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

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Ultrasound in Pregnancy

This article reviews the use of ultrasound in pregnancy pertinent to the emergency physician. The techniques for transabdominal and transvaginal studies are detailed including approaches to gestational dating. Diagnosis of ectopic pregnancy is reviewed focusing on the potential pitfalls: reliance on beta-human chorionic gonadotropin, pseudogestational sac, interstitial pregnancy, and heterotopic pregnancy. Techniques for the identification of placental issues and presenting parts during the second and third trimesters are reviewed. Ultrasound is a safe and effective tool for the experienced emergency physician and is integral to providing high-quality care to pregnant women.

Determination of Endovaginal Ultrasound Proficiency and Learning Curve Among Emergency Medicine Trainees

OBJECTIVES

Performing and interpreting endovaginal ultrasound is an important skill used during the evaluation of obstetric and gynecologic emergencies. This study aims to describe the level of proficiency and confidence achieved after performing 25 endovaginal examinations.

METHODS

This is a prospective study at a single urban academic emergency department. Participants performed a minimum of 25 endovaginal ultrasounds under the supervision of a point-of-care ultrasound expert. Anatomical structures were identified by the expert under ultrasound prior to each session. Each examination was scored for agreement of findings between the participant and expert. The data were used to develop a performance curve identifying when proficiency was achieved, where experiential benefit diminished, and when participants felt confident.

RESULTS

A total of 1117 endovaginal ultrasound examinations were performed by 50 participants. Agreement after 25 examinations was highest (>95%) for probe insertion and preparation, bladder and uterus identification, and directionality. Agreement was lowest for identification of the ovaries (76%). Experiential benefit plateaus occurred earliest (10 exams) for preparation and insertion followed by bladder identification and directionality. Surprisingly, ovarian experiential benefit plateaued at 16 exams. Participant confidence improved overall and was lowest for the identification of ovaries and abnormal pelvic anatomy.

CONCLUSIONS

There is a significant learning curve when performing endovaginal ultrasound. Our data do not support the use of 25 examinations as a minimum standard for identification of the ovaries or abnormal ovarian pathology.

Comparing Time to Diagnosis and Treatment of Patients with Ruptured Ectopic Pregnancy Based on Type of Ultrasound Performed: A Retrospective Inquiry

BACKGROUND

Hemorrhage from ruptured ectopic pregnancy is the leading cause of first trimester mortality in North America.

OBJECTIVES

Our objective was to compare patients with a ruptured ectopic pregnancy who had an emergency department (ED) point-of-care ultrasound (PoCUS) with those who received a radiology department-performed ultrasound (RADUS). Four time intervals were measured: ED arrival to ultrasound interpretation, obstetric consultation, operating room (OR) arrival, and ultrasound interpretation to OR arrival.

METHODS

This was a retrospective cohort study of patients with ruptured ectopic pregnancy seen between February 2012 and September 2018 at an urban tertiary care hospital. Patients who received an ultrasound in the ED, went directly to the OR, and had confirmed rupture were included.

RESULTS

Of 262 patients diagnosed with ectopic pregnancy during the study period, 36 (14%) were ruptured and 32 were enrolled. Comparing times between PoCUS (n = 10) and RADUS (n = 22) groups, the mean time from ED arrival to ultrasound interpretation was 15 vs. 138 min (difference 123, 95% confidence interval [CI] 88-158), from ED arrival to obstetric consultation was 35 vs. 150 min (difference 115, 95% CI 59-171), from ED arrival to OR arrival was 160 vs. 381 min (difference 222, 95% CI 124-320), and from ultrasound interpretation to OR arrival was 145 vs. 243 min (difference 98, 95% CI 12-184).

CONCLUSION

ED patients with a ruptured ectopic pregnancy who received a PoCUS first had shorter times to diagnosis, obstetric consultation, and OR arrival compared with those who received RADUS.

Diagnostic Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Point-of-care ultrasound has become an essential part of pediatric emergency medicine training and practice. It can have significant clinical benefits, including improving diagnostic accuracy and decreasing length of stay, and does not require radiation exposure for patients. In this review, we summarize the current diagnostic point-of-care ultrasound applications in pediatric emergency medicine, their evidence, and techniques.

Impact of point-of-care ultrasound on treatment time for ectopic pregnancy

BACKGROUND

Point-of-care ultrasound (POCUS) is useful in the evaluation of early pregnancy by confirming intrauterine pregnancy and recognizing hemorrhage from ectopic pregnancy. We sought to determine whether transabdominal POCUS by itself or in conjunction with consultative radiology ultrasound (RADUS), reduces Emergency Department (ED) treatment time for patients with ectopic pregnancy requiring operative care, when compared to RADUS alone. A secondary objective was to determine whether the incorporation of POCUS reduces time to operative care for patients with ruptured ectopic pregnancy specifically, when compared to RADUS alone.

METHODS

We performed a retrospective review of patients admitted for operative management of ectopic pregnancy. We excluded patients with known ectopic pregnancy and/or imaging prior to arriving to the treatment area, found not to have an ectopic pregnancy, or did not undergo operative care. Descriptive statistics, classical and nonparametric statistical analysis, and linear regression were performed.

RESULTS

There were 220 patients admitted with ectopic pregnancy, 111 met exclusion criteria, yielding 109 for analysis. Of 109, 36 received POCUS (23/36 also had RADUS), while 73 received RADUS only. Among the POCUS group 31/36 (86%) were classified as ruptured versus 47/73 (64%) in the RADUS group. The average ED treatment time in the POCUS group for all admitted ectopic pregnancies was 157.9 min (standard deviation [SD] 101.3) versus 206.3 min (SD 76.6) in the RADUS group (p = 0.0141). The median time to operating room (OR) for ruptured ectopic pregnancies was 203.0 min (interquartile range [IQR] 159.0) in the POCUS group versus 293.0 min (IQR 139.0) in the RADUS group (p = 0.0002). Regression analysis of the primary outcome was limited by multiple interactions and sample size. When controlling for race, positive shock index and ED visit time, POCUS was found to be associated with a significantly shorter time to OR among ruptured ectopic pregnancies compared to RADUS (p = 0.0052).

CONCLUSION

Compared to RADUS alone, incorporation of POCUS was associated with significantly faster ED treatment time for all ectopic pregnancies and significantly faster time to OR for ruptured ectopic pregnancies, even when combined with RADUS. When controlling for clinical differences, time to OR was still faster for patients who underwent POCUS. The integration of POCUS should be considered to expedite care for patients with ectopic pregnancy requiring operative care.

Point-of-Care Ultrasound Facilitates Management of Ruptured Ectopic Pregnancy

ABSTRACT

Abdominal pain in the pregnant adolescent presents a diagnostic dilemma with potential life-threatening etiologies. We present a case where point-of-care ultrasound was used to facilitate diagnosis and expedite lifesaving management of a ruptured ectopic pregnancy. We further review the technique and literature for first-trimester transabdominal point-of-care ultrasound.

Ruptured Ectopic Pregnancy with an Intrauterine Device: Case Report and Sonographic Considerations

INTRODUCTION

Ectopic pregnancy carries a high morbidity and mortality; patients are at risk for rupture and life-threatening hemorrhage.

CASE REPORT

We present a rare case of ruptured abdominal ectopic pregnancy in a patient with a well-positioned intrauterine device (IUD) and discuss the diagnostic utility that transabdominal point-of-care ultrasound (POCUS) can have when performed at the bedside.

CONCLUSION

While pregnancy with an IUD in place is rare, when it is encountered the emergency provider should maintain a high degree of suspicion for extrauterine pregnancy and perform prompt evaluation for hemorrhagic shock using diagnostic POCUS.

Morison's pouch: anatomical review and evaluation of pathologies and disease spread on cross-sectional imaging

The peritoneum is a complex structure. Having a better understanding of this complex anatomy will enable the radiologist to accurately assess and diagnose the wide range of intra-abdominal pathologies. In this article, we review the anatomy, boundaries, and connections of Morison's pouch. In addition, we discuss the incidence and development of common pathological conditions within Morison's pouch and the role of multiple imaging modalities in assessment and diagnosis of these conditions.

The development of a provincial multidisciplinary framework of consensus-based standards for Point of Care Ultrasound at the University of Saskatchewan

OBJECTIVES

The development and adoption of Point-of-Care Ultrasound (POCUS) across disciplines have created challenges and opportunities in implementing training and utilization standards. Within the context of a large, geographically disparate province, we sought to develop a multidisciplinary POCUS framework outlining consensus-based standards.

METHODS

A core working group of local POCUS leaders from Anesthesia, Emergency Medicine, Family Medicine, Intensive Care, Internal Medicine, Pediatrics, and Trauma, in collaboration with western Canadian colleagues, developed a list of key domains for the framework along with a range of potential standards for each area. The members of the working group and the registrants for a multidisciplinary Roundtable discussion at the University of Saskatchewan's annual POCUS conference (SASKSONO19, Saskatoon, Saskatchewan, March 2nd, 2019) were invited to complete a survey on POCUS standards for each domain. The survey results were presented to and discussed by participants at the Roundtable discussion at SASKSONO19 who reached consensus on modified standards for each domain. The modified standards were considered for endorsement by all conference attendees using an audience-response system.

RESULTS

The working group proposed standards in eight domains: scope of use, credentialing and privileges, documentation, quality assurance, leadership and governance, teaching, research, and equipment maintenance. Consensus on modified standards was achieved in the 18 participant Roundtable. Each standard was then endorsed by > 90% of conference respondents.

CONCLUSION

The resulting framework will inform the utilization of POCUS within Saskatchewan. Both this process and its outcomes could inform the development of multidisciplinary POCUS standards within other jurisdictions.

Focused assessment with sonography in trauma (FAST) for the regional anesthesiologist and pain specialist

This article in our point-of-care ultrasound (PoCUS) series is dedicated to the role the focused assessment with sonography in trauma (FAST) exam plays for the regional anesthesiologist and pain specialists in the perioperative setting. The FAST exam is a well-established and extensively studied PoCUS exam in both surgical and emergency medicine literature with over 20 years demonstrating its benefit in identifying the presence of free fluid in the abdomen following trauma. However, only recently has the FAST exam been shown to be beneficial to the anesthesiologist in the perioperative setting as a means to identify the extravasation of free fluid into the abdomen from the hip joint following hip arthroscopy. In this article, we will describe how to obtain the basic FAST views (subcostal four-chamber view, perihepatic right upper quadrant view, perisplenic left upper quadrant view, and pelvic view in the longitudinal and short axis) as well as cover the relevant sonoanatomy. We will describe pathological findings seen with the FAST exam, primarily free fluid in the peritoneal space as well as in the pericardial sac. As is the case with any PoCUS skill, the application evolves with understanding and utilization by new clinical specialties. Although this article will provide clinical examples of where the FAST exam is beneficial to the regional anesthesiologist and pain specialist, it also serves as an introduction to this powerful PoCUS skill in order to encourage clinical practitioners to expand the application of the FAST exam within the scope of regional anesthesia and pain management practice.

Impact of point-of-care ultrasound on clinical decision-making at an urban emergency department in Tanzania

BACKGROUND

Point of care ultrasound (PoCUS) is an efficient, inexpensive, safe, and portable imaging modality that can be particularly useful in resource-limited settings. However, its impact on clinical decision making in such settings has not been well studied. The objective of this study is to describe the utilization and impact of PoCUS on clinical decision making at an urban emergency department in Dar es Salaam, Tanzania.

METHODS

This was a prospective descriptive cross-sectional study of patients receiving PoCUS at Muhimbili National Hospital's Emergency Medical Department (MNH EMD). Data on PoCUS studies during a period of 10 months at MNH EMD was collected on consecutive patients during periods when research assistants were available. Data collected included patient age and sex, indications for ultrasound, findings, interpretations, and provider-reported diagnostic impression and disposition plan before and after PoCUS. Descriptive statistics, including medians and interquartile ranges, and counts and percentages, are reported. Pearson chi squared tests and p-values were used to evaluate categorical data for significant differences.

RESULTS

PoCUS data was collected for 986 studies performed on 784 patients. Median patient age was 32 years; 56% of patients were male. Top indications for PoCUS included trauma, respiratory presentations, and abdomino-pelvic pain. The most frequent study types performed were eFAST, cardiac, and obstetric or gynaecologic studies. Overall, clinicians reported that the use of PoCUS changed either diagnostic impression or disposition plan in 29% of all cases. Rates of change in diagnostic impression or disposition plan increased to 45% in patients for whom more than one PoCUS study type was performed.

CONCLUSIONS

In resource-limited emergency care settings, PoCUS can be utilized for a wide range of indications and has substantial impact on clinical decision making, especially when more than one study type is performed.

Urachal Cyst Diagnosed by Point-of-care Ultrasound

Irreducible umbilical swelling in infants is considered a surgical emergency because a delay in surgical intervention for an incarcerated umbilical hernia can lead to bowel ischemia and necrosis. We report two patients who presented to a pediatric emergency department with history and symptoms of irreducible umbilical mass suggestive of umbilical hernia. Point-of-care ultrasound was used at the bedside to demonstrate the presence of urachal cyst remnants and accurately guided the care of these children.

Bedside ultrasound training at Muhimbili National Hospital in Dar es Salaam, Tanzania and Hospital San Carlos in Chiapas, Mexico

INTRODUCTION

In resource-rich settings, bedside ultrasound has rapidly evolved to be a crucial part of emergency centre practice and a growing part of critical care practice. This portable and affordable technology may be even more valuable in resource-limited environments where other imaging modalities are inaccessible, but the optimal amount of training required to achieve competency in bedside ultrasound is largely unknown. We sought to evaluate the feasibility of implementation of a mixed-modality bedside ultrasound training course for emergency and generalist acute care physicians in limited resource settings, and to provide a description of our core course components, including specific performance goals, to facilitate implementation of similar initiatives.

METHODS

We conducted a standardised training course at two distinct sites-one large, urban tertiary hospital in Tanzania with a dedicated Emergency Centre, and one small, rural, hospital in southern Mexico with a general, acute intake area. We report on pre-training ultrasound use at both sites, as well as pre- and post-training views on most useful indications.

RESULTS

Overall, participants were very satisfied with the course, although approximately one-third of the providers at both sites would have preferred more hands-on training. All participants passed a standardised exam requiring image acquisition and interpretation.

DISCUSSION

Introducing bedside ultrasound training in two distinct resource-limited settings was feasible and well-received. After a brief intensive period of training, participants successfully passed a comprehensive examination, including demonstration of standardised image acquisition and accurate interpretation of normal and abnormal studies.

Point-of-care ultrasound versus radiology department pelvic ultrasound on emergency department length of stay

BACKGROUND

The study aimed to compare the time to overall length of stay (LOS) for patients who underwent point-of-care ultrasound (POCUS) versus radiology department ultrasound (RDUS).

METHODS

This was a prospective study on a convenience sample of patients who required pelvic ultrasound imaging as part of their emergency department (ED) assessment.

RESULTS

We enrolled a total of 194 patients who were on average 32 years-old. Ninety-eight (51%) patients were pregnant (<20 weeks). Time to completion of RDUS was 66 minutes longer than POCUS (95%CI 60-73, P<0.01). Patients randomized to the RDUS arm experienced a 120 minute longer ED length of stay (LOS) (95%CI 66-173, P<0.01).

CONCLUSION

In patients who require pelvic ultrasound as part of their diagnostic evaluation, POCUS resulted in a significant decrease in time to ultrasound and ED LOS.

Overview of point-of-care abdominal ultrasound in emergency and critical care

Point-of-care abdominal ultrasound (US), which is performed by clinicians at bedside, is increasingly being used to evaluate clinical manifestations, to facilitate accurate diagnoses, and to assist procedures in emergency and critical care. Methods for the assessment of acute abdominal pain with point-of-care US must be developed according to accumulated evidence in each abdominal region. To detect hemoperitoneum, the methodology of a focused assessment with sonography for a trauma examination may also be an option in non-trauma patients. For the assessment of systemic hypoperfusion and renal dysfunction, point-of-care renal Doppler US may be an option. Utilization of point-of-care US is also considered in order to detect abdominal and pelvic lesions. It is particularly useful for the detection of gallstones and the diagnosis of acute cholecystitis. Point-of-case US is justified as the initial imaging modality for the diagnosis of ureterolithiasis and the assessment of pyelonephritis. It can be used with great accuracy to detect the presence of abdominal aortic aneurysm in symptomatic patients. It may also be useful for the diagnoses of digestive tract diseases such as appendicitis, small bowel obstruction, and gastrointestinal perforation. Additionally, point-of-care US can be a modality for assisting procedures. Paracentesis under US guidance has been shown to improve patient care. US appears to be a potential modality to verify the placement of the gastric tube. The estimation of the amount of urine with bladder US can lead to an increased success rate in small children. US-guided catheterization with transrectal pressure appears to be useful in some male patients in whom standard urethral catheterization is difficult. Although a greater accumulation of evidences is needed in some fields, point-of-care abdominal US is a promising modality to improve patient care in emergency and critical care settings.

Diagnostic accuracy and clinical utility of emergency department targeted ultrasonography in the evaluation of first-trimester pelvic pain and bleeding: a systematic review

Objective:

Emergency department targeted ultrasonography (EDTU) offers the possibility of rapid exclusion of ectopic pregnancy in patients with first-trimester pelvic pain or bleeding. We sought to systematically review the evidence describing the diagnostic accuracy and clinical utility of EDTU in the first trimester of pregnancy, and to generate a pooled estimate of the sensitivity and specificity of EDTU for the detection of intrauterine pregnancy (IUP).

Methods:

The literature search, abstract review and study selection were performed using predefined criteria. We abstracted the sensitivity and specificity of EDTU for IUP from included studies, and evaluated and summarized the evidence assessing the effect of EDTU use on time to diagnosis, time to treatment of ectopic pregnancy, emergency department (ED) length of stay and health care costs.

Results:

The specificity of EDTU for IUP in most studies exceeds 98%. The sensitivity in most studies exceeds 90%. Pooled estimates were not calculated because of statistical heterogeneity between studies. Published evidence indicates that EDTU use reduces the frequency of missed ectopic pregnancies, decreases time to surgery for ectopic pregnancy, shortens the length of stay for patients with normal pregnancies and may be more cost-effective than diagnostic strategies requiring formal ultrasonography.

Conclusion:

EDTU is highly specific for the identification of IUP. Patients who have an IUP identified with EDTU may be safely discharged from the ED with outpatient follow-up. The specificity of EDTU for IUP, along with the potential improvements in patient care that EDTU affords, justifies its adoption as routine ED care in evaluating first-trimester pain or bleeding.

Clinician-performed abdominal sonography

INTRODUCTION

Point-of-care ultrasonography is increasingly utilized across a wide variety of physician specialties. This imaging modality can be used to evaluate patients rapidly and accurately for a wide variety of pathologic conditions.

METHODS

A literature search was performed for articles focused on clinician-performed ultrasonography for the diagnosis of appendicitis, gallbladder disease, small bowel obstruction, intussusception, and several types of renal pathology. The findings of this search were summarized including the imaging techniques utilized in these studies.

CONCLUSION

Clinician performed point-of-care sonography is particularly well suited to abdominal applications. Future investigations may further confirm and extend its utility at the bedside.

Predictive value of hemoperitoneum for outcome of methotrexate treatment in ectopic pregnancy: an observational comparative study

OBJECTIVE

To assess the predictive value of hemoperitoneum for the outcome of methotrexate (MTX) treatment of ectopic pregnancy (EP).

METHODS

This observational prospective single-center study included women presenting with EP treated with MTX from November 2007 to November 2009. The percentage of women with hemoperitoneum at the beginning of MTX treatment was compared between two groups: those whose treatment was successful and those whose treatment failed. The rate of hemoperitoneum in each group and its value in predicting the outcome of MTX treatment of EP were assessed.

RESULTS

MTX treatment was successful in 69 of 93 (74%) cases. The percentage of women with hemoperitoneum at the beginning of treatment was significantly higher in women in whom MTX treatment failed as compared to those in whom it was successful (15/24 (62.5%) vs 17/69 (24.6%); P = 0.001). The likelihood of requiring surgery following treatment with MTX was higher in women with hemoperitoneum (odds ratio, 5.1; 95% CI, 1.74-15.14). Study of the diagnostic performance of hemoperitoneum in predicting the need for surgical treatment after MTX treatment revealed a sensitivity of 0.63, a specificity of 0.76, a positive predictive value of 0.47 and a negative predictive value of 0.85.

CONCLUSIONS

The presence of hemoperitoneum appears to be a risk factor for MTX treatment failure. It is important to inform women as fully as possible about the risk of such failure. Nonetheless, the predictive value of this sign is insufficient for either routinely excluding women with hemoperitoneum from MTX treatment or omitting post-treatment monitoring.

Review article: Use of ultrasound in the developing world

As portability and durability improve, bedside, clinician-performed ultrasound is seeing increasing use in rural, underdeveloped parts of the world. Physicians, nurses and medical officers have demonstrated the ability to perform and interpret a large variety of ultrasound exams, and a growing body of literature supports the use of point-of-care ultrasound in developing nations. We review, by region, the existing literature in support of ultrasound use in the developing world and training guidelines currently in use, and highlight indications for emergency ultrasound in the developing world. We suggest future directions for bedside ultrasound use and research to improve diagnostic capacity and patient care in the most remote areas of the globe.

The efficacy and value of emergency medicine: a supportive literature review

Study objectives

The goal of this study was to identify publications in the medical literature that support the efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. In this study we use the term "value" to refer both to the "efficacy of clinical care" in terms of achieving desired patient outcomes, as well as "efficiency" in terms of effective and/or cost-effective utilization of healthcare resources in delivering emergency care. A comprehensive listing of publications describing the efficacy or value of EM has not been previously published. It is anticipated that the accumulated reference list generated by this study will serve to help promote awareness of the value of EM as a medical specialty, and acceptance and development of the specialty of EM in countries where EM is new or not yet fully established.

Methods

The January 1995 to October 2010 issues of selected journals, including the EM journals with the highest article impact factors, were reviewed to identify articles of studies or commentaries that evaluated efficacy, effectiveness, and/or value related to EM as a specialty or to clinical care delivered by EM practitioners. Articles were included if they found a positive or beneficial effect of EM or of EM physician-provided medical care. Additional articles that had been published prior to 1995 or in other non-EM journals already known to the authors were also included.

Results

A total of 282 articles were identified, and each was categorized into one of the following topics: efficacy of EM for critical care and procedures (31 articles), efficacy of EM for efficiency or cost of care (30 articles), efficacy of EM for public health or preventive medicine (34 articles), efficacy of EM for radiology (11 articles), efficacy of EM for trauma or airway management (27 articles), efficacy of EM for using ultrasound (56 articles), efficacy of EM faculty (34 articles), efficacy of EM residencies (24 articles), and overviews and editorials of EM efficacy and value (35 articles).

Conclusion

There is extensive medical literature that supports the efficacy and value for both EM as a medical specialty and for emergency patient care delivered by trained EM physicians.

Does tubal ectopic pregnancy with hemoperitoneum always require surgery?

OBJECTIVE

Hemoperitoneum is accepted as an indication for surgery in women with tubal ectopic pregnancy. The aim of this pilot study was to evaluate the feasibility of managing such women non-surgically.

METHODS

This was a prospective observational study. Women with tubal ectopic pregnancy and hemoperitoneum detected on transvaginal sonography (TVS) were managed as inpatients either expectantly or with methotrexate (MTX). Inclusion criteria for conservative management were: compliance, clinical stability, absence of acute abdomen, stable hemoglobin level on two measurements (0 and 12-24 h apart), serum human chorionic gonadotropin (hCG) < 5000 IU/L, absence of fetal cardiac activity on TVS and absence of significant hemoperitoneum, defined as blood above the level of the uterine fundus and/or in Morison's pouch (hepatorenal space). Subsequent management was based upon the hCG ratio at 48 h. All the women were managed as inpatients until the abdominal pain settled and the serum hCG levels were falling.

RESULTS

Forty-one women with tubal ectopic pregnancy presented between November 2006 and March 2008. Eight women (20%) fulfilled the entry criteria. The median gestational age at diagnosis was 49 (interquartile range, 38-52.5) days. All women presented with lower abdominal pain/right iliac fossa or left iliac fossa pain. Hemoglobin levels ranged from 11.2 to 14.2 g/dL at presentation and from 12.0 to 14.8 g/dL after 12-24 h. 6/8 (75%) women were managed expectantly and 2/8 (25%) received MTX. All women had resolution of their ectopic pregnancy within 3 weeks with no complications.

CONCLUSIONS

This pilot study suggests that the finding of hemoperitoneum on ultrasound examination may not be an absolute contraindication to conservative management of tubal ectopic pregnancy.

Emergency ultrasound usage among recent emergency medicine residency graduates of a convenience sample of 14 residencies

BACKGROUND

Emergency Medicine (EM) residency graduates are trained to perform Emergency Medicine bedside ultrasound (EMBU). However, the degree to which they use this skill in their practice after graduation is unknown.

OBJECTIVES

We sought to test the amount and type of usage of EMBU among recent residency graduates, and how usage and barriers vary among various types of EM practice settings.

METHODS

Graduates from 14 EM residency programs in 2003-2005 were surveyed on their current practice setting and use of EMBU.

RESULTS

There were 252 (73%) graduates who completed the survey. Of the 73% of respondents reporting access to EMBU, 98% had used it within the past 3 months. Access to EMBU was higher in academic (97%) vs. community teaching (79%) vs. community non-teaching settings (62%) (p < 0.001), and in Emergency Departments (EDs) where yearly census exceeded 60,000 visits (87% vs. 65%, p < 0.001). Physicians in academic settings reported "high use" of EMBU more frequently than those in community settings for most modalities. FAST (focused assessment by sonography in trauma) was the most common high-use application and the most useful in practice. The greatest impediment to EMBU use was "not enough time" (61%).

CONCLUSIONS

Ultrasound usage among recent EM residency graduates is significantly higher in teaching than in community settings and in high-volume EDs. Its use is more widespread than in previous reports in all types of practice. There is a wide range of utilization of ultrasound in the various applications in emergency practice, with the evaluation of trauma being the most common.

Bedside ultrasound in pediatric emergency medicine

Bedside emergency ultrasound has been used by emergency physicians for >20 years for a variety of conditions. In adult centers, emergency ultrasound is routinely used in the management of victims of blunt abdominal trauma, in patients with abdominal aortic aneurysm and biliary disease, and in women with first-trimester pregnancy complications. Although its use has grown dramatically in the last decade in adult emergency departments, only recently has this tool been embraced by pediatric emergency physicians. As the modality advances and becomes more available, it will be important for primary care pediatricians to understand its uses and limitations and to ensure that pediatric emergency physicians have access to the proper training, equipment, and experience. This article is meant to review the current literature relating to emergency ultrasound in pediatric emergency medicine, as well as to describe potential pediatric applications.

Free fluid in Morison's pouch on bedside ultrasound predicts need for operative intervention in suspected ectopic pregnancy

BACKGROUND

Ectopic pregnancies are frequently present in women who present to the emergency department with pregnancy and abdominal pain or bleeding, a subset of whom may require operative intervention.

OBJECTIVES

To prospectively determine if emergency physician (EP)-performed transabdominal pelvic ultrasonography (US) with determination of free abdominal fluid in the hepatorenal space predicted the need for operative intervention.

METHODS

Patients who were suspected to have an ectopic pregnancy were prospectively enrolled over a ten-month period. An EP-performed bedside transabdominal pelvic US that included a view of the hepatorenal space (Morison's pouch) for free fluid. The EP US was classified as intrauterine pregnancy (IUP) or no definitive IUP, with Morison's pouch classified as positive or negative. The majority of patients had a subsequent transvaginal pelvic US performed by the Department of Radiology. Patients were followed up for radiology results, need for operative intervention, and ultimate outcome of the pregnancy.

RESULTS

There were 242 patients enrolled, with an average time to complete the EP US of 4 minutes and 27 seconds. There were 28 ectopic pregnancies diagnosed (11.6%), of which 18 patients underwent operative intervention. Free fluid in Morison's pouch was identified in ten patients, nine of whom underwent operative intervention, yielding a positive likelihood ratio of 112 (95% confidence interval = 15 to 831) for patients with suspected ectopic pregnancy who required operative intervention.

CONCLUSIONS

Free intraperitoneal fluid found in Morison's pouch in patients with suspected ectopic pregnancy may be rapidly identified at the bedside by EP-performed US and predicts the need for operative intervention.

Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography

STUDY OBJECTIVE

Nearly all emergency medicine residency programs provide some training in emergency physician-performed ultrasonography, but the extent of emergency physician-performed ultrasonography in community emergency departments (EDs) is not known. We seek to determine the state of ultrasonography in community EDs in terms of access to ultrasonography by other specialists and performance of ultrasonography by emergency physicians.

METHODS

A 6-page survey that addressed access to ultrasonography performed by other specialists and emergency physician-performed ultrasonography was designed and pilot tested. A list of all US ED directors was obtained from the American College of Emergency Physicians. Twelve hundred of 5264 EDs were randomly selected to receive the anonymous survey, with responses tracked by separate postcard. There were 3 mailings from Fall 2003 to Spring 2004.

RESULTS

Overall response rate was 61% (684/1130). Respondents who self-reported as being academic with emergency medicine residents were excluded from further analysis (n=35). A sensitivity analysis (reported in parentheses) was performed on the key outcome question to adjust for response bias. As reported by ED directors, ultrasonography was available in the ED for use by emergency physicians at all times in 19% of EDs (12% to 28%), with an additional 15% (9% to 21%) reporting a machine available for use by emergency physicians in some capacity and 66% (51% to 80%) reporting that there was no access to a machine for emergency physician use. ED directors reported being requested or required to limit ultrasonography orders performed by radiology in 41% of EDs, with less timely access to radiology-performed ultrasonography in off hours. Of EDs with emergency physician-performed ultrasonography, the most common applications were Focused Assessment with Sonography for Trauma (FAST) examination (85%), code situation (72%), and check for pericardial effusion (67%). Of physicians performing ultrasonography, 16% stated they were currently requesting reimbursement (billing). The primary reason cited for not implementing emergency physician-performed ultrasonography was lack of emergency physician training. For the statement "emergency medicine residents now starting residency should be trained to perform and interpret focused bedside ultrasonography," 84% of ED directors agreed, 14% were neutral, and less than 2% disagreed.

CONCLUSION

Community ED directors continue to report barriers to obtaining ultrasonography from consultants, especially in off hours. Nineteen percent of community ED directors report having a machine available for emergency physician use at all times; however, two thirds of EDs report no access to ultrasonography for emergency physician use. A majority of community ED directors support residency training in emergency physician-performed ultrasonography.

Ultrasound in pregnancy

Ultrasound represents the cornerstone of the emergent evaluation of pregnancy-related complaints. Knowledge of the potential and the limitations of this imaging modality, regardless of who performs it, is important for physicians who evaluate and manage these patients and their unborn children in the ED.