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Vivek S Tayal

Publications and source records attributed to Vivek S Tayal.

15 recordsLinked to original sources
PubMed2006

Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients.

STUDY OBJECTIVE: Our objective is to determine whether a bedside ultrasonographic measurement of optic nerve sheath diameter can accurately predict the computed tomographic (CT) findings of elevated intracranial pressure in adult head injury patients in the emergency department (ED). METHODS: We conducted a prospective, blinded observational study on adult ED patients with suspected intracranial injury with possible elevated intracranial pressure. Exclusion criteria were age younger than 18 years or obvious ocular trauma. Using a 7.5-MHz ultrasonographic probe on the closed eyelids, a single optic nerve sheath diameter was measured 3 mm behind the globe in each eye. A mean binocular optic nerve sheath diameter greater than 5.00 mm was considered abnormal. Cranial CT findings of shift, edema, or effacement suggestive of elevated intracranial pressure were used to evaluate optic nerve sheath diameter accuracy. RESULTS: Fifty-nine patients were enrolled in the study. Average age was 38 years, and median Glasgow Coma Scale score was 15 (interquartile 6 to 15). Eight patients with an optic nerve sheath diameter of 5.00 mm or more had CT findings that correlated with elevated intracranial pressure. The sensitivity for the ultrasonography in detecting elevated intracranial pressure was 100% (95% confidence interval [CI] 68% to 100%) and specificity was 63% (95% CI 50% to 76%). The sensitivity of ultrasonography for detection of any traumatic intracranial injury found by CT was 84% (95% CI 60% to 97%) and specificity was 73% (95% CI 59% to 86%). CONCLUSION: Bedside ED optic nerve sheath diameter ultrasonography has potential as a sensitive screening test for elevated intracranial pressure in adult head injury.

Adult↗
PubMed2006

The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department.

OBJECTIVES: To evaluate the effect of diagnostic soft-tissue ultrasound (US) on management of emergency department (ED) patients with clinical cellulitis. METHODS: This was a prospective observational study in an urban ED of adult patients with clinical soft-tissue infection without obvious abscess. The treating physician's pretest opinions regarding the need for further drainage procedures and the probability of subcutaneous fluid collection were determined. Emergency sonologists then performed US of the infected area, and the effect on management plan was recorded. RESULTS: Ultrasound changed the management of patients with cellulitis in 71/126 (56%) of cases. In the pretest group that was believed not to need further drainage, US changed the management in 39/82 (48%), with 33 receiving drainage and 6 receiving further diagnostics or consultation. In the pretest group in which further drainage was believed to be needed, US changed the management in 32/44 (73%), including 16 in whom drainage was eliminated and 16 who had further diagnostic interventions. US had a management effect in all pretest probabilities for fluid from 10% to 90%. CONCLUSIONS: Soft-tissue US changes physician management in approximately half of patients in the ED with clinical cellulitis. US may guide management of cellulitis by detection of occult abscess, prevention of invasive procedures, and guidance for further imaging or consultation.

Abscess↗
PubMed2006

Emergency ultrasound evaluation of symptomatic nontraumatic pleural effusions.

OBJECTIVE: We hypothesized that thoracic ultrasound (ThorUS) performed by emergency physicians would be a rapid and effective management tool for the evaluation of nontraumatic pleural effusion (PleurEff). METHODS: This is a prospective observational study of symptomatic adults presenting to an urban ED with suspicion of PleurEff. ThorUS was performed bilaterally in the upright position. Measurements included treating physician's procedural time requirements, pre- and posttest likelihood of PleurEff, and management changes. RESULTS: There were 59 patients who were entered into the study. Investigating physician's actual time to perform ThorUS was 2.19 minutes. After ThorUS, 48 (81%) patients had an increase and 11 (19%) had a reduction in likelihood of PleurEff with average absolute change in likelihood of PleurEff of 34% (P < .02). ThorUS changed management in 41% of cases; thoracentesis occurred most frequently. CONCLUSION: ThorUS performed by emergency physicians is a rapid and effective management tool for the evaluation of nontraumatic PleurEff in symptomatic ED patients.

Adult↗
PubMed2006

Accuracy of trauma ultrasound in major pelvic injury.

BACKGROUND: Trauma ultrasound (US) utilizing the focused assessment with sonography in trauma (FAST) is often performed to detect traumatic free peritoneal fluid (FPF). Yet its accuracy is unclear in certain trauma subgroups such as those with major pelvic fractures whose emergent diagnostic and therapeutic needs are unique. We hypothesized that in patients with major pelvic injury (MPI) trauma ultrasound would perform with lower accuracy than has previously been reported. METHODS: Retrospective analysis of adult trauma patients with pelvic fractures seen at an urban Level I emergency department and trauma center. Patients were identified from the institutional trauma registry and ultrasound database from 1999 to 2003. All patients aged >16 years with MPI (Tile classification A2, all type B and C pelvic fractures, and type C acetabular fractures determined by a blinded orthopedic traumatologist) and who had a trauma US performed during the initial emergency department evaluation were included. All ultrasounds were performed by emergency physicians or surgeons using the four-quadrant FAST evaluation. Results of US were compared with one of three reference standards: abdominal/pelvic computed tomography, diagnostic peritoneal tap, or exploratory laparotomy. Two-by-two tables were constructed for diagnostic indices. RESULTS: In all, 96 patients were eligible; 9 were excluded for indeterminate ultrasound results. Of the remaining 87 patients, the pelvic fracture types were distributed as follows: 9% type A2, 72% type B, 16% type C, and 3% type C acetabular fractures. Overall US sensitivity for detection of FPF was 80.8%, specificity was 86.9%, positive predictive value was 72.4%, and negative predictive value was 91.4%. Categorization of sensitivity according to pelvic ring fracture type is as follows: type A2 fractures: sensitivity and specificity, 75.0%; type B fractures: sensitivity, 73.3%, specificity, 85.1%; and type C fractures (pelvis and acetabulum): sensitivity and specificity, 100%. Of the true-positive US results, blood was the FPF in 16 of 21 (76%) and urine from intraperitoneal bladder rupture in 4 in 21 (19%) patients. CONCLUSION: US in the initial evaluation of traumatic peritoneal fluid in major pelvic injury patients has lower sensitivity and specificity than previously reported for blunt trauma patients. Additionally, uroperitoneum comprises a substantial proportion of traumatic free peritoneal fluid in patients with MPI.

Adult↗
PubMed2005

Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with nontraumatic symptomatic undifferentiated hypotension.

The hypothesis of this study states that in emergency department (ED) patients with non-traumatic symptomatic hypotension, the presence of hyperdynamic left ventricular function (LVF) is specific for sepsis as the etiology of shock. We performed a secondary analysis of patients with non-traumatic symptomatic hypotension enrolled in a randomized, clinical diagnostic trial. The study was done in an urban tertiary ED with a census over 100,000 visits per year. Inclusion criteria were non-trauma ED patients aged >17 years, initial vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for one sign and symptom of circulatory shock. All patients underwent focused ED echocardiography (echo) during initial resuscitation. Echos were reviewed post-hoc by a blinded physician and categorized by qualitative LVF as hyperdynamic (ejection fraction [EF] >55%), normal to moderate impairment (EF 30%-55%), and severe impairment (EF <30%). Main outcome was the criterion standard diagnosis of septic shock. Analyses include the diagnostic performance of LVF, Cohen's kappa for interobserver agreement of LVF, and logistic regression for independent predictors of sepsis. There were 103 echos that were adequate for analysis. The mean age was 57+/-16.7 years, 59% were male, and the mean initial systolic blood pressure was 83+/-11.3 mm Hg. A final diagnosis of septic shock was made in 38% (39/103) of patients. Seventeen of 103 (17%) patients had hyperdynamic LVF with an interobserver agreement of kappa=0.8. The sensitivity and specificity of hyperdynamic LVF for predicting sepsis were 33% (95% CI 19%-50%) and 94% (85%-98%), respectively. Hyperdynamic LVF had a positive likelihood ratio of 5.3 for the diagnosis of sepsis and was a strong independent predictor of sepsis as the final diagnosis with an odds ratio of 5.5 (95% CI 1.1-45). Among ED patients with non-traumatic undifferentiated symptomatic hypotension, the presence of hyperdynamic LVF on focused echo is highly specific for sepsis as the etiology of shock.

Aged↗
PubMed2004

Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients.

OBJECTIVE: We examined a physician-performed, goal-directed ultrasound protocol for the emergency department management of nontraumatic, symptomatic, undifferentiated hypotension. DESIGN: Randomized, controlled trial of immediate vs. delayed ultrasound. SETTING: Urban, tertiary emergency department, census >100,000. PATIENTS: Nontrauma emergency department patients, aged >17 yrs, and initial emergency department vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion. INTERVENTIONS: Group 1 (immediate ultrasound) received standard care plus goal-directed ultrasound at time 0. Group 2 (delayed ultrasound) received standard care for 15 mins and goal-directed ultrasound with standard care between 15 and 30 mins after time 0. MEASUREMENTS AND MAIN RESULTS: Outcomes included the number of viable physician diagnoses at 15 mins and the rank of their likelihood of occurrence at both 15 and 30 mins. One hundred eighty-four patients were included. Group 1 (n = 88) had a smaller median number of viable diagnoses at 15 mins (median = 4) than did group 2 (n = 96, median = 9, Mann-Whitney U test, p <.0001). Physicians indicated the correct final diagnosis as most likely among their viable diagnosis list at 15 mins in 80% (95% confidence interval, 70-87%) of group 1 subjects vs. 50% (95% confidence interval, 40-60%) in group 2, difference of 30% (95% confidence interval, 16-42%). CONCLUSIONS: Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic, symptomatic, undifferentiated hypotension in adult patients results in fewer viable diagnostic etiologies and a more accurate physician impression of final diagnosis.

Adult↗
PubMed2004

Outcome of patients with an indeterminate emergency department first-trimester pelvic ultrasound to rule out ectopic pregnancy.

OBJECTIVES: Pelvic ultrasound performed by emergency physicians can identify a definite diagnosis in the majority of symptomatic first-trimester pregnant patients on the initial emergency department (ED) visit. However, a significant minority of such patients are diagnosed as having an indeterminate pregnancy state requiring further testing and consultation. The authors investigated the final outcome of patients with an initial indeterminate ED first-trimester pelvic ultrasound examination in the setting of an interdepartmental protocol to rule out ectopic pregnancy. METHODS: This was an observational prospective cohort study performed at a regional, urban ED with more than 100,000 patient visits over a 13-month period. Pelvic ultrasound for first-trimester patients was prospectively performed by emergency physicians with gynecologic consultation for lack of intrauterine pregnancy (IUP) ultrasound findings. IUP was defined as a fundal gestational sac with either a yolk sac or a fetal pole. Pelvic ultrasounds were classified into diagnostic categories including definite IUP, embryonic demise, molar pregnancy, definite ectopic pregnancy, and indeterminate. For all patients with indeterminate pelvic ultrasound findings, final diagnostic categories and patient outcome were established by the use of patient records, obstetric ultrasound reports, laboratory studies, operative reports, and pathology reports. All patients with ectopic pregnancy were followed for mode of treatment. Descriptive statistics were calculated. RESULTS: A total of 1,490 ED first-trimester pelvic ultrasound examinations were performed over 13 months establishing the following diagnostic rates for initial ED visit: IUP 1,037 (70%), demise 127 (8%), definite ectopic pregnancy 24 (2%), molar pregnancy 2 ( < 1%), and indeterminate 300 (20%). The 300 indeterminate patients were classified using the above protocol into the following final diagnostic categories: embryonic demise 158 (53%), IUP 88 (29%), ectopic pregnancy 44 (15%), and unknown outcome 10 (3%). Indeterminate patients with ectopic pregnancy were treated with methotrexate in 25 of 44 cases (57%) and surgically in 16 of 44 cases (36%); there were no laparotomies. In contrast, ectopic pregnancy patients diagnosed on initial ED visit were treated surgically in 20 of 24 cases (83%), including four laparotomies. CONCLUSIONS: The outcome of symptomatic first-trimester patients with indeterminate ED pelvic ultrasounds is poor, with significantly high rates of embryonic demise and ectopic pregnancy. However, those indeterminate patients with the eventual diagnosis of ectopic pregnancy have a higher rate of medical methotrexate treatment and a reduced rate of invasive surgical treatment compared with ectopic pregnancy patients diagnosed at initial ED visit.

Abortifacient Agents, Nonsteroidal↗
PubMed2004

FAST (focused assessment with sonography in trauma) accurate for cardiac and intraperitoneal injury in penetrating anterior chest trauma.

OBJECTIVE: To evaluate the FAST (focused assessment with sonography in trauma) examination for determining traumatic pericardial effusion and intraperitoneal fluid indicative of injury in patients with penetrating anterior chest trauma. METHODS: An observational prospective study was conducted over a 30-month period at an urban level I trauma center. FAST was performed in the emergency department by emergency physicians and trauma surgeons. FAST results were recorded before review of patient outcome as determined by 1 or more of the following: thoracotomy, laparotomy, pericardial window, cardiologic echocardiography, diagnostic peritoneal lavage, computed tomography, and serial examinations. RESULTS: FAST was undertaken in 32 patients with penetrating anterior chest trauma: 20 (65%) had stab wounds, and 12 (35%) had gunshot wounds. Sensitivity of FAST for cardiac injury (n = 8) in patients with pericardial effusion was 100% (95% confidence interval, 63.1%-100%); specificity was 100% (95% confidence interval, 85.8%-100%). The presence of pericardial effusion determined by FAST correlated with the need for thoracotomy in 7 (87.5%) of 8 patients (95% confidence interval, 47.3%-99.7%). One patient with a pericardial blood clot on cardiologic echocardiography was treated nonsurgically. FAST had 100% sensitivity for intraperitoneal injury (95% confidence interval, 63.1%-100%) in 8 patients with views indicating intraperitoneal fluid but without pericardial effusion, again with no false-positive results, giving a specificity of 100% (95% confidence interval, 85.8%-100%). This prompted necessary laparotomy in all 8. CONCLUSIONS: In this series of patients with penetrating anterior chest trauma, the FAST examination was sensitive and specific in the determination of both traumatic pericardial effusion and intraperitoneal fluid indicative of injury, thus effectively guiding emergent surgical decision making.

Ascites↗
PubMed2003

Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states.

OBJECTIVES: Emergency echocardiography (EM echo) has been proposed to assist in decision-making in patients with pulseless electric activity (PEA) or PEA-like states. We observed the value of EM echo by emergency physicians in detecting pericardial effusion in patients in PEA and near PEA states. MATERIALS AND METHODS: Observational, prospective series at a Level 1 urban ED of patients with non-traumatic PEA or near PEA states who had EM echoes performed by emergency physicians during an 18-month period. Outcomes of patients with EM echoes were established by review of clinical course, formal echocardiography, radiography, operation or autopsy. RESULTS: Twenty patients had EM echo for non-traumatic hemodynamic collapse. Eight of 20 patients (40%) were without cardiac ventricular motion and were refractory to ACLS measures. Twelve of 20 (60%) patients had cardiac kinetic motion observed on echo. Eight of the 12 (67%) patients with cardiac motion had a pericardial effusion observed on EM echo. Formal echocardiography or other imaging studies confirmed all pericardial effusion cases. The following diagnoses were subsequently confirmed in patients with pericardial effusion: one aortic aneurysm, two aortic dissections, two metastatic cancers, one post-dialysis effusion, two minimal effusions. Three patients had tamponade with emergency pericardial drainage or surgery. In two of four patients with cardiac activity without pericardial effusion, EM echo was useful by detecting pacer capture and ROSC, respectively. CONCLUSIONS: Emergency echocardiography performed by emergency physicians in patients in PEA or near PEA states can detect pericardial effusions with correctable etiologies versus true PEA with ventricular standstill.

Critical Care↗
PubMed2003

Sonographic intraperitoneal fluid in patients with pelvic fracture: two cases of traumatic intraperitoneal bladder rupture.

Two patients who presented to the Emergency Department (ED) in shock with severe pelvic fractures were evaluated for intra-abdominal injury with a focused assessment with sonography in trauma (FAST) examination. Free intraperitoneal fluid was identified in the hepato-renal recess of both patients. At laparotomy both patients were found to have extensive uroperitoneum resulting from intraperitoneal bladder rupture and no other intra-abdominal injuries. The source of shock in both cases was ultimately determined to be arterial hemorrhage from pelvic vessels. The utility of FAST examinations in the setting of major pelvic injury is relatively unstudied. Coincident injuries make the evaluation for source of hemorrhage in this subset of patients challenging. This is a report of sonographic intraperitoneal fluid in the setting of major pelvic injury and hemodynamic instability found to be uroperitoneum and not hemoperitoneum.

Abdominal Injuries↗
PubMed2003

Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study.

OBJECTIVES: To determine if a focused transthoracic echocardiography (TTE) training course would improve the accuracy of completion and interpretation of a goal-directed TTE by emergency medicine residents. METHODS: This was a prospective, observational, educational study of the impact of a focused training course on the change in physician performance on pre- and postcourse examinations testing competency in goal-directed TTE defined by five criteria: 1). image orientation, 2). anatomy identification, 3). chamber size grading, 4). ventricular function estimation, and 5). pericardial effusion identification. Subjects included were emergency medicine residents with between ten and 20 hours of noncardiac ultrasound didactics and between 20 and >150 proctored noncardiac ultrasound examinations. All underwent five hours of focused echocardiography didactics and one hour of proctored practical echocardiography training designed and implemented by an emergency physician ultrasound director and a cardiologist. Before the start of the training course, participants completed two examinations: 1) written 23-question test on the above concepts and 2) performance of a TTE on a healthy subject testing 16 elements that define a properly performed examination. After the training course, participants again completed both examinations. RESULTS: A total of 21 emergency medicine residents qualified for and underwent standardized testing and training. The percentage correct on the precourse written examination was 54% (95% CI = 50% to 59%), and the postcourse examination score was 76% (95% CI = 71% to 80%) (p < 0.005, paired t-test). The percentage correct on the precourse practical examination was 56% (95% CI = 51% to 60%), and the postcourse examination score was 94% (95% CI = 91% to 96%) (p < 0.005). CONCLUSIONS: A focused six-hour echocardiography training course significantly improved emergency medicine residents' percentage scores on both written and practical examinations testing essential components required for correct goal-directed TTE performance and interpretation.

Echocardiography↗
PubMed2003

Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years.

UNLABELLED: Determination of the presence of an abdominal aortic aneurysm (AAA) is essential in the management of the symptomatic emergency department (ED) patient. OBJECTIVES: To identify whether emergency ultrasound of the abdominal aorta (EUS-AA) by emergency physicians could accurately determine the presence of AAA and guide ED disposition. METHODS: This was a prospective, observational study at an urban ED with more than 100,000 annual patient visits with consecutive patients enrolled over a two-year period. All patients suspected to have AAA underwent standard ED evaluation consisting of EUS-AA, followed by a confirmatory imaging study or laparotomy. AAA was defined as any measured diameter greater than 3 cm. Demographic data, results of confirmatory testing, and patient outcome were collected by retrospective review. RESULTS: A total of 125 patients had EUS-AA performed over a two-year period. The patient population had the following characteristics: average age 66 years, male 54%, hypertension 56%, coronary artery disease 39%, diabetes 22%, and peripheral vascular disease 14%. Confirmatory tests included radiology ultrasound, 28/125 (22%); abdominal computed tomography, 95/125 (76%); abdominal magnetic resonance imaging, 1/125 (1%); and laparotomy, 1/125 (1%). AAA was diagnosed in 29/125 (23%); of those, 27/29 patients had AAA on confirmatory testing. EUS-AA had 100% sensitivity (95% CI = 89.5 to 100), 98% specificity (95% CI = 92.8 to 99.8), 93% positive predictive value (27/29), and 100% negative predictive value (96/96). Admission rate for the study group overall was 70%. Immediate operative management was considered in 17 of 27 (63%) patients with AAA; ten patients were taken to the operating room. CONCLUSIONS: EUS-AA in a symptomatic population for AAA is sensitive and specific. These data suggest that the presence of AAA on EUS-AA should guide urgent consultation. Emergency physicians were able to exclude AAA regardless of disposition from the ED.

Aged↗
PubMed2002

Determination of left ventricular function by emergency physician echocardiography of hypotensive patients.

OBJECTIVE: To determine whether emergency physicians (EPs) with goal-directed training can use echocardiography to accurately assess left ventricular function (LVF) in hypotensive emergency department (ED) patients. METHODS: Prospective, observational study at an urban teaching ED with >100,000 visits/year. Four EP investigators with prior ultrasound experience underwent focused echocardiography training. A convenience sample of 51 adult patients with symptomatic hypotension was enrolled. Exclusion criteria were a history of trauma, chest compressions, or electrocardiogram diagnostic of acute myocardial infarction. A five-view transthoracic echocardiogram was recorded by an EP investigator who estimated ejection fraction (EF) and categorized LVF as normal, depressed, or severely depressed. A blinded cardiologist reviewed all 51 studies for EF, categorization of function, and quality of the study. Twenty randomly selected studies were reviewed by a second cardiologist to determine interobserver variability. RESULTS: Comparison of EP vs. primary cardiologist estimate of EF yielded a Pearson's correlation coefficient R = 0.86. This compared favorably with interobserver correlation between cardiologists (R = 0.84). In categorization of LVF, the weighted agreement between EPs and the primary cardiologist was 84%, with a weighted kappa of 0.61 (p < 0.001). Echocardiographic quality was rated by the primary cardiologist as good in 33%, moderate in 43%, and poor in 22%. The EF was significantly lower in patients with a cardiac cause of hypotension vs. other patients (25 +/- 10% vs. 48 +/- 17%, p < 0.001). CONCLUSIONS: Emergency physicians with focused training in echocardiography can accurately determine LVF in hypotensive patients.

Adolescent↗
PubMed2002

Residency training in emergency ultrasound: fulfilling the mandate.

Although bedside ultrasound is listed in the Model of the Clinical Practice of Emergency Medicine as an integral diagnostic procedure, the manner in which the didactic, hands-on, and experiential components of emergency ultrasound are taught is not specifically prescribed by the Residency Review Committee for Emergency Medicine (RRC-EM) or any single sponsoring group. Seven professional organizations [the American Board of Emergency Medicine (ABEM), the American College of Emergency Medicine (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents Association (EMRA), the National Association of EMS Physicians (NAEMSP), the RRC-EM, and the Society for Academic Emergency Medicine (SAEM)] developed the Scope of Training Task Force, with the goal of identifying emerging areas of clinical importance to the specialty of emergency medicine, including emergency department (ED) ultrasound. The Task Force then identified a group of recognized authorities to thoughtfully address the issue of ED ultrasound training. This report represents a consensus of these identified experts on how emergency ultrasound training should be incorporated into emergency medicine residency programs.

Curriculum↗