Abstract. Objective: To measure the ability of cardiac sonography and capnography to predict survival of cardiac arrest patients in the emergency department (ED). Methods: Nonconsecutive cardiac arrest patients prospectively underwent either cardiac ultrasonography alone or in conjunction with capnography during cardiopulmonary resuscitation at two community hospital EDs with emergency medicine residency programs. Cardiac ultrasonography was carried out using the subxiphoid view during pauses for central pulse evaluation and end-tidal carbon dioxide (ETCO 2 ) levels were monitored by a mainstream capnograph. A post-resuscitation data collection form was completed by each of the participating clinicians in order to assess their impressions of the facility of performance and benefit of cardiac sonography during nontraumatic cardiac resuscitation. Results: One hundred two patients were enrolled over a 12-month period. All patients underwent cardiac sonographic evaluation, ranging from one to five scans, during the cardiac resuscitation. Fifty-three patients also had capnography measurements recorded. The presence of sonographically identified cardiac activity at any point during the resuscitation was associated with survival to hospital admission, 11/41 or 27%, in contrast to those without cardiac activity, 2/61 or 3% (p < 0.001). Higher median ETCO 2 levels, 35 torr, were associated with improved chances of survival than the median ETCO 2 levels for nonsurvivors, 13.7 torr (p < 0.01). The multivariate logistic regression model, which evaluated the combination of cardiac ultrasonography and capnography, was able to correctly classify 92.4% of the subjects; however, of the two diagnostic tests, only capnography was a significant predictor of survival. The stepwise logistic regression model, summarized by the area under the receiver operator curve of 0.9, furthermore demonstrated that capnography is an outstanding predictor of survival. Conclusions: Both the sonographic detection of cardiac activity and ETCO 2 levels higher than 16 torr were significantly associated with survival from ED resuscitation; however, logistic regression analysis demonstrated that prediction of survival using capnography was not enhanced by the addition of cardiac sonography.
A 44-year-old previously healthy man presented to the Emergency Department (ED) with a chief complaint of fever, chills, and right upper quadrant abdominal pain for 2 weeks. The patient was treated with oral levofloxacin for unclear reasons at the onset of his complaints 2 weeks prior without improvement. Past medical and surgical history was unremarkable. Review of systems was negative for cough, hematuria, urinary symptoms, nausea, vomiting or change in stool habits. Social history revealed that the patient had moved to the United States from Taiwan several years prior and had not traveled since that time. He denied risk factors for human immunodeficiency virus or hepatitis.Vital signs revealed temperature 39.5°C (103.3°F), blood pressure 109/66 mm Hg, heart rate 129 beats/min, and respiratory rate 18 breaths/min. Physical examination revealed a well-developed 44-year-old man in moderate distress secondary to abdominal discomfort. Pertinent physical findings included: anicteric sclerae, cardiopulmonary examination notable only for tachycardia, and abdominal examination significant for a palpable liver 2 cm below the right costal margin with right upper quadrant tenderness. There was no guarding or rebound. Bowel sounds were normal and there was no splenomegaly.Laboratory studies yielded the following abnormal results: hematocrit, 32.5 g/dL; white blood cell count, 20,800; platelet count, 609,000; sodium, 133 mEq/dL; and alkaline phosphatase, 158 U/L. The other laboratory results, including remaining chemistry, other liver and pancreatic enzymes, were within normal limits. Urinalysis was negative. Chest radiograph revealed elevation of the right hemidiaphragm with blunting of the right costophrenic angle.Bedside abdominal ultrasonography was performed in the ED (Figure 1), revealing a septated mass within the liver, as well as diffuse gallbladder wall thickening without the presence of gallstones. Given the appearance on bedside abdominal ultrasound, therapy was instituted with intravenous levofloxacin and metronidazole for the empiric treatment of hepatic abscess. Abdominal computed tomography (CT) scan (Figure 2), obtained several hours later, confirmed the presence of a hepatic abscess in the right hepatic lobe. The patient was admitted to the medical service where he underwent ultrasound and fluoroscopic-guided needle aspiration, yielding 400 cc of purulent yellow fluid. A pigtail catheter was inserted for continued drainage. Culture of the fluid subsequently grew klebsiella pneumoniae. The patient was discharged after a 12-day course of intravenous antibiotics. A follow-up abdominal CT scan at 2 weeks showed resolution of the abscess. DISCUSSIONThe incidence of pyogenic liver abscess ranges from 10 -20 cases per 100,000 hospital admissions. The most common location for abscess formation is the right hepatic lobe (75%) followed by the left hepatic lobe (20%)
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