Correspondence

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Ultrasonography as a tool for prehospital recognition of Tension pneumothorax?

Preliminary data

To the Editor,

perform the USG examination in suspected tPTX, and that this should be a routinely procedure given to patients with chest trauma.

In summary, paramedics after a short training on performing USG examination are capable of recognizing tPTX in an ultrasound image with high efficiency. Further studies on a larger group of participants are needed to confirm our results.

We read with great interest the article “Pneumothorax is a rare complica- tion of thoracic central venous catheterization in community EDs” by Vinson et al [1]. The authors of this study show that the incidence of pneumothorax (tPTX) from thoracic central venous catheterization in community emergen- cy departments is low. However, as research by Vinson et al [1] and other au- thors shows, the risk of tPTX is higher with a failed access at the initial vein, subclavian vein approach [2] or positive pressure ventilation [3]. It is worth noting that in the prehospital setting, tPTX is a common complication of inju- ries such as traffic accidents or shootings, and it can lead to death if untreated and is responsible for a significant number of Preventable deaths. Moreover, the typical signs and symptoms of tPTX, such as decreased breath sounds, hypoxia, hypotension, or tracheal deviation, cannot always be present in patients with tPTX. Heng et al [3] reported that 10 patients transported by paramedics over the period 12 months had an untreated tPTX on arrival at the hospital. In connection with the above, it seems reasonable to implement alternative confirmation methods of the tPTX presence. Assistance in recognition of tPTX can provide ultrasonography (USG) [4,5].

The aim of this study was to evaluate the effectiveness of recognize

tPTX by paramedics using USG examination.

A randomized, crossover, single-center study was carried out at in March 2016. Paramedics included in the study were recruited on a volun- tary basis. After written informed consent, 26 paramedics participated. None of the study participants had experience in performing USG examina- tion. Before study, all participants received 20-minute theoretical training in the field of USG performance as a tool to recognized tPTX. Then participants practiced USG examination on themselves under the supervision of an an- esthesiologist. Practice section was held until the participants felt comfort- able during the test. During the examination, a linear 6-MHz probe was used. Then, during an appropriate study, participants performed lung USG. The correctness of lungs was evaluated by the instructor. The second phase of study was carried out using a computer. Participants were given 10 USG films (5 with presence of tPTX and 5 without tPTX). The sequence of images displayed was random. Participants were asked to assess whether, on a given image, tPTX was present. At the end of the study, participants were asked to provide information whether in clinical settings they have applied USG examination to confirm or exclude the tPTX, and whether ultrasound to confirm tPTX should be a routine test in patients with trauma.

In our study, the effectiveness of the recognition of tPTX using USG

was 92.3%. The obtained result is comparable to a study conducted by Nandipati et al [5], where extended focused assessment with sonography for trauma performed by a surgeon at trauma room had senility at 95% level. Moreover, in our study, 100% of participants said that they would

? Source of support: No sources of financial and material support to be declared.

Lukasz Szarpak, PhD, DPH, EMT-P Department of Emergency Medicine Medical University of Warsaw, Warsaw, Poland

Ricardo Gadea Mateo, MS Emergency Medicine Student Scientific Circle at Department of Emergency Medicine Medical University of Warsaw, Warsaw, Poland Jaume I University, Castellon de la Plana, Spain

Giuseppe Marchese, MS Emergency Medicine Student Scientific Circle at Department of Emergency Medicine Medical University of Warsaw, Warsaw, Poland University of Palermo, Palermo, Italy

Lukasz Czyzewski, PhD, RN? Department of Nephrologic Nursing Medical University of Warsaw, Warsaw, Poland

?Corresponding author. Department of Nephrologic Nursing, Medical University of Warsaw, 61 Zwirki Wigury St, 02-091 Warsaw, Poland

Tel.: +48 696457655 (mobile)

E-mail address: [email protected]

Andrzej Kurowski, PhD, MD

Department of Anesthesiology Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland

Jacek Smereka, PhD, MD Department of Emergency Medical Service Wroclaw Medical University, Wroclaw, Poland

Zenon Truszewski PhD, MD Department of Emergency Medicine Medical University of Warsaw, Warsaw, Poland

http://dx.doi.org/10.1016/j.ajem.2016.03.069

References

1. Vinson DR, Ballard DW, Hance LG, Stevenson MD, Clague VA, Rauchwerger AS, et al. Pneu- mothorax is a rare complication of thoracic central venous catheterization in community EDs. Am J Emerg Med 2015;33(1):60-6. http://dx.doi.org/10.1016/j.ajem.2014.10.020.
2. Plewa MC, Ledrick D, Sferra JJ. Delayed tension pneumothorax complicating central venous catheterization and positive pressure ventilation. Am J Emerg Med 1995; 13(5):532-5.

   0735-6757/(C) 2016

   Heng K, Bystrzycki A, Fitzgerald M, Gocentas R, Bernard S, Niggemeyer L, et al. Complications of Intercostal catheter insertion using EMST techniques for chest trauma. ANZ J Surg 2004 Jun;74(6):420-3.

3. Balesa J, Rathi V, Kumar S, Tandon A. Chest sonography in the diagnosis of pneumo- thorax. Indian J Chest Dis Allied Sci 2015 Jan-Mar;57(1):7-11.
4. Nandipati KC, Allamaneni S, Kakarla R, Wong A, Richards N, Satterfield J, et al. Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: experience at a community based level I trauma center. Injury 2011;42(5):511-4. http://dx.doi.org/10.1016/j.injury.2010.01.105.

   What are the Cardiac effects of carbon monoxide poisoning in the acute and chronic periods?

   

   To the Editor,

   We read the published article by Kaya et al [1] titled “Carboxyhemoglobin levels predict the long-term development of acute myocardial infarction in carbon monoxide poisoning” with great interest. The researchers of the study demonstrated that elevated Carboxyhemoglobin levels in pa- tients who applied to emergency services with carbon monoxide (CO) poi- soning are an independent predictor of acute myocardial infarction (AMI) development in the long term. The cardiotoxic effects of CO are previously known, and many studies have been published for the acute period cardiac effects of CO poisoning. However, the study of Kaya et al is valuable, as it demonstrated the long-term cardiac effects of CO poisoning.

   In our prospective study, which included 20 patients who applied to emergency services with CO poisoning [2], 6 patients had elevated cardiac markers, and these patients underwent coronary angiography, but no le- sions were detected in their coronary arteries. Furthermore, COHb levels and CO exposure durations were higher than those of patients who did not have elevated cardiac markers. The patients were divided into 2 groups as patients with an ejection fraction (EF) less than 45% and pa- tients with an EF greater than 45%. All patients in the EF greater than 45% group were troponin (-). Reduction of EF was correlated with COHb levels and CO exposure duration. In addition, EF became greater than 55% in 24 hours for 7 of 8 patients whose EF was less than 45%. In this study, which evaluated long-term cardiovascular effects of CO, un- known cardiac markers and echocardiography findings were an impor- tant limitation, as mentioned by Kaya et al. One hundred patients who had AMI in the long term after CO poisoning, in the study of Kaya et al, might have consisted of patients who had elevated cardiac markers after poisoning and transient systolic dysfunction on echocardiography but did not have obstructive lesions in the coronary angiography, similar to our study. Furthermore, in these patients, the accelerated atheroscle- rotic process may be observed, which is triggered by the direct toxic effect of CO at the cellular level, after complete separation of the COHb mole- cules from hem molecules in the acute period. Moreover, a significant lim- itation was the fact that there was no clear information about the coronary angiographies of these patients in the study of Kaya et al.

   In the study of Kaya et al, CO exposure duration, age, and smoking were also determined as independent predictors of AMI development in the long-term period, in addition to COHb levels. It was already dem- onstrated that blood COHb levels were higher in smokers when com- pared with nonsmokers [3]. Thus, smoking might also contribute to COHb acute elevation in CO poisoning in this study. Although the authors mentioned in the discussion section that smoking is not related to acute COHb elevation, they did not provide any data about this subject.

   If the results of the study of Kaya et al are supported by a prospective study in which cardiac markers, echocardiography, and coronary angi- ography are evaluated, it can contribute to long-term Cardiovascular risk stratification and the development of the cardiovascular treatment of patients who experience CO poisoning.

   Nihat Kalay, MD

   Department of Cardiology Erciyes University Medical School, Kayseri, Turkey

   Department of Cardiology Erciyes University Medical School, Kayseri, Turkey Tel.: +90 3524374937; fax: +90 3522222222

   E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.03.071

   References

   Kaya H, Coskun A, Beton O, Zorlu A, Kurt R, Yucel H, et al. Carboxyhemoglobin levels predict the long-term development of acute myocardial infarction in carbon monox- ide poisoning. Am J Emerg Med 2016;34:840-4.

5. Kalay N, Ozdogru I, Cetinkaya Y, Eryol NK, Dogan A, Gul I, et al. Cardiovascular effects of carbon monoxide poisoning. Am J Cardiol 2007;99(3):322-4.
6. Hedblad B, Ogren M, Engstrom G, Wollmer P, Janzon L. Heterogeneity of cardiovascu- lar risk among smokers is related to degree of carbon monoxide exposure. Athero- sclerosis 2005;179:177-83.

   The Society of Clinical Ultrasound Fellowships: An innovation in the Point of Care Ultrasound fellowship application process

   

   Emergency Point-of-care ultrasound fellowship programs in the United States have grown and developed over the past 20 years. James Mateer, M.D., trained the first US fellow in 1993 at the Medical College of Wisconsin in Milwaukee (James Mateer, personal communi- cation). At that time, US was not the required sub-competency training for graduating emergency physicians that it is today [1]. (See Fig. 1.)

   In 2006, emergency US specialists met to discuss the goal of stan- dardizing the US Fellowship training process. At the time, both the Ultra- sound section of the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine Ultrasound Interest Group were involved with the fellowship application process. Existing US groups provided lists of fellowships, but further information ,regard- ing the number of positions, leadership, curriculum, and prerequisites, was obtained by individual enquiry.

   The EUSfellowships.com website [2] was originally developed to provide a repository for information on US fellowship programs. The EUSFellowships.com web address was registered in August 2007 and launched in September that same year. The website allows fellowship directors to directly enter and update information about their programs automatically. In the first year, 25 programs were listed. There has been tremendous growth since its inception, with a peak of 108 programs in 2015. 90 programs are currently active (See Fig. 2). Each registered fel- lowship program is asked questions based upon criteria listed in the 2011 ACEP Emergency Ultrasound Fellowship Guidelines [3]. Programs can be evaluated through these “best practice” program features, as well as descriptive characteristics that emphasize what is unique to each program. A detailed educational curriculum was defined in 2014 with the publication of “The Core Content of Clinical Ultrasonography Fellow- ship Training” [4]. This plus the 2012 consensus document on the mile- stone project [5] differentiated content expected of a residency graduate from that of a fellowship graduate. The website integrates these key publications by asking program directors to complete a check- list based on the requirements delineated in these documents.

   In 2009 the website was expanded to include an online application system. Applicants upload a curriculum vitae, personal statement, and so- licit letters of reference through the site. Letters, once uploaded, are only visible to the fellowship directors, and not the applicant. The website in- corporates an internal email system that facilitates communication