Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine

A nationwide survey of point-of-care ultrasound utilization in academic versus nonacademic general emergency departments

Objective

Despite mandatory point-of-care ultrasound (PoCUS) training in residency, utilization varies across emergency departments (EDs). We sought to characterize PoCUS utilization patterns in the United States, specifically comparing academic to nonacademic settings.

Methods

A nationwide cross-sectional survey was conducted from March to November 2024, targeting general EDs open 24/7. Site directors completed a 15-question survey on PoCUS use, workflow, and billing. Academic EDs (those with emergency medicine residents or ultrasound fellows) were compared to nonacademic EDs. Regular PoCUS use for a physician was defined as using two or more applications at least once per week; regular PoCUS use for an application was defined as at least one scan per week. A strong workflow required image storage to Picture Archiving and Communication System/Middleware and physician review. Differences in PoCUS utilization, workflow, and billing were analyzed using chi-square, Mann-Whitney U, and unpaired t-tests. Correlations between study variables and ED academic status were assessed using Pearson's and Spearman's coefficients. Odds ratios (ORs) measured the strength of associations.

Results

Of 664 invited EDs (15.3% of all U.S. EDs), 423 completed surveys (63.8% response rate) from all 50 states and Washington, DC. Academic EDs (n = 220) were more likely to own four or more ultrasound machines (54.1%) compared to nonacademic EDs (54.2% owned ≤1, p < 0.001). More physicians performed ultrasound regularly at academic sites (58.7% ± 28.1%) versus nonacademic sites (46.7% ± 27.2%, p < 0.001), but there was no association between recent residency training and ultrasound utilization (r = -0.008, p = 0.875). Academic EDs had stronger workflow integration (OR 3.9, 95% confidence interval [CI] 2.6-5.9, p < 0.001) and were more likely to bill for PoCUS (OR 3.8, 95% CI 2.4-6.0, p < 0.001).

Conclusion

PoCUS utilization is lower in nonacademic EDs, with suboptimal workflows and fewer billing practices. Addressing these disparities may enhance PoCUS implementation and improve patient care.

Effectiveness of a Web-Based Training Intervention in Teaching Emergency Physicians First-Trimester Point-of-Care Ultrasound Image Interpretation

STUDY OBJECTIVE

To examine the effectiveness of an education intervention on emergency physician accuracy in identifying pregnancy-related findings from first-trimester point-of-care ultrasound. Case features associated with the odds of a correct response were also determined.

METHODS

This was a multicenter prospective cross-sectional study in a convenience sample of emergency physicians in the United States and Canada. The unsupervised web-based education intervention included first-trimester point-of-care ultrasound cases acquired through the transabdominal (n=200 cases) or transvaginal (n=200 cases) approach. Physicians deliberately practiced identifying pregnancy-related imaging findings until they achieved a mastery standard.

RESULTS

In 204 participants, there were learning gains in accuracy (15.2%; 95% confidence interval [CI] 14.6 to 15.8), sensitivity (15.1%; 95% CI 14.3 to 15.9), and specificity (14.3%; 95% CI 13.7 to 15.0). Of these, 132 (64.7%) achieved the mastery standard in a median of 60 cases (interquartile range 58 to 83). Case features associated with an increased odds of a correct intrauterine pregnancy "present" diagnosis were transvaginal versus transabdominal-acquired images (odds ratio [OR]=1.5; 95% CI 1.3 to 1.8) and fetal heartbeat (OR=4.3; 95% CI 3.4 to 5.5). A decreased odds was associated with an eccentrically located intrauterine pregnancy (OR=0.2; 95% CI 0.1 to 0.2), subchorionic hemorrhage (OR=0.5; 95% CI 0.4 to 0.6), adnexal mass (OR=0.7; 95% CI 0.6 to 0.9), and endometrial collection (OR=0.1; 95% CI 0.09 to 0.2).

CONCLUSIONS

This study's intervention was effective in teaching first-trimester point-of-care ultrasound image interpretation and identified the specific variables that posed the greatest diagnostic challenges. The methods and results from this work can serve to expand learning opportunities for this critical skill in emergency medicine.

Evaluating the Role of Point-of-Care Ultrasound in Central Venous Pressure Monitoring for Critically Ill Patients. A Comprehensive Systematic Review and Meta-analysis

Central venous pressure (CVP) is a critical parameter for assessing volume status in critically ill patients, traditionally measured through invasive central venous catheterization. While effective, this method poses risks such as infection and procedural complications. Point-of-care ultrasound (POCUS) has emerged as a promising, non-invasive alternative, yet its accuracy in estimating CVP remains debated. From inception to December 2024, PubMed, Embase, MEDLINE, Web of Science, and Google Scholar databases were extensively searched. The search strategy used to identify relevant studies from these databases involved combining keywords such as "Point-of-care ultrasound," "central venous pressure," and "critically ill" with Boolean expression "AND" and "OR." Two independent reviewers then screened all potential studies and included those reporting the accuracy of POCUS in predicting CVP and those reporting the correlation between POCUS-measured indices and invasively-measured CVP in critically ill patients. Additionally, two independent reviewers extracted the relevant data from the included studies. Statistical analyses were conducted using MedCalc and Meta-Disc software, and quality appraisal was assessed using the QUADAS-2 tool. The review included studies evaluating POCUS-derived indices from the inferior vena cava (IVC) and internal jugular vein (IJV). Overall, strong correlations were observed between POCUS measurements and CVP, with IVC parameters showing the strongest associations. IJV measurements also demonstrated moderate reliability, particularly in scenarios where IVC assessments were impractical. Sensitivity and specificity analyses indicated that POCUS-derived indices could predict CVP with variable accuracy. These findings support the use of POCUS as a practical, non-invasive tool for estimating CVP in critically ill patients. IVC measurements appear to provide the most reliable correlations, while IJV assessments serve as a useful alternative. Despite its potential, variability in study methodologies and patient factors highlights the need for further research to refine POCUS-based CVP estimation and improve clinical application.

Multispecialty comparison of point-of-care-ultrasound use, training, and barriers: a national survey of VA medical centers

BACKGROUND

As more specialties have begun to use Point-of-Care Ultrasound (POCUS) in patient care, hospitals and healthcare systems have been investing increasing resources in POCUS infrastructure (training, equipment, and administration). Since each specialty uses different POCUS applications, healthcare systems seek to identify commonalities and differences between specialties to make thoughtful investments in POCUS infrastructure to support each specialty's use of POCUS while minimizing redundancies. Historically, past studies have focused on POCUS use in individual specialties, primarily emergency medicine and critical care, but comparative studies of different specialties are needed to guide investment in POCUS infrastructure and bolster POCUS implementation across healthcare systems. We conducted a cross-sectional survey of all Veterans Affairs (VA) medical centers in the United States and compared data from 5 different specialties on current usage, training needs, and barriers to POCUS implementation.

RESULTS

Data were collected from facility chiefs of staff (n = 130; 100% response rate) and chiefs of emergency medicine (n = 101; 92% response rate), critical care (n = 93; 83% response rate), hospital medicine (n = 105; 90% response rate), anesthesiology (n = 96; 77% response rate), and surgery (n = 104; 95% response rate). All specialties surveyed reported current POCUS use (surgery 54%, hospital medicine 64%, anesthesiology 83%, emergency medicine 90%, and critical care 93%) but more importantly, a greater desire for training was seen. Procedural POCUS applications were most often used by all specialties, despite decreased procedural POCUS use since 2015 for all specialties except critical care. Diagnostic POCUS use generally increased from 2015 to 2020, although use of specific POCUS applications varied significantly between specialties. Barriers limiting POCUS use included lack of training (53-80%), access to ultrasound equipment (25-57%), and POCUS infrastructure (36-65%).

CONCLUSIONS

From 2015 to 2020, POCUS use increased significantly in emergency medicine, critical care, internal medicine, anesthesiology, and surgery, although use of specific applications varied significantly between specialties. Lack of training and POCUS infrastructure were common barriers to POCUS use across specialties. Desire for training exceeded current use for several POCUS applications. These findings can guide implementation and standardization of  POCUS use  in hospitals and healthcare systems.

Racial inequities in point-of-care ultrasound for pregnancy

STUDY OBJECTIVE

Racial inequities are pervasive throughout healthcare. We sought to assess if race and ethnicity are associated with emergency department (ED) point-of-care ultrasound (POCUS) usage compared with radiology-ordered ultrasounds as our primary outcome and a secondary outcome of nurse-driven ultrasound ordering for early pregnancy.

METHODS

In this retrospective, observational cohort study between June 2015 and December 2021, we assessed ED physician POCUS use in relation to Radiology (RADUS) ultrasound for first trimester pregnancy with race and ethnicity as our primary variable. A secondary outcome assessed if race and ethnicity impacted nursing-driven ultrasound ordering. Univariate and multivariate logistic regression models were created to test relationships and interactions with clinical variables. Given the overlap of language and race/ethnicity, a multivariate model with language as the primary variable was included.

RESULTS

No significant differences based on race and ethnicity were found for the selection of POCUS versus RADUS (n = 2337: χ2 = 5.25, p = 0.155). For the secondary outcome, 1694 of 7662 (22.1 %) patients received a nurse ultrasound order. Hispanic/Latino patients had increased odds of receiving a nurse-driven order (aOR 1.25, 95 % CI 1.009-1.549) and those of other or unknown race/ethnicity (aOR 1.357, 95 %CI 1.043-1.765) when language was excluded; in addition to Non-English speakers (OR 1.213, 95 %CI 1.072-1.372) with race excluded.

CONCLUSIONS

For first trimester pregnancy complaints, race and ethnicity did not alter POCUS usage by ED physicians. Secondary analysis showed race and ethnicity differences in nurse-driven orders, however collinearity between the primary outcome and language makes it difficult to assess the magnitude of these factors.

Contribution of point-of-care ultrasound in the prehospital management of patients with non-trauma acute dyspnea: a systematic review and meta-analysis

Acute dyspnea is a common symptom whose management is challenging in prehospital settings. Point-of-care ultrasound (POCUS) is increasingly accessible because of device miniaturization. To assess the contribution of POCUS in the prehospital management of patients with acute nontraumatic dyspnea, we performed a systematic review on nontrauma patients of any age managed in the prehospital setting for acute dyspnea and receiving a POCUS examination. We searched seven databases and gray literature for English-language studies published from January 1995 to November 2023. Two independent reviewers completed the study selection, data extraction, and risk of bias assessment. The primary outcome was the assessment of the contribution of POCUS to feasibility, diagnostic, therapeutic, prognosis, patient referral, and transport vector modification. Twenty-three studies were included. The risk of bias assessment identified 3 intermediate-risk, 18 serious-risk, and 2 critical-risk studies. Three studies reported moderate to excellent feasibility for lung POCUS, and three studies reported poor to mediocre feasibility for cardiac POCUS. The median duration of the POCUS examination was less than 5 minutes (six studies). POCUS improved diagnostic identification (seven studies). The diagnostic accuracy of POCUS was excellent for pneumothorax (sensitivity = 100%, specificity = 100%, two studies), very good for acute heart failure (sensitivity = 71-100%, specificity = 72-95%, eight studies), good for pneumonia (sensitivity = 88%, specificity = 59%, one study), and moderate for pleural effusion (sensitivity = 26-53%, specificity = 83-92%, two studies). Treatment was modified in 11 to 54% of the patients (seven studies). POCUS had no significant effect on patient prognosis (two studies). POCUS contributed to patient referrals and transport vectors in 51% (four studies) and 25% (three studies) of patients, respectively. The evidence supports the use of POCUS for managing acute nontraumatic dyspnea in the prehospital setting in terms of feasibility, overall diagnostic contribution, and, particularly, lung ultrasound for acute heart failure diagnosis. Moreover, POCUS seems to have a therapeutic contribution. There is not enough evidence supporting the use of POCUS for pneumonia, pleural effusion, pneumothorax, chronic obstructive pulmonary disease, or asthma exacerbation diagnosis, nor does it support prognostic, patient referral, and transport vector contribution. A high level of evidence is lacking and needed.

POCUS literature primer: key papers on aorta and deep vein thrombosis POCUS

OBJECTIVE

The objective of this study is to identify the top five most influential papers published on the use of aorta point of care ultrasound (POCUS) and deep vein thrombosis (DVT) POCUS in adult patients.

METHODS

A 15-member expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. The members of the expert panel all have ultrasound fellowship training (or equivalent), are active in POCUS research, and provide POCUS leadership locally and nationally. The panel used a modified Delphi process of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers on aorta POCUS and DVT POCUS.

RESULTS

All panel members participated in all three rounds of this modified Delphi process. The panel initially nominated 33 relevant papers on aorta POCUS and 33 relevant papers on DVT POCUS. With the completion of round two, there were 11 candidate papers for aorta POCUS and 14 candidate papers for DVT POCUS. After meeting at the CAEP 2024 annual conference to discuss these papers and to build consensus, the panel ultimately identified the top five most influential papers on aorta POCUS and DVT POCUS after the completion of round three. Included papers focused on the diagnostic test characteristics of POCUS for the workup of suspected abdominal aortic aneurysm and DVT, as well as the clinical impact of POCUS on time to diagnosis and time to disposition in emergency settings.

CONCLUSION

This POCUS Literature Primer has generated a top-five list of the most influential papers on aorta POCUS and DVT POCUS. The papers in these lists can be considered core reading for all trainees and clinicians using these POCUS applications in their practice and serve as a foundation for future POCUS research.

Influence of Clinical Context on Emergency Medicine Residents' Interpretation of Gallbladder Ultrasound Images: A Pilot Analysis

INTRODUCTION

Clinical ultrasound is an essential tool for emergency medicine practitioners. It is particularly useful for evaluating abdominal pain to detect the presence of gallstones or to identify other signs compatible with the diagnosis of biliary colic or cholecystitis. Although these signs are well-defined in the literature, the influence of clinical context on ultrasound interpretation has not yet been studied. The primary objective of this study is to evaluate the impact of clinical context on emergency medicine residents' interpretation of clinical ultrasound images of normal and pathological gallbladders.

MATERIALS AND METHODS

This prospective observational pilot study was conducted from May to September 2023 with emergency medicine residents from three Belgian universities. Participants watched a 45-min tutorial video on clinical gallbladder ultrasound and then completed a multiple-choice questionnaire consisting of 40 dynamic ultrasound loop images, 20 without clinical context and the same 20 images with written descriptions of the clinical context. Paired Student's t-test was performed to compare diagnostic performances with and without clinical context.

RESULTS

Overall, 23 participants completed the study, with 920 ultrasound loops being analyzed. The inclusion of clinical context significantly improved the overall diagnostic performance and especially the diagnosis of acute cholecystitis (p = 0.0309 and p = 0.0164, respectively). The overall sensitivity and specificity without clinical context were 0.74 (95% CI, 0.69-0.79) and 0.82 (95% CI, 0.76-0.87) respectively, and 0.79 (95% CI, 0.74-0.84) and 0.84 (95% CI, 0.79-0.90) with clinical context. In the subgroup of acute cholecystitis, sensitivity and specificity without clinical context were 0.56 (95% CI, 0.44-0.67) and 0.97 (95% CI, 0.95-0.99) respectively, and 0.78 (95% CI, 0.68-0.88) and 0.97 (95% CI, 0.95-0.99) with clinical context.

CONCLUSION

The integration of clinical context appears to positively influence the interpretation of gallbladder ultrasound images, thereby enhancing diagnostic performance, especially sensitivity and particularly in the case of acute cholecystitis.

Emergency Medicine Faculty Utilization of Point-of-Care Ultrasound in the Clinical Setting

Introduction Point-of-care ultrasound (POCUS) curricula for emergency medicine residents and faculty are guided by emergency medicine societal ultrasound guidelines. These guidelines lack clinical data to support them and are mainly based on expert consensus recommendations. Data are needed to address critical gaps in the literature to identify which POCUS studies are most commonly utilized in the clinical setting to help guide guideline recommendations and POCUS curricular design. The primary aim of this study was to determine the most utilized POCUS modalities in the emergency department clinical setting. The findings of this study may be used to guide the curricular design of future POCUS trainings. Methods  This was a retrospective study evaluating all clinically indicated and billed POCUS studies performed and interpreted by faculty in the emergency department setting across 10 emergency departments over a three-year period in Indianapolis, Indina, USA. The number of exams and modalities were extracted from the POCUS workflow solution. The frequency and percentage of exams were calculated. Results A total of 5,324 POCUS examinations were performed. Cardiac, obstetric, soft tissue, and focused assessment with sonography in trauma (FAST) POCUS were the most billed modalities across all adult emergency departments regardless of academic or community setting. Although fewer data were available from the pediatric setting, we found that cardiac, soft tissue, FAST, and lung POCUS exams were the most utilized. Conclusion These data from a single healthcare system would suggest that emergency physician POCUS curricula should focus on cardiac, obstetric, soft tissue, FAST, and lung exams. More data are needed from the pediatric setting to determine which scans are most utilized.

Dobutamine-induced alterations in internal carotid artery blood flow and cerebral blood flow in healthy adults

PURPOSE

Dobutamine, a sympathomimetic agent, is widely used clinically, influencing cardiac output, heart rate (HR), and blood pressure (BP), which may impact cerebral blood flow (CBF), critical for brain metabolism. However, the effects of dobutamine on CBF and internal carotid artery (ICA) blood flow remain unclear, with contradictory reported in both clinical and animal studies. It is necessary to investigate the effects of dobutamine on cervical and cerebral hemodynamics. This study aimed to evaluate the effects of dobutamine infusion on ICA blood flow and CBF, explore their relationship, and identify factors influencing CBF to facilitate timely monitoring in clinical practice.

METHODS

Forty-eight healthy volunteers underwent physiological assessment, ICA ultrasound, and brain magnetic resonance imaging (MRI) data before and after the administration of dobutamine. Paired t and Wilcoxon signed-rank tests were used to analyze changes, while logistic regression explored associations between hemodynamic factors and CBF.

RESULTS

Dobutamine infusion significantly increased HR, respiration rate, systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure, while blood oxygen remained stable. Compared with those in the resting state, the peak systolic velocity (Vs), resistance index, pulsatility index, and systolic/diastolic ratio (S/D) increased, whereas end-diastolic velocity (Vd) decreased. ICA diameter and mean velocity showed no significant changes. CBF significantly decreased in the anterior and middle cerebral arteries. Logistic regression identified SBP, DBP, and S/D difference as key factors associated with CBF reduction.

CONCLUSIONS

Dobutamine altered ICA hemodynamics and reduced CBF in anterior and middle cerebral arteries. Real-time ICA ultrasound monitoring provides valuable guidance during clinical use.

Point-of-Care Ultrasound Infrastructure

Point-of-care ultrasound (POCUS) infrastructure is the underpinning of a well integrated POCUS program. In order to achieve its full potential and fully integrate into the health care system, a POCUS program requires a robust and resilient infrastructure. The essential components of POCUS infrastructure are hardware, software, and an informed, well-integrated governance structure. This infrastructure can be leveraged for clinical decision-making, education, research, credentialing, documentation, health record integration as well as quality assurance and improvement.

Review of Point-of-Care Diaphragmatic Ultrasound in Emergency Medicine: Background, Techniques, Achieving Competency, Research, and Recommendations

ABSTRACT

The diaphragm is the major muscle of inspiration accounting for approximately 70% of the inspired tidal volume. Point-of-care diaphragmatic ultrasound offers the ability to quantitatively assess diaphragmatic function, perform serial evaluations over time, and visualize structures above and below the diaphragm. Although interest in point-of-care ultrasound (POCUS) of the diaphragm is developing in the emergency medicine, assessment of the diaphragm and its function is not recognized as a core application by national organizations or expert guidelines. As a result, it is infrequently performed, and its potential value in research or clinical practice may not be fully appreciated. The purpose of this review is to describe the developmental aspects of the diaphragm as it pertains to POCUS, discuss the POCUS techniques for evaluating diaphragmatic function, address competency acquisition in this POCUS application, summarize relevant research in the ED, and provide a summary of recommendations for further research and clinical utilization of POCUS in diaphragm evaluation.

Rare Cause of Pediatric Abdominal Pain Diagnosed on Point of Care Ultrasound (POCUS)

An 11-year-old postmenarchal female presented to the pediatric emergency department (ED) with 2 days of periumbilical and right lower abdominal pain. Radiology-performed ultrasound (RADUS) did not visualize the appendix, and there was a plan for surgical consultation to decide between serial abdominal exams versus computed tomography (CT) scan. While awaiting consultation and to help further narrow the differential diagnosis, the emergency provider performed a point of care ultrasound (POCUS) of the urinary tract. This revealed several anomalies including a solitary left kidney with hydronephrosis, and a well-circumscribed, fluid-filled structure with mixed echogenicity posterior to the bladder and inferior to the uterus. Given these findings on POCUS, further imaging was pursued, including a RADUS of the pelvis followed by a magnetic resonance imaging (MRI) of the abdomen. Further imaging ultimately diagnosed a bicornuate uterus, septate vagina with hematocolpos and solitary left kidney consistent with Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) syndrome. This case is an illustration of how POCUS is an invaluable tool to narrow the differential diagnosis and guide advanced imaging or consultation for both common and rare causes of pediatric abdominal pain.

Ultrasound Administration and Reimbursement

One cannot successfully employ point-of-care ultrasound (POCUS) without a process to provide support and guidance. POCUS administration is a multifaceted topic that demands the utmost attention from those responsible for program implementation and long-term execution. This article delves into POCUS administration and is meant to serve as a guide for the practitioner seeking to start, maintain, or augment their POCUS program.

Common Ultrasound-Guided Procedures

Ultrasound guidance is fundamental to procedural safety and success. For many emergency department (ED) procedures, the use of ultrasound improves first-pass success rate, time-to-completion, and complication rate when compared with traditional landmark-based techniques. Once learned, the general principles of ultrasound guidance may be adapted across a broad range of bedside procedures.

Clinical Ultrasound in Obstetrics and Gynecology

Point-of-care ultrasound is a useful tool in the evaluation of women with pelvic complaints in the emergency department. Transabdominal and transvaginal approaches may be employed to assess a variety of obstetric or gynecologic pathologies.

Cardiac Point-Of-Care Ultrasound: An Emergency Medicine Review

Cardiac point-of-care ultrasound (POCUS) can make critical diagnoses and monitor the response to interventions. In contrast with consultative echocardiography, cardiac POCUS serves to answer a specific clinical question. This imaging modality can be used to evaluate for left ventricular systolic and diastolic dysfunction, pericardial effusion and tamponade, acute and chronic right ventricular dysfunction, valvular dysfunction, and cardiac activity in cardiac arrest.

POCUS literature primer: key papers on cardiac and lung POCUS

OBJECTIVE

Although point of care ultrasound (POCUS) use has become prevalent in medicine, clinicians may not be familiar with the evidence supporting its utility in patient care. The objective of this study is to identify the top five most influential papers published on the use of cardiac POCUS and lung POCUS in adult patients.

METHODS

A 14-member expert panel from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative used a modified Delphi process. Panel members are ultrasound fellowship trained or equivalent, are engaged in POCUS scholarship, and are leaders in POCUS locally and nationally in Canada. The modified Delphi process consisted of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers on cardiac POCUS and lung POCUS.

RESULTS

A total of 66 relevant papers on cardiac POCUS and 68 relevant papers on lung POCUS were nominated by the panel. There was 100% participation by the panel members in all three rounds of the modified Delphi process. At the end of this process, we identified the top five most influential papers on cardiac POCUS and lung POCUS. Papers include studies supporting the use of POCUS for accurately assessing left ventricular systolic function, diagnosing pericardial effusion, clarifying its test characteristics for pulmonary embolism, identifying pulmonary edema and pneumonia, as well as consensus statements on the use of cardiac and lung POCUS in clinical practice.

CONCLUSION

We have created a list of the top five influential papers on cardiac POCUS and lung POCUS as an evidence-based resource for trainees, clinicians, and researchers. This will help trainees and clinicians better understand how to use POCUS when scanning the heart and lungs, and it will also help researchers better understand where to direct their scholarly efforts with future research.

Current trends in emergency airway management: a clinical review

Airway management is a fundamental and complex process that involves a sequence of integrated tasks. Situations requiring emergency airway management may occur in the emergency department, intensive care units, and various other clinical spaces. A variety of challenges can arise during emergency airway preparation, intubation, and postintubation, which may result in significant complications for patients. Therefore, many countries are establishing step-by-step systemization and detailed guidelines and/or updating their content based on the latest research. This clinical review introduces the current trends in emergency airway management, such as emergency airway management algorithms, comparison of video and direct laryngoscopy, rapid sequence intubation, pediatric airway management, prehospital airway management, surgical airway management, and airway management education.

Revolutionizing Bladder Health: Artificial-Intelligence-Powered Automatic Measurement of Bladder Volume Using Two-Dimensional Ultrasound

INTRODUCTION

Measuring elevated post-void residual volume is important for diagnosing urinary outflow tract obstruction and cauda equina syndrome. Catheter placement is exact but painful, invasive, and may cause infection, whereas an ultrasound is accurate, painless, and safe.

AIM

The purpose of this single-center study is to evaluate the accuracy of a module for artificial-intelligence (AI)-based fully automated bladder volume (BV) prospective measurement using two-dimensional ultrasound images, as compared with manual measurement by expert sonographers.

METHODS

Pairs of transverse and longitudinal bladder images were obtained from patients evaluated in an urgent care clinic. The scans were prospectively analyzed by the automated module using the prolate ellipsoid method. The same examinations were manually measured by a blinded expert sonographer. The two methods were compared using the Pearson correlation, kappa coefficients, and the Bland-Altman method.

RESULTS

A total of 111 pairs of transverse and longitudinal views were included. A very strong correlation was found between the manual BV measurements and the AI-based module with r = 0.97 [95% CI: 0.96-0.98]. The specificity and sensitivity for the diagnosis of an elevated post-void residual volume using a threshold ≥200 mL were 1.00 and 0.82, respectively. An almost-perfect agreement between manual and automated methods was obtained (kappa = 0.85). Perfect reproducibility was found for both inter- and intra-observer agreements.

CONCLUSION

This AI-based module provides an accurate automated measurement of the BV based on ultrasound images. This novel method demonstrates a very strong correlation with the gold standard, making it a potentially valuable decision-support tool for non-experts in acute settings.

Pediatric ultrasound practice in Italy: an exploratory survey

BACKGROUND

The aim of this exploratory survey is to describe the current state of US (ultrasound) technique across different pediatric settings nationwide.

METHODS

A questionnaire was emailed to all members of the Italian Society of Pediatrics, including pediatric residents. The survey was open from December 2021 to March 2022.

RESULTS

There were 1098 respondents. Seven hundred and seven pediatricians (84.1%) reported any use of US, while 51 (44.3%) residents denied it. The majority of participants (n = 956, 87.1%) reported to have a US machine available within the department, mostly cart-based (n = 516, 66.9%) and provided from 1 to 5 years prior to the survey (n = 330, 42.8%). Lung and neonatal cerebral regions were the most frequently scanned (n = 289, 18.7% and n = 218, 14.1%, respectively). The suspicion of pneumonia or respiratory distress represented the main reasons for performing US in emergency room (n = 390, 78% and n = 330, 66%, respectively). The majority of family pediatricians reported to scan lung and kidney/urinary tract regions (n = 30, 16.9%, and n = 23,12.9%, respectively). Regarding US training, the majority of respondents (n = 358, 34.6%) declared an experience-based education, with a deficient certification enabling the use of US in 71.6% (n = 552) of cases. The most common barriers included the lack of a well-defined training program (n = 627, 57.1%), unavailability of the US machine (n = 196, 17.9%) and legal responsibility concern (n = 175, 15.9%).

CONCLUSIONS

Despite the growing interest on pediatric US nationally, significant barriers still limit widespread adoption. These obstacles may be addressed through the dissemination of a specific US education plan and providing additional resources.

Incorporating implementation science principles into curricular design

Implementation science (IS) is an approach focused on increasing the application of evidence-based health interventions into practice, through purposive and thoughtful planning to maximize uptake, scalability, and sustainability. Many of these principles can be readily applied to medical education, to help augment traditional approaches to curriculum design. In this paper, we summarize key components of IS with an emphasis on application to the medical educator.

Best Practices for Point of Care Ultrasound: An Interdisciplinary Expert Consensus

Despite the growing use of point of care ultrasound (POCUS) in contemporary medical practice and the existence of clinical guidelines addressing its specific applications, there remains a lack of standardization and agreement on optimal practices for several areas of POCUS use. The Society of Point of Care Ultrasound (SPOCUS) formed a working group in 2022 to establish a set of recommended best practices for POCUS, applicable to clinicians regardless of their training, specialty, resource setting, or scope of practice. Using a three-round modified Delphi process, a multi-disciplinary panel of 22 POCUS experts based in the United States reached consensus on 57 statements in domains including: (1) The definition and clinical role of POCUS; (2) Training pathways; (3) Credentialing; (4) Cleaning and maintenance of POCUS devices; (5) Consent and education; (6) Security, storage, and sharing of POCUS studies; (7) Uploading, archiving, and reviewing POCUS studies; and (8) Documenting POCUS studies. The consensus statements are provided here. While not intended to establish a standard of care or supersede more targeted guidelines, this document may serve as a useful baseline to guide clinicians, leaders, and systems considering initiation or enhancement of POCUS programs.

Blood or Fat? Differentiating Hemopericardium versus Epicardial Fat Using Focused Cardiac Ultrasound

Basic point-of-care ultrasound of the heart-also known as Focused Cardiac Ultrasound (FoCUS)-has emerged as a powerful bedside tool to narrow the differential diagnosis of causes of hypotension. The list of causes of hypotension that a FoCUS provider is expected to be able to recognize includes a compressive pericardial effusion due to hemopericardium (blood in the pericardial sac). But hemopericardium can be difficult to distinguish from a more common condition that is not immediately life-threatening: epicardial fat. This paper reviews illustrative images of both epicardial fat and hemopericardium to provide practice guidance to the FoCUS user on how to differentiate these two phenomena.

Diagnostic performance of ultrasound in acute cholecystitis: a systematic review and meta-analysis

BACKGROUND

An updated overview of ultrasound (US) for diagnosis of acute cholecystitis (AC) remains lacking. This systematic review was conducted to evaluate the diagnostic performance of US for AC.

METHODS

A systematic review was conducted following PRISMA guidelines. We meticulously screened articles from MEDLINE, Embase, and the Cochrane Library, spanning from inception to August 2023. We employed the search strategy combining the keywords "bedside US", "emergency US" or "point-of-care US" with "AC". Two reviewers independently screened the titles and abstracts of the retrieved articles to identify suitable studies. The inclusion criteria encompassed articles investigating the diagnostic performance of US for AC. Data regarding diagnostic performance, sonographers, and sonographic findings including the presence of gallstone, gallbladder (GB) wall thickness, peri-GB fluid, or sonographic Murphy sign were extracted, and a meta-analysis was executed. Case reports, editorials, and review articles were excluded, as well as studies focused on acalculous cholecystitis. The study quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.

RESULTS

Forty studies with 8,652 patients were included. The majority of studies had a low risk of bias and applicability concerns. US had a pooled sensitivity of 71% (95% CI, 69-72%), a specificity of 85% (95% CI, 84-86%), and an accuracy of 0.83 (95% CI, 0.82-0.83) for the diagnosis of AC. The pooled sensitivity and specificity were 71% (95% CI, 67-74%) and 92% (95% CI, 90-93%) performed by emergency physicians (EPs), 79% (95% CI, 71-85%) and 76% (95% CI, 69-81%) performed by surgeons, and 68% (95% CI 66-71%) and 87% (95% CI, 86-88%) performed by radiologists, respectively. There were no statistically significant differences among the three groups.

CONCLUSION

US is a good imaging modality for the diagnosis of AC. EP-performed US has a similar diagnostic performance to radiologist-performed US. Further investigations would be needed to investigate the impact of US on expediting the management process and improving patient-centered outcomes.