Biography:

In the past Srikar Adhikari has collaborated on articles with Romolo Gaspari and Michael Blaivas. One of their most recent publications is Imaging/original researchIsolated Deep Venous Thrombosis: Implications for 2-Point Compression Ultrasonography of the Lower Extremity. Which was published in journal Annals of Emergency Medicine.

More information about Srikar Adhikari research including statistics on their citations can be found on their Copernicus Academic profile page.

Srikar Adhikari's Articles: (7)

Imaging/original researchIsolated Deep Venous Thrombosis: Implications for 2-Point Compression Ultrasonography of the Lower Extremity

Study objectiveTwo-point compression ultrasonography focuses on the evaluation of common femoral and popliteal veins for complete compressibility. The presence of isolated thrombi in proximal veins other than the common femoral and popliteal veins should prompt modification of 2-point compression technique. The objective of this study is to determine the prevalence and distribution of deep venous thrombi isolated to lower-extremity veins other than the common femoral and popliteal veins in emergency department (ED) patients with clinically suspected deep venous thrombosis.MethodsThis was a retrospective study of all adult ED patients who received a lower-extremity venous duplex ultrasonographic examination for evaluation of deep venous thrombosis during a 6-year period. The ultrasonographic protocol included B-mode, color-flow, and spectral Doppler scanning of the common femoral, femoral, deep femoral, popliteal, and calf veins.ResultsDeep venous thrombosis was detected in 362 of 2,451 patients (14.7%; 95% confidence interval [CI] 13.3% to 16.1%). Thrombus confined to the common femoral vein alone was found in 5 of 362 cases (1.4%; 95% CI 0.2% to 2.6%). Isolated femoral vein thrombus was identified in 20 of 362 patients (5.5%; 95% CI 3.2% to 7.9%). Isolated deep femoral vein thrombus was found in 3 of 362 cases (0.8%; 95% CI –0.1% to 1.8%). Thrombus in the popliteal vein alone was identified in 53 of 362 cases (14.6%; 95% CI 11% to 18.2%).ConclusionIn our study, 6.3% of ED patients with suspected deep venous thrombosis had isolated thrombi in proximal veins other than common femoral and popliteal veins. Our study results support the addition of femoral and deep femoral vein evaluation to standard compression ultrasonography of the common femoral and popliteal vein, assuming that this does not have a deleterious effect on specificity.

Clinical paperA retrospective study of pulseless electrical activity, bedside ultrasound identifies interventions during resuscitation associated with improved survival to hospital admission. A REASON Study☆☆☆★

AbstractObjectiveOur objective was to determine whether organized or disorganized cardiac activity is associated with increased survival in patients who present in pulseless electrical activity (PEA) treated with either 1) standard advanced cardiac life support (ACLS) medications or 2) other interventions.MethodsThis was a secondary analysis of a prospective, multi-center observational study utilizing ultrasound in out-of-hospital or inemergency department PEA arrest. Bedside ultrasound was performed as ACLS protocol started and during pulse checks. Only cases with visible cardiac activity on ultrasound were included in the present analysis. Cardiac activity was categorized as disorganized (agonal twitching) or organized (contractions with changes in ventricular dimensions). Patients were categorized as receiving either standard bolus ACLS medications or alternative medications during the resuscitation (continuous adrenergic agents, thrombolytics, others). The primary outcome was survival to hospital admission. The secondary outcome was return of spontaneous circulation (ROSC). Multivariate modeling was performed to assess association between survival to hospital admission in patients with intravenous adrenergic agents and cardiac activity.ResultsIn our cohort of 225 patients in PEA cardiac arrest with cardiac activity on ultrasound, the overall survival rate was higher in patients with organized cardiac activity than with disorganized cardiac activity. PEA cardiac arrest patients with organized cardiac activity treated with standard ACLS interventions demonstrated improved survival to hospital admission compared to those with disorganized activity (37.7% (95%CI 24.8–50.2%) versus 17.9% (95%CI 10.9–28%). PEA cardiac arrest patients with organized cardiac activity who received continuous adrenergic agents during the resuscitation and prior to ROSC demonstrated higher survival to hospital admission 45.5% (95%CI 26.9–65.4%) and ROSC 90.9% (95%CI 71.0–98.7%) compared to those with disorganized cardiac activity who received continuous adrenergic agents during the resuscitation 0% (95%CI 0–23.0%) and 47.1% (95%CI 26–69%). Regression analysis demonstrates an association between increased survival in patients receiving intravenous adrenergic agents and organized cardiac activity.ConclusionSurvival in patients following PEA arrest is higher in patients with organized cardiac activity. The initiation of continuous adrenergic agents during PEA was associated with improved survival to hospital admission in patients with organized cardiac activity on bedside ultrasound, but this improvement was not seen in patients in PEA with disorganized cardiac activity. Bedside ultrasound may identify a subset of patients that respond differently to ACLS interventions.

Original ContributionDiagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience

AbstractObjectivesThe objective of this study was to describe diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasound (US) in an established emergency US program.MethodsThis was a retrospective study on patients presenting over a 2-year period performed at a level I urban academic emergency department (ED). The ED sees 78 000 patients annually and has a residency and active US program. Patients were eligible for inclusion if they were pregnant, seen in the ED for a first-trimester complication, and underwent a bedside emergency US suggesting an ectopic pregnancy. Emergency department US logs were reviewed for findings suggestive of ectopic pregnancy. Medical records were reviewed for history, physical examination findings, laboratory results, additional diagnostic testing, management, hospital course, and a discharge diagnosis by the admitting obstetric service (OB). Patients with incomplete data were excluded from analysis. Statistical analysis consisted of descriptive statistics.ResultsSeventy-four patients ranging in age from 16 to 39 years (mean, 25 years) were included in the study. Eight patients with incomplete data were excluded from analysis. Emergency-physician US diagnoses included definite ectopic pregnancy (6/74), probable ectopic pregnancy (28/74), and possible ectopic pregnancy (40/74). Forty-seven (64%) of these patients were eventually diagnosed with definite ectopic pregnancy by the OB. During initial consultation, the OB disagreed with the diagnosis of ectopic pregnancy in 15 (32%) of the 47 eventual patients with ectopic pregnancy, calling them miscarriages. Other eventual diagnoses included 9 (12%) patients with possible ectopic pregnancy, 11 (14%) patients with miscarriage, and 7 (9%) with intrauterine pregnancy. Emergency sonologists found tubal rings in 9 (19%) patients with eventual ectopic pregnancy, complex adnexal mass in 29 (61%) patients, and a large amount of echogenic fluid in the cul-de-sac in 10 (21%) patients. Six (13%) patients had live ectopic pregnancy. The OB ordered a radiology US in 10 cases but did not change the diagnosis or management. β-Human chorionic gonadotropin (β-hCG) levels ranged from 41 to 59 846 mIU/mL (mean, 4602 mIU/mL), but for live ectopic pregnancy, the range was 2118 to 59 846 mIU/mL (mean, 36 341 mIU/mL). Seventeen (36%) patients had β-hCG levels of lower than 1000 mIU/mL. Of 47 eventual ectopic pregnancies, 29 (62%) patients underwent operative intervention, 17 (36%) patients received methotrexate, and 1 patient left against medical advice. Five (11%) of these patients with definite ectopic pregnancy were initially managed by emergency physicians with follow-up ED visits and serial US examinations without OB consultation.ConclusionOur study demonstrates that with increased experience, emergency sonologists can accurately diagnose ectopic pregnancy. Furthermore, patients at risk for ectopic pregnancy should not be denied US examinations if their β-hCG levels fall below an arbitrary discriminatory zone.

Brief ReportAbility of emergency physicians with advanced echocardiographic experience at a single center to identify complex echocardiographic abnormalities☆☆☆

AbstractObjectivesTo determine the ability of emergency physicians to detect complex abnormalities on point-of-care (POC) echocardiograms.MethodsSingle-blinded, nonrandomized, cross-sectional study. Twenty-five different emergency medicine clinical scenarios (video clips and digital images) covering a variety of echocardiographic abnormalities were presented to a group of emergency physician sonologists. The echocardiographic abnormalities included right ventricular dysfunction, left ventricular systolic dysfunction, diastolic dysfunction, regional wall motion abnormalities, Doppler abnormalities of pericardial tamponade physiology, left ventricular hypertrophy, hypertrophic cardiomyopathy, and aortic abnormalities. All emergency physician sonologists were blinded to the study hypothesis. They reviewed echocardiography video clips and images individually, and their interpretations were compared with the criterion standard (expert echocardiographer interpretations).ResultsA total of 200 echocardiography studies (video clips and images) were independently reviewed by 8 emergency physician sonologists with varying POC echocardiography experiences. Emergency physicians accurately identified left ventricular systolic dysfunction 94% of the time, diastolic dysfunction (100%), and right ventricular dysfunction 80% of the time. Regional wall motion abnormalities were detected only 50% of the time. Doppler echocardiographic abnormalities of pericardial tamponade physiology were accurately identified 57% of the time. Emergency physicians who performed more than 250 POC echocardiograms were found to be more accurate in identifying complex echocardiographic abnormalities.ConclusionsOur study results suggest that with increased experience, emergency physicians can accurately identify most of complex echocardiographic abnormalities.

Original ContributionEpidemiology of elevated blood pressure in the ED☆☆☆★

AbstractObjectivesTo determine the prevalence and demographics of elevated blood pressure (BP) in emergency department (ED) patients.MethodsRetrospective study at an academic ED. ED patients with any systolic blood pressure (SBP) ≥ 140 mm Hg or diastolic blood pressure (DBP) ≥ 90 mm Hg over a 1-year period were included. Data pertaining to frequency of elevated BP across different ethnic categories, age groups, days of the week, shifts, and gender were collected.ResultsA total of 44 435 patient records were accessed. Overall 47.6% (95% CI, 47.2%-48.1%) of patients had elevated BP (SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg). Fifty three percent (95% CI, 52%-54%) were women. Among patients with elevated BP, 18% (95% CI, 17.8%-18.9%) had severe BP elevation (SBP ≥ 180 or DBP ≥ 110). Overall, patients > 45 years old were more likely to have elevated BP in ED. Across all ethnic groups, BP increased with age. Significant differences were noted in the prevalence of elevated BP between whites (52%), and other ethnic groups (African Americans [45%] and Hispanics [31%]) (P < .01). Overall, 64% (95% CI, 63.3%-64.6%) of patients with elevated BP were discharged from the ED. Forty four percent (95% CI, 42.4%-45.5%) of patients with severe BP elevation were also discharged from the ED.ConclusionsThis study provides knowledge of distribution of elevated BP among different age, gender and ethnic groups in the ED which can be used to develop specific interventions to improve recognition, prevention, detection, and treatment of hypertension.

Ultrasound in emergency medicineDiagnostic Utility of Cholescintigraphy in Emergency Department Patients with Suspected Acute Cholecystitis: Comparison with Bedside RUQ Ultrasonography

AbstractTc-99m-HIDA cholescintigraphy studies of gallbladder (GB) emptying are considered to be the most accurate method to diagnose acute cholecystitis (AC). With increasing use of bedside ultrasound (US) by emergency physicians for the evaluation of GB pathology, it is important to determine the role of cholescintigraphy as an adjunct to emergency ultrasound of the gallbladder. The objective of this study was to determine the utility of cholescintigraphy as an adjunct to bedside ultrasound in the evaluation of Emergency Department (ED) patients with suspected acute cholecystitis. We retrospectively reviewed US studies of 102 patients being evaluated for AC at a large community ED with a residency program. All patients over 18 years of age presenting to the ED over a 1-year period who received an ED US of the GB followed by a cholescintigraphy were enrolled. Bedside ultrasonography was performed after an initial physical examination by a hospital-credentialed emergency sonologist. Criteria used to diagnose AC include the finding of gallstones with a sonographic Murphy sign, significant wall thickening over 5 mm, pericholecystic fluid, impacted stone, or a combination of these. US reports were compared to cholescintigraphy results, final diagnosis, disposition, and pathology results when applicable. Statistical analysis included descriptive statistics calculated using StatsDirect software. A total of 102 patients fit criteria for this study over a 1-year period. Three patients were dropped from data analysis due to incomplete data. ED US and cholescintigraphy examinations agreed for presence or absence of AC in 76 of 99 patients (77%; 95% confidence interval [CI] 68–84%) resulting in a correlation value of rs = 0.74. A total of 38 of 99 (38%; 95% CI 30–49%) patients were diagnosed with AC on cholescintigraphy and ED US agreed in 20 patients. ED US diagnosed 25 (25%; 95% CI 18–34%) patients with AC and cholescintigraphy agreed in 20 patients. Of 99 patients enrolled, 63 were admitted to the hospital (63%; 95% CI 53–72%). Of the admitted patients, 36 (36%; 95% CI 27–46%) went to the operating room (OR) for presumed AC. Of the 31 (79%; 95% CI 64–89%) with AC on cholescintigraphy who went to the OR, only 13 (42%; 95% CI 26–59%) had pathology-based diagnosis of AC; 15 (48%; 95% CI 32–65%) had chronic inflammation only and 3 (10%; 95% CI 4–25%) had a diagnosis of cholelithiasis only. In 12 of 15 OR cases (80%; 95% CI 62–98%), where cholescintigraphy diagnosed AC but ED US did not, operative diagnosis agreed with US. Five patients with normal cholescintigraphy but ED US diagnosis of AC were taken to OR; pathology agreed with ultrasonography in all. Three other patients diagnosed with AC on cholescintigraphy, but not on ED US, never required operative intervention based on consulting surgeon evaluation. Our study demonstrates that the utility of cholescintigraphy in the evaluation of ED patients with suspected acute cholecysitis after a negative ultrasound examination is very limited.

Clinical PotpourriCritical care ultrasound training: A survey of US fellowship directors☆

AbstractPurposeThe purpose of this study is to describe the current state of bedside ultrasound use and training among critical care (CC) training programs in the United States.Materials and methodsThis was a cross-sectional survey of all program directors for Accreditation Council for Graduate Medical Education accredited programs during the 2012 to 2013 academic year in CC medicine, surgical CC, pulmonary and critical care, and anesthesia CC. Availability, current use, and barriers to training in CC ultrasound were assessed.ResultsSixty of 195 (31%; 95% confidence interval [CI], 24%-38%) program directors responded. Most of the responding programs had an ultrasound system available for use (54/60, 90%; 95% CI, 79%-96%) and identified ultrasound training as useful (59/60, 98%; 95% CI, 91%-100%) but lacked a formal curriculum (25/60, 42%; 95% CI, 29%-55%) or trained faculty (mean percentage of faculty trained in ultrasound: pulmonary and critical care, 25%; surgical CC, 33%; anesthesia CC, 20%; CC medicine, 7%), and relied on informal teaching (45/60, 77%; 95% CI, 62%-85%). Faculty with expertise (53/60, 88%; 95% CI, 77%-95%), simulation training (60/60, 100%; 95% CI, 94%-100%), establishing and meeting required number of examinations (47/60, 78%; 95% CI, 66%-88%), and regular review sessions (49/60, 82%; 95% CI, 70%-90%) were identified as necessary to improve ultrasound training. Most responding programs (32/35 91%; 95% CI, 77%-98%) without a formal curriculum plan to create one in the next 5 years.ConclusionsThis study identified deficiencies in current training, suggesting a need for a formal curriculum for bedside ultrasound training in CC fellowship programs.

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