Emergency department echocardiography improves outcome in penetrating cardiac injury

Intraperitoneal blood missed on a FAST examination using portable ultrasound

Bedside ultrasonography is rapidly gaining popularity in the evaluation of emergency patients. Several manufacturers have developed hand-held ultrasound machines that make the technology easy to transport and available in settings where such diagnostic tests were previously unobtainable. The miniaturization of equipment often means compromises and no studies exist comparing the high quality imaging capabilities of larger conventional ultrasound units to hand-held machines on actual patients. We present 3 cases in which intra-abdominal fluid stripes, important markers of intraperitoneal bleeding, were not visible with a popular hand-held unit, but were identified with a larger mobile ultrasound machine. These findings should caution emergency physicians to be aware of this limitation along with the many advantages of these new and popular hand-held ultrasound units.

Bedside echocardiography by emergency physicians

STUDY OBJECTIVE

Timely diagnosis of a pericardial effusion is often critical in the emergency medicine setting, and echocardiography provides the only reliable method of diagnosis at the bedside. We attempt to determine the accuracy of bedside echocardiography as performed by emergency physicians to detect pericardial effusions in a variety of high-risk populations.

METHODS

Emergency patients presenting with high-risk criteria for the diagnosis of pericardial effusion underwent emergency bedside 2-dimensional echocardiography by emergency physicians who were trained in ultrasonography. The presence or absence of a pericardial effusion was determined, and all images were captured on video or as thermal images. All emergency echocardiograms were subsequently reviewed by the Department of Cardiology for the presence of a pericardial effusion.

RESULTS

During the study period, a total of 515 patients at high risk were enrolled. Of these, 103 patients were ultimately deemed to have a pericardial effusion according to the comparative standard. Emergency physicians detected pericardial effusion with a sensitivity of 96% (95% confidence interval [CI] 90.4% to 98.9%), specificity of 98% (95% CI 95.8% to 99.1%), and overall accuracy of 97.5% (95% CI 95.7% to 98.7%).

CONCLUSION

Echocardiography performed by emergency physicians is reliable in evaluating for pericardial effusions; this bedside diagnostic tool may be used to examine specific patients at high risk. Emergency departments incorporating bedside ultrasonography should teach focused echocardiography to evaluate the pericardium.

Screening cardiac ultrasonographic examination in patients with suspected cardiac disease in the emergency department

BACKGROUND/OBJECTIVE

Our purpose was to evaluate the utility of a brief screening cardiac ultrasonographic (SCU) examination. We prospectively compared the SCU with conventional clinical evaluation in 124 emergency department (ED) patients with suspected cardiac disease. Furthermore, we assessed the impact and quality of SCU examinations as obtained by briefly trained ED personnel (EP).

METHODS

Patients underwent clinical evaluation by an ED physician and SCU examination by a sonographer or cardiologist. Patient disposition, hospital stay length, and the number of full echo examinations were compared with the presence of significant findings on SCU. In patients who received a full echocardiogram during hospitalization, results of the initial clinical examination were compared with results of the SCU examination in the diagnosis of significant findings. A similar analysis, but with quality assessment, was performed on only those SCU examinations acquired by 4 EP.

RESULTS

Of the 124 patients enrolled in the main study, 40 of 124 (32%) had significant findings on SCU. Of patients with abnormal SCUs versus normal SCUs, 16 of 40 (40%) versus 18 of 84 (21%) had hospital stay lengths >2 days (P < or =.05). Using the 36 inpatient full echo studies obtained for standard indications during hospitalization as a gold standard, initial clinical examination identified only 7 of 30 (23%) significant findings and had 16 false-positive diagnoses, whereas SCU identified 22 of 30 (73%) with 8 false positives. Although similar study results occurred with interpretation of 68 SCUs obtained by EP, quality was achieved in only 55% ED personnel versus 97% of sonographer-obtained SCUs (P <.05).

CONCLUSIONS

An SCU examination detects significant findings misdiagnosed on initial clinical evaluation in the ED and provides prognostic data regarding length of hospital stay.

Triage in the trauma bay with the focused abdominal sonography for trauma (FAST) examination

Bedside ultrasonography has been applied to the evaluation of blunt trauma patients for over a decade. The Focused Abdominal Sonography for Trauma (FAST) examination has been used to successfully triage blunt trauma patients. Although not traditionally thought to be as useful in penetrating trauma patients, ultrasound can help determine the extent of injury especially of the heart. We present two cases of multiple-stabbing victims who arrived at our Level I trauma center at the same time, when our trauma system was particularly overburdened by multiple consecutive traumas. The FAST examination helped us to accurately determine which of the two patients required operative intervention first, despite that patient's appearance of relative hemodynamic stability in comparison to the other stabbing victim.

Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies

OBJECTIVE

To determine whether the time to diagnosis and treatment of patients with ruptured ectopic pregnancy is significantly less for patients who had emergency department (ED) right upper quadrant (RUQ) ultrasound (US) compared with those who had US in the radiology department.

METHODS

The authors conducted a retrospective review of eligible patients presenting to an urban ED between January 1990 and December 1998. Patients were included in the study if they were seen in the ED, had a discharge diagnosis of ruptured ectopic pregnancy, were brought immediately to the operating room after a definitive diagnosis of ectopic pregnancy rupture was made, and had more than 400 mL of intraperitoneal blood found at the time of surgery. The ED, hospital, radiology, and operative records were reviewed to determine presenting vital signs, intraperitoneal blood loss, time to diagnosis, time to treatment, and type of US performed.

RESULTS

There were 37 patients enrolled; 16 received ED RUQ US (group I) and 21 had a formal US in radiology (group II). The ages, pulses, systolic blood pressures, and volumes of hemoperitoneum were similar between the two groups. The average time to diagnosis from ED arrival was 58 minutes for group I (SD = 57; 95% CI = 28 to 87) and 197 minutes for group II (SD = 82; 95% CI = 162 to 232) (p < or = 0.0001). The average time to operative treatment was 111 minutes (group I) (SD = 86; 95% CI = 69 to 153) and 322 minutes (group II) (SD = 107; 95% CI = 270 to 364) (p < or = 0.0001), respectively.

CONCLUSIONS

Patients with ruptured ectopic pregnancy, who were selected to have RUQ US performed in the ED by emergency physicians, had an average decrease in time to diagnosis of two and a quarter hours, and an average decrease in time to treatment of three and a half hours, compared with those having a formal pelvic US in the radiology department. Further prospective investigation is needed to determine whether ED RUQ US can safely expedite care of patients with suspected ectopic pregnancy.

Management of traumatically injured patients in the emergency department observation unit

An EDOU may be an ideal setting for the short-term monitoring and treatment of certain acutely injured patients. The patients choosen for observation, and the diagnostic studies used, will be specific to a particular institution's availability and expertise. Pathways should be developed in conjunction with all services caring for these patients.

Potential errors in the diagnosis of pericardial effusion on trauma ultrasound for penetrating injuries

OBJECTIVE

To evaluate ultrasound error in patients presenting with penetrating injury with a potential for pericardial effusion.

METHODS

Residents and faculty from an emergency medicine training program at Level 1 trauma center with an active ultrasound program were asked to view digitized video clips of subxiphoid cardiac examinations in patients with chest trauma. Participants were asked to fill out a standardized questionnaire on each video clip asking whether a pericardial effusion was present. Other questions included size of effusion and presence of tamponade. The study also asked participants to rate their confidence in their impressions. Data were analyzed using interquartile ranges and confidence levels.

RESULTS

All participants had difficulty distinguishing between epicardial fat pads and true pericardial effusions. The overall sensitivity was 73% and specificity was 44%. Confidence shown by participants in their answers increased with level of training or experience, regardless of whether they were correct or incorrect. Additional views were frequently requested to help decide whether an effusion was present.

CONCLUSIONS

A serious potential exists for misdiagnosing epicardial fat pads as pericardial effusion in critically ill trauma patients. Emergency physicians need to be aware of this and should consider one of two suggested alternative methods to improve the accuracy of diagnosis.

Indications for limited echocardiographic imaging: a mathematical model

BACKGROUND

Few data exist on the magnitude of potential time savings obtained by using a limited echocardiographic (echo) imaging strategy on a referral population.

METHODS

A mathematical model of a limited echo screening strategy was devised that used as variables the length of the limited examination and the probability of detecting the referral diagnosis or a significant incidental finding, and assumed that any abnormality would mandate a full study. Data from prior echo population studies were used in the model as examples.

RESULTS

The model demonstrated a direct relation in time savings for populations with a low prevalence of disease and incidental findings. The model predicted that a limited echo imaging strategy could result in significant time savings when applied to certain specific referral populations.

CONCLUSIONS

The time savings of a limited echo screening strategy can be modeled as a function of the length of the limited screen and the presence of significant findings. This model may provide the framework in which future prospective studies can confirm indications for limited echo.

Ultrasound training for emergency physicians--a prospective study

OBJECTIVES

Bedside ultrasound examination by emergency physicians (EPs) is being integrated into clinical emergency practice, yet minimum training requirements have not been well defined or evaluated. This study evaluated the accuracy of EP ultrasonography following a 16-hour introductory ultrasound course.

METHODS

In phase I of the study, a condensed 16-hour emergency ultrasound curriculum based on Society for Academic Emergency Medicine guidelines was administered to emergency medicine houseofficers, attending staff, medical students, and physician assistants over two days. Lectures with syllabus material were used to cover the following ultrasound topics in eight hours: basic physics, pelvis, right upper quadrant, renal, aorta, trauma, and echo-cardiography. In addition, each student received eight hours of hands-on ultrasound instruction over the two-day period. All participants in this curriculum received a standardized pretest and posttest that included 24 emergency ultrasound images for interpretation. These images included positive, negative, and nondiagnostic scans in each of the above clinical categories. In phase II of the study, ultrasound examinations performed by postgraduate-year-2 (PGY2) houseofficers over a ten-month period were examined and the standardized test was readministered.

RESULTS

In phase I, a total of 80 health professionals underwent standardized training and testing. The mean +/- SD pretest score was 15.6 +/- 4.2, 95% CI = 14. 7 to 16.5 (65% of a maximum score of 24), and the mean +/- SD posttest score was 20.2 +/- 1.6, 95% CI = 19.8 to 20.6 (84%) (p < 0. 05). In phase II, a total of 1,138 examinations were performed by 18 PGY2 houseofficers. Sensitivity was 92.4% (95% CI = 89% to 95%), specificity was 96.1% (95% CI = 94% to 98%), and overall accuracy was 94.6% (95% CI = 93% to 96%). The follow-up ultrasound written test showed continued good performance (20.7 +/- 1.2, 95% CI = 20.0 to 21.4).

CONCLUSIONS

Emergency physicians can be taught focused ultrasonography with a high degree of accuracy, and a 16-hour course serves as a good introductory foundation.

[Evaluation and treatment of cardiac injuries]

Cardiac injuries caused by a heart traumatism are not frequent but, of great importance given their high morbidity. Two different groups in terms of etiology, clinical picture, application of diagnostic techniques, treatment and prognosis can be considered. On one hand, there are cardiac injuries caused by a thoracal contusion, which provokes a contused lesion can affect the free wall, the interventricular septum, the valves, the subvalvular apparatus, the conduction system and the coronary vessels and, on the other hand, cardiac injuries caused by penetrating objects. Cardiac injury can lead to a life-threatening hemodynamic instability which mandates prompt and clear diagnostic and therapeutic approaches.

Imaging of penetrating thoracic trauma

The management of penetrating chest injuries has evolved significantly over the past few years, with an increasing emphasis on less invasive diagnostic and therapeutic modalities. Only 15% of patients need a therapeutic operative procedure. The challenge is to detect and treat these injuries rapidly while maximizing the use of noninvasive examinations and decreasing costs. The areas potentially at risk for injury include the heart, major vessels, thoracoabdomen, neck, spine, and aerodigestive tract. A review of injuries to these areas, including the use of new diagnostic modalities such as echocardiography and computed tomography (CT) scans, are discussed.

A preliminary evaluation of emergency ultrasound in the setting of an emergency medicine training program

In this article we seek to evaluate the diagnostic accuracy of emergency physicians performing emergency ultrasonography in the setting of an emergency medicine training program. A prospective observational study was performed at an inner city Level I trauma center with an emergency medicine residency training program. From July 1994 to December 1996 a convenience sample of ultrasound exams was recorded. The diagnostic quality ("acceptable or technically limited") was determined by a board-certified cardiologist or radiologist with fellowship training in ultrasonography. The emergency department interpretations were then compared to those of the blinded cardiologist or radiologist. Four hundred and fifty-six ultrasound examinations were videotaped and entered into the study; 408 (89%) of the studies performed were determined to be "acceptable." The diagnostic accuracy (sensitivity, specificity, positive and negative predictive values) of these studies were as follows: cardiac, to rule out effusion (n = 67; 0.83, 0.98, 0.88, 0.98); transabdominal, to rule out abdominal aortic aneurysms (AAA), cholelithiasis, or free peritoneal fluid (n = 263; 0.91, 0.89, 0.88, 0.92); renal, to rule out hydronephrosis (n = 45; 0.94, 0.96, 0.94, 0.96); pelvic, to rule in intrauterine pregnancy (n = 33; 1.0, 0.90, 0.96, 1.0). The 48 "technically limited studies" included: 39 transabdominal (33 gallbladder, 1 abdominal aortic aneurysm, 5 free peritoneal fluid), 6 cardiac, 2 renal, and 1 pelvic ultrasound. This study suggests that emergency physicians with a minimal amount of training display acceptable technical skill and interpretive acumen in their approach to emergency ultrasonography.

Transthoracic ultrasonography is an alternative to subxyphoid ultrasonography for the diagnosis of hemopericardium in penetrating precordial trauma

BACKGROUND

Surgeon-performed ultrasonography is increasingly becoming part of the initial evaluation of patients after blunt or penetrating trauma. Currently, most institutions obtain a subxyphoid or subcostal view of the heart and pericardial space, and a three-view ultrasonogram of the abdomen to detect blood in the pericardial sac or in three dependent abdominal areas.

METHODS

A left parastemal standard transverse transthoracic view is described in addition to the aforementioned views. This facilitates the visualization of the pericardial sac when a subxyphoid or subcostal view cannot be obtained because of anatomical reasons (narrow subxyphoid space) or local factors (pain, fractures, subcutaneous emphysema, or chest wall contusion).

RESULTS

The transthoracic view can be useful in patients where the subxyphoid view is difficult to obtain through the conventional approach. In most patients an excellent view of the pericardial sac and ventricles can be obtained and, therefore, expedites the diagnosis and treatment of patients with hemopericardium.

CONCLUSION

Surgeon-performed ultrasonography has become the diagnostic test of choice for patients suspected of having hemopericardium and cardiac tamponade. Transthoracic ultrasonography is an excellent alternative for those patients where a subxyphoid or subcostal view to visualize the pericardial sac and heart cannot be obtained owing to local or anatomical factors.

Current evaluation of cardiac stab wounds

BACKGROUND

Patients with penetrating cardiac injuries may be stable or only mildly shocked, especially if the laceration has sealed off and the patient has been aggressively resuscitated. Clinical signs, chest roentgenograms, pericardiocentesis, and subxiphoid window are not always helpful in establishing the diagnosis. We reflect on the current evaluation based on 128 patients.

METHODS

There were four groups of patients, ranging from lifeless (group I) to stable (group IV). Patients in groups I and II were prepared immediately for operation. Those in groups III and IV were often investigated further (chest roentgenogram and cardiac ultrasound).

RESULTS

Mortality was 8%. Significant findings were a precordial stab, central venous pressure of more than 15 cm of water, one or more clinical signs of tamponade, and initial shock. Cardiac ultrasound was performed in 5 patients in group II (15%), 14 patients in group III (48%), and 37 patients in group IV (86%). There were no false positives, and 6 false negatives (11%). Thirty-one patients (24%) had clotted lacerations. There were no negative sternotomies.

CONCLUSIONS

Efficient fluid resuscitation and rapid confirmation of diagnosis with cardiac ultrasound should decrease mortality. Stable patients with a precordial wound should undergo cardiac ultrasound or echocardiogram. Diagnosis may be reliably confirmed in these patients whose clinical signs often fluctuate (or rapidly deteriorate).

Patient satisfaction and diagnostic accuracy with ultrasound by emergency physicians

In recent years, there has been considerable interest and controversy concerning the performance of ultrasound by emergency physicians (ED Sono), but patient satisfaction with ED Sono has not been well studied. The primary purpose of this investigation was to assess the level of patient satisfaction with ED Sono and to compare satisfaction with ED Sono with ultrasound by the Medical Imaging Department (MI Sono). A secondary objective was to assess the accuracy of ED Sono at our facility. During a 5-month period, which included the startup phase of a program for ED Sono, emergency physicians prospectively identified patients who were candidates for ultrasound as a part of their workup. Patients were contacted by telephone after their ED visit and asked to rate satisfaction on a 0 to 10 scale for various aspects of their care, including the ultrasound if one was done. The accuracy of ED Sono was determined by comparing ED ultrasound interpretations with surgical pathology, repeat imaging studies, or clinical follow-up. Two hundred forty patients were entered into the study, and 186 (78%) responded to the satisfaction survey. Satisfaction ratings were similarly high for ED Sono (mean, 8.9; 95% Cl, 8.6 to 9.2) and for MI Sono (mean, 8.8; 95% Cl, 8.2 to 9.4). Eighteen percent of ultrasounds performed by emergency physicians were indeterminate. Excluding indeterminate scans and scans for which confirmation was not possible, the accuracy of ED Sono was 99.1% (95% Cl, 95.1% to >99.9%). We conclude that during the startup phase of our ED Sono program, patient satisfaction was high, and the error rate was very low.

A comparison of emergency medicine ultrasound training with guidelines of the Society for Academic Emergency Medicine

STUDY OBJECTIVES

To compare the current state of emergency medicine residency ultrasound training with guidelines for that training from the Society for Academic Emergency Medicine (SAEM).

METHODS

A brief questionnaire was sent to program directors from 119 emergency medicine residency programs in the United States. Responses were compared with the SAEM guidelines for clinical experience (150 total ultrasounds) and didactic experience (40 hours of didactic instruction).

RESULTS

The overall response rate was 92%. Seventy-six (69%) of the programs own an ultrasound machine (ownership defined as 24-hour availability and complete discretion over use). Of these, 12 (16%) indicated that their average 1998 graduate had done at least 150 total ultrasound scans during residency, although none of the programs had average numbers that exceeded the minimum guidelines for all 4 procedure categories. Information on didactic curriculum was available from 74 ultrasound-owning programs: the duration was 0 to 20 hours in 49 (66%), 20 to 40 hours in 19 (26%), and 40 to 100 hours in 6 (8%). Only 1 program's average graduate met or exceeded the SAEM guidelines for both didactic and clinical training.

CONCLUSION

Most emergency medicine residency programs own at least 1 ultrasound machine, with more than half of these obtaining their first machine within the past 3 years. Only 1 program currently meets SAEM training guidelines.

Ultrasound in the ED: a different point of view

Many published papers report excellent sensitivity, specificity and accuracy when non-radiologists employ ultrasound (U/S) to detect free intraperitoneal fluid in cases of blunt abdominal trauma (BAT). In this setting, it is best to view the FAST (focused abdominal sonogram in trauma) as a noninvasive diagnostic peritoneal lavage (DPL): It tells us whether there is free intraperitoneal fluid but does not determine the specific parenchymal injury. In other words it is a screening tool.

Should UK emergency physicians undertake diagnostic ultrasound examinations?

From the published evidence there is no doubt that emergency physicians in America can undertake focused ultrasound examinations and that, by extrapolation, this would also be the case for UK emergency physicians. If this skill is to become part of the diagnostic armamentarium of the emergency physician, however, it needs to be demonstrated to be cost effective compared with the alternatives already available to the hospital. Trials to test for this benefit should adopt a hospital and not an emergency department perspective if the results are to influence health policy and specialty training.

Penetrating Cardiac Injuries

Our objective was to determine the influence of several clinical factors on the survival of patients with penetrating wounds to the heart. A retrospective review of 80 consecutive penetrating cardiac injuries treated in a Level II urban trauma center from 1980 through 1994 were examined. Thirty-six patients (45%) had gunshot wounds (including 1 shotgun wound), and 44 (55%) had stab wounds. Intervention consisted of emergency room (ER) or operating room thoracotomy. We measured the effect of several clinical factors on morbidity and patient survival. Survival rate was 17 of 36 (47%) in gunshot injuries and 35 of 44 (80%) in stab injuries, with an overall survival rate of 52 of 80 patients (65%). The average age was 24 years (range, 9–53), and there were 3 female patients. Twelve patients (15%) had multiple cardiac injuries, and 63 (79%) had other associated injuries. Fourteen patients (17%) presented with no blood pressure, and 55 (69%) were hypotensive on admission. ER thoracotomy was performed on 7 of 52 survivors (13%) and 24 of 28 nonsurvivors (86%). Survival after ER thoracotomy was 7 of 31 patients (22%). A selective approach is recommended, because ER thoracotomy has a limited role in penetrating cardiac injury. A high index of suspicion, prompt resuscitation, and immediate definitive surgical management resulted in a high survival rate for these frequently lethal injuries.

Transvaginal ultrasonography by emergency physicians decreases patient time in the emergency department

OBJECTIVES

An important argument for emergency physician use of ultrasonography is that it results in more rapid patient disposition, but there are few articles to support this position. This study sought to demonstrate a significant decrease in the time spent in the ED when emergency physicians performed transvaginal ultrasonography (TVUS), as compared with when TVUS was performed by consultants, in the evaluation of first-trimester pelvic pain or vaginal bleeding.

METHODS

A retrospective analysis was conducted of the time spent in the ED (time placed in gynecologic examination room to time released from ED) by patients with first-trimester pelvic pain or vaginal bleeding necessitating further evaluation with TVUS. TVUS was performed in the ED by obstetrics/gynecology (ob/gyn) residents who were consulted to the ED from January 11, 1996, to March 31, 1996, and by emergency physicians from April 17, 1996, to July 7, 1996.

RESULTS

Emergency physicians evaluated 46 patients by TVUS, with a mean time of 164.70 minutes (SEM +/- 13.29). Ob/gyn consultants evaluated 38 patients by TVUS, with a mean time of 234.79 minutes (SEM +/- 12.74). This was a significant difference at the level of p < 0.0003 (Student's t-test). There were no known missed ectopic pregnancies as ascertained by 100% patient follow-up. There was no significant difference between the groups in the percentage of ectopic pregnancies (Fisher's exact test). The number of patients in the emergency physician group requiring subsequent consultation was reduced by 85%.

CONCLUSIONS

This study demonstrates a more rapid ED transit time when TVUS was performed at the bedside by emergency physicians as compared with when pelvic ultrasonography required consultation. Additionally, fewer calls to consultants were required.

Prevalence and structure of ultrasound curricula in emergency medicine residencies

Emergency medicine (EM) residency program directors were surveyed to determine the presence and structure of curricula for teaching ultrasound to EM residents. For those EM programs without an ultrasound curriculum (USC), information was requested on plans to implement one within the next 12 months. Ninety of 116 (78%) EM programs replied to the survey. One-half of EM residencies surveyed have USCs, and another 30% plan to implement one in the near future.

Echocardiography in thoracic trauma

The availability of bedside ultrasonography can dramatically impact the care of patients with cardiac or aortic injuries. A focused, limited echocardiographic examination in the initial evaluation of victims with thoracic injuries can provide vital information the clinician needs to expedite the management of these patients. This article reviews the current use of transthoracic and transesophageal echocardiography in patients with thoracic trauma.

Evaluation of an instructional model for emergency ultrasonography

OBJECTIVE

To evaluate a 4-hour ultrasonography course in the setting of an emergency medicine (EM) training program.

METHODS

EM residents and faculty at a large urban center were provided a 4-hour emergency ultrasonography course. Then, during an 18-month period, a nonconsecutive sample of ultrasonographic examinations were videotaped and later reviewed. The interpretations of the emergency, physician examinations were compared with the following reference standards: 1) an official ultrasound performed and interpreted by the departments of radiology or cardiology; 2) an operative report; 3) A CT scan or i.v. pyelogram (IVP); or 4) a cardiologist's or a radiologist's interpretation of the videotaped examinations.

RESULTS

Of 258 examinations reviewed, 28 (11%) of these were excluded because the cardiologist or radiologist reviewing the videotape determined them to be "technically limited" studies. Of the remaining 230 examinations, there were: 127 gallbladder studies [disease prevalence = 0.58; sensitivity = 0.89; specificity = 0.80; kappa (kappa) = 0.69; 95% CI: 56-82%]; 39 echocardiograms to rule out pericardial effusions [disease prevalence = 0.15; sensitivity = 0.83; specificity = 0.97 kappa = 0.80; 95% CI: 54-100%]; 25 abdominal ultrasounds to rule out free peritoneal fluid [disease prevalence = 0.32; sensitivity = 0.88; specificity = 0.94; kappa = 0.81; 95% CI: 26-95%]; 16 renal ultrasounds to rule out hydronephrosis [disease prevalence = 0.25; sensitivity = 1.0; specificity = 0.92; kappa = 0.84; 95% CI: 56-100%]; 12 pelvic ultrasounds to rule in an intrauterine pregnancy [disease prevalence = 0.67; sensitivity = 1.0; specificity = 0.75; kappa = 0.80; 95% CI: 43-100%]; and 11 abdominal ultrasounds to rule out abdominal aortic aneurysms [disease prevalence = 0.09; sensitivity = 1.0; 95% CI: 2.5-91%; specificity = 1.0; 95% CI: 68-100%].

CONCLUSIONS

This 4-hour ultrasonography course has potential to serve as a foundation for an instructional model for ultrasonography training in the setting of an EM residency program.

Credentialing issues in emergency ultrasonography

The use of ultrasonography, traditionally performed by radiologists, is becoming increasingly widespread in emergency medicine. Consequently, much debate has evolved over whether emergency medicine physicians are qualified to provide this service, and the criteria by which training and credentialing can be achieved. This article discusses training and credentialing guidelines, paths to becoming credentialed in emergency sonography, and quality assurance issues. Also, strategies are proposed for emergency departments seeking to perform emergency sonography.

[The assessment of cardiac involvement in a case of a thoracic injury from a firearm]

We report the case of a patient with a gunshot wound in the chest with a multiple small-caliber intrathoracic projectiles. The different noninvasive techniques employed to evaluate the anatomical location of these projectiles are discussed, together with their cardiac structural repercussions. The data provided by a simple chest X-ray, Computed Tomography (CT) and transthoracic echocardiography are commented on. A simple chest X-ray was unable to discern the location of the projectiles, in contrast to CT, which was able to identify both the number of projectiles and their location. The information provided was enhanced by transthoracic echocardiography, particularly in relation to those projectiles situated in anterior cardiac regions.

Trauma ultrasound examination versus chest radiography in the detection of hemothorax

STUDY OBJECTIVE

To compare the sensitivity, specificity, and accuracy of ultrasonography with those of the initial plain chest radiograph for detection of hemothorax in trauma patients.

METHODS

Data from a prior prospective study of trauma ultrasonography at a Level I trauma center were retrospectively analyzed. The medical records of a convenience sample of adult patients who presented with major blunt or penetrating torso trauma during a 17-month period were reviewed. Emergency physicians performed a trauma ultrasound examination, which included evaluation for pleural fluid. Ultrasound interpretations were recorded before other diagnostic tests were obtained and were not used in patient management decisions. Records of the study patients were reviewed for confirmation of the presence or absence of hemothorax by other diagnostic and therapeutic interventions. The chest radiograph and computed tomography (CT) scan interpretations were performed by attending radiologists who were not blinded to patient outcome.

RESULTS

Five of the 245 patients enrolled in the study were excluded because tube thoracostomy was performed before the ultrasound examination was done. Altogether, 26 of the 240 study patients had hemothorax, as confirmed by tube thoracostomy or CT. Both ultrasound examination and the initial chest radiograph resulted in 0 false-positive, 1 false-negative, 25 true-positive, and 214 true-negative findings. Overall, both modailties were 96.2% sensitive, 100% specific, and 99.6% accurate.

CONCLUSION

Ultrasonography is comparable to the initial chest radiograph for accuracy in detection of hemothorax and may expedite the diagnosis and treatment of this condition for patients with major trauma.

Emergency department ultrasound services by emergency physicians: model for gaining hospital approval

We anticipate that over the next few years, emergency physician use of emergency department ultrasound will become the standard of care. However, many EDs are hampered in their efforts to gain hospital approval for emergency physician use of ultrasound because of the lack of publicized information regarding the goals of such use, the scope of emergency physician ultrasound privileges, emergency physician ultrasound credentialing criteria, and ED ultrasound quality-improvement plans. In this article we address these issues and provide an example of a proposal used successfully to gain hospital approval for ED use of ultrasound by emergency physicians.

Penetrating cardiac injuries

Penetrating cardiac injuries pose a tremendous challenge to any trauma surgeon. Time, sound judgment, aggressive intervention, and surgical technique are the most important factors contributing to positive outcomes. This article extensively reviews the history, surgical management, and techniques needed to deal with these critical injuries. This year commemorates the one hundredth anniversary of the first successful repair of a cardiac injury.

The role of surgeon-performed ultrasound in patients with possible cardiac wounds

OBJECTIVE

The authors evaluate surgeon-performed ultrasound in determining the need for operation in patients with possible cardiac wounds.

BACKGROUND DATA

Ultrasound quickly is becoming part of the surgeon's diagnostic armamentarium; however, its role for the patient with penetrating injury is less well-defined. Although accurate for the detection of hemopericardium, the lack of immediate availability of the cardiologist to perform the test may delay the diagnosis, adversely affecting patient outcome. To be an effective diagnostic test in trauma centers, ultrasound must be immediately available in the resuscitation area and performed and interpreted by surgeons.

METHODS

Surgeons performed pericardial ultrasound examinations on patients with penetrating truncal wounds but no immediate indication for operation. The subcostal view detected hemopericardium, and patients with positive examinations underwent immediate operation by the same surgeon. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded.

RESULTS

During 13 months, 247 patients had surgeon-performed ultrasound. There were 236 true-negative and 10 true-positive results, and no false-negative or false-positive results; however, the pericardial region could not be visualized in one patient. Sensitivity, specificity, and accuracy were 100%; mean examination time was 0.8 minute (246 patients). Of the ten true-positive examinations, three were hypotensive. The mean time (8 patients) from ultrasound to operation was 12.1 minutes; all survived. Operative findings (site of cardiac wounds) were: left ventricle (4), right ventricle (3), right atrium (2), right atrium/superior vena cava (1), and right atrium/inferior vena cava (1).

CONCLUSIONS

Surgeon-performed ultrasound is a rapid and accurate technique for diagnosing hemopericardium. Delay times from admission to operating room are minimized when the surgeon performs the ultrasound examination.

[Management of suspected heart injuries]

Penetrating cardiac injury has to be ruled out in any patients with penetrating thoracic injuries, even in those with no alterations in vital functions. Undelayed echocardiography should be performed to screen for the presence of pericardial effusion. The first case underlines the risk of cardiac tamponade if the diagnosis is missed. Echocardiography was not performed because no echocardiographist was present at the time, and a high suspicion of a neck vascular injury existed. Sudden deterioration due to the onset of acute tamponade was only reversed by an immediate pericardiocentesis followed by surgical haemostasis. The second patient, although stable, had a large echographic pericardial effusion. Emergent sternotomy revealed a large amount of blood in the pericardial space and two cardiac wounds with one on a coronary artery. Penetrating wounds in proximity to the heart, even in a stable patient, require aggressive attempts at ruling out a cardiac injury. Immediate echocardiography should be systematically performed to screen for pericardial fluid.

Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians

The objective of this prospective study was to determine the sensitivity, specificity, and accuracy of the rapid trauma ultrasound examination, performed by emergency physicians, for detecting free peritoneal and thoracic fluid in patients presenting to a level I trauma center with major blunt or penetrating torso trauma. Emergency medicine residents and faculty were trained to perform an ultrasound examination of the torso evaluating for free intraperitoneal, retroperitoneal, pleural, and pericardial fluid. In the 245 study patients, emergency physicians examined 975 intracavitary spaces and demonstrated 64 positive findings for free fluid as documented by computed tomography scan, diagnostic peritoneal lavage, exploratory laparotomy, chest radiography, tube thoracostomy, or formal two-dimensional echocardiography. The rapid trauma ultrasound examination was 90% sensitive, 99% specific, and 99% accurate. Ultrasonography can serve as an accurate diagnostic adjunct in detecting free peritoneal and thoracic fluid in trauma patients. Appropriately trained emergency physicians can accurately perform and interpret these trauma ultrasound examinations.

Penetrating cardiac injuries: clinical classification and management strategy

The management of penetrating cardiac injury is controversial. To facilitate decision making, a simple clinical classification of patients with such an injury is proposed. Five categories are considered: (1) lifeless, (2) critically unstable, (3) cardiac tamponade, (4) thoracoabdominal injury and (5) benign presentation. Investigation, if indicated, and the timing and setting of surgical intervention are discussed for each category.

Comparative efficacy of transthoracic and transesophageal echocardiography in detection of an intracardiac bullet fragment

A 19-year-old man received a gunshot wound to the heart. Transthoracic echocardiography was unable to localize the bullet fragment, whereas transesophageal echocardiography localized the bullet fragment in the posteroseptal wall at the base of the posteromedial papillary muscle.

A prospective study of ultrasonography in the ED by emergency physicians

The objective of this study was to examine the use of limited, goal-directed, two-dimensional ultrasound studies performed by emergency physicians and to assess the frequency, variety, and accuracy of their readings. A 1-year prospective study was performed by using an emergency department (ED) ultrasound machine with a 3.5-mHz mechanical oscillating sector transducer and a 5.0-mHz vaginal transducer. In a series of proctoring sessions, radiologists trained emergency physicians to do limited, goal-directed ultrasonography. Laser print ultrasonograms were collected from all ED ultrasound examinations performed during a 1-year period and were compared with either formal ultrasonograms performed in the radiology department, the patient's hospital record, or both. Sensitivity, specificity, and positive predictive value (PPV), as well as negative predictive values (NPV), were calculated. The setting was a 104-bed community hospital with an ED volume of 25,000 patients annually, and patients whom the emergency physician believed needed ultrasound studies in the ED were entered. ED ultrasonography was performed in 167 patients by 14 physicians during a 1-year period. For 132 patients who completed formal follow-up, the overall diagnostic accuracy of interpretations of ED ultrasonograms yielded a sensitivity of .95, specificity of .98, PPV of .99, and NPV of .89. Eleven categories of ultrasound use were reported. The three studies most commonly performed were for gallbladder disease (53%), intrauterine pregnancy (28%), and abdominal aortic aneurysms (7%). Accuracy of ED gallbladder ultrasonograms for 65 patients showed a sensitivity of .86, specificity of .97, PPV of .97, and NPV of .85.(ABSTRACT TRUNCATED AT 250 WORDS)

Model curriculum for physician training in emergency ultrasonography

A model curriculum for the implementation and training of physicians in emergency medicine ultrasonography is described. Widespread use of limited bedside ultrasonography by emergency physicians will improve diagnostic accuracy and efficiency, increase the quality of care, and prove to be a cost-effective technique for the practice of emergency medicine.