Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside

Right atrial and ventricular clot as a cause of peri-arrest during caesarean birth requiring immediate thrombectomy

Venous thromboembolic disease remains a leading cause of maternal morbidity and mortality. We report a case of a 30-year-old woman at 37+6 gestation with a history of thalassaemia intermedia and splenectomy. During pregnancy, she had been managed with frequent blood transfusions and enoxaparin. She was admitted for induction of labour, and during labour, she developed pre-eclampsia with severe features. Despite magnesium sulphate therapy, she had a short self-terminating seizure shortly after an epidural had been sited. A decision to proceed with an urgent caesarean birth under epidural anaesthesia was made. After birth, she had another seizure associated with oxygen desaturation. Bag-valve-mask ventilation was insufficient, prompting conversion to general anaesthesia and tracheal intubation, after which cardiac collapse developed. Resuscitation was initiated and bedside cardiac ultrasound revealed a large clot-in-transit through the right atrium and ventricle, prompting immediate transfer to cardiac theatres for thrombectomy. The thrombus was successfully removed. The patient recovered well and her trachea was extubated the next day. She was discharged in a stable condition 8 days later. This case highlights the critical role of point-of-care ultrasound in the prompt diagnosis of life-threatening conditions and guiding emergency interventions.

Observations of out-of-pocket travel costs in seeking free cardiac care in India: would point-of-care ultrasound help?

BACKGROUND

In consideration of patient out-of-pocket costs in low- and middle-income countries, this observational cohort study sought to quantify the travel expenses associated with receiving free cardiac services in India and create a point-of-care ultrasound (POCUS) referral model.

METHODS

In a tertiary hospital that offers free services in Bangalore, India, we interviewed outpatients awaiting cardiac evaluation regarding their out-of-pocket expenses. A subgroup underwent POCUS for signs of left atrial enlargement, inferior vena cava plethora, and extravascular lung water, and subsequent chart review for significant findings on echocardiography or need for immediate care. A model was tested in which a normal POCUS would negate the requirement for referral.

RESULTS

Patients (N = 219), of age (mean ± SD) 49.0 ± 12.9 y, traveled [median (IQR)] 1178 miles (248-1240), spent $104 ($26-$195), and lost 4.5 (0-10) days of work at a daily wage of $3.90 ($1.95-$6.50). The one-way travel cost equated to 27 days of daily pay. In the POCUS subgroup, symptoms were commonly chest pain (57%) and dyspnea (48%) and were less than moderate in severity (71%). Abnormal echo findings were present in 54% of patients, of whom 29% needed immediate care, and 71% were dismissed without follow-up. POCUS signs were related to an abnormal echo (p < 0.001), but not immediate care (p = 0.50). POCUS-based referral would have prevented 51% (35/68) of unnecessary referrals and missed 13% (9/68) of cases that required immediate care.

CONCLUSIONS

Out-of-pocket costs, relative to income, can be significant for those seeking free cardiac care. POCUS performed locally could potentially reduce the costs of travel but would risk missing cases, depending on symptom type.

Continuing professional development for primary care physicians: a pre-post study on lung point-of-care ultrasound curriculum

BACKGROUND

Point-of-care ultrasound is rapidly gaining traction in clinical practice, including primary care. Yet, logistical challenges and geographical isolation hinder skill acquisition. Concurrently, an evidentiary gap exists concerning such guidance's effectiveness and optimal implementation in these settings.

METHODS

We developed a lung point-of-care ultrasound (POCUS) curriculum for primary care physicians in a rural, medically underserved region of the south of Israel. The course included recorded lectures, pre-course assessments, hands-on training, post-workshop lectures, and individual practice. To evaluate our course, we measured learning outcomes and physicians' proficiency in different lung POCUS domains using hands-on technique assessment and gathered feedback on the course with a multi-modal perception approach: an original written pre- and post-perception and usage questionnaire.

RESULTS

Fifty primary care physicians (PCPs) showed significant improvement in hands-on skills, increasing from 6 to 76% proficiency (p < 0.001), and in identifying normal versus abnormal views, improving from 54 to 74% accuracy (p < 0.001). Ten weeks after training, primary care physicians reported greater comfort using lung ultrasound, rising from 10 to 54% (p < 0.001), and improved grasp of its potential and limits, increasing from 27.5% to 84% (p < 0.001). Weekly usage increased from none to 50%, and the number of primary care physicians not using at all decreased from 72 to 26% (p < 0.001).

CONCLUSIONS

A two-day focused in-person and remote self-learning lung-POCUS training significantly improved primary care physicians' lung ultrasound skills, comfort, and implementation.

Is it worth trying? A cross-sectional study on the implementation of point-of-care ultrasound in Hungarian primary care

BACKGROUND

Although the number of point-of-care ultrasound devices available in Hungarian primary care practices are increasing due to government funding, their use in day-to-day patient care is limited and unregulated. Our study aimed to evaluate the attitudes and needs of general practitioners (GPs) and patients in Hungary regarding the introduction of bedside ultrasonography in primary care practices.

METHODS

As a part of a cross-sectional study, an anonymous, self-administered questionnaire was distributed to GPs and patients on a social media platform. Data collection was carried out from August 2023 to October 2023. Chi-square test was used to determine the associations between categorical variables.

RESULTS

The survey was completed by 415 GPs (mean age 53.8 ± 11.1 years, 54.9% female, mean 19.5 ± 11.9 years of practice) and 693 patients (mean age 45.5 ± 12.3 years, 95.2% female). There was a statistically significant increase in interest in PoCUS among young and middle-aged GPs (age 28-59; p = 0.02). In addition, this population of GPs was also more likely to undertake training in PoCUS than their older colleagues (p < 0.0001). An inverse relationship was found between the duration of practice and training willingness (p = 0.0011). Even with the government's financial support, only 8.2% of GPs currently use PoCUS in a daily basis, and 59.5% of GPs are unfamiliar with the indications and the ways of using it. Patients would even pay to have the examination done in a primary care setting, even though only 45.9% of patients would pay a GP who is not certified in PoCUS, but the willingness to pay increased to 99.4% for those with formal training (p = 0.024).

CONCLUSION

Our findings indicate a significant interest in adapting PoCUS in primary care from both GPs and patients. Based on the fact that a significant proportion of Hungarian GPs are unaware of PoCUS and its indications, it is particularly important to develop educational frameworks, and practical guidelines for the effective incorporation of PoCUS in Hungary.

Multi-organ clinical ultrasound as a complement to the diagnostic process in an internal medicine consultation

INTRODUCTION

Evaluating outpatient cases in internal medicine consultations presents a significant diagnostic challenge. Ultrasound can be a highly useful tool in assessment and decision-making.

PATIENTS AND METHODS

A prospective observational study was conducted on a cohort of patients attending an internal medicine rapid assessment clinic. Eighty patients were prospectively recruited. A medical consultation was conducted as per usual clinical practice, followed by a POCUS evaluation; collecting pulmonary, cardiac, and abdominal data. All findings were analyzed and recorded, particularly those that were significant or altered the initial diagnosis, subsequent tests, or treatment.

RESULTS

Significant ultrasound findings were found in 37.5% of the patients. Of all ultrasound scans, the most clinically relevant were in the heart region (31.9%), followed by the abdomen (26%). These findings led to a change in overall management in 27.5% of patients. Using logistic regression, a model was developed to estimate the presence of clinically relevant findings with an area under the curve (AUC) of 0.78 (95% CI 0.66-0.89; p < 0.001) with 80% Sensitivity and 66% Specificity.

CONCLUSION

The systematic and standardized incorporation of clinical ultrasound in internal medicine consultations contributes to decision-making, can provide significant findings that allow for modifications in clinical suspicion and therapeutic management.

Recommendations for Cardiac Point-of-Care Ultrasound Nomenclature

Point-of-care ultrasound (POCUS) involves the acquisition, interpretation, and immediate clinical integration of ultrasonographic imaging performed by a treating clinician. The current state of cardiac POCUS terminology is heterogeneous and ambiguous, in part because it evolved through siloed specialty practices. In particular, the medical literature and colloquial medical conversation contain a wide variety of terms that equate to cardiac POCUS. While diverse terminology aided in the development and dissemination of cardiac POCUS throughout multiple specialties, it also contributes to confusion and raises patient safety concerns. This statement is the product of a diverse and inclusive Writing Group from multiple specialties, including medical linguistics, that employed an iterative process to contextualize and standardize a nomenclature for cardiac POCUS. We sought to establish a deliberate vocabulary that is sufficiently unrelated to any specialty, ultrasound equipment, or clinical setting to enhance consistency throughout the academic literature and patient care settings. This statement (1) reviews the evolution of cardiac POCUS-related terms; (2) outlines specific recommendations, distinguishing between intrinsic and practical differences in terminology; (3) addresses the implications of these recommendations for current practice; and (4) discusses the implications for novel technologies and future research.

The Role of Point-of-Care Ultrasound in the Emergency Department in the Diagnosis and Management of Infective Endocarditis

Infective endocarditis (IE) is a serious cardiovascular condition with the potential to lead to severe valvular regurgitation. We present a case of a 65-year-old male who presented with a fever and was diagnosed with IE through point-of-care ultrasound (POCUS). The patient's condition subsequently led to severe aortic regurgitation. Timely diagnosis facilitated by POCUS played a crucial role in the management of this case. The patient underwent successful timely surgical intervention to prevent further infective embolism and heart failure due to severe acute aortic regurgitation. This case underscores the pivotal role of POCUS in the early diagnosis and multidisciplinary management of cardiology diseases, highlighting its importance in delivering optimal patient care.

Evolving the Scope of Cardiac Point-of-Care Ultrasound in the Current Era

Point-of-care ultrasound (POCUS) has become a flexible and multifaceted diagnostic instrument in the realm of cardiac care, transforming the landscape of cardiovascular assessment. This review aims to explore the extensive scope of POCUS applications in cardiac care, highlighting its diverse utility across various medical specialties. POCUS, conducted at the patient's bedside, offers real-time insights into cardiac anatomy and function, providing a valuable adjunct to traditional diagnostic methods. In critically ill patients, POCUS has demonstrated its effectiveness in the rapid evaluation of the left and right ventricular function, identification of pericardial effusion and tamponade, assessment of volume status, and detection of valvular lesions. Its role as an adjunct to the physical examination has been particularly impactful, leading to early diagnoses and significantly influencing medical management decisions. The review also discusses the current limitations of POCUS technology. As the utilization of POCUS continues to expand across diverse medical disciplines, its ability to offer timely and accurate diagnostic information is poised to reshape the standard of care in cardiac medicine. This comprehensive review provides insights into the evolving role of POCUS in cardiac care and underscores its potential to enhance patient outcomes through rapid and informed decision-making at the point of care.

Point-of-Care Cardiac Ultrasound Training Programme: Experience from the University Hospital Hradec Králové

Point-of-care ultrasound examinations performed by physicians of different specialties are a rapidly growing phenomenon, which has led to a worldwide effort to create a standardised approach to ultrasound examination training. The implementation of emergency echocardiography by noncardiologists is mainly aimed at the standardisation of the procedure, a structured training system, and an agreement on competencies. This article summarises the current training programmes for nonechocardiographers at the University Hospital in Hradec Králové. In cooperation with cardiologists specialised in cardiac ultrasound (ECHO), an extended acute echo protocol dedicated to emergency department physicians was developed and validated in daily practice. According to our retrospective evaluation, after one year of clinical practice, we can confirm that point-of-care ultrasound examinations performed using the standardised limited echo protocol are safe and accurate. The observed concordance with comprehensive ECHO was 78%. This trial is registered with NCT05306730.

Bedside Clinical Hand-held Ultrasound in an Internal Medicine Department: The "Bed Med-Us" Experience of Codogno and its Clinical Utility in the Management of Diagnosis and Therapy in 1007 Patients

Purpose Handheld ultrasound (HH-US) answers simple clinical questions in emergencies. We performed conventional US with HH-US at the patient's bedside (BED) during a medical visit (MED) (BED MED-US). The purpose of this prospective study is to estimate BED MED-US reliability, its clinical impact in helping the clinician to formulate correct diagnoses, and its ability to save time and money. Materials and Methods 1007 patients (519 M; age:76.42) were assessed (from March 2021 to November 2022) in one or more districts. Final diagnosis was determined with clinical and reference tests (chest RX/CT, abdominal CT, endoscopy, etc.). Sensitivity, specificity, LR+ and LR-, and corresponding AUROC were evaluated. HH-US diagnoses were classified as: confirmation (HH-US revealed the sonographic signs that confirmed the clinical diagnosis) (CO), exclusion (HH-US excluded the presence of the ultrasound signs of other pathologies, in the clinical differential diagnosis) (EX), etiological (HH-US reaches diagnosis in clinically doubtful cases) (ET), or clinically relevant incidental (HH-US diagnoses that change the patient's process completely) (INC). Results HH-US reliability: true-pos: 752; true-neg: 242; false-pos: 7; false-neg: 6 (sens: 99.1%, spec: 97.6%, LR+: 98.5; LR-: 00.15, AUROC: 0.997); clinical impact: CO-diagnosis: 21%; EX: 25%; ET: 47%; INC: 7%; saved time and money: approximately 35,572 minutes of work and 9324 euros. Conclusion BED MED-US is a reliable clinical imaging system, with an important clinical impact both in diagnosis (etiological in 47%, incidental in 7%) and in the management of personnel resources.

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.

Initial Evaluation and Management of Patients Presenting with Acute Chest Pain in the Emergency Department

PURPOSE OF THE REVIEW

To review the initial evaluation of chest pain in the emergency department (ED), with a focus on coronary artery disease (CAD) and acute coronary syndromes (ACS), using consensus statements from major cardiovascular disease organizations.

RECENT FINDINGS

Major cardiovascular organizations have released consensus statements on this topic, notably the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain and the 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Also, recent studies have evaluated the use of high sensitivity troponin (hs-cTn) to safely rule out myocardial infarction (MI), with the development of rule-out pathways designed to be utilized in the ED. This review highlights the comprehensive differential diagnoses of chest pain in the ED and urgent management of these etiologies, with a focus on cardiovascular etiologies. There exist a few rule-out pathways recommended by major cardiovascular organizations, notably the high-STEACS and the ESC 0/1 and 0/2 pathways that can safely and quickly discharge patients with low risk of MI.

Hand-held echocardiography during complex electrophysiologic procedures

Introduction

Complex electrophysiologic (EP) procedures are time consuming and open to complications. Accurate and rapid recognition of cardiac pathologies is essential before, during, and immediately after such procedures. In this study, we aimed to compare hand-held echocardiography (HHE) with standard echocardiography (SE) to determine whether HHE can be used as a practical and reliable diagnostic tool during such procedures.

Methods

One hundred consecutive patients undergoing complex EP procedures and catheter ablation were included in the study. All patients were evaluated with SE or HHE in terms of main cardiac pathologies at the beginning and immediately after the procedure. The diagnostic accuracy and evaluation time of both methods were compared at the beginning and after the procedure. The agreement between both methods was calculated.

Results

At the beginning and after the procedure, opening and evaluation times with HHE were significantly shorter than with SE (P<0.001 for all). There was significant agreement between the two methods in the diagnosis of cardiac pathologies (Agreement was 95% for minimal mild aortic regurgitation (AR), 99% for moderate/ severe AR, 93% for minimal/ mild mitral regurgitation (MR), 95% for moderate/ severe MR, 100% for pericardial effusion, and 100% for left ventricular thrombus at the beginning of the procedure).

Conclusion

With the use of HHE during complex EP procedures, cardiac pathologies can be diagnosed with similar accuracy as SE. In addition, HHE has a significant advantage over SE in terms of time to diagnosis.

Evaluating the Effect of Nursing-Performed Point-of-Care Ultrasound on Septic Emergency Department Patients

Introduction Nursing-performed point-of-care ultrasound (NP-POCUS) studies have been performed on applications such as ultrasound-guided peripheral intravenous line placement and assessing bladder volume. However, research on the use of NP-POCUS in the management of septic patients remains limited. The purpose of this quality improvement study was to investigate how NP-POCUS could impact fluid treatment decisions affecting septic patients in the emergency department (ED) using a focused IVC and lung ultrasound protocol. Methods Nurses received standardized training in POCUS and performed inferior vena cava (IVC) and lung ultrasound scans on septic patients in the ED at predetermined intervals (hours: zero, three, and six). Based on their findings, they were asked to make recommendations on fluid management. Emergency physicians (EPs), both residents and attendings, are providing recommendations for fluid management without the use of ultrasound, which is being compared to the nurse-driven POCUS assessment of fluid management. EPs reviewed the NP-POCUS assessments of patient fluid status to determine nursing accuracy. Results A total of 104 patients were scanned, with a mean age of 60.7 years. EPs agreed with nursing ultrasound assessments in 99.1% of cases. Nursing ultrasound images changed management or increased physician confidence in current treatment plans 83.7% and 96.6% of the time, respectively. Before reviewing saved nursing ultrasound images, EPs underestimated fluid tolerance in 37.5% of cases, overestimated fluid tolerance in 26% of cases, and correctly estimated fluid tolerance (within 500 ml) in 36.5% of cases. Throughout resuscitation, IVCs became less collapsible, the number of cases with B-lines was essentially unchanged, and less fluid was recommended. Conclusion  This study demonstrated that nurse-performed POCUS is feasible and may have a meaningful impact on how physicians manage septic patients in the emergency department.

Survey of echocardiography practice across five continents

BACKGROUND AND AIM

The term echocardiography refers to a diverse range of cardiovascular ultrasound imaging methods, both inside and outside specialist cardiology practice. While guidelines exist, we hypothesized that there are significant worldwide differences in the way echocardiography is practiced. We surveyed echocardiography practitioners around the world to characterize the workforce and their practice.

METHOD

Social media and word of mouth were used in an explosive sampling approach to recruit echo users, who then completed an online survey that included personal demographics and questions about their practice, their resources, and daily use of echocardiography.

RESULTS

In total, 594 participants completed the survey: 54.9% sonographers; 30% cardiologists, with the remainder other physicians or trainees. Significant variation in the number of echoes performed and the time allocated to scanning was observed. There were also differences in the gathering of adjunct measures such as blood pressure and body size.

CONCLUSION

There is wide variation in echocardiography practices across the world. Differences are likely to be both clinician- and healthcare system-driven. Guidelines for practice developed in well-resourced western countries and intended for use in cardiology-based echocardiography laboratories may not be applicable to other countries or indeed to new echo users.

New International Guidelines and Consensus on the Use of Lung Ultrasound

Following the innovations and new discoveries of the last 10 years in the field of lung ultrasound (LUS), a multidisciplinary panel of international LUS experts from six countries and from different fields (clinical and technical) reviewed and updated the original international consensus for point-of-care LUS, dated 2012. As a result, a total of 20 statements have been produced. Each statement is complemented by guidelines and future developments proposals. The statements are furthermore classified based on their nature as technical (5), clinical (11), educational (3), and safety (1) statements.

The Role of Hand-Held Cardiac Ultrasound in Patients with COVID-19

The role of point-of-care ultrasound (POCUS) in patient management has been established in recent years as an important tool. It is increasingly used by multiple medical disciplines in numerous clinical settings, for different applications and diagnostic purposes and in the guidance of procedures. The introduction of small-sized and inexpensive hand-held ultrasound devices (HUDs) has addressed some of the POCUS-related challenges and has thus extended POCUS' applicability. HUD utilization is even more relevant in the COVID-19 setting given the operators' infection risk, excessive workload concerns and general equipment contamination. This review focuses on the available technology, usefulness, feasibility and clinical applications of HUD for echocardiogram assessment in patients with COVID-19.

The current training for non‑echocardiographers in University Hospital Hradec Králové

Emergency echocardiography is a reproducible method providing clinically significant information during the process of primary assessment of the acute cardiovascular diseases. The main aim of the course is implementation of the emergency echocardiography by non-cardiologist is the standardization of the procedure, structured training system and agreement on the competences. The article summaries the current training for non-echocardiographers in University Hospital Hradec Králové.

Point-of-care ultrasound: An emerging clinical tool to enhance physical assessment

ABSTRACT

Point-of-care ultrasound (PoCUS) is a cost-effective diagnostic technology that, with training, is accessible, portable, and a convenient diagnostic modality to complement physical assessments. PoCUS is beneficial in that it can reduce the number of imaging tests required, while also mitigating barriers to healthcare for rural and remote communities.

The Parasternal Long Axis View in Isolation: Is it Good Enough?

BACKGROUND

Focused cardiac ultrasound (FOCUS) is a vital tool to evaluate patients at the bedside, but its use can be limited by patient habitus, sonographer skill, and time to perform the examination.

OBJECTIVE

Our primary goal was to determine the diagnostic accuracy of the parasternal long axis (PSLA) view in isolation for identifying pericardial effusion, left ventricular (LV) dysfunction, and right ventricular (RV) dilatation compared with a four-view FOCUS examination.

METHODS

This was a retrospective study looking at FOCUS images. Examinations were blinded and randomized for review by point-of-care ultrasound faculty. The primary objective was measured by comparing ultrasound findings on PSLA view in isolation with findings on a full four-view FOCUS examination, which served as the criterion standard. Sensitivity and specificity were calculated.

RESULTS

Of 100 FOCUS examinations; 36% were normal, 16% had a pericardial effusion, 41% had an LV ejection fraction < 50%, and 7% had RV dilatation. Sensitivity and specificity for identifying pericardial effusion, LV dysfunction, and RV dilatation were 81% (confidence interval [CI] 0.54-0.95) and 98% (95% CI 0.91-0.99), 100% (95% CI 0.88-1) and 91% (95% CI 0.80-0.97), and 71% (95% CI 0.30-0.94) and 99% (95% CI 0.93-1), respectively. All moderate to large effusions were identified correctly. Overall, there were only four clinically significant disagreements between PSLA alone and the four-view interpretations.

CONCLUSIONS

In isolation, the PSLA view was highly sensitive and specific for identifying LV ejection fraction and moderate to large pericardial effusions. It was highly specific for identifying RV dilatation, but had only moderate sensitivity.

Usefulness of Multi-Organ Point-of-Care Ultrasound as a Complement to the Decision-Making Process in Internal Medicine

Accumulated data show the utility of diagnostic multi-organ point-of-care ultrasound (PoCUS) in the assessment of patients admitted to an internal medicine ward. We assessed whether multi-organ PoCUS (lung, cardiac, and abdomen) provides relevant diagnostic and/or therapeutic information in patients admitted for any reason to an internal medicine ward. We conducted a prospective, observational, and single-center study, at a secondary hospital. Multi-organ PoCUS was performed during the first 24 h of admission. The sonographer had access to the patients’ medical history, physical examination, and basic complementary tests performed in the Emergency Department (laboratory, X-ray, electrocardiogram). We considered a relevant ultrasound finding if it implied a significant diagnostic and/or therapeutic change. In the second semester of 2019, we enrolled 310 patients, 48.7% were male and the mean age was 70.5 years. Relevant ultrasound findings were detected in 86 patients (27.7%) and in 60 (19.3%) triggered a therapeutic change. These findings were associated with an older age (Mantel−Haenszel χ2 = 25.6; p < 0.001) and higher degree of dependency (Mantel−Haenszel χ2 = 5.7; p = 0.017). Multi-organ PoCUS provides relevant diagnostic information, complementing traditional physical examination, and facilitates therapy adjustment, regardless of the cause of admission. Multi-organ PoCUS to be useful need to be systematically integrated into the decision-making process in internal medicine.

Motivations, barriers, and professional engagement: a multisite qualitative study of internal medicine faculty's experiences learning and teaching point-of-care ultrasound

BACKGROUND

Point-of-care ultrasound (POCUS) graduate medical education is expanding across many specialties, but a lack of trained faculty is a common barrier. Even well-designed faculty development programs struggle with retention, yet little is known about the experiences of practicing physicians learning POCUS. Our objective is to explore the experiences of clinician-educators as they integrate POCUS into their clinical and teaching practices to help inform curriculum design.

METHODS

Qualitative study using instrumental case study design to analyze interview data from 18 internal medicine clinician-educators at 3 academic health centers. Interviewees were recruited by program directors at each site to include participants with a range of POCUS use patterns. Interviews took place from July-August 2019.

RESULTS

Analysis yielded 6 themes: teaching performance, patient care, curriculum needs, workflow and access, administrative support, and professional engagement. Participants felt POCUS enhanced their teaching skills, clinical decision making, and engagement with patients. The themes highlighted the importance of longitudinal supervision and feedback, streamlined integration of POCUS into clinical workflow, and administrative support of time and resources. Interviewees reported learning and teaching POCUS helped combat burn-out and enhance their sense of professional engagement.

CONCLUSIONS

Learning POCUS as a practicing clinician-educator is a complicated endeavor that must take into account mastery of psychomotor skills, existing practice habits, and local institutional concerns. Based upon the themes generated from this study, we make recommendations to help guide POCUS faculty development curriculum design. Although this study focused on internists, the findings are likely generalizable to other specialties with growing interest in POCUS education.

The use of point-of-care ultrasound in new-onset dyspnea: an unexpected diagnosis

In this article, we report a patient with new-onset dyspnea and symptoms suggestive of heart failure, who had an unexpected diagnosis of a large left atrial myxoma with diastolic protrusion into the left ventricle. We further underline the role of cardiac Point-of-Care Ultrasound (POCUS) in the initial evaluation of patients with cardiac complaints in the emergency room setting. It can help to differentiate the patients' symptoms in order to achieve a more accurate diagnosis and thus increase the efficacy of the established therapy. In some cases, as with this patient, it can help to establish a diagnosis which needs prompt therapy.

Focus on POCUS: Carcinoid Heart Disease Found with Point-of-Care Ultrasound during Basic Physical Exam

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Use of POCUS aided in early identification of carcinoid heart disease.

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POCUS may increase the diagnostic accuracy of the cardiac examination.

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High-risk cardiac pathology can be visualized at earlier stages when POCUS is used.

Advanced Ultrasound and Photoacoustic Imaging in Cardiology

Cardiovascular diseases (CVDs) remain the leading cause of death worldwide. An effective management and treatment of CVDs highly relies on accurate diagnosis of the disease. As the most common imaging technique for clinical diagnosis of the CVDs, US imaging has been intensively explored. Especially with the introduction of deep learning (DL) techniques, US imaging has advanced tremendously in recent years. Photoacoustic imaging (PAI) is one of the most promising new imaging methods in addition to the existing clinical imaging methods. It can characterize different tissue compositions based on optical absorption contrast and thus can assess the functionality of the tissue. This paper reviews some major technological developments in both US (combined with deep learning techniques) and PA imaging in the application of diagnosis of CVDs.

Focal cardiac ultrasound learning with pocked ultrasound device: A bicentric prospective blinded randomized study

PURPOSE

Point-of-care ultrasound using a pocket-ultrasound-device (PUD) is increasing in clinical medicine but the optimal way to teach focused cardiac ultrasound is not clear. We evaluated whether teaching using a PUD or a conventional-ultrasound-device (CUD) is different when the final exam was conducted on a PUD. The primary aim was to compare the weighted total quality scale (WTQS, out of 100) obtained by participants in the two groups (CUD and PUD) on a live volunteer 2-4 weeks after their initial training. The secondary aims were to compare examination time and students' confidence levels (out of 50).

METHODS

This bicentric, prospective single-blind randomized trial included undergraduate medical students. After watching a 15 min video about echocardiography views, students had a 45 min hands-on training session with a live volunteer using a PUD or a CUD. The final examination was conducted with a PUD on a live volunteer.

RESULTS

Eighty-six comparable students were included, with 4 ± 1 years of medical training. In the PUD group, the mean WTQS was 65 ± 16 versus 60 ± 15 in the CUD group [p = 0.22; in multivariate analysis, OR 0.8 95% CI (0.1;1.6), p = 0.34]. The examination time was 10.0 [6.2-12.4] min in the PUD group versus 11.4 [7.3-13.2] in the CUD group (p = 0.39), while the confidence level was 27.9 ± 7.7 in the PUD group versus 27.4 ± 7.2 in the CUD group (p = 0.76).

CONCLUSION

There was no difference between teaching echocardiographic views using a PUD as compared to a CUD on the PUD image quality, exam time, or confidence level of students.

Stethoscope - An essential diagnostic tool or a relic of the past?

Rene Laennec came up with the idea of a stethoscope in 1816 to avoid the embarrassment of performing immediate auscultation on women. Soon many doctors around the world started using this tool because of its increased accuracy and ease of use. Stethoscopes hold great significance in the medical community. However, is the importance placed on stethoscopes justified today? We now have devices like portable ultrasound machines that make it much easier to visualize the body. These devices offset their higher initial cost by reducing downstream costs due to their greater accuracy and their capability of detecting diseases at an earlier stage. Also, because of the COVID-19 pandemic, new ways are being investigated to reduce the transmission of diseases. Stethoscopes being a possible vector for infectious agents coupled with the advent of newer devices that can visualize the body with greater accuracy put into question the continued use of stethoscopes today. With that said, the use of stethoscopes to diagnose diseases is still crucial in places where buying these new devices is not yet possible. The stethoscope is a great symbol of medicine, but its use needs to be in line with what is best for the patient.

Point-of-Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist

Point-of-Care Ultrasound (POCUS) is a valuable bedside diagnostic tool for a variety of expeditious clinical assessments or as guidance for a multitude of acute care procedures. Varying aspects of nearly all organ systems can be evaluated using POCUS and, with the increasing availability of affordable ultrasound systems over the past decade, many now refer to POCUS as the 21^st-century stethoscope. With the current available and growing evidence for the clinical value of POCUS, its utility across the perioperative arena adds enormous benefit to clinical decision-making. Cardiothoracic anesthesiologists routinely have used portable ultrasound systems for nearly as long as the technology has been available, making POCUS applications a natural extension of existing cardiothoracic anesthesia practice. This narrative review presents a broad discussion of the utility of POCUS for the cardiothoracic anesthesiologist in varying perioperative contexts, including the preoperative clinic, the operating room (OR), intensive care unit (ICU), and others. Furthermore, POCUS-related education, competence, and certification are addressed.

Evaluating Chest Pain and Heart Murmurs in Pediatric and Adolescent Patients

Chest pain and heart murmurs are common issues primary care providers must evaluate and manage. Both are a source of anxiety for patients, parents, and providers, necessitating evaluation and understanding to ensure appropriate management. Most pediatric chest pain can be treated symptomatically and with reassurance. This article examines the approach to pediatric chest pain including identification of key historical points, common causes of chest pain, and when to refer. The article also delineates our approach to auscultation, describes common benign murmurs, and offers suggestions on when to refer for further evaluation.

Review of X-ray and computed tomography scan findings with a promising role of point of care ultrasound in COVID-19 pandemic

As healthcare professionals continue to combat the coronavirus disease 2019 (COVID-19) infection worldwide, there is an increasing interest in the role of imaging and the relevance of various modalities. Since imaging not only helps assess the disease at the time of diagnosis but also aids evaluation of response to management, it is critical to examine the role of different modalities currently in use, such as baseline X-rays and computed tomography scans carefully. In this article, we will draw attention to the critical findings for the radiologist. Further, we will look at point of care ultrasound, an increasingly a popular tool in diagnostic medicine, as a component of COVID-19 management.

Current role of imaging in COVID-19 infection with recent recommendations of point of care ultrasound in the contagion: a narrative review

Radiological studies have an important role in the diagnosis and follow up of many infectious diseases. With current pandemic of Coronavirus disease 2019 (COVID-19) though the molecular analysis with reverse transcriptase polymerase chain reaction (RT-PCR) remains the cornerstone of diagnosis, the critical role of chest imaging including CT scan and baseline X-ray became apparent early in the course due to concern for less than optimal sensitivity of PCR testing. Delay in molecular diagnosis due to a shortage of testing kits and laboratory personnel also makes imaging an important modality in early diagnosis for appropriate triage and isolation decisions. CT scan technology is widely available in developed parts of the world but in developing countries, CT scanner is not widely available especially in rural settings. CT imaging usually requires patient movement to the radiology department and the scanner is not easy to disinfect. Point of care ultrasound (POCUS) has been used for many years in the assessment of critically ill patients in emergency departments and intensive care units. It is rapidly gaining popularity across many specialties and part of many general medicine training programs across the United States. It can be learned rapidly and with experienced hands, POCUS can help identify disease patterns in the lung parenchyma, and during the current pandemic has been gaining special attention. In this article, we review the most prominent imaging findings on chest X-ray and CT scan in patients with COVID-19. We also focus on the background and evolution of POCUS with studies showing the promising role of this diagnostic modality in COVID-19 infection. In addition, we describe step by step guidance on the use and disinfection of the portable ultrasound machine.

I Will Be at Your (Bed)Side - The Role of Bedside Echocardiography for Non-Cardiologists

As the availability of portable echocardiographic equipment is becoming more and more widespread, physicians can add a powerful tool to their bedside examination skills, thus helping them to more effectively face the growing complexity of patients admitted to internal medicine departments or the emergency room. Focused cardiac ultrasound (FoCUS) can be defined as a goal-directed, simplified, qualitative examination performed at the bedside using portable echocardiographic devices. FoCUS is not meant to be a substitute for a standard 2D color Doppler echocardiographic examination. Nevertheless, it can provide rapid and reliable information when limited to basic questions, even when performed by non-cardiologists with brief training. Furthermore, a focused cardiac ultrasound examination maximizes its diagnostic role when integrated with an ultrasonographic assessment of the lung, abdomen and deep veins, in a multisystem approach that is particularly dear to internists. In this article, we will focus on the specific targets of a focused cardiac ultrasound examination, as well as the most common pitfalls that can be encountered in ultrasonographic practice. We will also address the application of FoCUS in the management of two typical scenarios in clinical practice, such as dyspnea and non-post-traumatic hypotension.

“Asymptomatic” Flash Pulmonary Edema by Point-of-Care Ultrasound

A 65-year-old man with remitted chest pain and no tachypnea was taken urgently to catheterization because of diffuse lung ultrasound B-lines on bedside examination. He was found to have severe left-main disease. This case emphasizes the value of ultrasound to recognize acute cardiogenic interstitial pulmonary edema despite minimal symptoms. (Level of Difficulty: Advanced.)

The Modern Physical Exam - A Transatlantic Perspective from the Resident Level

Issue: The physical examination has been in decline for many years and poorer skills contribute to medical errors and adverse events. Diagnostic error is also increasing with the complexity of medicine. Comparing the physical examination in Ireland and the United States with a focus on education, assessment, culture, and health systems may provide insight into the decline of the physical exam in the United States, uncover possible strategies to improve clinical skills, and limit diagnostic error. Evidence: The physical exam is a core component of both undergraduate and postgraduate medical education in Ireland. This is reflected by the time and effort invested by medical schools and medical societies in Ireland in teaching and assessing skills. This high standard of skills results in the physical exam being a key component of the diagnostic process and a gatekeeper to expensive investigations essential in a resource-limited health system such as Ireland. Use of the physical exam in the United States is hindered by the high-tech transformation of healthcare and a more litigious society. Known strategies to highlight the role of the physical exam in clinical practice include creating an evidence base to show that better physical exam skills improve outcomes, identifying accurate physical exam maneuvers, stressing the therapeutic alliance the physical exam brings to the patient encounter, and the incorporation of technology into the bedside exam. Implications: Contrasting the education and clinical use of the physical examination in the United States with Ireland allowed us to identify a number of strategies which could be used to promote the physical exam among learners in both countries. Highlighting simple and pragmatic physical exam maneuvers combined with evidence-based physical exam diagnostic data may renew confidence in the physical exam as a core diagnostic tool. Use of the hypothesis-driven approach may streamline a clinician's physical exam during a patient encounter, focusing on the key examination components and avoiding unnecessary and low yield maneuvers. The absence of assessment of physical exam skills using real patients in United States licensing exams communicates to learners that these skills are not important. However, steps to introduce a culture of assessment to drive learning are being introduced. One area Ireland could learn from the United States is incorporating more technology into the bedside exam. Enhanced physical examination skills in both countries could reduce reliance on expensive investigations and improve diagnostic accuracy.

Development of a Focused Cardiac Ultrasound Image Acquisition Assessment Tool

Background: Focused cardiac ultrasound (FCU) is widely used by healthcare providers to answer specific questions about cardiac structure and function at the bedside. Currently, no widely accepted FCU image acquisition checklist exists to assess learners with varying skill levels from different specialties.

Objective: The primary objective of this project was to develop a consensus-based FCU image acquisition checklist using a multispecialty group of point-of-care ultrasound (POCUS) experts.

Methods: The essential components of an FCU examination were identified on the basis of published recommendations from echocardiography and international ultrasound societies. A checklist of the essential components of an FCU examination was drafted. A panel of POCUS experts from different medical specialties in the United States and Canada was convened to vote on each checklist item by answering two questions: 1) Is this item important to include in a checklist of essential FCU skills applicable to any medical specialty? and 2) Should the learner be required to successfully complete this item to be considered competent? A modified Delphi approach was used to assess the level of agreement for each checklist item during four rounds of voting. Checklist items that achieved an agreement of 80% or greater were included in the final checklist.

Results: Thirty-one POCUS experts from seven different medical specialties voted on sixty-five items to be included in the FCU image acquisition assessment tool. The majority of POCUS experts (61%) completed all four rounds of voting. During the first round of voting, 59 items reached consensus, and after revision and revoting, an additional 3 items achieved 80% or greater consensus. A total of 62 items were included in the final checklist, and 57 items reached consensus as a requirement for demonstration of competency.

Conclusion: We have developed a multispecialty, consensus-based FCU image acquisition checklist that may be used to assess the skills of learners from different specialties. Future steps include studies to develop additional validity evidence for the use of the FCU assessment tool and to evaluate its utility for the translation of skills into clinical practice.

Moving the needle towards the democratization of echocardiography: a case report

Background

Echocardiography has been traditionally performed in echo labs and the potential benefits of its use by primary care physicians (PCPs) are still unexplored. We present a case where POCUS (point-of-care ultrasound) was used as a complement of physical examination by a family doctor, allowing a prompt clinical decision in a heart failure (HF) patient.

Case summary

An 85-year-old woman, living independently, asks her family doctor for a home consultation due to increasing dyspnoea. On examination, severe dyspnoea and bilateral ankle oedema was noted and a point-of-care echocardiogram was performed by the primary care physician, who observed: severely compromised left ventricular systolic function, moderate mitral and tricuspid regurgitation, and severe dilation of the inferior vena cava. As a result, the diagnosis of HF with decreased ejection fraction was formed supporting the therapeutic decision.

Discussion

This case represents an elderly patient with dyspnoea, without previous HF diagnosis. The primary care physician, used portable ultrasound as a complement of physical examination, which confirmed a HF diagnosis, allowing a prompt decision-making on therapy. POCUS, can be a powerful tool to expedite treatment in different settings, including the home consultations by PCPs.

Preclerkship Point-of-Care Ultrasound: Image Acquisition and Clinical Transferability

INTRODUCTION

The integration of point-of-care ultrasound (POCUS) in preclerkship medical education is currently popular and based on the notion that POCUS may improve diagnostic and procedural skills in medical students. However, empirical evidence demonstrating that POCUS can enhance clinical skills in preclerkship students has been lacking. We sought to evaluate anatomical sonographic knowledge and ultrasound generation capabilities associated with the implementation of a 3-h echocardiography training camp led by 2 emergency physicians and using a flipped classroom design.

METHODS

Preclerkship students from the University of Ottawa (n = 32) were recruited to participate. A flipped classroom model was adopted, providing students with a 3-chaptered peer-designed, expert validated ultrasound manual before the workshop, to maximize scanning times (2 h of reading). A pretest Likert-type design was used to assess student perception of the ultrasound tool. Similarly, a pretest/post-test model was used to assess sonographic anatomical identification. In addition, a subsequent Objective Structured Clinical Examination (OSCE) test was done 3 weeks after the hands-on session, to evaluate image generation (4 cardiac views: parasternal long, parasternal short, subxiphoid, and apical 4 chambers), understanding of knobology and structural labeling.

RESULTS

For the sonographic anatomy, there was a statistically significant increase (P < .001) between pretest (average = 12.12) and post-test (average = 18.85). The OSCE, which also ascertained knowledge retention, found that 81% of students were able to generate all 4 cardiac views perfectly, 6% were able to obtain 3 views, 10% obtained 2 views and 3% successfully generated a single view. The most challenging scan to generate was the apical 4-chamber view.

CONCLUSION

The positive outcomes stemming from this study reinforces the notion that formal curricular integration of POCUS at the preclerkship level has tangible benefits for medical students.

Point-of-care ultrasound in Management for Dyspneic Uremic Patients: a case report

Background

Point-of-Care Ultrasound (PoCUS) is considered as an extension of clinicians’ patient care and can be integrated into daily clinical practice. Dyspnea is a common presentation in uremic patients. With the aids of PoCUS and integrated assessments of lung, heart and inferior vena cava (IVC), the etiology of dyspnea in uremic patients can be determined earlier.

Case presentation

A 67-year-old woman presented with progressive shortness of breath and bilateral legs edema for 3 weeks. The laboratory data revealed marked elevated level of serum creatinine and blood urea. A large amount of pericardial effusion was timely detected by PoCUS. Uremic pericarditis was suspected. Emergent hemodialysis was initiated and her symptoms improved.

Conclusions

PoCUS is a noninvasive and cost-effective imaging modality and it has been popular in the emergency department (ED). In uremic patients presenting with dyspnea, the integration of PoCUS into traditional physical examinations help emergency physicians narrow down the differential diagnoses.

Focused cardiac ultrasound in preoperative assessment: the perioperative provider's new stethoscope?

Focused cardiac ultrasound (FoCUS)—a simplified, qualitative version of echocardiography—is a well-established tool in the armamentarium of critical care and emergency medicine. This review explores the extent to which FoCUS could also be used to enhance the preoperative physical examination to better utilise resources and identify those who would benefit most from detailed echocardiography prior to surgery. Among the range of pathologies that FoCUS can screen for, the conditions it provides the most utility in the preoperative setting are left ventricular systolic dysfunction (LVSD) and, in certain circumstances, significant aortic stenosis (AS). Thus, FoCUS could help answer two common preoperative diagnostic questions. First, in a patient with high cardiovascular risk who subjectively reports a good functional status, is there evidence of LVSD? Second, does an asymptomatic patient with a systolic murmur have significant aortic stenosis? Importantly, many cardiac pathologies of relevance to perioperative care fall outside the scope of FoCUS, including regional wall motion abnormalities, diastolic dysfunction, left ventricular outflow obstruction, and pulmonary hypertension. Current evidence suggests that after structured training in FoCUS and performance of 20–30 supervised examinations, clinicians can achieve competence in basic cardiac ultrasound image acquisition. However, it is not known precisely how many training exams are necessary to achieve competence in FoCUS image interpretation. Given the short history of FoCUS use in preoperative evaluation, further research is needed to determine what additional questions FoCUS is suited to answer in the pre-operative setting.

Reliability of focused cardiac ultrasound performed by first-year internal medicine residents at a community hospital after a short training

The use of bedside ultrasound over the past few decades has created a new wave of options for visualizing pathological processes allowing for faster and better detection of disease. We aimed to evaluate the reliability of focused cardiac ultrasound (FCU) performed by first-year internal medicine residents at a community hospital after a short period of training. They received a two-hour lecture and initially performed a supervised FCU followed by ten unsupervised/independent FCUs each. The four parameters that were assessed were left systolic ventricular function, right systolic ventricular function, presence of pericardial effusion, and presence of IVC dilation. Interpretation and analysis of ultrasound images were then carried out by both the residents and an attending physician with expertise in FCU analysis and interpretation. Cohen's Kappa values were obtained comparing the results found by the interns versus the attending. Our findings indicate that more training is required for reliable analysis of FCU by first-year medical residents. Our results also emphasize the need to carefully evaluate the medical residents' FCU skills after the training.