Article: EVIDENCE-BASED MEDICINE IMPROVES THE EMERGENT MANAGEMENT OF PERITONSILLAR ABSCESSES USING POINT-OF-CARE ULTRASOUND Gibbons RC, Costantino TG. Evidence-Based Medicine Improves the Emergent Management of Peritonsillar Abscesses Using Point-of-Care Ultrasound. J Emerg Med. 2020;59(5):693-698. doi:10.1016/j.jemermed.2020.06.030

Objective: To compare the use of point-of-care ultrasound in the emergent management of peritonsillar abscesses between cohorts (48 patients in 2007/8 vs. 114 patients in 2013/14).

Design: Retrospective, case-control study

Patient Selection: All adults ≥ 18 years old with a final diagnosis of peritonsillar abscess.

Methods: Retrospective chart review and abstraction of all patients diagnosed with peritonsillar abscess from January 1, 2007 to January 31, 2008 (cohort 1) and from January 1, 2013 to December 31, 2014 (cohort 2). Patients were separated based upon if they had POCUS performed as part of PTA management versus individuals who had no ultrasound (NUS). Each POCUS was performed by emergency medicine residents (PGY-1,2,3) under the supervision of an attending physician. PTA were aspirated under POCUS guidance. Primary endpoint of this study was POCUS utilization between cohorts and secondary endpoints of successful aspiration, need for advanced imaging, need for specialty consults, unscheduled returns to the ED within 1 week, and length of stay.

Exclusion Criteria: Certain patients were excluded if they were found to have peritonsillar cellulitis, phlegmonous changes, if a CT was preformed prior to POCUS, or if they were transferred to another facility.

Results Cohort 1: 12/48 (25%) patients had POCUS performed by nine different emergency physicians. Successful aspiration in POCUS group was 91.6% versus 38.8% in NUS (p<.002). ENT consultation was required for 16/36 (44.4%) patients in the NUS group (compared to 1/12 or 8.3% in POCUS group).

Results Cohort 2: 89/114 (78%) patients had POCUS performed by 36 different emergency physicians. Successful aspiration in POCUS group was 88.7% versus 4% in NUS (p<.0001). ENT consultation was required for 24/25 (96%) patients in the NUS group (compared to 12/89 or 13.5% in POCUS group). CT usage was less in the POCUS group (26.9% versus 64% for NUS). Length of stay for POCUS patients was 166 minutes versus 267 minutes for NUS.

Discussion: Emergency physician use of POCUS for PTA has increased from 25% in 2008 to 78% in 2014. The number of emergency physicians utilizing ultrasound for PTA increased from 9 providers to 44 providers. POCUS improved both diagnostic accuracy and successful aspiration of PTAs, along with reduced CT usage, ENT consultations, return visits, and length of stay. In considering both cohorts, 90% of patients who received POCUS had successful drainage compared to 24% without POCUS.

Takeaway: POCUS use leads to improved diagnosis and treatment of peritonsillar abscesses while providing safer, more accurate, and efficient patient care. Moreover, this article proves emergency physician practice patterns adapt to embrace evidence-based medicine and more providers can add POCUS to their repertoire without significant additional ultrasound training.

Author: Jeremy Klein, MS4