title: Impact of decontamination therapy on ultrasound visualization of ingested pills.
abstract: BACKGROUND
  Acute toxic ingestion is a common cause of morbidity and mortality. Emergency physicians (EP) caring for overdose (OD) patients are often required to make critical decisions with incomplete information. Point of care ultrasound (POCUS) may have a role in assisting EPs manage OD patients. We evaluated the impact of different liquid adjuncts used for gastric decontamination on examiners' ability to identify the presence of tablets using POCUS, and assessed examiners' ability to quantify the numbers of tablets in a simulated massive OD.
  
  
  METHODS
  This prospective, blinded, pilot study was performed at an academic emergency department. Study participants were volunteer resident and staff EPs trained in POCUS. Five nontransparent, sealed bags were prepared with the following contents: 1 liter (L) of water, 1 L of water with 50 regular aspirin (ASA) tablets, 1 L of water with 50 enteric-coated aspirin tablets (ECA), 1 L of polyethylene glycol (PEG) with 50 ECA, and 1 L of activated charcoal (AC) with 50 ECA. After performing POCUS on each of the bags using a 10-5 MHz linear array transducer, participants completed a standardized questionnaire composed of the following questions: (1) Were pills present? YES/NO; (2) If tablets were identified, estimate the number (1-10, 11-25, >25). We used a single test on proportions using the binomial distribution to determine if the number of EPs who identified tablets differed from 50% chance. For those tablets identified in the different solutions, another test on proportions was used to determine whether the type of solution made a difference. Since 3 options were available, we used a probability of 33.3%.
  
  
  RESULTS
  Thirty-seven EPs completed the study. All (37/37) EP's correctly identified the absence of tablets in the bag containing only water, and the presence of ECA in the bags containing water and PEG. For Part 2 of the study, most participants - 25/37 (67.5%) using water, 23/37 (62.1%) using PEG, and all 37 (100%) using AC - underestimated the number of ECA pills in solution by at least 50%.
  
  
  CONCLUSIONS
  There may be a potential role for POCUS in the evaluation of patients suspected of acute, massive ingested OD. EPs accurately identified the presence of ECA in water and PEG, but underestimated the number of tablets in all tested solutions.
authors.affiliation: Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington.
authors.forename: Jason
authors.initials: J
authors.lastname: Bothwell
authors.affiliation: Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington.
authors.forename: Carl
authors.initials: C
authors.lastname: Skinner
authors.affiliation: Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut.
authors.forename: David
authors.initials: D
authors.lastname: Della-Giustina
authors.affiliation: Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington.
authors.forename: Christopher
authors.initials: C
authors.lastname: Kang
authors.affiliation: Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington.
authors.forename: Laura
authors.initials: L
authors.lastname: Cookman
authors.affiliation: Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington.
authors.forename: Brooks
authors.initials: B
authors.lastname: Laselle
mesh_terms: D000931:Antidotes / Q000494:pharmacology; D002606:Charcoal / Q000494:pharmacology; D062787:Drug Overdose / Q000000981:diagnostic imaging* / Q000188:drug therapy; D005766:Gastrointestinal Contents; D006801:Humans; D010865:Pilot Projects; D019095:Point-of-Care Systems; D011446:Prospective Studies; D016037:Single-Blind Method; D013270:Stomach / Q000000981:diagnostic imaging; D013607:Tablets / Q000009:adverse effects; D014463:Ultrasonography
chemical_list: D000931:Antidotes; D013607:Tablets; D002606:Charcoal