFTS and ESI groups respectively. Time to ECG in HFTS group was significantly shorter than that of ESI group (2.05 vs. 16.82 minutes). Triage level between HFTS and ESI groups was significantly different among patients admitted to CCU (1.0 vs. 2.8), cardiac unit (2.26 vs. 3.06) and discharged patients from the ED (3.53 vs. 2.86). Used resources in HFTS group were significantly different among triage levels (H=25.89; df=3; P<0.001).
    CONCLUSION: HFTS is associated with less mistriage than ESI for triaging HF patients. It is recommended to make use of HFTS to triage HF patients in the ED.

    A survey of ventilation strategies during cardiopulmonary resuscitation
    Ye-cheng Liu, Yan-meng Qi, Hui Zhang, Joseph Walline, Hua-dong Zhu
    2019, 10(4):  222-227.  doi:10.5847/wjem.j.1920-8642.2019.04.005
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    BACKGROUND: Many controversies still exist regarding ventilator parameters during cardiopulmonary resuscitation (CPR). This study aimed to investigate the CPR ventilation strategies currently being used among physicians in Chinese tertiary hospitals.
    METHODS: A survey was conducted among the cardiac arrest team physicians of 500 tertiary hospitals in China in August, 2018. Surveyed data included physician and hospital information, and preferred ventilation strategy during CPR.
    RESULTS: A total of 438 (88%) hospitals completed the survey, including hospitals from all 31 Chinese mainland provinces. About 41.1% of respondents chose delayed or no ventilation during CPR, with delayed ventilations all starting within 12 minutes. Of all the respondents who provided ventilation, 83.0% chose to strictly follow the 30:2 strategy, while 17.0% chose ventilations concurrently with uninterrupted compressions. Only 38.3% respondents chose to intubate after initiating CPR, while 61.7% chose to intubate immediately when resuscitation began. During bag-valve-mask ventilation, only 51.4% of respondents delivered a frequency of 10 breaths per minute. In terms of ventilator settings, the majority of respondents chose volume control (VC) mode (75.2%), tidal volume of 6-7 mL/kg (72.1%), PEEP of 0-5 cmH2O (69.9%), and an FiO2 of 100% (66.9%). However, 62.0% of respondents had mistriggers after setting the ventilator, and 51.8% had high pressure alarms.
    CONCLUSION: There is a great amount of variability in CPR ventilation strategies among cardiac arrest team physicians in Chinese tertiary hospitals. Guidelines are needed with specific recommendations on ventilation during CPR.

    Orginal Article
    Application of 4% formaldehyde under electronic colonoscope as a minimally invasive treatment of chronic hemorrhagic radiation proctitis
    Yan-dong Li, Jia-he Xu, Jian-jiang Lin, Wei-fang Zhu
    2019, 10(4):  228-231.  doi:10.5847/wjem.j.1920-8642.2019.04.006
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    BACKGROUND:To investigate the effectiveness of topical application of 4% formaldehyde as a minimally invasive treatment of rectal bleeding due to chronic radiation proctitis (CRP) under direct vision of electronic colonoscope.
    METHODS: The clinical data of 13 CRP patients complicated with ≥ grade II bleeding admitted to our hospital between January 2003 and December 2018 were retrospectively analyzed. Under the guidance of electronic colonoscope, 4% formaldehyde combined with 5-aminosalicylic acid (5-ASA) suppositories was topically applied. Patients were followed up for two months after treatment, and the therapeutic effectiveness was observed and analyzed.
    RESULTS: The rectal bleeding due to CRP was markedly reduced after topical application of 4% formaldehyde under colonoscope in all 13 patients. The bleeding stopped after one treatment session in 11 patients and after the second session in 2 patients. 5-ASA was also applied along with the use of 4% formaldehyde. The therapeutic effectiveness was satisfactory during the 1- and 2-month follow-up period.
    CONCLUSION: Topical application of 4% formaldehyde under the direct vision of colonoscope as a minimally invasive treatment for CRB-induced bleeding is a simple, effective, affordable, and repeatable technique without obvious complications, which deserves further exploration and promotion.

    Review Article
    The utility of point-of-care ultrasound in the assessment of volume status in acute and critically ill patients
    Ali Pourmand, Matthew Pyle, David Yamane, Kazi Sumon, Sarah E. Frasure
    2019, 10(4):  232-238.  doi:10.5847/wjem.j.1920-8642.2019.04.007
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    BACKGROUND: Volume resuscitation has only been demonstrated to be effective in approximately fifty percent of patients. The remaining patients do not respond to volume resuscitation and may even develop adverse outcomes (such as acute pulmonary edema necessitating endotracheal intubation). We believe that point-of-care ultrasound is an excellent modality by which to adequately predict which patients may benefit from volume resuscitation.
    DATA RESOURCES: We performed a search using PubMed, Scopus, and MEDLINE. The following search terms were used: fluid responsiveness, ultrasound, non-invasive, hemodynamic, fluid challenge, and passive leg raise. Preference was given to clinical trials and review articles that were most relevant to the topic of assessing a patient’s cardiovascular ability to respond to intravenous fluid administration using ultrasound.
    RESULTS: Point-of-care ultrasound can be easily employed to measure the diameter and collapsibility of various large vessels including the inferior vena cava, common carotid artery, subclavian vein, internal jugular vein, and femoral vein. Such parameters are closely related to dynamic measures of fluid responsiveness and can be used by providers to help guide fluid resuscitation in critically ill patients.
    CONCLUSION: Ultrasound in combination with passive leg raise is a non-invasive, cost- and time-effective modality that can be employed to assess volume status and response to fluid resuscitation. Traditionally sonographic studies have focused on the evaluation of large veins such as the inferior vena cava, and internal jugular vein. A number of recently published studies also demonstrate the usefulness of evaluating large arteries to predict volume status.

    Research Letter
    Characteristics of non-conveyance ambulance runs: A retrospective study in the Netherlands
    Remco H.A. Ebben, Mariola Castelijns, Joost Frenken, Lilian C.M. Vloet
    2019, 10(4):  239-243.  doi:10.5847/wjem.j.1920-8642.2019.04.008
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    Case Letters
    Empyema and mediastinal abscess in pyriform sinus fistula: A case report
    Hai-jiang Zhou, Wen-peng Yin, Tian-fei Lan, Shu-bin Guo
    2019, 10(4):  244-247.  doi:10.5847/wjem.j.1920-8642.2019.04.009
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    Continuous B scan ultrasound guided post-traumatic sub-periosteal orbital hematoma drainage: An advantage over routine needle drainage procedure
    Amar Pujari, Pallavi Singh, Ayushi Sinha, Shreya Nayak, Mandeep S. Bajaj
    2019, 10(4):  248-250.  doi:10.5847/wjem.j.1920-8642.2019.04.010
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    My mother is looking blue
    Howard Tat Chun Chan, Anselm Wang Hei Hui, Colin Graham, Joseph Walline
    2019, 10(4):  251-252.  doi:10.5847/wjem.j.1920-8642.2019.04.011
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