Pub Date : 2025-12-01DOI: 10.1016/j.ajem.2025.08.020
Shamma Almheiri , Ali Khorrami , Micheal Ferrante , Josh J. Wang
{"title":"Reader Comment Regarding Comparison of intradermal sterile water injection and dexketoprofen trometamol in pain management of renal colic patients","authors":"Shamma Almheiri , Ali Khorrami , Micheal Ferrante , Josh J. Wang","doi":"10.1016/j.ajem.2025.08.020","DOIUrl":"10.1016/j.ajem.2025.08.020","url":null,"abstract":"","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"98 ","pages":"Page 359"},"PeriodicalIF":2.2,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144979797","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.ajem.2025.09.047
Eduardo Saadi Neto , Murilo Scapin , Francisco Lazaro-Paulina , Ronna L. Campbell , Daniel Fiterman Molinari , Tobias Kummer
{"title":"Erratum to “Duration of resuscitation interruption using point-of-care ultrasound versus traditional manual pulse check: A systematic review and meta-analysis” [American Journal of Emergency Medicine 98C (2025) 145–152]","authors":"Eduardo Saadi Neto , Murilo Scapin , Francisco Lazaro-Paulina , Ronna L. Campbell , Daniel Fiterman Molinari , Tobias Kummer","doi":"10.1016/j.ajem.2025.09.047","DOIUrl":"10.1016/j.ajem.2025.09.047","url":null,"abstract":"","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"98 ","pages":"Pages 430-431"},"PeriodicalIF":2.2,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145253971","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.ajem.2025.08.004
Lorenzo Pelagatti , Alberto Marabotti , Stefano Batacchi , Simone Vanni , Peiman Nazerian
Background
Awake intubation using a flexible bronchoscope is a well-established technique in the operating room but remains underutilized in the Emergency Department (ED), despite its potential benefits in managing anticipated difficult airways.
Case presentation
We describe three cases in which awake fiberoptic intubation was successfully performed in the ED setting. The first involved an elderly woman with caustic ingestion and progressive oropharyngeal edema. The second was a post-thyroidectomy patient presenting with massive cervicothoracic subcutaneous emphysema and suspected tracheal injury. The third case concerned a previously healthy woman with refractory angioedema and severe trismus. In all cases, conventional sedated intubation was deemed high-risk due to potential airway collapse or distortion. Awake intubation allowed for maintenance of spontaneous ventilation, real-time airway navigation, and safe endotracheal tube placement. All patients were successfully intubated and transferred to the Intensive Care Unit.
Conclusion
These cases illustrate the feasibility and clinical utility of awake intubation with a flexible bronchoscope in emergency settings. When conventional techniques are contraindicated or unsafe, this approach may provide a life-saving alternative. Increased familiarity with fiberoptic-guided intubation could significantly expand the airway management toolkit of emergency physicians.
{"title":"Awake intubation with a flexible bronchoscope in the emergency department: Expanding the emergency physician's airway toolkit","authors":"Lorenzo Pelagatti , Alberto Marabotti , Stefano Batacchi , Simone Vanni , Peiman Nazerian","doi":"10.1016/j.ajem.2025.08.004","DOIUrl":"10.1016/j.ajem.2025.08.004","url":null,"abstract":"<div><h3>Background</h3><div>Awake intubation using a flexible bronchoscope is a well-established technique in the operating room but remains underutilized in the Emergency Department (ED), despite its potential benefits in managing anticipated difficult airways.</div></div><div><h3>Case presentation</h3><div>We describe three cases in which awake fiberoptic intubation was successfully performed in the ED setting. The first involved an elderly woman with caustic ingestion and progressive oropharyngeal edema. The second was a post-thyroidectomy patient presenting with massive cervicothoracic subcutaneous emphysema and suspected tracheal injury. The third case concerned a previously healthy woman with refractory angioedema and severe trismus. In all cases, conventional sedated intubation was deemed high-risk due to potential airway collapse or distortion. Awake intubation allowed for maintenance of spontaneous ventilation, real-time airway navigation, and safe endotracheal tube placement. All patients were successfully intubated and transferred to the Intensive Care Unit.</div></div><div><h3>Conclusion</h3><div>These cases illustrate the feasibility and clinical utility of awake intubation with a flexible bronchoscope in emergency settings. When conventional techniques are contraindicated or unsafe, this approach may provide a life-saving alternative. Increased familiarity with fiberoptic-guided intubation could significantly expand the airway management toolkit of emergency physicians.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"98 ","pages":"Pages 408-412"},"PeriodicalIF":2.2,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144812706","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.ajem.2025.08.058
Hamid Shokoohi MD, MPH , Alexander G. Belaia MD , Kwabena Asimeng Danso MD , Lucius L. Xuan MS , Andrew S. Liteplo MD
{"title":"Quantifying deep tendon reflexes using Doppler ultrasound: The novel TAP method","authors":"Hamid Shokoohi MD, MPH , Alexander G. Belaia MD , Kwabena Asimeng Danso MD , Lucius L. Xuan MS , Andrew S. Liteplo MD","doi":"10.1016/j.ajem.2025.08.058","DOIUrl":"10.1016/j.ajem.2025.08.058","url":null,"abstract":"","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"98 ","pages":"Pages 364-366"},"PeriodicalIF":2.2,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144979781","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A previously healthy 40-year-old man presented to the emergency department with acute abdominal pain and repeated bilious vomiting that began the previous day and progressively worsened. On examination, he was afebrile and hemodynamically stable, with mild diffuse abdominal tenderness and no peritoneal signs. Laboratory studies showed leukocytosis with neutrophil predominance, an elevated C-reactive protein, and no eosinophilia. Contrast-enhanced abdominal computed tomography revealed segmental thickening of the small bowel wall with localized obstruction, without evidence of a mechanical cause such as adhesions, masses, or strangulation.
A detailed dietary history disclosed that the patient had consumed raw flounder obtained directly from a fisherman three days earlier. Given the coastal endemic setting and high clinical suspicion, serologic testing for Anisakis-specific IgE was performed, yielding markedly elevated levels (>100 UA/mL), supporting the diagnosis of allergic-mediated intestinal Anisakiasis.
The patient was treated conservatively in the ED observation unit with nasogastric decompression, bowel rest, and intravenous hydration. Over the next 48 h, symptoms resolved, vomiting ceased, and bowel function returned to normal. He was discharged on a cooked-seafood-only diet.
At follow-up, he reported complete resolution of chronic intermittent abdominal discomfort that had been present for several years. Repeat IgE testing demonstrated a substantial decline, correlating with sustained symptom relief.
This case underscores the importance for emergency physicians in endemic areas to consider allergic intestinal anisakiasis in patients presenting with unexplained small bowel obstruction, to obtain a thorough dietary history, and to utilize specific IgE testing to guide diagnosis and avoid unnecessary surgical intervention.
{"title":"A case of chronic abdominal pain related to the ingestion of raw seafood: Anisakiasis","authors":"Fumiue Harada MD, PhD , Morihito Takita MD, PhD , Hiroaki Saito MD, PhD , Masahiro Kami MD, PhD","doi":"10.1016/j.ajem.2025.08.034","DOIUrl":"10.1016/j.ajem.2025.08.034","url":null,"abstract":"<div><div>A previously healthy 40-year-old man presented to the emergency department with acute abdominal pain and repeated bilious vomiting that began the previous day and progressively worsened. On examination, he was afebrile and hemodynamically stable, with mild diffuse abdominal tenderness and no peritoneal signs. Laboratory studies showed leukocytosis with neutrophil predominance, an elevated C-reactive protein, and no eosinophilia. Contrast-enhanced abdominal computed tomography revealed segmental thickening of the small bowel wall with localized obstruction, without evidence of a mechanical cause such as adhesions, masses, or strangulation.</div><div>A detailed dietary history disclosed that the patient had consumed raw flounder obtained directly from a fisherman three days earlier. Given the coastal endemic setting and high clinical suspicion, serologic testing for <em>Anisakis-</em>specific IgE was performed, yielding markedly elevated levels (>100 UA/mL), supporting the diagnosis of allergic-mediated intestinal Anisakiasis.</div><div>The patient was treated conservatively in the ED observation unit with nasogastric decompression, bowel rest, and intravenous hydration. Over the next 48 h, symptoms resolved, vomiting ceased, and bowel function returned to normal. He was discharged on a cooked-seafood-only diet.</div><div>At follow-up, he reported complete resolution of chronic intermittent abdominal discomfort that had been present for several years. Repeat IgE testing demonstrated a substantial decline, correlating with sustained symptom relief.</div><div>This case underscores the importance for emergency physicians in endemic areas to consider allergic intestinal anisakiasis in patients presenting with unexplained small bowel obstruction, to obtain a thorough dietary history, and to utilize specific IgE testing to guide diagnosis and avoid unnecessary surgical intervention.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"98 ","pages":"Pages 416-418"},"PeriodicalIF":2.2,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144979764","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.ajem.2025.11.028
Angela F. Jarman MD, MPH , Sevet Assatormasihkhah MD , Rebecca Leece MD , Sandra Taylor PhD , Zainab Akinjobi MS , Bryn E. Mumma MD, MAS
Background
Patient experience surveys are used to evaluate emergency physician (EP) performance, but they may be subject to gender bias. This study aimed to quantify the impact of EP gender on (1) the use of communal and agentic descriptors in free-text comments and (2) quantitative scores on patient experience surveys.
Methods
This retrospective study was conducted in a single urban, academic tertiary care emergency department (ED) that serves a diverse patient population. We included surveys for patients discharged from the ED during 1/1/19–12/31/21. Primary outcomes were the use of positive communal and agentic descriptors of the EP in the free-text portions of the patient experience surveys. Secondary outcome was mean quantitative physician score. Analyses included descriptive statistics and bivariate analyses, as well as a mixed effects model adjusted for patient and physician demographics and ED length of stay.
Results
We studied 883 encounters (501 [57 %] female patients) with applicable free-text comments in the patient experience surveys. In a multivariable mixed effects model adjusted for patient, physician, and operational variables, all-women, all-men, and mixed gender physician teams were equally likely to be described by positive communal terms and positive agentic terms. We also studied 3707 encounters (2077 [56 %] female patients) with quantitative physician scores available in the patient experience surveys. In a similar multivariable mixed effects model, physician gender was not associated with differences in mean physician scores. The median age in the larger cohort was 50 (IQR 26–64), and older patient age was associated with higher quantitative scores (p = 0.004).
Conclusion
Among ED patients, physician gender was not associated with the language used to describe physicians or the quantitative scores assigned to them.
{"title":"The influence of emergency physician gender on patient experience surveys","authors":"Angela F. Jarman MD, MPH , Sevet Assatormasihkhah MD , Rebecca Leece MD , Sandra Taylor PhD , Zainab Akinjobi MS , Bryn E. Mumma MD, MAS","doi":"10.1016/j.ajem.2025.11.028","DOIUrl":"10.1016/j.ajem.2025.11.028","url":null,"abstract":"<div><h3>Background</h3><div>Patient experience surveys are used to evaluate emergency physician (EP) performance, but they may be subject to gender bias. This study aimed to quantify the impact of EP gender on (1) the use of communal and agentic descriptors in free-text comments and (2) quantitative scores on patient experience surveys.</div></div><div><h3>Methods</h3><div>This retrospective study was conducted in a single urban, academic tertiary care emergency department (ED) that serves a diverse patient population. We included surveys for patients discharged from the ED during 1/1/19–12/31/21. Primary outcomes were the use of positive communal and agentic descriptors of the EP in the free-text portions of the patient experience surveys. Secondary outcome was mean quantitative physician score. Analyses included descriptive statistics and bivariate analyses, as well as a mixed effects model adjusted for patient and physician demographics and ED length of stay.</div></div><div><h3>Results</h3><div>We studied 883 encounters (501 [57 %] female patients) with applicable free-text comments in the patient experience surveys. In a multivariable mixed effects model adjusted for patient, physician, and operational variables, all-women, all-men, and mixed gender physician teams were equally likely to be described by positive communal terms and positive agentic terms. We also studied 3707 encounters (2077 [56 %] female patients) with quantitative physician scores available in the patient experience surveys. In a similar multivariable mixed effects model, physician gender was not associated with differences in mean physician scores. The median age in the larger cohort was 50 (IQR 26–64), and older patient age was associated with higher quantitative scores (<em>p</em> = 0.004).</div></div><div><h3>Conclusion</h3><div>Among ED patients, physician gender was not associated with the language used to describe physicians or the quantitative scores assigned to them.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"100 ","pages":"Pages 142-147"},"PeriodicalIF":2.2,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145684457","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-27DOI: 10.1016/j.ajem.2025.11.019
Cassidy Lavin BS , Anthony Roggio MD , Claire Perry , Jacob Epstein BS , Khai Dinh BS , Cody Couperus MD , Neeraja Murali DO, MPH , Afrah A. Ali MBBS , Sarah Sommerkamp MD , Quincy K. Tran MD PhD
Introduction
Emergency Department (ED) visits in the United States are increasing. Patients have to wait longer to be evaluated by clinicians. Telemedicine has been used to provide remote medical screening examination to initiate the triage process (TeleTriage) for ED patients. However, whether the types of TeleTriage clinicians (physician or Non-Physician Practitioners [NPP]) will influence patients' length of stay in the ED (EDLOS) is unknown. We hypothesized that there was no difference in EDLOS for patients TeleTriaged by physicians or NPPs.
Methods
This is a retrospective, multicenter study involving one academic and one community ED. All patients undergoing TeleTriage between January 1st to December 31st, 2023 at these 2 sites were eligible. We excluded patients who left without being seen or prior to completion of treatment, were discharged against medical advice, or presented with psychiatric complaints. Multivariable logistic regression was performed to assess clinical factor and outcome (EDLOS >6 h).
Results
We analyzed 8145 patients, with mean (+/−SD) age of 47 (+/− 18) years and 44 % being male. A total of 4419 (54 %) patients were TeleTriaged by NPP, while 3726 (46 %) were TeleTriaged by a physician. Median [Interquartile (IQR)] EDLOS for NPP TeleTriaged patients were 739 [396–1463] minutes, compared with 528 [306–1070] minutes for physician-TeleTriaged group (difference 148, 95 % CI 126–171, P < 0.001). Multivariable logistic regression showed that patients presenting at evening 4 pm–10 pm shift (OR 1.2877, 95 % CI 1.04–1.58, P < 0.001), and to an academic ED (OR 1.52, 95 %CI 1.32–1.76, P < 0.001) were associated with longer EDLOS, while being triaged by physicians were associated with shorter EDLOS (OR 0.80, 95 %CI 0.69–0.91, P < 0.001).
Conclusion
Emergency patients who were TeleTriaged by physicians were associated with lower odds for EDLOS >6 h, when compared to those TeleTriaged by NPP. However, there are potentially other factors, besides types of clinicians, that may influence patients' EDLOS. Further studies are needed to investigate our observation.
简介：在美国，急诊科（ED）的访问量正在增加。患者必须等待更长时间才能接受临床医生的评估。远程医疗已被用于为急诊科病人提供远程医疗筛选检查，以启动分诊过程（TeleTriage）。然而，远程分诊临床医生（医师或非医师从业者[NPP]）的类型是否会影响患者在急诊科（EDLOS）的住院时间尚不清楚。我们假设由医生或NPPs远程分诊的患者在EDLOS方面没有差异。方法：这是一项回顾性的多中心研究，涉及一名学术ED和一名社区ED。所有在2023年1月1日至12月31日期间在这两个地点接受TeleTriage的患者均符合条件。我们排除了未就诊或未完成治疗就离开的患者，不遵医嘱出院的患者，或出现精神疾病的患者。采用多变量logistic回归评估临床因素和预后（EDLOS bbb6 h）。结果：我们分析了8145例患者，平均（+/- sd）年龄为47（+/- 18）岁，44%为男性。共有4419例（54%）患者通过NPP进行了电分诊，3726例（46%）患者由医生进行了电分诊。NPP远程分诊组的EDLOS中位数[四分位数间隔（IQR）]为739[396-1463]分钟，而医生-远程分诊组的EDLOS为528[306-1070]分钟（差异为148,95% CI 126-171， P）。结论：与NPP远程分诊组相比，由医生远程分诊的急诊患者在6小时内发生EDLOS的几率较低。然而，除了临床医生的类型之外，可能还有其他因素影响患者的EDLOS。需要进一步的研究来证实我们的观察结果。
{"title":"Emergency department length of stay: Does it matter who performs TeleTriage?","authors":"Cassidy Lavin BS , Anthony Roggio MD , Claire Perry , Jacob Epstein BS , Khai Dinh BS , Cody Couperus MD , Neeraja Murali DO, MPH , Afrah A. Ali MBBS , Sarah Sommerkamp MD , Quincy K. Tran MD PhD","doi":"10.1016/j.ajem.2025.11.019","DOIUrl":"10.1016/j.ajem.2025.11.019","url":null,"abstract":"<div><h3>Introduction</h3><div>Emergency Department (ED) visits in the United States are increasing. Patients have to wait longer to be evaluated by clinicians. Telemedicine has been used to provide remote medical screening examination to initiate the triage process (TeleTriage) for ED patients. However, whether the types of TeleTriage clinicians (physician or Non-Physician Practitioners [NPP]) will influence patients' length of stay in the ED (EDLOS) is unknown. We hypothesized that there was no difference in EDLOS for patients TeleTriaged by physicians or NPPs.</div></div><div><h3>Methods</h3><div>This is a retrospective, multicenter study involving one academic and one community ED. All patients undergoing TeleTriage between January 1st to December 31st, 2023 at these 2 sites were eligible. We excluded patients who left without being seen or prior to completion of treatment, were discharged against medical advice, or presented with psychiatric complaints. Multivariable logistic regression was performed to assess clinical factor and outcome (EDLOS >6 h).</div></div><div><h3>Results</h3><div>We analyzed 8145 patients, with mean (+/−SD) age of 47 (+/− 18) years and 44 % being male. A total of 4419 (54 %) patients were TeleTriaged by NPP, while 3726 (46 %) were TeleTriaged by a physician. Median [Interquartile (IQR)] EDLOS for NPP TeleTriaged patients were 739 [396–1463] minutes, compared with 528 [306–1070] minutes for physician-TeleTriaged group (difference 148, 95 % CI 126–171, <em>P</em> < 0.001). Multivariable logistic regression showed that patients presenting at evening 4 pm–10 pm shift (OR 1.2877, 95 % CI 1.04–1.58, <em>P</em> < 0.001), and to an academic ED (OR 1.52, 95 %CI 1.32–1.76, P < 0.001) were associated with longer EDLOS, while being triaged by physicians were associated with shorter EDLOS (OR 0.80, 95 %CI 0.69–0.91, P < 0.001).</div></div><div><h3>Conclusion</h3><div>Emergency patients who were TeleTriaged by physicians were associated with lower odds for EDLOS >6 h, when compared to those TeleTriaged by NPP. However, there are potentially other factors, besides types of clinicians, that may influence patients' EDLOS. Further studies are needed to investigate our observation.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"100 ","pages":"Pages 208-212"},"PeriodicalIF":2.2,"publicationDate":"2025-11-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145828728","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-27DOI: 10.1016/j.ajem.2025.11.027
Jordan Dow , Margarita Popova , Safinaz AlShiakh , Emily Zhao , Nardos Temesgen , Jannet Lewis , Keith Boniface
Objective
The Rule of Thirds (RoT) estimates the relationship between right ventricular outflow tract (RVOT), aortic outflow tract (AOT), and left atrium (LA) on parasternal long-axis echocardiography, proposing a 1:1:1 size ratio. Enlargement of any of the structures may reflect pathology. Despite common teaching, RoT's diagnostic performance has not been evaluated.
Methods
This retrospective cohort study involved two blinded emergency ultrasound fellows independently reviewing 272 consecutive comprehensive echocardiograms obtained by cardiology technicians. RoT assessment from parasternal long-axis view was recorded as normal (1:1:1 ratio) or abnormal (disproportionate structure size). This assessment of RoT-predicted pathology was compared in blinded fashion to cardiology-determined RVSP >40 mmHg, AOT > 4 cm, and the presence of LV systolic or diastolic dysfunction. Percent agreement and Cohen's kappa assessed interobserver variability.
Results
Abnormal RVOT on RoT showed 12.9 % sensitivity (95 % CI 9.2–17.3 %) and 84 % specificity (74.1–91.2 %). Abnormal AOT demonstrated 22.7 % sensitivity (11.5–37.8 %) and 94.9 % specificity (92.6–96.6 %). Abnormal LA had 43.9 % sensitivity (37.5–50.3 %) and 84.3 % specificity (79.8–88.2 %). Evaluator agreement was 69.9 % with Cohen's kappa of 0.36 (95 % CI 0.25–0.47), indicating fair agreement.
Conclusion
The Rule of Thirds functions best as a rule-in tool but should not be used alone when evaluating critically ill patients. Interobserver agreement was only fair. Although broadly taught, caution should be exercised when utilizing RoT screening results.
{"title":"The diagnostic test characteristics of the “rule of thirds” on the parasternal long axis view: A cross-sectional study","authors":"Jordan Dow , Margarita Popova , Safinaz AlShiakh , Emily Zhao , Nardos Temesgen , Jannet Lewis , Keith Boniface","doi":"10.1016/j.ajem.2025.11.027","DOIUrl":"10.1016/j.ajem.2025.11.027","url":null,"abstract":"<div><h3>Objective</h3><div>The Rule of Thirds (RoT) estimates the relationship between right ventricular outflow tract (RVOT), aortic outflow tract (AOT), and left atrium (LA) on parasternal long-axis echocardiography, proposing a 1:1:1 size ratio. Enlargement of any of the structures may reflect pathology. Despite common teaching, RoT's diagnostic performance has not been evaluated.</div></div><div><h3>Methods</h3><div>This retrospective cohort study involved two blinded emergency ultrasound fellows independently reviewing 272 consecutive comprehensive echocardiograms obtained by cardiology technicians. RoT assessment from parasternal long-axis view was recorded as normal (1:1:1 ratio) or abnormal (disproportionate structure size). This assessment of RoT-predicted pathology was compared in blinded fashion to cardiology-determined RVSP >40 mmHg, AOT > 4 cm, and the presence of LV systolic or diastolic dysfunction. Percent agreement and Cohen's kappa assessed interobserver variability.</div></div><div><h3>Results</h3><div>Abnormal RVOT on RoT showed 12.9 % sensitivity (95 % CI 9.2–17.3 %) and 84 % specificity (74.1–91.2 %). Abnormal AOT demonstrated 22.7 % sensitivity (11.5–37.8 %) and 94.9 % specificity (92.6–96.6 %). Abnormal LA had 43.9 % sensitivity (37.5–50.3 %) and 84.3 % specificity (79.8–88.2 %). Evaluator agreement was 69.9 % with Cohen's kappa of 0.36 (95 % CI 0.25–0.47), indicating fair agreement.</div></div><div><h3>Conclusion</h3><div>The Rule of Thirds functions best as a rule-in tool but should not be used alone when evaluating critically ill patients. Interobserver agreement was only fair. Although broadly taught, caution should be exercised when utilizing RoT screening results.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"100 ","pages":"Pages 133-137"},"PeriodicalIF":2.2,"publicationDate":"2025-11-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145684459","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-26DOI: 10.1016/j.ajem.2025.11.025
Jarad Anderson , William F. Rushton , Samuel L. Burleson , Maxwell Thompson , Sukhshant Atti , Katherine B. Griesmer
Introduction
Treatment of severe calcium channel antagonist (CCA) toxicity remains challenging due to progression to profound shock through vasoplegia, cardiogenic collapse, or a combination of both. Various treatment options are available that aim to increase systemic vascular resistance or enhance cardiac contractility. Accurately identifying the type of shock is essential for guiding appropriate therapy. However, given the range of potential interventions, careful assessment of the predominant shock state and appropriate tailoring of therapy are critical, as each treatment carries distinct risks and potential adverse effects. Point-of-Care Ultrasound (POCUS) has been previously used in other critical illnesses to assess myocardial function, but there is a paucity of literature with regards to cardiovascular drug toxicity.
Cases
We present a case series of three CCA toxicities—including two cases of mixed cardiovascular drug toxicities-with POCUS use throughout to guide therapies and assess clinical response. Each case presented with rapid deterioration requiring multiple pressors as well as specialized interventions including methylene blue, hyperinsulinemia euglycemia (HIE), or extracorporeal membrane oxygenation (ECMO). Real-time echocardiographic assessments allowed for early identification of cardiovascular compromise, differentiation between vasodilatory and cardiogenic shock, and ongoing evaluation of treatment response in mixed shock states.
Discussion
This case series highlights the role of POCUS in managing severe CCA toxicity. Techniques such as velocity time integral (VTI) measurement and inferior vena cava (IVC) collapsibility provided dynamic, noninvasive data that guided resuscitative efforts and helped optimize perfusion in the acute care setting.
{"title":"Calcium channel antagonists and point-of-care ultrasound: A case series","authors":"Jarad Anderson , William F. Rushton , Samuel L. Burleson , Maxwell Thompson , Sukhshant Atti , Katherine B. Griesmer","doi":"10.1016/j.ajem.2025.11.025","DOIUrl":"10.1016/j.ajem.2025.11.025","url":null,"abstract":"<div><h3>Introduction</h3><div>Treatment of severe calcium channel antagonist (CCA) toxicity remains challenging due to progression to profound shock through vasoplegia, cardiogenic collapse, or a combination of both. Various treatment options are available that aim to increase systemic vascular resistance or enhance cardiac contractility. Accurately identifying the type of shock is essential for guiding appropriate therapy. However, given the range of potential interventions, careful assessment of the predominant shock state and appropriate tailoring of therapy are critical, as each treatment carries distinct risks and potential adverse effects. Point-of-Care Ultrasound (POCUS) has been previously used in other critical illnesses to assess myocardial function, but there is a paucity of literature with regards to cardiovascular drug toxicity.</div></div><div><h3>Cases</h3><div>We present a case series of three CCA toxicities—including two cases of mixed cardiovascular drug toxicities-with POCUS use throughout to guide therapies and assess clinical response. Each case presented with rapid deterioration requiring multiple pressors as well as specialized interventions including methylene blue, hyperinsulinemia euglycemia (HIE), or extracorporeal membrane oxygenation (ECMO). Real-time echocardiographic assessments allowed for early identification of cardiovascular compromise, differentiation between vasodilatory and cardiogenic shock, and ongoing evaluation of treatment response in mixed shock states.</div></div><div><h3>Discussion</h3><div>This case series highlights the role of POCUS in managing severe CCA toxicity. Techniques such as velocity time integral (VTI) measurement and inferior vena cava (IVC) collapsibility provided dynamic, noninvasive data that guided resuscitative efforts and helped optimize perfusion in the acute care setting.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"100 ","pages":"Pages 138-141"},"PeriodicalIF":2.2,"publicationDate":"2025-11-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145684458","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-24DOI: 10.1016/j.ajem.2025.11.026
Nicolette Meka MS , Kaitlin Krauss DO , Katie Rong MD , Timothy Herbst MD , Caroline Berberian , James Galske , Michael Kosover , Delaney Kehoe , Stephen Baker , Evan Masley DO , Regina Lopez-Merrill MD , Regina Kostyun PhD , Meghan Kelly Herbst MD
Introduction
Recognizing gastric distention is important for preprocedural aspiration risk stratification. We sought to determine the diagnostic performance of coronal and sagittal ultrasound views for identifying gastric distention in the Emergency Department (ED) setting, using computed tomography (CT) as the reference standard.
Methods
This was a single-site, prospective cohort study of adult ED patients receiving abdominal CT from 6/1/2024–6/30/2024. Prior gastric surgery or hiatal hernia were exclusion criteria. Trained investigators performed a gastric ultrasound, obtaining sagittal and coronal views. Two blinded emergency physicians independently reviewed ultrasound images for quality, antral dimensions (sagittal), and stomach appearance (sagittal and coronal). Sagittal antral dimensions were used to calculate gastric volume (GV). Sonographic gastric distention was defined as GV exceeding 1.5 mL/kg (sagittal) or visualization of a fluid-filled stomach with “starry night” appearance (coronal). The reference standard for gastric distention was gastric distention on CT. A Cohen's kappa (κ), comparison of proportions, and test characteristics were calculated.
Results
Of 230 consenting adults who underwent CT imaging, 12 were excluded, and 42 had inadequate images, leaving 176 for analysis. Of these, 51 (29.0 %) had gastric distention on CT. Agreement among emergency physicians for distention was fair for sagittal (κ = 0.29, 95 % CI 0.04–0.61 for dimensions; κ = 0.35, 95 % CI 0.05–0.65 for appearance) and almost perfect for coronal (κ = 0.85, 95 % CI 0.75–0.95). Sagittal ultrasound detected 2/51 (3.9 %) patients with gastric distention, whereas coronal ultrasound detected 19/51 (37.3 %), p < 0.001.
Conclusion
In the ED, visualization of a fluid-filled stomach on coronal ultrasound resulted in higher detection of gastric distention than sagittal views.
认识胃膨胀对术前误吸风险分层有重要意义。我们试图确定冠状面和矢状面超声在急诊科（ED）环境下识别胃胀的诊断性能，使用计算机断层扫描（CT）作为参考标准。方法：本研究是一项单地点、前瞻性队列研究，研究对象为2024年6月1日至2024年6月30日接受腹部CT检查的成年ED患者。排除标准为既往胃手术或裂孔疝。训练有素的调查人员进行了胃超声检查，获得了矢状面和冠状面图像。两名盲法急诊医生独立审查了超声图像的质量、心房尺寸（矢状面）和胃外观（矢状面和冠状面）。胃体积（GV）采用矢状面胃壁尺寸计算。超声胃胀定义为GV超过1.5 mL/kg（矢状面）或胃充满液体呈“星夜”状（冠状面）。胃胀的参照标准为CT胃胀。计算科恩kappa （κ）、比例比较和试验特性。结果在230名同意接受CT成像的成年人中，12人被排除在外，42人图像不充分，留下176人进行分析。其中51例（29.0%）CT表现为胃胀。急诊医生对矢状面膨胀的诊断结果一致（κ = 0.29, 95% CI 0.04-0.61; κ = 0.35, 95% CI 0.05-0.65），冠状面膨胀的诊断结果几乎一致（κ = 0.85, 95% CI 0.75-0.95）。矢状面超声检出率为2/51(3.9%)，冠状面超声检出率为19/51 (37.3%),p < 0.001。结论在ED中，冠状位超声显示充满液体的胃比矢状位超声显示胃膨胀率高。
{"title":"Comparison of sagittal and coronal views in point-of-care ultrasound assessment of gastric distention: A prospective cohort study","authors":"Nicolette Meka MS , Kaitlin Krauss DO , Katie Rong MD , Timothy Herbst MD , Caroline Berberian , James Galske , Michael Kosover , Delaney Kehoe , Stephen Baker , Evan Masley DO , Regina Lopez-Merrill MD , Regina Kostyun PhD , Meghan Kelly Herbst MD","doi":"10.1016/j.ajem.2025.11.026","DOIUrl":"10.1016/j.ajem.2025.11.026","url":null,"abstract":"<div><h3>Introduction</h3><div>Recognizing gastric distention is important for preprocedural aspiration risk stratification. We sought to determine the diagnostic performance of coronal and sagittal ultrasound views for identifying gastric distention in the Emergency Department (ED) setting, using computed tomography (CT) as the reference standard.</div></div><div><h3>Methods</h3><div>This was a single-site, prospective cohort study of adult ED patients receiving abdominal CT from 6/1/2024–6/30/2024. Prior gastric surgery or hiatal hernia were exclusion criteria. Trained investigators performed a gastric ultrasound, obtaining sagittal and coronal views. Two blinded emergency physicians independently reviewed ultrasound images for quality, antral dimensions (sagittal), and stomach appearance (sagittal and coronal). Sagittal antral dimensions were used to calculate gastric volume (GV). Sonographic gastric distention was defined as GV exceeding 1.5 mL/kg (sagittal) or visualization of a fluid-filled stomach with “starry night” appearance (coronal). The reference standard for gastric distention was gastric distention on CT. A Cohen's kappa (κ), comparison of proportions, and test characteristics were calculated.</div></div><div><h3>Results</h3><div>Of 230 consenting adults who underwent CT imaging, 12 were excluded, and 42 had inadequate images, leaving 176 for analysis. Of these, 51 (29.0 %) had gastric distention on CT. Agreement among emergency physicians for distention was fair for sagittal (κ = 0.29, 95 % CI 0.04–0.61 for dimensions; κ = 0.35, 95 % CI 0.05–0.65 for appearance) and almost perfect for coronal (κ = 0.85, 95 % CI 0.75–0.95). Sagittal ultrasound detected 2/51 (3.9 %) patients with gastric distention, whereas coronal ultrasound detected 19/51 (37.3 %), <em>p</em> < 0.001.</div></div><div><h3>Conclusion</h3><div>In the ED, visualization of a fluid-filled stomach on coronal ultrasound resulted in higher detection of gastric distention than sagittal views.</div></div>","PeriodicalId":55536,"journal":{"name":"American Journal of Emergency Medicine","volume":"100 ","pages":"Pages 107-113"},"PeriodicalIF":2.2,"publicationDate":"2025-11-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145624403","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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