ACEP emergency ultrasound guidelines–2001

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.

Deficiency workflow: Utilizing electronic medical records to improve compliance with point-of-care ultrasound documentation

BACKGROUND

Point-of-care ultrasound (POCUS) is a common modality utilized in emergency departments (EDs). Image acquisition and storage workflows have significantly improved. Saving POCUS images is considered standard of care. However, documentation compliance is a struggle for clinicians in the chaotic ED environment. We sought to implement a simple electronic medical record (EMR) deficiency workflow to improve capture of POCUS documentation and billing in a large healthcare setting.

METHODS

A retrospective review of all POCUS studies across 12 EDs was performed from January 1 to December 31, 2023. All EDs utilized the same EMR with standardized workflow. Clinicians were recommended to complete charting within 48 h of patient disposition. A POCUS deficiency workflow was implemented on June 1, 2023 to improve compliance. Deficiency workflow was defined as automated in-basket messaging that appeared after POCUS order entry. Deficiency remained in the clinicians in-basket until procedure note was completed. We compared POCUS chart deficiencies for lack of procedural documentation. Descriptive statistics were performed.

RESULTS

5013 POCUS were reviewed during the study period, 42 % before and 58 % after implementation. There was a 3.0 % absolute reduction (CI 2.01 %, 3.97 %) in procedure note deficiency from the pre-intervention to post-intervention period, 4.44 %. to 1.45 %.

CONCLUSION

A POCUS deficiency workflow improved documentation across our healthcare system. This directly improved billing of POCUS studies and decreased late chart notifications. This workflow can be implemented in any medical specialty that utilizes POCUS. We recommend large healthcare systems investigate similar workflows to improve documentation and billing of POCUS exams.

Sono-starters: A qualitative study of pioneers in the field of point-of-care ultrasound

Objectives

Point-of-care ultrasound (POCUS) within emergency medicine (EM) was a new field that has since developed into a robust discipline through the efforts of early EM POCUS pioneers. This study explored the experiences that led to POCUS pioneers' success. These data can inform emerging fields of study including non-EM specialties adopting POCUS as well as other new subspecialties within medicine.

Methods

This was a qualitative study using semistructured interviews with physician pioneers in the field of EM POCUS. EM POCUS pioneers were defined as early key contributors to the field of EM POCUS and were identified using combined author networks and purposive, stratified sampling with a snowball sampling technique. A thematic analysis of interviews was performed using a modified grounded theory approach with a constructivist-interpretivist paradigm.

Results

Twelve physicians were interviewed in this study. We identified four major themes: career motivators, barriers encountered, promoters of success, and advancement of the field. Career motivators included the need for representation and the ability to impact a new and growing field. Barriers encountered included discouragement by other colleagues, political battles, lack of funding, and rudimentary technology. Participants felt their career success was attributed to guidance from mentors, demonstration of initiative, work ethic, and skills in active listening. Participants felt the field advanced through the creation of national organizations, publication of training and credentialing guidelines, generation of research, and investment into the next generation of POCUS leaders.

Conclusions

This study identified several key themes in EM POCUS pioneers' careers including motivators, barriers, and methods used to overcome obstacles. Based on these data, we recommend a comprehensive set of strategies to support the advancement of an emerging field. These include early content exposure, mentorship, funding, research and industry collaboration, diversity, national organization involvement, and investment into future leaders.

The development of point-of-care ultrasound (POCUS): Worldwide contributions and publication trends

PURPOSE

Point-of-care ultrasound (POCUS) concept is widely used in both emergency medicine (EM) and intensive care medicine (ICM). This study aimed to analyze the scientific articles on POCUS published by statistical methods and to evaluate the subject holistically.

METHODS

This study is bibliographical, descriptive, and analytical in nature. POCUS-related publications published were downloaded from the Web of Science (WoS) database and analyzed using statistical methods. Network visualization maps were used to identify trending topics.

RESULTS

The literature search revealed 5714 publications on POCUS in the WoS database. According to the WoS categorization of publications, the most common categories were emergency medicine (1751; 30.6%). The topics studied in recent years were deep learning, artificial intelligence, COVID-19, acute kidney injury, heart failure, and telemedicine.

CONCLUSION

This study on POCUS, we summarized 5714 publications published. According to our results, the trending topics in POCUS research in recent years include deep learning, artificial intelligence, COVID-19, acute kidney injury, heart failure and telemedicine. Our study can be a valuable resource for clinicians and scientists who are working on POCUS or will be working on POCUS in the future.

Point-of-Care Ultrasound-History, Current and Evolving Clinical Concepts in Emergency Medicine

Point-of-care ultrasound (PoCUS) has become an indispensable standard in emergency medicine. Emergency medicine ultrasound (EMUS) is the application of bedside PoCUS by the attending emergency physician to assist in the diagnosis and management of many time-sensitive health emergencies. In many ways, using PoCUS is not only the mere application of technology, but also a fusion of already existing examiner skills and technology in the context of a patient encounter. EMUS practice can be defined using distinct anatomy-based applications. The type of applications and their complexity usually depend on local needs and resources, and practice patterns can vary significantly among regions, countries, or even continents. A different approach suggests defining EMUS in categories such as resuscitative, diagnostic, procedural guidance, symptom- or sign-based, and therapeutic. Because EMUS is practiced in a constantly evolving emergency medical setting where no two patient encounters are identical, the concept of EMUS should also be practiced in a fluid, constantly adapting manner driven by the physician treating the patient. Many recent advances in ultrasound technology have received little or no attention from the EMUS community, and several important technical advances and research findings have not been translated into routine clinical practice. The authors believe that four main areas have great potential for the future growth and development of EMUS and are worth integrating: 1. In recent years, many articles have been published on novel ultrasound applications. Only a small percentage has found its way into routine use. We will discuss two important examples: trauma ultrasound that goes beyond e-FAST and EMUS lung ultrasound for suspected pulmonary embolism. 2. The more ultrasound equipment becomes financially affordable; the more ultrasound should be incorporated into the physical examination. This merging and possibly even replacement of aspects of the classical physical exam by technology will likely outperform the isolated use of stethoscope, percussion, and auscultation. 3. The knowledge of pathophysiological processes in acute illness and ultrasound findings should be merged in clinical practice. The translation of this knowledge into practical concepts will allow us to better manage many presentations, such as hypotension or the dyspnea of unclear etiology. 4. Technical innovations such as elastography; CEUS; highly sensitive color Doppler such as M-flow, vector flow, or other novel technology; artificial intelligence; cloud-based POCUS functions; and augmented reality devices such as smart glasses should become standard in emergencies over time.

The effect of e-learning on point-of-care ultrasound education in novices

BACKGROUND

Current studies assessed the learning efficacy of e-learning in ultrasound (US) training using questionnaires, or simulation in well-controlled conditions. This study investigates the effect of e-learning on the clinical US performance of the first postgraduate year (PGY-1) residents.

METHODS

In this prospective observational study, we enrolled PGY-1 and second postgraduate year (PGY-2) residents. The e-learning was introduced on the first day and each PGY-1 was authorized to access the e-learning platform. The point-of-care ultrasound (PoCUS) curriculum for the focused assessment of sonography for trauma (FAST) was conducted on the 7^th day for PGY-1 and the objective structured clinical examination (OSCE) followed. The PGY-2 received bedside one-to-one random learning before the study and did not have the authorization to access the e-learning. The FAST examinations performed by the PGY-1 and PGY-2 were collected on the 30th day. The clinical FAST performance was assessed by the instructor not involved in the curriculum and blinded to the use of e-learning, including numbers, image quality, and diagnostic accuracy between PGY-1 e-learning users, non-users, and the PGY-2.

RESULTS

One hundred and seventy PGY-1 with 736 FAST examinations and 53 PGY-2 residents with 134 examinations were included. Seventy PGY-1 used e-learning with a median time spent of 13.2 mins (IQR, 6.5-21.1 mins) at the first access. The PGY-2 had more PoCUS experience than the PGY-1, however, the 70 e-learning users performed more FAST examinations than the PGY-2 (median [IQR], 4 [2-6] vs. 2 [1-3], p = 0.0004) and had better image quality than the PGY-2 (3 [3-3.2] vs. 3 [2.7-3], p = 0.044). There were no significant differences in the diagnostic accuracy between the PGY-1 and PGY-2.

CONCLUSIONS

E-learning has a positive effect on US learning. The PGY-1 users had comparable performance with the PGY-2 and even better image acquisition although the PGY-2 had more PoCUS experience.

TRIAL REGISTRATION

NCT03738033 at ClinicalTrials.gov.

Evaluation of remote radiologist-interpreted point-of-care ultrasound for suspected dengue patients in a primary health care facility in Colombia

BACKGROUND

Early identification of plasma leakage may guide treatment decisions in dengue patients. This study evaluated the value of point-of-care ultrasound (POCUS) to detect plasma leakage and predict hospitalization or referral to a higher level of care in suspected dengue patients under routine conditions at a primary care facility in Colombia.

METHODS

We conducted a cohort study between April 2019 and March 2020 in a primary care hospital in Cali, Colombia. We prospectively included and followed 178 patients who were at least 2 years old with fever of less than 10 days and clinician-suspected dengue. A trained general practitioner performed a standardized POCUS protocol. Images were quality-rated and overread by an expert radiologist, and her results and those of the general practitioner were compared using the Kappa index. Logistic regression was used to identify factors associated with plasma leakage at enrollment and explore its prognostic value regarding hospital admission or referral to a higher level of care.

RESULTS

Half (49.6%) POCUS images were of suitable quality to be interpreted. The proportion of plasma leakage reported by the radiologist was 85.1% (95% CI: 78.6-90.2%) and 47.2% by the study physician (Kappa = 0.25, 95% CI: 0.15-0.35). The most frequent ultrasound findings were ascites (hepatorenal 87.2%, splenorenal 64%, or pelvic 21.8%) and gallbladder wall thickening (10.5%). Plasma leakage was higher in subjects with thrombocytopenia (aOR = 4, 95% CI: 1.3-12.1) and lower in patients 30-59 years old (aOR = 0.1, 95% CI: 0.0-0.4) than in those 18 years old or younger. POCUS evidence of plasma leakage (aOR = 8.2, 95% CI: 2.2-29.9), thrombocytopenia (aOR = 6.3, 95% CI: 2.4-16.0) and pulse pressure (aOR = 1.1, 95% CI: 1.07-1.2) were associated with hospital admission or referral to a higher level of care.

CONCLUSIONS

Ultrasound is useful to detect plasma leakage in primary care and, challenges remain to guarantee high-quality images and diagnostic accuracy, for which a standardized dengue POCUS protocol and training program is needed.

The Feasibility of Using Point-of-Care Ultrasound During Cardiac Arrest in Children: Rapid Apical Contractility Evaluation

INTRODUCTION

Resuscitation guidelines emphasize minimal interruption of compressions during cardiopulmonary resuscitation. Point-of-care ultrasound (POCUS) enables the clinician to visualize cardiac contractility and central artery pulsatility. The apical 4-chamber (A4), subxiphoid (SX), and femoral artery views may be used when defibrillator pads or active compressions preclude parasternal cardiac views. We hypothesized that clinicians can rapidly obtain interpretable POCUS views in healthy children from the A4, SX, and femoral positions.

METHODS

A prospective study of pediatric emergency medicine providers in an urban academic hospital was performed. Stable patients of 12 years or younger were scanned. Sonologists were each allotted 10 seconds to acquire A4, SX, and femoral views. Two attempts at each view were allowed. The primary outcome was whether cardiac and femoral artery scans were interpretable for contractility and pulsatility, respectively. The secondary outcome was whether cardiac scans were interpretable for effusion or right ventricular strain. A POCUS expert reviewed scans to confirm interpretability.

RESULTS

Twenty-two sonologists performed a total of 50 scans on 22 patients. A view that was interpretable for contractility was obtained on the first attempt in 86% of A4 and 94% of SX scans. A femoral view that was interpretable for pulsatility was obtained on the first attempt in 74% of scans. Expert review was concordant with sonologist interpretation.

CONCLUSIONS

Pediatric emergency medicine physicians can obtain interpretable cardiac and central artery views within 10 seconds most of the time. Point-of-care ultrasound has the potential to enhance care during pediatric resuscitation. Future studies on the impact of POCUS pulse checks in actual pediatric resuscitations should be performed.

Translating Guidelines into Practical Practice: Point-of-Care Ultrasound for Pediatric Critical Care Clinicians

Point-of-care ultrasound (POCUS) is now transitioning from an emerging technology to a standard of care for critically ill children. POCUS can provide immediate answers to clinical questions impacting management and outcomes within this fragile population. Recently published international guidelines specific to POCUS use in neonatal and pediatric critical care populations now complement previous Society of Critical Care Medicine guidelines. The authors review consensus statements within guidelines, identify important limitations to statements, and provide considerations for the successful implementation of POCUS in the pediatric critical care setting.

Point of Care Ultrasound (POCUS) Utilization and Barriers by Senior Emergency Medicine and Critical Care Residents at Two Teaching Referral Hospitals, Addis Ababa, Ethiopia

Background. POCUS has become an integral part of the practice of emergency medicine. POCUS is a highly focused, limited, goal-directed exam with the expressed purpose of answering selected questions used at the bedside for critically ill patients who are not stable. We aimed to assess POCUS utilization and barriers by senior-year emergency medicine and critical care residents at two tertiary academic and referral hospitals in Addis Ababa, Ethiopia. Methodology. A cross-sectional study was conducted from June 1 to August 30, 2022 in St Paul’s Hospital Millennium Medical College and Tikur Anbessa Specialized Hospital using an electronic survey of senior-year (second and third years) emergency medicine and critical care residents. Data were collected using Goggle form, exported to SPSS version 24, and then analyzed. Result. Seventy-six residents out of 78 (97.4%) responded to the online survey. The mean age was 29.9 years with an SD of 2.87. Fifty-six residents (73.7%) were male and 45 (59.2%) were year 2 residents. Sixty-one (76.3%) had previous POCUS training. Fifty residents (82.0%) received training from the classroom. Twenty-seven residents (35.5%) rated their current level of knowledge as good for sterile transducer techniques, 28 (36.8%) rated fair for their knobology, and 27 (35.5%) rated very good for their transducer selection knowledge. Thirty-two (42.1%) rated very good about their ability to interpret IVC. 26 (34.2%) responded that they had good ability to interpret FAST/EFAST. Forty-nine (64.5%) residents claimed lack of an ultrasound machine followed by 33 (43.4%) lack of organized curriculum were the main barriers to POCUS utilization. Forty-two (55.3%) residents preferred to complete face-to-face teaching, while 33 (43.4%) preferred blended learning both face-to-face and online. Conclusion. POCUS is performed by the majority of EMCC residents. The most frequent scans performed by residents were FAST, IVC, and lung scans. Lack of ultrasound machine and organized curriculum was the main barrier to US utilization. Availability of equipment, face-to-face training, and having an organized curriculum are recommended by residents to improve their skills in the future.

Pediatric Emergency Medicine Faculty Response to Point-of-Care Ultrasound Credentialing Curriculum

OBJECTIVES

As point-of-care ultrasound (POCUS) continues to evolve in pediatric emergency medicine (PEM), new protocols and curricula are being developed to help establish the standards of practice and delineate training requirements. New suggested guidelines continue to improve, but a national standard curriculum for training and credentialing PEM providers is still lacking. To understand the barriers and perception of curriculum implementation for PEM providers, we created an ultrasound program at our institution and observed attitudes and response to training.

METHODS

Fourteen PEM-fellowship-trained faculty with limited to no previous experience with POCUS underwent training within a 12-month time frame using a modified practice-based training that included didactics, knowledge assessment, and hands-on practice. As part of the curriculum, the faculty completed a 3-phase survey before, after, and 6 months after completion of the curriculum.

RESULTS

There was a 100%, 78.6%, and 71.4% response rate for the presurvey, postsurvey, and 6 months postsurvey, respectively. Lack of confidence with using POCUS went from 100% on the presurvey to 57% on the postsurvey and down to 30% on the 6th month postsurvey. All other barriers also decreased from precurriculum to postcurriculum, except for length of time to perform POCUS. Participants rated the curriculum highly, with a mean Likert score and standard error of the mean at 3.9 ± 0.73, respectively. The average rating for whether POCUS changed clinical practice was low (2.6 ± 1.34).

CONCLUSION

These results show that a simplified structured curriculum can improve perception of POCUS and decrease barriers to usage while helping to understand obstacles for implementation of POCUS among PEM-fellowship-trained faculty.

The Incremental Role of Multiorgan Point-of-Care Ultrasounds in the Emergency Setting

Point-of-care ultrasonography (POCUS) represents a goal-directed ultrasound examination performed by clinicians directly involved in patient healthcare. POCUS has been widely used in emergency departments, where US exams allow physicians to make quick diagnoses and to recognize early life-threatening conditions which require prompt interventions. Although initially meant for the real-time evaluation of cardiovascular and respiratory pathologies, its use has been extended to a wide range of clinical applications, such as screening for deep-vein thrombosis and trauma, abdominal ultrasonography of the right upper quadrant and appendix, and guidance for invasive procedures. Moreover, recently, bedside ultrasounds have been used to evaluate the fluid balance and to guide decongestive therapy in acutely decompensated heart failure. The aim of the present review was to discuss the most common applications of POCUS in the emergency setting.

Point-of-Care Ultrasound for Pulse Checks in Pediatric Cardiac Arrest: Two Illustrative Cases

ABSTRACT

Cardiac arrest is an infrequent but high-stakes scenario in pediatrics. Manual central pulse checks are unreliable. Point-of-care ultrasound is a noninvasive technique to visualize the heart and central vessels during resuscitation. We describe 2 cases in which point-of-care ultrasound helped aid management decisions in pediatric cardiac arrest.

Evaluation of a Novel Point-of-Care Ultrasound Curriculum for First-Year Pediatric Residents

OBJECTIVE

The aim of the study is to evaluate a novel point-of-care ultrasound (POCUS) educational curriculum for pediatric residents.

METHODS

The cohort study in graduate medical education was completed from January 2017 to March 2019. Postgraduate year 1 (PGY1) pediatric residents attended the educational curriculum that consisted of 3 half-day sessions over a 3-month period. Each session consisted of a lecture (introduction, extended focused assessment with sonography for trauma, soft tissue/musculoskeletal, cardiac, and resuscitative applications) followed by supervised hands-on scanning sessions. Group ratio was 3 learners to 1 machine/expert instructor. Main outcome measures included pre- and post-written test scores, as well as objective structured clinical examination (OSCE) scores.

RESULTS

Forty-nine PGY1 residents (78% women) completed the curriculum. The mean (SD) pretest score was 68% (8.5), and the mean posttest score was 83% (8.3) with a difference of 15 (95% confidence interval, 12.5-17.6; P < 0.001). Mean (SD) focused assessment with sonography for trauma OSCE score after the curriculum was 88.7% (11.9). The number of PGY1 pediatric residents that were comfortable performing POCUS examinations increased from pretraining to posttraining for soft tissue/musculoskeletal (14%-61%, P < 0.001), extended focused assessment with sonography for trauma (24%-90%, P < 0.001), and cardiac (18%-86%, P < 0.001). All participants found the curriculum useful, and 42 of 49 (86%) stated the curriculum increased their ability to acquire and interpret images.

CONCLUSIONS

Postgraduate year 1 pediatric residents learned the basics of POCUS through 3 brief educational sessions. The increase in posttest scores demonstrated improved POCUS knowledge, and the high OSCE score demonstrated their ability to acquire ultrasound images. Point-of-care ultrasound guidelines are needed for pediatric residency programs.

Training Ultrasound Image Classification Deep-Learning Algorithms for Pneumothorax Detection Using a Synthetic Tissue Phantom Apparatus

Ultrasound (US) imaging is a critical tool in emergency and military medicine because of its portability and immediate nature. However, proper image interpretation requires skill, limiting its utility in remote applications for conditions such as pneumothorax (PTX) which requires rapid intervention. Artificial intelligence has the potential to automate ultrasound image analysis for various pathophysiological conditions. Training models require large data sets and a means of troubleshooting in real-time for ultrasound integration deployment, and they also require large animal models or clinical testing. Here, we detail the development of a dynamic synthetic tissue phantom model for PTX and its use in training image classification algorithms. The model comprises a synthetic gelatin phantom cast in a custom 3D-printed rib mold and a lung mimicking phantom. When compared to PTX images acquired in swine, images from the phantom were similar in both PTX negative and positive mimicking scenarios. We then used a deep learning image classification algorithm, which we previously developed for shrapnel detection, to accurately predict the presence of PTX in swine images by only training on phantom image sets, highlighting the utility for a tissue phantom for AI applications.

Evaluation of diagnostic efficiency of bedside cardiac ultrasonography performed by emergency specialist

BACKGROUND

In emergency medicine, ultrasound is frequently used in the diagnostic and therapeutic procedures and evaluation of treatment of critically ill patients simultaneously, due to its bedside applicability, rapidness and inexpensive cost.

AIM

The competence of emergency physician in focused cardiac ultrasound evaluations and the success of diagnosing cardiac diseases were evaluated in a patient group presenting to the emergency department with complaints of non-traumatic chest pain and shortness of breath.

METHODS

We included patients with complaints of chest pain and shortness of breath and underwent cardiac ultrasound performed by emergency physician. Then, patients were evaluated by a cardiologist. The diagnoses made by the emergency physician were compared with the diagnoses made by the cardiologist.

RESULTS

A total of 303 patients were included. The diagnoses made by the emergency medicine specialist and cardiologist as a result of the evaluation were recorded as 56.7% vs 52.10% for acute coronary syndrome, 29.70% vs 31.60% for congestive heart failure, 3.6% vs 3.30% for pulmonary embolism, 2.1% vs 2.10% for hypertensive pulmonary edema, 1.9% vs 2.10% for pericarditis, and 0.60% vs 1.30% for aortic dissection.

CONCLUSION

It was determined that focused cardiac ultrasound performed by emergency physician was sufficient in terms of accuracy of findings and diagnosis, and played an important role in excluding or including fatal diagnoses and conditions. The success rates of emergency physician can be further increased with long-term and comprehensive training programs.

Making Artificial Intelligence Lemonade Out of Data Lemons: Adaptation of a Public Apical Echo Database for Creation of a Subxiphoid Visual Estimation Automatic Ejection Fraction Machine Learning Algorithm

OBJECTIVES

A paucity of point-of-care ultrasound (POCUS) databases limits machine learning (ML). Assess feasibility of training ML algorithms to visually estimate left ventricular ejection fraction (EF) from a subxiphoid (SX) window using only apical 4-chamber (A4C) images.

METHODS

Researchers used a long-short-term-memory algorithm for image analysis. Using the Stanford EchoNet-Dynamic database of 10,036 A4C videos with calculated exact EF, researchers tested 3 ML training permeations. First, training on unaltered Stanford A4C videos, then unaltered and 90° clockwise (CW) rotated videos and finally unaltered, 90° rotated and horizontally flipped videos. As a real-world test, we obtained 615 SX videos from Harbor-UCLA (HUCLA) with EF calculations in 5% ranges. Researchers performed 1000 randomizations of EF point estimation within HUCLA EF ranges to compensate for ML and HUCLA EF mismatch, obtaining a mean value for absolute error (MAE) comparison and performed Bland-Altman analyses.

RESULTS

The ML algorithm EF mean MAE was estimated at 23.0, with a range of 22.8-23.3 using unaltered A4C video, mean MAE was 16.7, with a range of 16.5-16.9 using unaltered and 90° CW rotated video, mean MAE was 16.6, with a range of 16.3-16.8 using unaltered, 90° CW rotated and horizontally flipped video training. Bland-Altman showed weakest agreement at 40-45% EF.

CONCLUSIONS

Researchers successfully adapted unrelated ultrasound window data to train a POCUS ML algorithm with fair MAE using data manipulation to simulate a different ultrasound examination. This may be important for future POCUS algorithm design to help overcome a paucity of POCUS databases.

Point-of-Care Ultrasonography as an Extension of the Physical Examination for Abdominal Pain in the Emergency Department: The Diagnosis of Small-Bowel Volvulus as a Rare Complication after Changing the Feeding Jejunostomy Tube

Point-of-care ultrasonography (POCUS) has become the most popular modality of testing for physicians in recent years and is used for improving the quality of care and increasing patient safety. However, POCUS is not always acceptable to all physicians. To address the benefits and importance of POCUS, numerous studies have examined the use of POCUS in clinical practice and even medical education. This article aims to highlight the effects of POCUS as an extension of the physical examination, and we present a case to address the reasons it should be performed. For a man experiencing abdominal pain immediately after his feeding jejunostomy tube was changed, there was high suspicion of small-bowel volvulus after a “whirlpool sign” was observed during the POCUS, whereby mesenteric vessels presented in a whirling or spiral shape. This impression was subsequently confirmed by computed tomography. Small-bowel volvulus is a rare complication of changing a feeding jejunostomy tube. The images submitted here add to the sparse evidence from the literature on the use of POCUS as an extension of the physical examination for evaluating abdominal pain. POCUS can be used after taking the patient’s history and conducting a physical examination. The observation of a whirlpool sign may indicate the presence of a volvulus that is life-threatening.

Performance of Pediatric Emergency Medicine Faculty After Point-of-Care Ultrasound Credentialing Implementation

OBJECTIVE

As point-of-care ultrasound (POCUS) continues to evolve, a national standardized curriculum for training and credentialing pediatric emergency medicine (PEM) physicians is still lacking. The goal of this study was to assess PEM faculty in performing and interpreting POCUS during implementation of a training curriculum.

METHODS

Sixteen full-time PEM faculty with either limited or no prior POCUS experience were trained to perform 4 ultrasound studies. Twelve of the 16 completed the training with a goal of credentialing within 12 months of implementation. For each faculty, we assessed competency by comparing precurriculum and postcurriculum test assessments and by evaluating quality of POCUS acquisition and accuracy of interpretation. We also monitored the amount of continuing medical education (CME) hours completed to ensure a minimum didactic component.

RESULTS

We found a significant improvement in POCUS competency comparing precurriculum to postcurriculum test assessments (55.4% vs 75.6%, P < 0.0002). One thousand two hundred seventy images were submitted over the course of the curriculum. Accuracy, sensitivity, and specificity were 98.23% (confidence interval [CI] = 97.18-98.97), 97.01% (CI = 92.53-99.81), and 98.43% (CI = 97.33-99.81), respectively. Faculty self-rating of image quality was significantly higher than expert reviewer rating of image quality (3.4 ± 0.86 vs 3.2 ± 0.56, P < 0.0001). We found no change in expert reviewer rating of image quality over time. Faculty completed a combined 232.5 CME hours (average, 17.4 ± 10.8), with the majority of hours coming from an institutional POCUS CME workshop.

CONCLUSIONS

These results show that a structured curriculum can improve PEM faculty POCUS competency.

Criteria, Processes, and Determination of Competence in Basic Critical Care Echocardiography Training: A Delphi Process Consensus Statement by the Learning Ultrasound in Critical Care (LUCC) Initiative

BACKGROUND

With the paucity of high-quality studies on longitudinal basic critical care echocardiography (BCCE) training, expert opinion guidelines have guided BCCE competence educational standards and processes. However, existing guidelines lack precise detail due to methodological flaws during guideline development.

RESEARCH QUESTIONS

To formulate methodologically robust guidelines on BCCE training using evidence and expert opinion, detailing specific criteria for every step, we conducted a modified Delphi process using the principles of the validated AGREE-II tool. Based on systematic reviews, the following domains were chosen: components of a longitudinal BCCE curriculum; pass-grade criteria for image-acquisition and image-interpretation; and formative/summative assessment and final competence processes.

STUDY DESIGN AND METHODS

Between April 2020 and May 2021, a total of 21 BCCE experts participated in four rounds. Rounds 1 and 2 used five web-based questionnaires, including branching-logic software for directed questions to individual panelists. In round 3 (videoconference), the panel finalized the recommendations by vote. During the journal peer-review process, Round 4 was conducted as Web-based questionnaires. Following each round, the agreement threshold for each item was determined as ≥ 80% for item inclusion and ≤ 30% for item exclusion.

RESULTS

Following rounds 1 and 2, agreement was reached on 62 of 114 items. To the 49 unresolved items, 12 additional items were added in round 3, with 56 reaching agreement and five items remaining unresolved. There was agreement that longitudinal BCCE training must include introductory training, mentored formative training, summative assessment for competence, and final cognitive assessment. Items requiring multiple rounds included two-dimensional views, Doppler, cardiac output, M-mode measurement, minimum scan numbers, and pass-grade criteria. Regarding objective criteria for image-acquisition and image-interpretation quality, the panel agreed on maintaining the same criteria for formative and summative assessment, to categorize BCCE findings as major vs minor and a standardized approach to errors, criteria for readiness for summative assessment, and supervisory options.

INTERPRETATION

In conclusion, this expert consensus statement presents comprehensive evidence-based recommendations on longitudinal BCCE training. However, these recommendations require prospective validation.

Advanced practice providers proficiency-based model of ultrasound training and practice in the ED

Competency in the application of point-of-care ultrasound (POCUS) has come to be an expected fundamental skill set for advanced practice providers (APPs) in the emergency department. Both American College of Emergency Physicians and the Society of Emergency Medicine Physician Assistants approve of and endorse POCUS use by APPs. However, clinical exposure to and practice of ultrasound in this setting is often variable and without structure. POCUS training must be evolved into a system where developed skills are compatible with clinical need and expectations of APPs. At our institution, we developed a formal, structured POCUS training program for emergency medicine (EM) APPs (including physician assistants and nurse practitioners) and evaluated its efficacy quantitatively by means of a proficiency index. This report examines the EM POCUS training most common to physician assistants and nurse practitioners before practicing at our institution and explores the components of our POCUS training program that have affected program development.

The P2Network-Advancing Pediatric Emergency Care With Point-of-Care Ultrasound

ABSTRACT

Over the last 2 decades, the use of point-of-care ultrasound (POCUS) in pediatric emergency medicine (PEM) has grown exponentially. In 2014, a group of PEM POCUS leaders met and formed the P2Network. The P2Network provides a platform to build collaborative relationships and share expertise among members from various countries and practice settings. It works with educators and researchers within and outside of the field to advance POCUS practice in PEM. As an organization, the P2Network promotes the evidence-based application of POCUS to facilitate and improve care in the PEM setting and addresses issues related to integration of the PEM POCUS practitioner in this nascent field. The P2Network is building and augmenting its infrastructure for PEM POCUS research and education and has already made some progress in the areas, with published manuscripts and ongoing clinical research studies under its sponsorship. Future goals include developing a PEM POCUS research agenda, formalizing teaching and assessment of PEM POCUS skills, and implementing multicenter research studies on potentially high impact applications.

The Current Status of Ultrasound Education in United States Medical Schools

OBJECTIVES

Ultrasound is used by nearly every medical specialty. Medical schools are integrating ultrasound education into their curriculum but studies show this to be inconsistent. The purpose of this study was to provide an updated description of ultrasound in the curricula of United States Accredited Medical Schools (USAMS).

METHODS

In 2019, USAMS curricular offices were contacted. Institutions were asked about the presence of ultrasound curriculum and for contact information for faculty involved with education. Schools reporting ultrasound curriculum were surveyed regarding details of their curriculum.

RESULTS

Two hundred USAMS were contacted with a response rate of 84%. Of 168 schools, 72.6% indicated they have an ultrasound curriculum. For schools with a curriculum, 79 (64.8%) completed our survey. The majority of survey respondents, 66 (83.5%), indicated having mandatory ultrasound. Ultrasound is primarily integrated into courses (73.8% in basic science courses, 66.2% in clinical skills courses, and 35.4% in clinical rotations). Emergency medicine physicians accounted for 54.7% of course directors. Ten or fewer faculty participate in education in 68.4% of schools and mostly as volunteers. Dedicated machines for education were reported by 78.5% of schools.

CONCLUSIONS

Compared to prior studies, this study had a higher response rate at 84%, and more schools reported ultrasound in their curricula. Emergency medicine represents the majority of leadership in ultrasound education. Despite increased integration of ultrasound into American medical school curricula, its instruction is still inconsistent.

Agreement of emergency physician-performed ultrasound versus RADiology-performed UltraSound for cholelithiasis or cholecystitis: a systematic review

Cholecystitis secondary to gallstone migration is the most common suspected diagnosis for right upper quadrant pain in emergency departments, with radiology-performed ultrasound (RADUS) being the main diagnostic tool. The primary aim of this review was to assess the ability of emergency physicians to perform emergency ultrasound (EUS) compared to RADUS to diagnose cholelithiasis and cholecystitis. A systematic search was performed using Embase, Central (Cochrane library), Web of Science, MEDLINE, Google Scholar, prospective trial registries, and OpenSIGLE databases as well as hand-search of articles. Two physicians independently selected the articles. Assessment of methodological quality was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Clinical and methodological heterogeneity were qualitatively reported and discussed. Seven prospective studies were selected involving a total of 1061 subjects undergoing EUS. The included studies all used RADUS as the reference standard and emergency physician-performed EUS as the index test. Included studies mostly reported diagnostic accuracy for cholelithiasis diagnosis whereas only one study mentioned diagnostic accuracy for cholecystitis. Clinical and methodological heterogeneity between included studies prevented a meta-analysis. This review shows there is good agreement between EUS and RADUS to assess the gallbladder for cholelithiasis and therefore supports its use by emergency physicians for that matter. Nevertheless, this work identified clinical and methodological heterogeneity along with a poor description EUS operators' experience. In the future, larger studies should include a larger population of EUS operators, specify their background, and compare EUS to the final diagnosis to evaluate performances for gallbladder diagnostic accuracy.

The Use of Point-of-Care Ultrasound (POCUS) in the Diagnosis of Deep Vein Thrombosis

Acute lower extremity proximal deep venous thrombosis (DVT) requires accurate diagnosis and treatment in order to prevent embolization and other complications. Point-of-care ultrasound (POCUS), a clinician performed, and clinician interpreted bedside ultrasound examination has been increasingly used for DVT evaluation mainly in the urgent and critical care setting, but also in the ambulatory clinics and the medical wards. Studies have demonstrated that POCUS has excellent diagnostic accuracy for acute proximal DVT when performed by well-trained users. However, there is significant heterogeneity among studies on the necessary extent of training and universally acceptable standardized education protocols are needed. In this review, we summarize the evidence that supports the use of POCUS to diagnose acute proximal DVT and focus on methodology and current technology, sensitivity and specificity, pre-test probability and the role of D-dimer, time and resources, education, limitations, and future directions.

Pulmonary thromboembolism with transthoracic ultrasound and computed tomography angiography

OBJECTIVE

The detection of pulmonary embolism in emergency department requires an urgent therapeutic and diagnostic attention. This study was performed to determine the accuracy and efficacy of ultrasound in the diagnosis of pulmonary embolism.

METHODS

In this study, 110 patients who referred to the emergency department with traumatic embolism symptoms were enrolled. All the patients underwent computed tomography (CT) angiography. Patients were divided into positive and negative outcomes according to the results of transthoracic ultrasonography and CT angiography.

RESULTS

In this study, 110 patients were enrolled, of whom 52 (47.3%) were male and 58 (52.7%) were female. Among the patients, 100 (90.9%) patients presented with dyspnea, whereas the frequency of pleural pain was 27% (24.5%). Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasound were 45.67%, 77.41%, 88.09%, and 35.29%, respectively. The positive outcomes from CT scan were significantly associated with gender, p = 0.005. The gender and transthoracic ultrasonography outcomes were also significantly correlated, p = 0.019, and the outcomes of ultrasound were significantly different from those of CT scan, p = 0.008.

CONCLUSION

Transthoracic ultrasonography may be used to diagnose pulmonary embolism as a technique in the emergency department, especially in patients who are unable to move due to the severity of the disease. However, further comparative studies are required in this aspect.

Video-assisted liver ultrasound training for non-radiologists: protocol and preliminary results

BACKGROUND

Ultrasound (US) is increasingly used as a bedside diagnostic tool, with training courses for non-radiologists being developed. However, the training time constraint is an important barrier for non-radiologists. We therefore created a short self-learning course for liver-US for non-radiologists.

AIM

Assess the participants' ability in identifying the organ structures during a liver-US.

METHOD

A short video-lecture on liver-US training and a portable guidebook for image acquisition were developed. Eighteen non-radiologist physicians studied the course and attended hands-on liver-US examinations to capture the assigned images and label the acquired organ/structures, which were evaluated by an expert radiologist.

RESULT

130 liver-US examinations were performed, 44 (33.8%) was cirrhosis. The overall of mean image acquisition score was 84.5 ± 9.7%. The mean score of the 1st examination was 75.2 ± 16.4. The mean score was >80% since the 2nd examination. The score was significant lower in cirrhotic cases as compared to non-cirrhotic cases (78.8 ± 17.3 vs. 88.3 ± 14.4, p = 0.001). The participants' year of study and experience in previous US training did not affect the image acquisition score.

CONCLUSION

The liver-US training course in a short video format with a portable guidebook is effective and relatively low time-consuming for teaching non-radiologists to perform bedside liver-US.

Operating bedside cardiac ultrasound program in emergency medicine residency: A retrospective observation study from the perspective of performance improvement

Background

Point-of-care ultrasound is one of useful diagnostic tools in emergency medicine practice and considerably depends on physician’s performance. This study was performed to evaluate performance improvements and favorable attitudes through structured cardiac ultrasound program for emergency medicine residents.

Methods

Retrospective observational study using the point-of-care ultrasound (PoCUS) database in one tertiary academic-teaching hospital emergency department has been conducted. Cardiac ultrasound education and rotation program has been implemented in emergency medicine residency program. Structured evaluation sheet for cardiac ultrasound and questionnaire toward PoCUS have been developed. An early-phase and a late-phase case were selected randomly for each participant. Two emergency medicine specialists with expertise in PoCUS evaluated saved images independently. We used a paired t-test to compare the performance score of each phase and the results of the questionnaire. Multivariable linear regression analysis was conducted to evaluate the association between the characteristics of participants and performance improvements.

Results

During the study period, a total of 1,652 bedside cardiac ultrasounds were administered. Forty-six examinations conducted by 23 emergency medicine residents were randomly selected for analysis. The performance score increased from 39.5 to 56.1 according to expert A and 45.3 to 62.9 according to expert B (p-value <0.01 for both). The average questionnaire score, which was analyzed for 17 participants, showed improvement from 18.9 to 20.7 (p-value <0.01). In multivariable linear regression analysis, younger age, higher early-phase score and higher confidence had a negative association with a greater improvement of performance, while the number of examinations had a positive association.

Conclusions

Bedside cardiac ultrasound performance and attitudes toward PoCUS have been improved through structured residency program.

Assessing Competence in Critical Care Echocardiography: Development and Initial Results of an Examination and Certification Processes

OBJECTIVES

To describe the development and initial results of an examination and certification process assessing competence in critical care echocardiography.

DESIGN

A test writing committee of content experts from eight professional societies invested in critical care echocardiography was convened, with the Executive Director representing the National Board of Echocardiography. Using an examination content outline, the writing committee was assigned topics relevant to their areas of expertise. The examination items underwent extensive review, editing, and discussion in several face-to-face meetings supervised by National Board of Medical Examiners editors and psychometricians. A separate certification committee was tasked with establishing criteria required to achieve National Board of Echocardiography certification in critical care echocardiography through detailed review of required supporting material submitted by candidates seeking to fulfill these criteria.

SETTING

The writing committee met twice a year in person at the National Board of Medical Examiner office in Philadelphia, PA.

SUBJECTS

Physicians enrolled in the examination of Special Competence in Critical Care Electrocardiography (CCEeXAM).

MEASUREMENTS AND MAIN RESULTS

A total of 524 physicians sat for the examination, and 426 (81.3%) achieved a passing score. Of the examinees, 41% were anesthesiology trained, 33.2% had pulmonary/critical care background, and the majority had graduated training within the 10 years (91.6%). Most candidates work full-time at an academic hospital (46.9%).

CONCLUSIONS

The CCEeXAM is designed to assess a knowledge base that is shared with echocardiologists in addition to that which is unique to critical care. The National Board of Echocardiography certification establishes that the physician has achieved the ability to independently perform and interpret critical care echocardiography at a standard recognized by critical care professional societies encompassing a wide spectrum of backgrounds. The interest shown and the success achieved on the CCEeXAM by practitioners of critical care echocardiography support the standards set by the National Board of Echocardiography for testamur status and certification in this imaging specialty area.

The expected frequency and amount of free peritoneal fluid estimated using the abdominal FAST-applied abdominal fluid scores in healthy adult and juvenile dogs

OBJECTIVE

To estimate the frequency and amount of free peritoneal fluid in juvenile and adult dogs using the abdominal focused assessment with sonography for trauma (AFAST) abdominal fluid scoring system.

DESIGN

Prospective case series.

ANIMALS

Healthy, privately owned juvenile and adult dogs.

PROCEDURES

Dogs undergoing routine surgical sterilization were evaluated at induction with AFAST and assigned measurements and fluid scores. A surgeon scored the degree of peritoneal fluid found during ovariohysterectomy.

RESULTS

Ninety-two dogs were enrolled (46 juveniles and 46 adults). Ninety-three percent and 52% were AFAST positive for peritoneal fluid, respectively. The AFAST-positive view frequency for right lateral recumbency in juveniles was diaphragmatico-hepatic (DH) 100%, spleno-renal (SR) 20%, cysto-colic (CC) 40%, and hepato-renal (HR) 20% versus adults, DH 60%, SR 20%, CC 0%, and HR 0%, respectively. The AFAST-positive view frequency for left lateral recumbency was DH 93%, SR 44%, CC 24%, and HR 12% in juveniles, and DH 50%, SR 3%, CC 3%, and HR 10% in adults. Overall abdominal fluid scores (AFS) in juvenilles were 0 (n = 3), 1 (n = 14), 2 (n = 22), 3 (n = 6), and 4 (n = 1); and in adults, scores were 0 (n = 22), 1 (n = 18), 2 (n = 6), and 3 and 4 (n = 0). The AFS differed between adults and juveniles (P < 0.001). Most dogs had maximum fluid dimensions ≤3 × 3 mm and width of fluid stripes ≤3 mm. The AFS was positively correlated to fluid amount observed during ovariohysterectomy with fair agreement (kappa = 0.233, P = 0.012).

CONCLUSIONS AND CLINICAL RELEVANCE

This study establishes the frequency and amount of free peritoneal fluid in healthy juvenile and adult dogs during AFAST. Maximum fluid pocket dimensions of ≤3 × 3 mm and fluid stripe widths of ≤3 mm in dogs with AFS 1 and 2 may be normal. The DH view was most frequently positive.

Mapping the Ultrasound Landscape to Define Point-of-Care Ultrasound and Diagnostic Ultrasound: A Proposal From the Society of Radiologists in Ultrasound and ACR Commission on Ultrasound

Current descriptions of ultrasound evaluations, including use of the term "point-of-care ultrasound" (POCUS), are imprecise because they are predicated on distinctions based on the device used to obtain images, the location where the images were obtained, the provider who obtained the images, or the focus of the examination. This is confusing because it does not account for more meaningful distinctions based on the setting, comprehensiveness, and completeness of the evaluation. In this article, the Society of Radiologists in Ultrasound and the members of the American College of Radiology Ultrasound Commission articulate a map of the ultrasound landscape that divides sonographic evaluations into four distinct categories on the basis of setting, comprehensiveness, and completeness. Details of this classification scheme are elaborated, including important clarifications regarding what ensures comprehensiveness and completeness. Practical implications of this framework for future research and reimbursement paradigms are highlighted.

The Use of Ultrasonography in the Emergency Department to Screen Patients After Blunt and Penetrating Trauma: A Clinical Update for the Advanced Practice Provider

Use of bedside ultrasonography to identify life-threatening injuries for patients with blunt and penetrating trauma is the standard of care in the emergency department. The "FAST" examination-focused assessment with sonography for trauma-ultrasound scan of the chest and abdomen allows clinicians to assess critical regions for free fluid without use of invasive procedures as quickly and as often as needed. In addition, ultrasonography has a high degree of sensitivity and specificity and is safe during pregnancy. For patients requiring evaluation of the pleura, the "eFAST" (or extended FAST) may be conducted, which may serve to locate pleural effusions, hemothorax, and pneumothorax. However, ultrasound quality is operator dependent and is recommended with other diagnostic measures to provide a complete clinical picture of trauma patients. Ongoing development of ultrasound competency among established clinicians and nurse practitioner students is vital to maintain diagnostic accuracy and ensure quality care for trauma patients in the emergency department.

Standardizing Point-of-Care Ultrasound Credentialing Across a Large Health Care System

BACKGROUND

Point-of-care ultrasound (POCUS) is becoming prevalent in the daily practice of bedside clinicians. As large health care systems standardize practice patterns, an organized approach of credentialing physicians in POCUS is paramount for quality and patient safety. This study describes a systematic approach of credentialing a diverse group of community emergency physicians (EPs) across a large health care system.

METHODS

A multimodal POCUS credentialing initiative for EPs was implemented across 11 hospitals between January 1, 2017, and July 1, 2018, that included (1) standardization of POCUS credentialing for all hospitals in the system, (2) tiered POCUS credentialing (Basic and Intermediate) for manageable attainment of goals with a required POCUS course, (3) automatic privileges for EPs who completed residency or practice-based POCUS pathways prior to employment, and (4) implementation of a practice-based pathway for competency assessment for noncredentialed physicians. Key factors for implementation included executive administrative support, dedicated POCUS courses, equipment standardization, a robust electronic medical record capable of logging training scans, and competency assessment for attainment of privileges.

RESULTS

Through the initiative, 78/106 EPs achieved Intermediate credentialing, and 28/106 were without POCUS privileges. All 28 noncredentialed EPs completed the required Basic POCUS course. Almost half (13/28) completed the initiative and became credentialed. From 2016 to 2018, the number of EPs performing scans increased from 52 to 112, and the number of POCUS scans increased from 928 to 3,007.

CONCLUSION

A standardized POCUS credentialing initiative can be successfully implemented in large health care systems. Other specialties can use this initiative to implement POCUS into their daily practice.

Diagnostic Yield and Accuracy of Bedside Echocardiography in the Emergency Department in Hemodynamically Stable Patients

OBJECTIVES

The goal of this study was to determine the diagnostic yield of focused cardiac ultrasound (FOCUS) in hemodynamically stable patients in the emergency department and secondarily to confirm the accuracy of these studies when compared to formal echocardiography.

METHODS

All hemodynamically stable adult patients who had an emergency physician-performed FOCUS examination completed over a 1-year period were identified using our electronic ultrasound database. Hemodynamic stability was defined as presenting systolic blood pressure higher than 90 mm Hg and not requiring any form of positive pressure ventilation.

RESULTS

There were 1198 FOCUS examinations performed: 976 in hemodynamically stable patients who were included in our analysis. Twenty-seven percent of patients had new findings, including 154 (16%) new diagnoses of reduced left ventricular function, 105 (11%) new pericardial effusions, and 44 (5%) new diagnoses of RV dilatation. Dyspnea as an indication for the FOCUS examination was the strongest predictor of a positive study. Of patients included, 28% underwent formal echocardiography within 2 days and were analyzed for concordance with regard to left ventricular function and the presence of pericardial effusion. Of 270 studies, 208 were accurate, and 62 were inaccurate, for raw agreement of 77% (κ = 0.53). When stratified by sonographer experience, there was no impact on accuracy.

CONCLUSIONS

Focused cardiac ultrasound in the emergency department for hemodynamically stable patients revealed new findings in 27% of studies, with a modest correlation with formal echocardiography. In stable patients, FOCUS has the potential for rapid diagnosis of cardiac disease, particularly in patients with dyspnea.

Torso computed tomography in blunt trauma patients with normal vital signs can be avoided using non-invasive tests and close clinical evaluation

PURPOSE

To determine whether torso CT can be avoided in patients who experience high-energy blunt trauma but have normal vital signs.

METHODS

High-energy blunt trauma patients with normal vital signs were retrieved retrospectively from our registry. We reviewed 1317 patients (1027 men and 290 women) and 761 (57.8%) fulfilled the inclusion criteria. All patients were initially evaluated at the emergency room (ER), with a set of tests, part of a specific protocol. Patients with at least one altered exam at initial examination or after six-hour observation received a torso CECT. Sensitivity, specificity, accuracy, positive (PPV) and negative predictive values (NPV), and likelihood ratio (LH) of the protocol were evaluated.

RESULTS

Of 761 patients, 354 (46.5%) received torso CECT because of the positive ER test, with 330 being true positive and 24 being false positive. The remaining 407 patients were negative at ER tests and did not receive torso CECT, showing a significantly (P < 0.001) lower Injury Severity Score (ISS). The positive and negative LH of the protocol to detect torso injuries were respectively 16.5 and 0.01 (overall accuracy of 0.96).

CONCLUSIONS

Torso CT can be avoided without adverse clinical outcomes in patients who experience high-energy blunt trauma, are hemodynamically stable, and have normal initial laboratory and imaging tests.

Risk Factors for Emergency Department Unscheduled Return Visits

Background and Objectives: This study aims to identify reasons for unscheduled return visits (URVs), and risk factors for diagnostic errors leading to URVs, with comparisons to data from a similar study conducted in the same institution 9 years ago. Materials and Methods: This retrospective study included adult patients who attended the emergency department (ED) of a tertiary hospital in Singapore between January 2014 and June 2014, with re-attendance within 72 h for the same or similar complaint. The primary outcome was wrong or delayed diagnoses. Secondary outcomes include admission to the ED observation unit or ward on return visit. Findings were compared with the previous study performed in 2005 to identify trends. Results: Of 67,422 attendances, there were 1298 (1.93%) URVs from 1207 patients (median age 34, interquartile range 24 to 52 years; 59.7% male). The most common presenting complaint was abdominal pain (22.2%). One hundred ninety-one (15.8%) patients received an initial wrong or delayed diagnosis. Factors (adjusted odds ratio; 95% CI) associated with this were: presenting complaints of abdominal pain (2.99; 2.12–4.23), fever (1.60; 1.1–2.33), neurological deficit (4.26; 1.94–9.35), and discharge without follow-up (1.61; 1.1–2.26). Among re-attendances, 459 (38.0%) required admission. Factors (adjusted odds ratio; 95% CI) associated with admission were: male gender (1.88; 1.42 to 2.48); comorbidities of diabetes mellitus (2.07; 1.29–3.31), asthma (5.23; 1.59–17.26), and renal disease (7.48; 2.00–28.05); presenting complaints of abdominal pain (1.83; 1.32–2.55), fever (3.05; 2.10–4.44), and giddiness or vertigo (2.17; 1.26–3.73). There was a reduction in URV rate compared to the previous study in 2005 (1.93% versus 2.19%). Abdominal pain at the index visit remains a significant cause of URVs (22.2% versus 25.1%). Conclusions: Presenting complaints of neurological deficits, abdominal pain, fever, and discharge without follow-up were associated with wrong or delayed diagnoses among URVs.

[Point-of-care ultrasound: Is it time to include it in the paediatric specialist training program?]

Point-of-care ultrasound (POCUS) has become an essential tool for clinical practice in recent years. It should be considered as an extension of the standard physical examination, which complements and enriches it without substituting it. POCUS enables the physician to answer specific clinical questions about the diagnosis, to understand better the pathophysiological context, to orientate the treatment, and to perform invasive procedures more safely. Despite its current use in many centres, and in most paediatric sub-specialties, there are currently no specific recommendations addressing educational aims in the different training areas, as well as methodology practice and the certification process in paediatrics. These ingredients are essential for POCUS implementation in daily practice, with a quality guarantee in terms of efficiency and safety. Several POCUS experts in different paediatric medicine environments performed a non-systematic review addressing the main paediatric POCUS applications in paediatrics. The lack of educational programs in POCUS in Spain is also discussed, and the experience in the United States of America in this topic is provided. Considering the current situation of POCUS in paediatrics, we strongly believe that it is urgent to establish evidence-based recommendations for POCUS training that should be the base to develop educational programs and to include POCUS in the paediatric residency training.

Point-of-care ultrasound: its growing application in hospital medicine

Point-of-care ultrasound is emerging as an important adjunct to the clinical examination. Ultrasonography has long been seen as a modality for experts but this is changing and it is hoped that, with appropriate training, point-of-care ultrasound will become a modern-day diagnostic necessity.

Detection of Type B Aortic Dissection in the Emergency Department with Point-of-Care Ultrasound

Aortic dissection (AD) is a rare, time-sensitive, and potentially fatal condition that can present with subtle signs requiring timely diagnosis and intervention. Although definitive diagnosis is most accurately made through computed tomography angiography, this can be a time-consuming study and the patient may be unstable, thus preventing the study’s completion. Chest radiography (CXR) signs of AD are classically taught yet have poor diagnostic reliability. Point-of-care ultrasound (POCUS) is increasingly used by emergency physicians for the rapid diagnosis of emergent conditions, with multiple case reports illustrating the sonographic signs of AD. We present a case of Stanford type B AD diagnosed by POCUS in the emergency department in a patient with vague symptoms, normal CXR, and without aorta dilation. A subsequent review of CXR versus sonographic signs of AD is described.

Emergency department non-invasive cardiac output study (EDNICO): a feasibility and repeatability study

Background

There is little published data investigating non-invasive cardiac output monitoring in the emergency department (ED). We assessed six non-invasive fluid responsiveness monitoring methods which measure cardiac output directly or indirectly for their feasibility and repeatability of measurements in the ED: (1) left ventricular outflow tract echocardiography derived velocity time integral, (2) common carotid artery blood flow, (3) suprasternal aortic Doppler, (4) bioreactance, (5) plethysmography with digital vascular unloading method, and (6) inferior vena cava collapsibility index.

Methods

This is a prospective observational study of non-invasive methods of assessing fluid responsiveness in the ED. Participants were non-ventilated ED adult patients requiring intravenous fluid resuscitation. Feasibility of each method was determined by the proportion of clinically interpretable measurements from the number of measurement attempts. Repeatability was determined by comparing the mean difference of two paired measurements in a fluid steady state (after participants received an intravenous fluid bolus).

Results

76 patients were recruited in the study. A total of 207 fluid responsiveness measurement sets were analysed. Feasibility rates were 97.6% for bioreactance, 91.3% for vascular unloading method with plethysmography, 87.4% for common carotid artery blood flow, 84.1% for inferior vena cava collapsibility index, 78.7% for LVOT VTI, and 76.8% for suprasternal aortic Doppler. The feasibility rates difference between bioreactance and all other methods was statistically significant.

Conclusion

Our study shows that non-invasive fluid responsiveness monitoring in the emergency department may be feasible with selected methods. Higher repeatability of measurements were observed in non-ultrasound methods. These findings have implications for further studies specifically assessing the accuracy of such non-invasive cardiac output methods and their effect on patient outcome in the ED in fluid depleted states such as sepsis.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0586-6) contains supplementary material, which is available to authorized users.

Documenting the Growth of Ultrasound Research in Emergency Medicine Through a Bibliometric Analysis of Accepted Academic Conference Abstracts

OBJECTIVES

Ultrasound (US) has become an indispensable skill for emergency physicians. Growth in the use of US in emergency medicine (EM) has been characterized by practice guidelines, education requirements, and the number of EM US practitioners. Our purpose was to further document the growth of EM US by profiling the breadth, depth, and quality of US-related research presented at EM's most prominent annual research conference: the Society for Academic Emergency Medicine Annual Meeting.

METHODS

We reviewed published research abstracts from the annual Society for Academic Emergency Medicine conferences from 1999 to 2015. Abstracts related to US were identified and examined for the number of authors and rigor of the research design. Designs were categorized as experimental, quasiexperimental, and nonexperimental. Abstract submissions were analyzed by the average rate of change over time.

RESULTS

From 1999 to 2015, we observed a 10.2% increase in the number of accepted abstracts related to US research. This rate compared to a 3.2% average rate of change for all abstracts in general. The number of unique authors engaged in US research increased at a rate of 26.6%. Of the 602 abstracts identified as US related, only 12% could be considered experimental research.

CONCLUSIONS

We observed larger increases in the number of US-related research relative to the total number of abstracts presented at a national conference. The number of investigators engaging in this research has also steadily increased. The research design of these studies was found to be primarily quasiexperimental. To improve the quality of EM's use of point-of-care US, more rigorous research with experimental designs is needed.

Entrusting internal medicine residents to use point of care ultrasound: Towards improved assessment and supervision

Background: Internal medicine physicians and trainees are increasingly using, and seeking training in, diagnostic point of care ultrasound (POCUS). Numerous internal medicine training programs have described their curricula, but little has been written about how learners should be assessed, supervised, and allowed to progress toward independent practice, yet these practices are imperative for safe and effective use. Entrustable professional activities (EPAs) offer a practical method to assess observable units of professional work and make supervision decisions. Methods: An EPA for POCUS is used as a framework to assess and determine appropriate levels of supervision in an internal medicine residency program. Results: All learners have been able to advance to level 2 with a mandatory introductory boot camp course. Learners have been able to advance to higher levels of independence, often after taking formal elective programmatic coursework. However, not all learners taking the same coursework have been granted the same level of independence. Conclusions: It is feasible to assess and supervise internal medicine residents' ability to use diagnostic point of care ultrasound using an EPA.

Defining the Role of Point-of-Care Ultrasound in Cardiovascular Disease

Echocardiography is the foundation for diagnostic cardiac testing, allowing for direct identification and management of various conditions. Point-of-care ultrasound (POCUS) has emerged as an invaluable tool for bedside diagnosis and management. The objective of this review is to address the current use and clinical applicability of POCUS to identify, triage, and manage a wide spectrum of cardiac conditions. POCUS can change diagnosis and management decisions of various cardiovascular conditions in a range of settings. In the outpatient setting, it is used to risk stratify and diagnose a variety of medical conditions. In the emergency department (ED) and critical care settings, it is used to guide triage and critical care interventions. Furthermore, the skills needed to perform POCUS can be taught to noncardiologists in a way that is retained and allows identification of normal and grossly abnormal cardiac findings. Various curricula have been developed that teach residents and advanced learners how to appropriately employ point-of-care ultrasound. In conclusion, POCUS can be a useful adjunct to the physical exam, particularly in critical care applications.