Original Research Archives - Page 22 of 40 - The Western Journal of Emergency Medicine

Gender Differences in Emergency Department Visits and Detox Referrals for Illicit and Nonmedical Use of Opioids

Volume 17, Issue 3, May 2016
Hyeon-Ju Ryoo, BA et al.

Introduction: Visits to the emergency department (ED) for use of illicit drugs and opioids have increased in the past decade. In the ED, little is known about how gender may play a role in drug-related visits and referrals to treatment. This study performs gender-based comparison analyses of drug-related ED visits nationwide.
Methods: We performed a cross-sectional analysis with data collected from 2004 to 2011 by the Drug Abuse Warning Network (DAWN). All data were coded to capture major drug categories and opioids. We used logistic regression models to find associations between gender and odds of referral to treatment programs. A second set of models were controlled for patient “seeking detox,” or patient explicitly requesting for detox referral.
Results: Of the 27.9 million ED visits related to drug use in the DAWN database, visits by men were 2.69 times more likely to involve illicit drugs than visits by women (95% CI [2.56, 2.80]). Men were more likely than women to be referred to detox programs for any illicit drugs (OR 1.12, 95% CI [1.02–1.22]), for each of the major illicit drugs (e.g., cocaine: OR 1.27, 95% CI [1.15–1.40]), and for prescription opioids (OR 1.30, 95% CI [1.17–1.43]). This significant association prevailed after controlling for “seeking detox.”
Conclusion: Women are less likely to receive referrals to detox programs than men when presenting to the ED regardless of whether they are “seeking detox.” Future research may help determine the cause for this gender-based difference and its significance for healthcare costs and health outcomes.

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Variations in Substance Use Prevalence Estimates and Need for Interventions among Adult Emergency Department Patients Based on Different Screening Strategies Using the ASSIST

Volume 17, Issue 3, May 2016
Roland C. Merchant, MD, MPH, ScD

Introduction: Among adult emergency department (ED) patients, we sought to examine how estimates of substance use prevalence and the need for interventions can differ, based on the type of screening and assessment strategies employed.
Methods: We estimated the prevalence of substance use and the need for interventions using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in a secondary analysis of data from two cross-sectional studies using random samples of English- or Spanish-speaking 18–64-year-old ED patients. In addition, the test performance characteristics of three simplified screening strategies consisting of selected questions from the ASSIST (lifetime use, past three-month use, and past three-month frequency of use) to identify patients in need of a possible intervention were compared against using the full ASSIST.
Results: Of 6,432 adult ED patients, the median age was 37 years-old, 56.6% were female, and 61.6% were white. Estimated substance use prevalence among this population differed by how it was measured (lifetime use, past three-month use, past three-month frequency of use, or need for interventions). As compared to using the full ASSIST, the predictive value and accuracy to identify patients in need of any intervention was best for a simplified strategy asking about past three-month substance use. A strategy asking about daily/near-daily use was better in identifying patients needing intensive interventions. However, some patients needing interventions were missed when using these simplified strategies.
Conclusion: Substance use prevalence estimates and identification of ED patients needing interventions differ by screening strategies used. EDs should carefully select strategies to identify patients in need of substance use interventions.

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Undertriage of Trauma-Related Deaths in U.S. Emergency Departments

Volume 17, Issue 3, May 2016
Jenelle Holst, MD. et al.

Introduction: Accurate field triage of critically injured patients to trauma centers is vital for improving survival. We sought to estimate the national degree of undertriage of trauma patients who die in emergency departments (EDs) by evaluating the frequency and characteristics associated with triage to non-trauma centers.
Methods: This was a retrospective cross-sectional analysis of adult ED trauma deaths in the 2010 National Emergency Department Sample (NEDS). The primary outcome was appropriate triage to a trauma center (Level I, II or III) or undertriage to a non-trauma center. We subsequently focused on urban areas given improved access to trauma centers. We evaluated the associations of patient demographics, hospital region and mechanism of injury with triage to a trauma versus non-trauma center using multivariable logistic regression.
Results: We analyzed 3,971 included visits, representing 18,464 adult ED trauma-related deaths nationally. Of all trauma deaths, nearly half (44.5%, 95% CI [43.0–46.0]) of patients were triaged to non-trauma centers. In a subgroup analysis, over a third of urban ED visits (35.6%, 95% CI [34.1–37.1]) and most rural ED visits (86.4%, 95% CI [81.5–90.1]) were triaged to non-trauma centers. In urban EDs, female patients were less likely to be triaged to trauma centers versus non-trauma centers (adjusted odds ratio [OR] 0.83, 95% CI [0.70–0.99]). Highest median household income zip codes (≥$67,000) were less likely to be triaged to trauma centers than lowest median income ($1–40,999) (OR 0.54, 95% CI [0.43–0.69]). Compared to motor vehicle trauma, firearm trauma had similar odds of being triaged to a trauma center (OR 0.90, 95% CI [0.71–1.14]); however, falls were less likely to be triaged to a trauma center (OR 0.50, 95 %CI [0.38–0.66]).
Conclusion: We found that nearly half of all trauma patients nationally and one-third of urban trauma patients, who died in the ED, were triaged to non-trauma centers, and thus undertriaged. Sex and other demographic disparities associated with this triage decision represent targeted opportunities to improve our trauma systems and reduce undertriage.

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Vital Signs Predict Rapid-Response Team Activation Within Twelve Hours of Emergency Department Admission

Volume 17, Issue 3, May 2016
James Walston, MD. et al.

Introduction: Rapid-response teams (RRTs) are interdisciplinary groups created to rapidly assess and treat patients with unexpected clinical deterioration marked by decline in vital signs. Traditionally emergency department (ED) disposition is partially based on the patients’ vital signs (VS) at the time of hospital admission. We aimed to identify which patients will have RRT activation within 12 hours of admission based on their ED VS, and if their outcomes differed.
Methods: We conducted a case-control study of patients presenting from January 2009 to December 2012 to a tertiary ED who subsequently had RRT activations within 12 hours of admission (early RRT activations). The medical records of patients 18 years and older admitted to a non-intensive care unit (ICU) setting were reviewed to obtain VS at the time of ED arrival and departure, age, gender and diagnoses. Controls were matched 1:1 on age, gender, and diagnosis. We evaluated VS using cut points (lowest 10%, middle 80% and highest 10%) based on the distribution of VS for all patients. Our study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting observational studies.
Results: A total of 948 patients were included (474 cases and 474 controls). Patients who had RRT activations were more likely to be tachycardic (odds ratio [OR] 2.02, 95% CI [1.25–3.27]), tachypneic (OR 2.92, 95% CI [1.73–4.92]), and had lower oxygen saturations (OR 2.25, 95% CI [1.42–3.56]) upon arrival to the ED. Patients who had RRT activations were more likely to be tachycardic at the time of disposition from the ED (OR 2.76, 95% CI [1.65–4.60]), more likely to have extremes of systolic blood pressure (BP) (OR 1.72, 95% CI [1.08–2.72] for low BP and OR 1.82, 95% CI [1.19–2.80] for high BP), higher respiratory rate (OR 4.15, 95% CI [2.44–7.07]) and lower oxygen saturation (OR 2.29, 95% CI [1.43–3.67]). Early RRT activation was associated with increased healthcare utilization and worse outcomes including increased rates of ICU admission within 72 hours (OR 38.49, 95%CI [19.03–77.87]), invasive interventions (OR 5.49, 95%CI [3.82–7.89]), mortality at 72 hours (OR 4.24, 95%CI [1.60–11.24]), and mortality at one month (OR 4.02, 95%CI [2.44–6.62]).
Conclusion: After matching for age, gender and ED diagnosis, we found that patients with an abnormal heart rate, respiratory rate or oxygen saturation at the time of ED arrival or departure are more likely to trigger RRT activation within 12 hours of admission. Early RRT activation was associated with higher mortality at 72 hours and one month, increased rates of invasive intervention and ICU admission. Determining risk factors of early RRT activation is of clinical, operational, and financial importance, as improved medical decision-making regarding disposition would maximize allocation of resources while potentially limiting morbidity and mortality.

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Impact of Doximity Residency Rankings on Emergency Medicine Applicant Rank Lists

Volume 17, Issue 3, May 2016
William J. Peterson, MD, et al.

Introduction: This study investigates the impact of the Doximity rankings on the rank list choices
made by residency applicants in emergency medicine (EM).
Methods: We sent an 11-item survey by email to all students who applied to EM residency
programs at four different institutions representing diverse geographical regions. Students were
asked questions about their perception of Doximity rankings and how it may have impacted their
rank list decisions.
Results: Response rate was 58% of 1,372 opened electronic surveys. This study found that a
majority of medical students applying to residency in EM were aware of the Doximity rankings prior
to submitting rank lists (67%). One-quarter of these applicants changed the number of programs
and ranks of those programs when completing their rank list based on the Doximity rankings
(26%). Though the absolute number of programs changed on the rank lists was small, the results
demonstrate that the EM Doximity rankings impact applicant decision-making in ranking residency
programs.
Conclusion: While applicants do not find the Doximity rankings to be important compared to other
factors in the application process, the Doximity rankings result in a small change in residency
applicant ranking behavior. This unvalidated ranking, based principally on reputational data rather
than objective outcome criteria, thus has the potential to be detrimental to students, programs, and
the public. We feel it important for specialties to develop consensus around measurable training
outcomes and provide freely accessible metrics for candidate education.

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Population Health Research Design

Authorship Trends of Emergency Medicine Publications over the Last Two Decades

Volume 17, Issue 3, May 2016
Richard Lammers, MD, et al.

Introduction: With the recent merger of the American Osteopathic Association (AOA) and
the Accreditation Council for Graduate Medical Education (ACGME) a heightened pressure for
publication may become evident. Our objective was to determine whether there was a gap in the
type of both medical degree designation and advanced degree designation among authorship in
three United States-based academic emergency medicine journals.
Methods: We reviewed the Journal of Emergency Medicine, Academic Emergency Medicine and
Annals of Emergency Medicine for the type of degree designation that the first and senior authors
had obtained for the years 1995, 2000, 2005, 2010 and 2014.
Results: A total of 2.48% of all authors held a degree in osteopathic medicine. Osteopathic
physician first authors contributed to 3.26% of all publications while osteopathic physician senior
authors contributed 1.53%. No statistical trend could be established for the years studied for
osteopathic physicians. However, we noted an overall trend for increased publication for allopathic
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senior authors (p=0.001), allopathic first authors with a dual degree (p=0.003) and allopathic
senior authors with a dual degree (p=0.005). For each journal studied, no statistical trend could
be established for osteopathic first or senior authors but a trend was noted for allopathic first
and senior authors in the Journal of Emergency Medicine (p-value=0.020 and 0.006). Of those
with dual degrees, osteopathic physicians were in the minority with 1.85% of osteopathic first
authors and 0.60% of osteopathic senior authors attaining a dual degree. No statistical trend could
be established for increased dual degree publications for osteopathic physicians over the study
period, nor could a statistical trend be established for any of the journals studied.
Conclusion: Very few osteopathic physicians have published in the Journal of Emergency
Medicine, Academic Emergency Medicine or Annals of Emergency Medicine over the last two
decades. Despite a trend for increased publication by allopathic physicians in certain journals,
there appears to be no trend for increased publication of osteopathic physicians in emergency
medicine.

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Out-of-Hospital Surgical Airway Management: Does Scope of Practice Equal Actual Practice?

Volume 17. Issue 3, May 2016
Molly Furin, MD, MS et al.

Introduction: Pennsylvania, among other states, includes surgical airway management, or
cricothyrotomy, within the paramedic scope of practice. However, there is scant literature that evaluates
paramedic perception of clinical competency in cricothyrotomy. The goal of this project is to assess
clinical exposure, education and self-perceived competency of ground paramedics in cricothyrotomy.
Methods: Eighty-six paramedics employed by four ground emergency medical services agencies
completed a 22-question written survey that assessed surgical airway attempts, training, skills verification,
and perceptions about procedural competency. Descriptive statistics were used to evaluate responses.
Results: Only 20% (17/86, 95% CI [11-28%]) of paramedics had attempted cricothyrotomy, most (13/17
or 76%, 95% CI [53-90%]) of whom had greater than 10 years experience. Most subjects (63/86 or 73%,
95% CI [64-82%]) did not reply that they are well-trained to perform cricothyrotomy and less than half
(34/86 or 40%, 95% CI [30-50%]) felt they could correctly perform cricothyrotomy on their first attempt.
Among subjects with five or more years of experience, 39/70 (56%, 95% CI [44-68%]) reported 0-1 hours
per year of practical cricothyrotomy training within the last five years. Half of the subjects who were able
to recall (40/80, 50% 95% CI [39-61%]) reported having proficiency verification for cricothyrotomy within
the past five years.
Conclusion: Paramedics surveyed indicated that cricothyrotomy is rarely performed, even among those
with years of experience. Many paramedics felt that their training in this area is inadequate and did not
feel confident to perform the procedure. Further study to determine whether to modify paramedic scope of
practice and/or to develop improved educational and testing methods is warranted.

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Pilot Study to Determine Accuracy of Posterior Approach Ultrasound for Shoulder Dislocation by Novice Sonographers

Volume 17, Issue 3, May 2016.
Shadi Laham, MD, MS, et al.

Introduction: The goal of this study was to investigate the efficacy of diagnosing shoulder
dislocation using a single-view, posterior approach point-of-care ultrasound (POCUS) performed
by undergraduate research students, and to establish the range of measured distance that
discriminates dislocated shoulder from normal.
Methods: We enrolled a prospective, convenience sample of adult patients presenting to
the emergency department with acute shoulder pain following injury. Patients underwent
ultrasonographic evaluation of possible shoulder dislocation comprising a single transverse
view of the posterior shoulder and assessment of the relative positioning of the glenoid fossa
and the humeral head. The sonographic measurement of the distance between these two
anatomic structures was termed the Glenohumeral Separation Distance (GhSD). A positive GhSD
represented a posterior position of the glenoid rim relative to the humeral head and a negative
GhSD value represented an anterior position of the glenoid rim relative to the humeral head. We
compared ultrasound (US) findings to conventional radiography to determine the optimum GhSD
cutoff for the diagnosis of shoulder dislocation. Sensitivity, specificity, positive predictive value,
and negative predictive value of the derived US method were calculated.
Results: A total of 84 patients were enrolled and 19 (22.6%) demonstrated shoulder dislocation
on conventional radiography, all of which were anterior. All confirmed dislocations had a negative
measurement of the GhSD, while all patients with normal anatomic position had GhSD>0. This
value represents an optimum GhSD cutoff of 0 for the diagnosis of (anterior) shoulder dislocation.
This method demonstrated a sensitivity of 100% (95% CI [82.4-100]), specificity of 100% (95% CI
[94.5-100]), positive predictive value of 100% (95% CI [82.4-100]), and negative predictive value
of 100% (95% CI [94.5-100]).
Conclusion: Our study suggests that a single, posterior-approach POCUS can diagnose anterior
shoulder dislocation, and that this method can be employed by novice ultrasonographers, such as
non-medical trainees, after a brief educational session. Further validation studies are necessary
to confirm these findings.

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Reduction in Radiation Exposure through a Stress Test Algorithm in an Emergency Department Observation Unit

Volume 17, Issue 2, March 2016.
Margarita E. Pena, MD, et al.

Introduction: Clinicians are urged to decrease radiation exposure from unnecessary medical
procedures. Many emergency department (ED) patients placed in an observation unit (EDOU) do not
require chest pain evaluation with a nuclear stress test (NucST). We sought to implement a simple
ST algorithm that favors non-nuclear stress test (Non-NucST) options to evaluate the effect of the
algorithm on the proportion of patients exposed to radiation by comparing use of NucST versus NonNucST
pre- and post-algorithm.
Methods: An ST algorithm was introduced favoring Non-NucST and limiting NucST to a subset of
EDOU patients in October 2008. We analyzed aggregate data before (Jan-Sept 2008, period 1) and
after (Jan-Sept 2009 and Jan-Sept 2010, periods 2 and 3 respectively) algorithm introduction. A
random sample of 240 EDOU patients from each period was used to compare 30-day major adverse
cardiac events (MACE). We calculated confidence intervals for proportions or the difference between
two proportions.
Results: A total of 5,047 STs were performed from Jan-Sept 2008-2010. NucST in the EDOU
decreased after algorithm introduction from period 1 to 2 (40.7%, 95% CI [38.3-43.1] vs. 22.1%, 95%
CI [20.1-24.1]), and remained at 22.1%, 95% CI [20.3-24.0] in period 3. There was no difference in
30-day MACE rates before and after algorithm use (0.1% for period 1 and 3, 0% for period 2).
Conclusion: Use of a simple ST algorithm that favors non-NucST options decreases the proportion
of EDOU chest pain patients exposed to radiation exposure from ST almost 50% by limiting NucST
to a subset of patients, without a change in 30-day MACE.

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Impact of a Dedicated Emergency Medicine Teaching Resident Rotation at a Large Urban Academic Center

Volume 17, Issue 2, March 2016.
James Ahn, MD, et al.

Introduction: In the face of declining bedside teaching and increasing emergency department
(ED) crowding, balancing education and patient care is a challenge. Dedicated shifts by teaching
residents (TRs) in the ED represent an educational intervention to mitigate these difficulties. We
aimed to measure the perceived learning and departmental impact created by having TR.
Methods: TRs were present in the ED from 12pm-10pm daily, and their primary roles were to
provide the following: assist in teaching procedures, give brief “chalk talks,” instruct junior trainees
on interesting cases, and answer clinical questions in an evidence-based manner. This observational
study included a survey of fourth-year medical students (MSs), residents and faculty at an academic
ED. Surveys measured the perceived effect of the TR on teaching, patient flow, ease of procedures,
and clinical care.
Results: Survey response rates for medical students, residents, and faculty are 56%, 77%, and
75%, respectively. MSs perceived improved procedure performance with TR presence and the
majority agreed that the TR was a valuable educational experience. Residents perceived increased
patient flow, procedure performance, and MS learning with TR presence. The majority agreed that
the TR improved patient care. Faculty agreed that the TR increased resident and MS learning, as
well as improved patient care and procedure performance.
Conclusion: The presence of a TR increased MS and resident learning, improved patient care and
procedure performance as perceived by MSs, residents and faculty. A dedicated TR program can
provide a valuable resource in achieving a balance of clinical education and high quality healthcare.

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Can Simulation Measure Differences in Task-Switching Ability Between Junior and Senior Emergency Medicine Residents?

Volume 17, Issue 2, March 2016.
Dustin Smith, MD, et al.

Introduction: Work interruptions during patient care have been correlated with error. Task-switching
is identified by the Accreditation Council for Graduate Medical Education (ACGME) as a core
competency for emergency medicine (EM). Simulation has been suggested as a means of assessing
EM core competencies. We assumed that senior EM residents had better task-switching abilities
than junior EM residents. We hypothesized that this difference could be measured by observing the
execution of patient care tasks in the simulation environment when a patient with a ST-elevation
myocardial infarction (STEMI) interrupted the ongoing management of a septic shock case.
Methods: This was a multi-site, prospective, observational, cohort study. The study population
consisted of a convenience sample of EM residents in their first three years of training. Each subject
performed a standardized simulated encounter by evaluating and treating a patient in septic shock.
At a predetermined point in every sepsis case, the subject was given a STEMI electrocardiogram
(ECG) for a separate chest pain patient in triage and required to verbalize an interpretation and
action. We scored learner performance using a dichotomous checklist of critical actions covering
sepsis care, ECG interpretation and triaging of the STEMI patient.
Results: Ninety-one subjects participated (30 postgraduate year [PGY]1s, 32 PGY2s, and 29
PGY3s). Of those, 87 properly managed the patient with septic shock (90.0% PGY1s, 100%
PGY2, 96.6% PGY 3s; p=0.22). Of the 87 who successfully managed the septic shock, 80 correctly
identified STEMI on the simulated STEMI patient (86.7% PGY1s, 96.9% PGY2s, 93.1% PGY3s;
p=0.35). Of the 80 who successfully managed the septic shock patient and correctly identified the
STEMI, 79 provided appropriate interventions for the STEMI patient (73.3% PGY1s, 93.8% PGY2s,
93.8% PGY3s; p=0.07).
Conclusion: When management of a septic shock patient was interrupted with a STEMI ECG in a
simulated environment we were unable to measure a significant difference in the ability of EM residents
to successfully task-switch when compared across PGY levels of training. This study may help refine
the use of simulation to assess EM resident competencies.

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Impact of Mental Health and Substance Use Disorders on Emergency Department Visit Outcomes for HIV Patients

Volume 17, Issue 2, March 2016.
Brian Y. Choi, MD, MPH, et al.

Introduction: A disproportionate number of individuals with human immunodeficiency virus (HIV)
have mental health and substance-use disorders (MHSUDs), and MHSUDs are significantly
associated with their emergency department (ED) visits. With an increasing share of older adults
among HIV patients, this study investigated the associations of MHSUDs with ED outcomes of HIV
patients in four age groups: 21-34, 35-49, 50-64, and 65+ years.
Methods: We used the 2012 Nationwide Emergency Department Sample (NEDS) dataset (unweighted
n=23,244,819 ED events by patients aged 21+, including 115,656 visits by patients with
HIV). Multinomial and binary logistic regression analyses, with “treat-and-release” as the base
outcome, were used to examine associations between ED outcomes and MHSUDs among visits that
included a HIV diagnosis in each age group.
Results: Mood and “other” mental disorders had small effects on ED-to-hospital admissions, as
opposed to treat-and-release, in age groups younger than 65+ years, while suicide attempts had
medium effects (RRR=3.56, CI [2.69-4.70]; RRR=4.44, CI [3.72-5.30]; and RRR=5.64, CI [4.38-
7.26] in the 21-34, 35-49, and 50-64 age groups, respectively). Cognitive disorders had mediumto-large
effects on hospital admissions in all age groups and large effects on death in the 35-49
(RRR=7.29, CI [3.90-13.62]) and 50-64 (RRR=5.38, CI [3.39-8.55]) age groups. Alcohol use
disorders (AUDs) had small effects on hospital admission in all age groups (RRR=2.35, 95% CI
[1.92-2.87]; RRR=2.15, 95% CI [1.95-2.37]; RRR=1.92, 95% CI [1.73-2.12]; and OR=1.93, 95%
CI [1.20-3.10] in the 21-34, 35-49, 50-64, and 65+ age groups, respectively). Drug use disorders
(DUDs) had small-to-medium effects on hospital admission (RRR=4.40, 95% CI [3.87-5.0];
RRR=4.07, 95% CI [3.77-4.40]; RRR=4.17, 95% CI [3.83-4.55]; and OR=2.53, 95% CI [2.70-
3.78] in the 21-34, 35-49, 50-64, and 65+ age groups, respectively). AUDs and DUDs were also
significantly related to the risk of death, and DUDs had a small effect on the risk of discharge
against medical advice in the 35-49 and 50-64 age groups.
Conclusion: The high prevalence of MHSUDs and their significant roles in ED visit outcomes in
patients with HIV provide support for integrated care for these patients outside the ED to reduce
their ED visits and costly hospital admissions and institutional care that follows, especially for the
increasing numbers of older adults with HIV.

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Retrospective Review of Ocular Point-of-Care Ultrasound for Detection of Retinal Detachment

Volume 17, Issue 2, March 2016.
Bradley Jacobsen, BS, et al.

Introduction: Retinal detachment is an ocular emergency that commonly presents to the
emergency department (ED). Ophthalmologists are able to accurately make this diagnosis with a
dilated fundoscopic exam, scleral depression or ophthalmic ultrasound when a view to the retina is
obstructed. Emergency physicians (EPs) are not trained to examine the peripheral retina, and thus
ophthalmic ultrasound can be used to aid in diagnosis. We assessed the accuracy of ocular point-ofcare
ultrasound (POCUS) in diagnosing retinal detachment.
Methods: We retrospectively reviewed charts of ED patients with suspected retinal detachment
who underwent ocular POCUS between July 2012 and May 2015. Charts were reviewed for
patients presenting to the ED with ocular complaints and clinical concern for retinal detachment.
We compared ocular POCUS performed by EPs against the criterion reference of the consulting
ophthalmologist’s diagnosis.
Results: We enrolled a total of 109 patients. Of the 34 patients diagnosed with retinal detachment
by the ophthalmologists, 31 were correctly identified as having retinal detachment by the EP using
ocular POCUS. Of the 75 patients who did not have retinal detachment, 72 were ruled out by ocular
POCUS by the EP. This resulted in a POCUS sensitivity of 91% (95% CI [76-98]) and specificity of
96% (95% CI [89-99]).
Conclusion: This retrospective study suggests that ocular POCUS performed by EPs can aid in the
diagnosis of retinal detachment in ED.

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Mistakes and Pitfalls Associated with Two-Point Compression Ultrasound for Deep Vein Thrombosis

Volume 17, Issue 2, March 2016.
Tony Zitek, MD, et al.

Introduction: Two-point compression ultrasound is purportedly a simple and accurate means to
diagnose proximal lower extremity deep vein thrombosis (DVT), but the pitfalls of this technique
have not been fully elucidated. The objective of this study is to determine the accuracy of emergency
medicine resident-performed two-point compression ultrasound, and to determine what technical
errors are commonly made by novice ultrasonographers using this technique.
Methods: This was a prospective diagnostic test assessment of a convenience sample of adult
emergency department (ED) patients suspected of having a lower extremity DVT. After brief training
on the technique, residents performed two-point compression ultrasounds on enrolled patients.
Subsequently a radiology department ultrasound was performed and used as the gold standard.
Residents were instructed to save videos of their ultrasounds for technical analysis.
Results: Overall, 288 two-point compression ultrasound studies were performed. There were 28
cases that were deemed to be positive for DVT by radiology ultrasound. Among these 28, 16 were
identified by the residents with two-point compression. Among the 260 cases deemed to be negative
for DVT by radiology ultrasound, 10 were thought to be positive by the residents using two-point
compression. This led to a sensitivity of 57.1% (95% CI [38.8-75.5]) and a specificity of 96.1% (95%
CI [93.8-98.5]) for resident-performed two-point compression ultrasound. This corresponds to a
positive predictive value of 61.5% (95% CI [42.8-80.2]) and a negative predictive value of 95.4%
(95% CI [92.9-98.0]). The positive likelihood ratio is 14.9 (95% CI [7.5-29.5]) and the negative
likelihood ratio is 0.45 (95% CI [0.29-0.68]). Video analysis revealed that in four cases the resident
did not identify a DVT because the thrombus was isolated to the superior femoral vein (SFV), which
is not evaluated by two-point compression. Moreover, the video analysis revealed that the most
common mistake made by the residents was inadequate visualization of the popliteal vein.
Conclusion: Two-point compression ultrasound does not identify isolated SFV thrombi, which
reduces its sensitivity. Moreover, this technique may be more difficult than previously reported, in
part because novice ultrasonographers have difficulty properly assessing the popliteal vein.

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Computerized Diagnostic Assistant for the Automatic Detection of Pneumothorax on Ultrasound: A Pilot Study

Volume 17, Issue 2, March 2016.
Shane M. Summers, MD, RDMS, et al.

Introduction: Bedside thoracic ultrasound (US) can rapidly diagnose pneumothorax (PTX) with
improved accuracy over the physical examination and without the need for chest radiography (CXR);
however, US is highly operator dependent. A computerized diagnostic assistant was developed
by the United States Army Institute of Surgical Research to detect PTX on standard thoracic US
images. This computer algorithm is designed to automatically detect sonographic signs of PTX
by systematically analyzing B-mode US video clips for pleural sliding and M-mode still images for
the seashore sign. This was a pilot study to estimate the diagnostic accuracy of the PTX detection
computer algorithm when compared to an expert panel of US trained physicians.
Methods: This was a retrospective study using archived thoracic US obtained on adult patients
presenting to the emergency department (ED) between 5/23/2011 and 8/6/2014. Emergency
medicine residents, fellows, attending physicians, physician assistants, and medical students
performed the US examinations and stored the images in the picture archive and communications
system (PACS). The PACS was queried for all ED bedside US examinations with reported positive
PTX during the study period along with a random sample of negatives. The computer algorithm then
interpreted the images, and we compared the results to an independent, blinded expert panel of
three physicians, each with experience reviewing over 10,000 US examinations.
Results: Query of the PACS system revealed 146 bedside thoracic US examinations for analysis.
Thirteen examinations were indeterminate and were excluded. There were 79 true negatives, 33
true positives, 9 false negatives, and 12 false positives. The test characteristics of the algorithm
when compared to the expert panel were sensitivity 79% (95 % CI [63-89]) and specificity 87%
(95% CI [77-93]). For the 20 images scored as highest quality by the expert panel, the algorithm
demonstrated 100% sensitivity (95% CI [56-100]) and 92% specificity (95% CI [62-100]).
Conclusion: This novel computer algorithm has potential to aid clinicians with the identification of
the sonographic signs of PTX in the absence of expert physician sonographers. Further refinement
and training of the algorithm is still needed, along with prospective validation, before it can be utilized
in clinical practice.

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Critical Care

Effects of Intraosseous Tibial vs. Intravenous Vasopressin in a Hypovolemic Cardiac Arrest Model

Volume 17, Issue 2, March 2016.
Justin Fulkerson, MSN, et al.

Introduction: This study compared the effects of vasopressin via tibial intraosseous (IO) and
intravenous (IV) routes on maximum plasma concentration (Cmax), the time to maximum
concentration (Tmax), return of spontaneous circulation (ROSC), and time to ROSC in a
hypovolemic cardiac arrest model.
Methods: This study was a randomized prospective, between-subjects experimental design. A
computer program randomly assigned 28 Yorkshire swine to one of four groups: IV (n=7), IO tibia
(n=7), cardiopulmonary resuscitation (CPR) + defibrillation (n=7), and a control group that received
just CPR (n=7). Ventricular fibrillation was induced, and subjects remained in arrest for two minutes.
CPR was initiated and 40 units of vasopressin were administered via IO or IV routes. Blood samples
were collected at 0.5, 1, 1.5, 2, 2.5, 3, and 4 minutes. CPR and defibrillation were initiated for
20 minutes or until ROSC was achieved. We measured vasopressin concentrations using highperformance
liquid chromatography.
Results: There was no significant difference between the IO and IV groups relative to achieving
ROSC (p=1.0) but a significant difference between the IV compared to the CPR+ defibrillation
group (p=0.031) and IV compared to the CPR-only group (p=0.001). There was a significant
difference between the IO group compared to the CPR+ defibrillation group (p=0.031) and IO
compared to the CPR-only group (p=0.001). There was no significant difference between the CPR
+ defibrillation group and the CPR group (p=0.127). There was no significant difference in Cmax
between the IO and IV groups (p=0.079). The mean ± standard deviation of Cmax of the IO group
was 58,709±25,463pg/mL compared to the IV group, which was 106,198±62,135pg/mL. There was
no significant difference in mean Tmax between the groups (p=0.084). There were no significant
differences in odds of ROSC between the tibial IO and IV groups.
Conclusion: Prompt access to the vascular system using the IO route can circumvent the
interruption in treatment observed with attempting conventional IV access. The IO route is an
effective modality for the treatment of hypovolemic cardiac arrest and may be considered first line for
rapid vascular access.

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Lethal Means Counseling for Parents of Youth Seeking Emergency Care for Suicidality

Volume 17, Issue 1, January 2016.
Carol W. Runyan, MPH, PhD, et al.

Introduction: A youth’s emergency department (ED) visit for suicidal behaviors or ideation
provides an opportunity to counsel families about securing medications and firearms (i.e., lethal
means counseling).
Methods: In this quality improvement project drawing on the Counseling on Access to Lethal Means
(CALM) model, we trained 16 psychiatric emergency clinicians to provide lethal means counseling
with parents of patients under age 18 receiving care for suicidality and discharged home from a
large children’s hospital. Through chart reviews and follow-up interviews of parents who received
the counseling, we examined what parents recalled, their reactions to the counseling session, and
actions taken after discharge.
Results: Between March and July 2014, staff counseled 209 of the 236 (89%) parents of eligible
patients. We conducted follow-up interviews with 114 parents, or 55% of those receiving the
intervention; 48% of those eligible. Parents had favorable impressions of the counseling and
good recall of the main messages. Among the parents contacted at follow up, 76% reported all
medications in the home were locked as compared to fewer than 10% at the time of the visit. All who
had indicated there were guns in the home at the time of the visit reported at follow up that all were
currently locked, compared to 67% reporting this at the time of the visit.
Conclusion: Though a small project in just one hospital, our findings demonstrate the feasibility
of adding a counseling protocol to the discharge process within a pediatric psychiatric emergency
service. Our positive findings suggest that further study, including a randomized control trial in more
facilities, is warranted.

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Ethical and Legal Issues

Emergency Physicians as Good Samaritans: Survey of Frequency, Locations, Supplies and Medications

Volume 17, Issue 1, January 2015.
Taylor W. Burkholder, MD, MPH, et al.

Introduction: Little is known about the frequency and locations in which emergency physicians
(EPs) are bystanders to an accident or emergency; equally uncertain is which contents of an
“emergency kit” may be useful during such events. The aim of this study was to describe the
frequency and locations of Good Samaritan acts by EPs and also determine which emergency kit
supplies and medications were most commonly used by Good Samaritans.
Methods: We conducted an electronic survey among a convenience sample of EPs in Colorado.
Results: Respondents reported a median frequency of 2.0 Good Samaritan acts per five years of
practice, with the most common locations being sports and entertainment events (25%), road traffic
accidents (21%), and wilderness settings (19%). Of those who had acted as Good Samaritans, 86%
reported that at least one supply would have been useful during the most recent event, and 66%
reported at least one medication would have been useful. The most useful supplies were gloves
(54%), dressings (34%), and a stethoscope (20%), while the most useful medications were oxygen
(19%), intravenous fluids (17%), and epinephrine (14%).
Conclusion: The majority of EPs can expect to provide Good Samaritan care during their careers
and would be better prepared by carrying a kit with common supplies and medications where they
are most likely to use them.

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Healthcare Utilization

Randomized Controlled Trial of Electronic Care Plan Alerts and Resource Utilization by High Frequency Emergency Department Users with Opioid Use Disorder

Volume 17, Issue 1, January 2016.
Niels Rathlev, MD, et al.

Introduction: There is a paucity of literature supporting the use of electronic alerts for patients
with high frequency emergency department (ED) use. We sought to measure changes in opioid
prescribing and administration practices, total charges and other resource utilization using electronic
alerts to notify providers of an opioid-use care plan for high frequency ED patients.
Methods: This was a randomized, non-blinded, two-group parallel design study of patients who
had 1) opioid use disorder and 2) high frequency ED use. Three affiliated hospitals with identical
electronic health records participated. Patients were randomized into “Care Plan” versus “Usual Care
groups”. Between the years before and after randomization, we compared as primary outcomes
the following: 1) opioids (morphine mg equivalents) prescribed to patients upon discharge and
administered to ED and inpatients; 2) total medical charges, and the numbers of; 3) ED visits, 4) ED
visits with advanced radiologic imaging (computed tomography [CT] or magnetic resonance imaging
[MRI]) studies, and 5) inpatient admissions.
Results: A total of 40 patients were enrolled. For ED and inpatients in the “Usual Care” group, the
proportion of morphine mg equivalents received in the post-period compared with the pre-period was
15.7%, while in the “Care Plan” group the proportion received in the post-period compared with the
pre-period was 4.5% (ratio=0.29, 95% CI [0.07-1.12]; p=0.07). For discharged patients in the “Usual
Care” group, the proportion of morphine mg equivalents prescribed in the post-period compared with
the pre-period was 25.7% while in the “Care Plan” group, the proportion prescribed in the post-period
compared to the pre-period was 2.9%. The “Care Plan” group showed an 89% greater proportional
change over the periods compared with the “Usual Care” group (ratio=0.11, 95% CI [0.01-0.092];
p=0.04). Care plans did not change the total charges, or, the numbers of ED visits, ED visits with CT
or MRI or inpatient admissions.
Conclusion: Electronic care plans were associated with an incremental decrease in opioids (in
morphine mg equivalents) prescribed to patients with opioid use disorder and high frequency ED
use.

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Healthcare Utilization

Frequency of Fractures Identified on Post-Reduction Radiographs After Shoulder Dislocation

Volume 17, Issue 1, January 2016.
Michael Gottlieb, MD, et al.

Introduction: Most emergency physicians routinely obtain shoulder radiographs before and after
shoulder dislocations. However, currently there is limited literature demonstrating how frequently
new fractures are identified on post-reduction radiographs. The primary objective of this study
was to determine the frequency of new, clinically significant fractures identified on post-reduction
radiographs with a secondary outcome assessing total new fractures identified.
Methods: We conducted a retrospective chart review using appropriate International Classification
of Diseases, 9th Revision (ICD-9) codes to identify all potential shoulder dislocations that were
reduced in a single, urban, academic emergency department (ED) over a five-year period. We
excluded cases that required operative reduction, had associated proximal humeral head or shaft
fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted
separately by two study investigators with disagreements settled by consensus among three
investigators. Images from indeterminate cases were reviewed by a radiology attending physician
with musculoskeletal expertise. The primary outcome was the percentage of new, clinically
significant fractures defined as those altering acute ED management. Secondary outcomes included
percentage of new fractures of any type.
Results: We identified 185 total patients meeting our study criteria. There were no new,
clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI
[3.3%-10.7%]) total new fractures identified, all of which were without clinical significance for
acute ED management.
Conclusion: Post-reduction radiographs do not appear to identify any new, clinically significant
fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED
setting for shoulder dislocations.

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Healthcare Utilization

Identifying Frequent Users of an Urban Emergency Medical Service Using Descriptive Statistics and Regression Analyses

Volume 17, Issue 1, January 2015.
Chenelle Norman, MPH, et al.

This retrospective cohort study provides a descriptive analysis of a population that frequently uses
an urban emergency medical service (EMS) and identifies factors that contribute to use among all
frequent users. For purposes of this study we divided frequent users into the following groups: lowfrequent
users (4 EMS transports in 2012), medium-frequent users (5 to 6 EMS transports in 2012),
high-frequent users (7 to 10 EMS transports in 2012) and super-frequent users (11 or more EMS
transports in 2012). Overall, we identified 539 individuals as frequent users.
For all groups of EMS frequent users (i.e. low, medium, high and super) one or more hospital
admissions, receiving a referral for follow-up care upon discharge, and having no insurance were
found to be statistically significant with frequent EMS use (P<0.05). Within the diagnostic categories,
41.61% of super-frequent users had a diagnosis of “primarily substance abuse/misuse” and among
low-frequent users a majority, 53.33%, were identified as having a “reoccurring (medical) diagnosis.”
Lastly, relative risk ratios for the highest group of users, super-frequent users, were 3.34 (95% CI
[1.90-5.87]) for obtaining at least one referral for follow-up care, 13.67 (95% CI [5.60-33.34]) for
having four or more hospital admissions and 5.95 (95% CI [1.80-19.63]) for having a diagnoses of
primarily substance abuse/misuse.
Findings from this study demonstrate that among low- and medium-frequent users a majority of
patients are using EMS for reoccurring medical conditions. This could potentially be avoided with
better care management. In addition, this study adds to the current literature that illustrates a strong
correlation between substance abuse/misuse and high/super-frequent EMS use. For the subgroup
analysis among individuals 65 years of age and older, we did not find any of the independent
variables included in our model to be statistically significant with frequent EMS use.

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Point-of-Care Multi-Organ Ultrasound Improves Diagnostic Accuracy in Adults Presenting to the Emergency Department with Acute Dyspnea

Volume 17, Issue 1, January 2015.
Daniel Mantuani, MD, et al.

Introduction: Determining the etiology of acute dyspnea in emregency department (ED) patients is
often difficult. Point-of-care ultrasound (POCUS) holds promise for improving immediate diagnostic
accuracy (after history and physical), thus improving use of focused therapies. We evaluate the impact
of a three-part POCUS exam, or “triple scan” (TS) – composed of abbreviated echocardiography,
lung ultrasound and inferior vena cava (IVC) collapsibility assessment – on the treating physician’s
immediate diagnostic impression.
Methods: A convenience sample of adults presenting to our urban academic ED with acute dyspnea
(Emergency Severity Index 1, 2) were prospectively enrolled when investigator sonographers
were available. The method for performing components of the TS has been previously described
in detail. Treating physicians rated the most likely diagnosis after history and physical but before
other studies (except electrocardiogram) returned. An investigator then performed TS and disclosed
the results, after which most likely diagnosis was reassessed. Final diagnosis (criterion standard)
was based on medical record review by expert emergency medicine faculty blinded to TS result.
We compared accuracy of pre-TS and post-TS impression (primary outcome) with McNemar’s
test. Test characteristics for treating physician impression were also calculated by dichotomizing
acute decompensated heart failure (ADHF), chronic obstructive pulmonary disease (COPD) and
pneumonia as present or absent.
Results: 57 patients were enrolled with the leading final diagnoses being ADHF (26%), COPD/
asthma (30%), and pneumonia (28%). Overall accuracy of the treating physician’s impression
increased from 53% before TS to 77% after TS (p=0.003). The post-TS impression was 100%
sensitive and 84% specific for ADHF.
Conclusion: In this small study, POCUS evaluation of the heart, lungs and IVC improved the
treating physician’s immediate overall diagnostic accuracy for ADHF, COPD/asthma and pneumonia
and was particularly useful to immediately exclude ADHF as the cause of acute dyspnea.

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Emergency Department of a Rural Hospital in Ecuador

Volume 17, Issue 1, January 2016.
Tara Johnson, MD, MPH, et al.

Introduction: There is a paucity of data studying patients and complaints presenting to emergency
departments (EDs) in low- and middle-income countries. The town of Pedro Vicente Maldonado
(PVM) is located in the northwestern highlands of Ecuador. Hospital PVM (HPVM) is a rural teaching
hospital providing family medicine residency training. These physicians provide around-the-clock
acute medical care in HPVM’s ED. This study provides a first look at a functioning ED in rural Latin
America by reviewing one year of ED visits to HPVM.
Methods: All ED visits between April 14, 2013, and April 13, 2014, were included and analyzed,
totaling 1,239 patient visits. Data were collected from their electronic medical record and exported
into a de-identified Excel® database where it was sorted and categorized. Variables included age,
gender, mode of arrival, insurance type, month and day of the week of the service, chief complaint,
laboratory and imaging requests, and disposition. We performed descriptive statistics, and where
possible, comparisons using Student’s T or chi-square, as appropriate.
Results: Of the 1239 total ED visits, 48% were males and 52% females; 93% of the visits were
ambulatory, and 7% came by ambulance. Sixty-three percent of the patients had social security
insurance. The top three chief complaints were abdominal pain (25.5%), fever (15.1%) and trauma
(10.8%). Healthcare providers requested labs on 71.3% of patients and imaging on 43.2%. The
most frequently requested imaging studies were chest radiograph (14.9%), upper extremity
radiograph (9.4%), and electrocardiogram (9.0%). There was no seasonal or day-of-week
variability to number of ED patients. The chief complaint of human or animal bite made it more
likely the patient would be admitted, and the chief complaint of traumatic injury made it more likely
the patient would be transferred.
Conclusion: Analysis of patients presenting to a rural ED in Ecuador contributes to the global study
of acute care in the developing world and also provides a self-analysis identifying disease patterns
of the area, training topics for residents, areas for introducing protocols, and information to help
planning for rural EDs in low- and middle-income countries.

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Medication Overdoses at a Public Emergency Department in Santiago, Chile

Volume 17, Issue 1, January 2016.
Pablo Aguilera, MD, et al.

Introduction: While a nationwide poison control registry exists in Chile, reporting to the center is
sporadic and happens at the discretion of the treating physician or by patients’ self-report. Moreover,
individual hospitals do not monitor accidental or intentional poisoning in a systematic manner. The
goal of this study was to identify all cases of intentional medication overdose (MO) that occurred
over two years at a large public hospital in Santiago, Chile, and examine its epidemiologic profile.
Methods: This study is a retrospective, explicit chart review conducted at Hospital Sótero del Rio
from July 2008 until June 2010. We included all cases of identified intentional MO. Alcohol and
recreational drugs were included only when they were ingested with other medications.
Results: We identified 1,557 cases of intentional MO and analyzed a total of 1,197 cases,
corresponding to 0.51% of all emergency department (ED) presentations between July 2008 and
June 2010. The median patient age was 25 years. The majority was female (67.6%). Two peaks
were identified, corresponding to the spring of each year sampled. The rate of hospital admission
was 22.2%. Benzodiazepines, selective serotonin reuptake inhibitors, and tricyclic antidepressants
(TCA) were the causative agents most commonly found, comprising 1,044 (87.2%) of all analyzed
cases. Acetaminophen was involved in 81 (6.8%) cases. More than one active substance was
involved in 35% of cases. In 7.3% there was ethanol co-ingestion and in 1.0% co-ingestion of some
other recreational drug (primarily cocaine). Of 1,557 cases, six (0.39%) patients died. TCA were
involved in two of these deaths.
Conclusion: Similar to other developed and developing nations, intentional MO accounts for a
significant number of ED presentations in Chile. Chile is unique in the region, however, in that
its spectrum of intentional overdoses includes an excess burden of tricyclic antidepressant and
benzodiazepine overdoses, a relatively low rate of alcohol and recreational drug co-ingestion, and a
relatively low rate of acetaminophen ingestion.

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Ethical and Legal Issues

Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department

Volume 16, Issue 7, December 2015.
Jessica Wall, MD, MPH, et al.

Introduction: We conducted an epidemiologic evaluation of advance directives and do-notresuscitate
(DNR) prevalence among residents of extended care facilities (ECF) presenting to the
emergency department (ED).

Methods: We performed a retrospective medical record review on ED patients originating from an
ECF. Data were collected on age, sex, race, triage acuity, ED disposition, DNR status, power-of
attorney (POA) status, and living will (LW) status. We generated descriptive statistics, and used
logistic regression to evaluate predictors of DNR status.

Results: A total of 754 patients over 20 months met inclusion criteria; 533 (70.7%) were white, 351
(46.6%) were male, and the median age was 66 years (IQR 54-78). DNR orders were found in 124
(16.4%, 95% CI [13.9-19.1%]) patients. In univariate analysis, there was a significant difference in
DNR by gender (10.5% female vs. 6.0% male with DNR, p=0.013), race (13.4% white vs. 3.1% nonwhite
with DNR, p=0.005), and age (4.0% <65 years; 2.9% 65-74 years, p=0.101; 3.3% 75-84 years,
p=0.001; 6.2% >84 years, p<0.001). Using multivariate logistic regression, we found that factors
associated with DNR status were gender (OR 1.477, p=0.358, note interaction term), POA status
(OR 6.612, p<0.001), LW (18.032, p<0.001), age (65-74 years OR 1.261, p=0.478; 75-84 years OR
1.737, p=0.091, >84 years OR 5.258, P<0.001), with interactions between POA and gender (OR
0.294, P=0.016) and between POA and LW (OR 0.227, p<0.005). Secondary analysis demonstrated
that DNR orders were not significantly associated with death during admission (p=0.084).

Conclusion: Age, gender, POA, and LW use are predictors of ECF patient DNR use. Further, DNR
presence is not a predictor of death in the hospital.

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Treatment Protocol Assessment

Abdominal CT Does Not Improve Outcome for Children with Suspected Acute Appendicitis

Volume 16, Issue 7, December 2015.
Danielle I. Miano, BS

Introduction: Acute appendicitis in children is a clinical diagnosis, which often requires preoperative
confirmation with either ultrasound (US) or computed tomography (CT) studies. CTs expose children to
radiation, which may increase the lifetime risk of developing malignancy. US in the pediatric population
with appropriate clinical follow up and serial exam may be an effective diagnostic modality for many
children without incurring the risk of radiation. The objective of the study was to compare the rate of
appendiceal rupture and negative appendectomies between children with and without abdominal CTs;
and to evaluate the same outcomes for children with and without USs to determine if there were any
associations between imaging modalities and outcomes.

Methods: We conducted a retrospective chart review including emergency department (ED) and inpatient
records from 1/1/2009–2/31/2010 and included patients with suspected acute appendicitis.

Results: 1,493 children, aged less than one year to 20 years, were identified in the ED with suspected
appendicitis. These patients presented with abdominal pain who had either a surgical consult or an
abdominal imaging study to evaluate for appendicitis, or were transferred from an outside hospital or
primary care physician office with the stated suspicion of acute appendicitis. Of these patients, 739 were
sent home following evaluation in the ED and did not return within the subsequent two weeks and were
therefore presumed not to have appendicitis. A total of 754 were admitted and form the study population,
of which 20% received a CT, 53% US, and 8% received both. Of these 57%, 95% CI [53.5,60.5] had
pathology-proven appendicitis. Appendicitis rates were similar for children with a CT (57%, 95% CI
[49.6,64.4]) compared to those without (57%, 95% CI [52.9,61.0]). Children with perforation were similar
between those with a CT (18%, 95% CI [12.3,23.7]) and those without (13%, 95% CI [10.3,15.7]).
The proportion of children with a negative appendectomy was similar in both groups: CT (7%, 95% CI
[2.1,11.9]), US (8%, 95% CI [4.7,11.3]) and neither (12%, 95% CI [5.9,18.1]).

Conclusion: In this uncontrolled study, the accuracy of preoperative diagnosis of appendicitis and
the incidence of pathology-proven perforation appendix were similar for children with suspected acute
appendicitis whether they had CT, US or neither imaging, in conjunction with surgical consult. The
imaging modality of CT was not associated with better outcomes for children presenting to the ED with
suspected appendicitis.

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