POCUS in the PICU: A Narrative Review of Evidence-Based Bedside Ultrasound Techniques Ready for Prime-Time in Pediatric Critical Care

Point-of-care ultrasound (POCUS) is an accessible technology that can identify and treat life-threatening pathology in real time without exposing children to ionizing radiation. We aim to review current evidence supporting the use of POCUS by pediatric intensivists with novice-level experience with bedside ultrasound. Current evidence supports the universal adoption of POCUS-guided internal jugular venous catheter placement and arterial line placement by pediatric critical care physicians. Focused cardiac ultrasound performed by PICU physicians who have completed appropriate training with quality assurance measures in place can identify life-threatening cardiac pathology in most children and important physiological changes in children with septic shock. POCUS of the lungs, pleural space, and diaphragm have great potential to provide valuable information at the bedside after validation of these techniques for use in the PICU with additional research. Based on currently available evidence, a generalizable and attainable POCUS educational platform for pediatric intensivists should include training in vascular access techniques and focused cardiac examination. A POCUS educational program should strive to establish credentialing and quality assurance programs that can be expanded when additional research validates the adoption of additional POCUS techniques by pediatric intensive care physicians.

Prolapsing Intrigue: A Case of Superior Vena Cava Mass Visualized by Echocardiography From the Subcostal Window Unveiling an Anterior Mediastinal Type B2 Thymoma

Imaging the superior vena cava (SVC) during two-dimensional (2D) transthoracic echocardiographic examination is challenging and should be performed routinely. Here, we present a case where a lower (juxta-atrial) SVC mass was seen prolapsing into the right atrium by 2D transthoracic echocardiography; in this case, the imaging of the lower (juxta-atrial) SVC was done from the subcostal window. It was not possible to image the SVC from the suprasternal, right supraclavicular, left parasternal, or apical windows. CT scan of the chest with intravenous contrast was done in this case and showed an anterior mediastinal mass invading the SVC and prolapsing into the right atrium. CT-guided biopsy proved the mass to be a type B2 thymoma.

Accuracy of portable ultrasound for obstetric biometry

OBJECTIVE

We assessed the accuracy of two portable ultrasound machines (PUM) in obtaining fetal biometry and estimating gestational age.

METHODS

We analyzed data from the Fetal Age Machine Learning Initiative, an observational study of pregnant women in the United States and Zambia. Each participant underwent assessment by an experienced sonographer using both a high-specification ultrasound machine (HSUM) and a PUM (either Butterfly iQ or Clarius C3) to measure fetal biometry and calculate estimated gestational age (EGA) at each visit. Through comparison of paired PUM-HSUM scans, we estimated agreement between individual biometry measurements and aggregate gestational age estimates by reporting mean difference, along with intraclass correlation coefficient (ICC) and Bland-Altman plots, adjusting for trend.

RESULTS

881 participants contributed 1386 paired PUM-HSUM ultrasound studies between April and December 2021. PUM studies included 991 Butterfly and 395 Clarius. Gestational age at scan ranged from 7 to 38 weeks. Compared to HSUM, the Butterfly PUM had a mean difference of -0.20 days (95%CI±0.40) in the 1st trimester and -0.68 days (95%CI±0.68) in the 2nd/3rd trimesters. Also compared to HSUM, the Clarius PUM had a mean difference of 0.47 days (95%CI±0.64) in the 1st trimester and -1.67 days (95%CI±0.43) in the 2nd/3rd trimesters. ICCs were 0.989 or greater throughout. Increasing gestational age was associated with increasing error and absolute error. Both PUM devices demonstrated a modest trend toward underestimation of EGA at advancing gestational ages in 2nd/3rd trimester scans, compared to HSUM.

CONCLUSION

Both the Butterfly iQ and Clarius C3 PUM devices were highly accurate in performing fetal biometry in a diverse population from the US and Zambia. This article is protected by copyright. All rights reserved.

Exploring the role of point-of-care ultrasound for people with HIV in a resource affluent setting: A prospective observational study

BACKGROUND

In low resource settings point of care ultrasound (POCUS) has proven value for the detection of opportunistic diseases in HIV, especially tuberculosis. Few studies have explored POCUS in people with HIV and potential opportunistic infections in resource affluent settings.

METHODS

We performed a prospective observational study in the Netherlands. Outpatients newly diagnosed with HIV and a CD4 T-cell count below 350 cells/mm3 and inpatients with HIV on the infectious diseases ward were included. POCUS of chest and abdomen were performed to detect opportunistic diseases and patients were followed for 1 year to register the presence or absence of opportunistic diseases as detected during routine care. Primary outcome was the number of HIV-related and unrelated conditions detected by POCUS and interobserver variation (ClinicalTrials.gov registration NCT04246983).

RESULTS

We included 34 patients (79% males, median CD4 T-cell count 115/mm3). Observers had 97.5% agreement (Cohen's kappa for interobserver reliability 0.75). POCUS examination indicated at least one new opportunistic disease in 11 patients. In all these patients additional investigations confirmed opportunistic disease, predominantly Pneumocystis jirovecii pneumonia, bacterial pneumonia, Mycobacterium avium complex infection and lymphoma. In four patients an opportunistic disease was diagnosed in foci inaccessible for POCUS and a normal POCUS correctly excluded opportunistic diseases of the investigated structures in all patients, yielding a sensitivity of 73% and a specificity of 100%.

CONCLUSIONS

POCUS can be a reliable, valuable addition to physical examination of people with HIV and advanced immune suppression. The data support further exploration of POCUS in people with HIV in resource affluent settings.

Point-of-Care Ultrasound Unveils Life-Threatening Conditions: A Case Series Highlighting Its Vital Diagnostic Role

Point-of-care ultrasound (POCUS) has emerged as a powerful diagnostic tool in healthcare, offering rapid and cost-effective evaluation of cardiovascular and respiratory conditions. This case series highlights the vital role of POCUS in diagnosing life-threatening conditions and emphasizes the need for adequate training in its use. The first case describes a patient with chest pain, where POCUS revealed findings suggestive of thoracic aortic dissection, leading to timely transfer and surgical repair. The second case involves a patient with altered mental status and hypoxia, where POCUS identified a right atrial thrombus leading to thrombectomy. The discussion explores the expanding applications of POCUS in various medical specialties, including critical care and trauma, and its potential to improve patient outcomes. While POCUS has shown great promise, it remains a user-dependent technology, necessitating comprehensive training and collaboration among healthcare professionals to ensure its effective and safe use.

Point-of-Care Ultrasound Unveiling Rotator Cuff Injuries in the Emergency Department: A Case Series

Acute shoulder pain is a common ED presentation with a wide range of pathologies that are often initially investigated with radiography. However, diagnosing rotator cuff injuries often requires further imaging for proper diagnosis and management. Bedside shoulder ultrasound is an application that allows for the evaluation of ligaments and tendons in addition to bony structures, all while utilizing direct patient feedback of focally tender areas, expediting diagnosis and therapeutic intervention. In this case series, we discuss our evaluation of patients with suspected rotator cuff pathology and the practice of using the stepwise shoulder ultrasound protocol. Four cases are presented that illustrate the use of shoulder ultrasound in diagnosing biceps tendon injury, supraspinatus tear, chronic supraspinatus tear with hemarthrosis, and subacromial-subdeltoid bursitis. This narrative highlights the valuable role of shoulder ultrasound for the expedited diagnosis and management of patients whose initial shoulder radiographs do not indicate any bony abnormalities.

Difficult Intravenous Access Requiring Ultrasound in the Emergency Department: Associations With Delays in Care and Areas for Quality Improvement

Background Patients with difficult intravenous access (DIVA) requiring ultrasound-guided intravenous (USGIV) access have been associated with delays in treatment, imaging, and disposition in academic emergency department (ED) patient populations. Our objective in this study was to characterize differences in time to intravenous access, imaging, and disposition between patients with DIVA versus those without DIVA requiring USGIV access in a community ED while also assessing for DIVA-associated comorbidities. Methods A cross-sectional, observational analysis was performed on admitted ED patients evaluated from September 2 to September 31, 2022, at a community ED. Patients with DIVA were defined as patients with two failed attempts at traditional intravenous placement. These patients require USGIV placement per institutional protocol. Patients younger than 18 years of age, trauma admissions, repeated visits from the same patient, patients with missing data, and direct hospital admissions were excluded. Continuous variables were recorded with medians and included ED throughput measures of time to vascular access, contrast CT imaging, and disposition. Differences in median times between DIVA patients versus non-DIVA patients were assessed with the Mann-Whitney U-test. Categorical data involving comorbidities were reported as percentages, and differences in proportions between DIVA versus non-DIVA patients were assessed via chi-square tests. Multivariate logistic regression analysis evaluated for correlations between DIVA and times to access, contrast CT imaging, disposition, and significant covariates while adjusting for demographic information. Results A total of 1250 patients were included in this investigation (5.8% associated with DIVA requiring USGIV access). The median age of all subjects was 69 (interquartile range = 58, 79) with no significant difference between the DIVA and non-DIVA groups. Patients with DIVA were more likely to be female in comparison to patients without DIVA (65.3% and 51.2%, respectively, p < 0.05). Patients with a history of end-stage renal disease (ESRD) (p < 0.001), intravenous drug use (IVDU) (p < 0.001), and venous thromboembolism (p < 0.05) had statistically significant associations with DIVA. On regression analysis, patients with DIVA were more likely to have a history of ESRD with an odds ratio (OR) of 3.56 (95% confidence interval (CI): 1.62-7.81) and a history of IVDU with an OR of 14.29 (95% CI: 5.17-39.54). Patients with DIVA were associated with statistically significant greater median times to vascular access, contrast CT imaging, and disposition (p < 0.001 for time to access and disposition and p < 0.01 for time to contrast CT imaging). Conclusion In this study, DIVA cases requiring USGIV access were positively associated with significantly longer times to access, contrast CT imaging, and disposition compared to patients without DIVA at our community ED. Comorbidities such as IVDU and ESRD had statistically significant associations with DIVA requiring USGIV access.

Point-of-Care Ultrasound Overview and Curriculum Implementation in Internal Medicine Residency Training Programs in the United States

Point-of-care ultrasonography (POCUS) augments physical examination and expedites diagnostic care and clinical decision-making. The use of POCUS in internal medicine (IM) appears inconsistent despite its commendable benefits. It is not fully incorporated into the IM residency core competency skills or academic curriculum. This narrative literature review explores the benefits of POCUS and evaluates the need for an IM-focused POCUS curriculum. The obstacles and a proposed curriculum are also described.

Agreement on Interpretation of Point-of-Care Ultrasonography for Cardiac Tamponade Among Emergency Physicians

STUDY OBJECTIVE

Cardiac tamponade is an impending calamitous disorder that emergency physicians need to consider and diagnose rapidly. A pericardial effusion with right atrial systolic collapse (earliest sign) or right ventricular diastolic collapse (most specific sign) and a plethoric inferior vena cava are indicators of cardiac tamponade physiology and may be identified with point-of-care ultrasonography (POCUS). The goal of this study is to assess the agreement among emergency physicians with varying levels of sonographic training and expertise in interpreting echocardiographic signs of cardiac tamponade in adult patients.  Methods: Emergency physicians at different levels of training as sonographers were surveyed at didactic conferences at three major academic medical centers in northern New Jersey. Two cardiologists were also included in the study for comparison. Survey respondents were shown 15, 20-second video clips of patients who had presented to the emergency department (ED) with or without significant pericardial effusions and were asked to rate whether tamponade physiology was present or not. Data were collected anonymously on Google Forms (Google LLC, Mountain View, CA) and included self-reported levels of POCUS expertise and level of training. Data were analyzed using Fleiss' kappa (k). All patients had an echocardiogram performed by the department of cardiology within 24 hours of the POCUS, and the results are presented in the paper.  Results: There were 97 participant raters, including attendings, fellows, and resident physicians specializing in adult emergency medicine and two cardiologists. There was a fair degree of inter-rater agreement among all participants in interpreting whether tamponade physiology was present or not. This low level of agreement persisted across self-reported training levels and self-reported POCUS expertise, even at the expert level in both emergency medicine and cardiology specialties.

CONCLUSION

According to the results of our study, there appears to be a low level of agreement in the interpretation of cardiac tamponade in adult patients. The lack of agreement persisted across specialties, self-reported training levels, and self-reported ultrasonographic expertise. This low level of agreement seen among both specialists indicates that emergency physicians are not limited in their ability to determine cardiac tamponade on POCUS. This highlights the technical nature of POCUS clips and strengthens the importance of physical exam findings when diagnosing cardiac tamponade in emergency department patients. Further research utilizing POCUS for the diagnosis of tamponade is warranted.

The Effectiveness of Student-Led Musculoskeletal and Vascular Ultrasound Workshops at a Single Institution: A Retrospective Survey Analysis

Introduction Point-of-care ultrasound (POCUS) is a rapidly evolving field of diagnostic medicine as its low cost, portability, and versatility have made handheld ultrasound (US) probes an invaluable tool for many modern physicians. Despite US's benefits as a bedside evaluative tool, many medical schools have not integrated POCUS into their pre-clerkship medical education due to a lack of equipment and faculty. The first objective of our study was to determine whether student tutors (STs) would be effective resources to teach musculoskeletal (MSK) and vascular US to preclinical medical students. The second objective of our study was to determine whether students who previously attended ST-run MSK US workshops perform better in vascular US than those who did not. Methods Six POCUS workshops were led by STs after approval from experienced US faculty. These included US workshops on gastrointestinal structures, forearm structures, joint structures, basic echocardiography, and US-guided IV access. We collected data from two of our six workshops. We developed surveys to gauge the confidence and ability of students to perform US after an MSK workshop and US-guided IV access workshop led by STs. We also measured students' US abilities and collected student feedback after our US-guided IV access workshop. We evaluated students' US competency in US-guided IV access via their ability to correctly position the US probe, angle the needle of insertion, move the probe with the needle, and access the vein based on the accuracy of the movements. We divided student results into two groups: students who previously attended the MSK workshop before attending the US-guided IV access workshop and students who did not attend the MSK workshop before attending the US-guided IV access workshop. We used averages, frequencies, and two-tailed t-tests to analyze the survey responses and US-guided IV access skill assessments. Results Fifty percent of first- and second-year surveyed students "agreed," and 32.4% "strongly agreed" that they felt confident using US after an ST-run MSK workshop. About 29.4% of surveyed students "agreed" and 41.2% "strongly agreed" that they felt comfortable explaining basic US concepts, such as proper probe positioning and echogenicity. The group of students who attended the MSK workshop prior to the peripheral IV workshop scored similarly to the students who did not attend the MSK workshop (14.33±1.03 versus 14.20±0.84 points). Both groups of students had an average of over 94% accuracy in technique, positioning, angling, moving the US probe, and achieving US-guided venous access after being taught by STs. Qualitative surveying noted positive student feedback, such as "Teacher was great at guiding us through the procedure." Survey responses also included suggestions on adding and diversifying equipment, such as "[It would be useful to have a] different type of needle to see the difference on ultrasound." Conclusion Based on the high percentages of accuracy and confidence, we found that STs were effective resources to teach MSK and vascular POCUS and that students who attended previous MSK ST-run US workshops had stronger vascular US ability over time compared to those who did not. Our data support the use of STs as US educational resources, especially in institutions without an existing pre-clerkship US curriculum and limited US resources.

Point-of-Care Ultrasound (POCUS) Literature Primer: Key Papers on Renal and Biliary POCUS

Objective The objective of this study is to identify the top five influential papers published on renal point-of-care ultrasound (POCUS) and the top five influential papers on biliary POCUS in adult patients. Methods A 14-member expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. All panel members have had ultrasound fellowship training or equivalent, are actively engaged in POCUS scholarship, and are involved with POCUS at their local site and nationally in Canada. We used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five influential papers for renal POCUS and biliary POCUS. Results The panel identified 27 relevant papers on renal POCUS and 30 relevant papers on biliary POCUS. All panel members participated in all three rounds of the modified Delphi process, and after completing this process, we identified the five most influential papers on renal POCUS and the five most influential papers on biliary POCUS. Conclusion We have developed a list, based on expert opinion, of the top five influential papers on renal and biliary POCUS to better inform all trainees and clinicians on how to use these applications in a more evidence-based manner. This list will also be of interest to clinicians and researchers who strive to further advance the field of POCUS.

Diagnosing Pulmonary Embolism Using Point-of-Care Ultrasound in a Patient With Malingering and Coccidioidomycosis Infection

We report a case of a 41-year-old male diagnosed with pulmonary coccidioidomycosis and pulmonary embolism (PE) based on a point-of-care ultrasound (POCUS) finding who was suspected to be malingering for right-sided chest pain considering his psychiatric history. POCUS was performed and showed right ventricular strain with a D-shaped left ventricle and B-lines with subpleural consolidations, and PE was confirmed with computed tomography pulmonary angiography. No other risk factors for PE were found except for coccidioidomycosis. The patient was treated with apixaban and fluconazole and discharged in stable condition. We discuss the usefulness of POCUS in diagnosing PE and the very rare association between coccidioidomycosis and PE.

Morel-Lavallee Lesion: A Case of Lower Extremity Internal Degloving Injury

A 22-year-old female patient was seen in the emergency department with a two-week onset of progressively worsening pain and swelling to the medial aspect of her distal left femur. The patient was involved in an automobile versus pedestrian accident two months prior sustaining superficial swelling, tenderness, and bruising to the affected area. Radiographs revealed soft tissue swelling without osseous abnormalities. Examination of the distal femur region revealed a large, tender, ovoid area of fluctuance with a dark crusted lesion and surrounding erythema. Bedside ultrasonography revealed a large anechoic fluid collection in the deep subcutaneous plane with mobile internal echogenic debris which was suspicious for a Morel-Lavallee lesion. The patient underwent contrast enhanced CT of the affected lower extremity demonstrating a 8.7 cm x 4.1 cm x 11.1 cm fluid collection superficial to the deep fascia of the distal posteromedial left femur, confirming the diagnosis of a Morel-Lavallee lesion. A Morel-Lavallee lesion is a rare, post-traumatic degloving injury that results in the separation of the skin and subcutaneous tissues from the underlying fascial plane. The resultant disruption of the lymphatic vessels and underlying vasculature leads to progressively worsening hemolymph accumulation. If not recognized and treated in the acute or subacute period, complications can ensue. Complications of Morel-Lavallee include recurrence, infection, skin necrosis, neurovascular injury, as well as chronic pain. Treatment is based on the size of the lesion and ranges from conservative management and surveillance for small lesions to percutaneous drainage as well as debridement, sclerosing agents, and surgical fascial fenestration approaches for larger lesions. Additionally, the utilization of point-of-care ultrasonography can help in the early identification of this disease process. This is important as a delay in diagnosis and subsequent treatment of this disease state is associated with long-term complications.

Development and implementation of a comprehensive ultrasound curriculum for medical students: The Bonn internship point-of-care-ultrasound curriculum (BI-POCUS)

Background

Point-of-care ultrasound (POCUS) is rapidly gaining ground within different areas of applications. Despite the high and increasing relevance of ultrasound, the availability of structured training programs in medical schools is still limited. Therefore, many doctors keep acquiring all their ultrasound skills throughout their postgraduate training. As a result, new residents lack theoretical and practical ultrasound abilities that are critical in everyday clinical practice. In order to improve this, we created and implemented a complete ultrasound curriculum for all medical students throughout their internship year that focuses on hands-on abilities in ultrasound imaging.

Methods

We used Kern's six-step model of curricular development comprising (1) problem identification and general needs assessment, (2) needs assessment of the targeted learners, (3) goals and objectives, (4) educational strategies, (5) implementation, and (6) evaluation and feedback by board-certified ultrasound experts. A two rounds Delphi process with multilevel, self-completed questionnaires and individual using a 9-point Likert scale and free text comments was used to identify learning objectives and reach agreement on the content of the curriculum.

Results

The curriculum developed is aimed at students with no or little experience in their internship year and will be taught as part of their weekly-based internship training courses consisting of 2 hours of theory and 3 hours of practical training. The training will be conducted within a modular framework focusing on the key requirements of POCUS with increasing levels of complexity in accordance with the recommendations of the German Society for Ultrasound in Medicine (DEGUM), the European Federation of Societies for ultrasound in Medicine and Biology (EFSUMB) and the World Federation for ultrasound in Medicine and Biology (WFUMB). A longitudinal e-learning system will be implemented in addition to the practical and theoretical teaching units to track and examine the progress of the students.

Conclusion

Early integration of ultrasound training into medical education as part of a structured and standardized broad ultrasound curriculum enables medical students to acquire basic skills and apply them practically. Fundamental scanning skills are acquired by hands-on exercises in small, supervised groups as part of BI-POCUS. BI-POCUS therefore provides an excellent opportunity to improve the clinical skills of future physicians. More research is needed to analyze the learning outcomes for medical students and the improvement of the patient's outcome by establishing such an ultrasound curriculum.

Bradycardia as a Rare Sign of Pulmonary Embolism: A Case Report of Pulmonary Embolism Diagnosis in Cardiac Arrest Using Point-of-Care Ultrasound

We describe a case of cardiac arrest with pulmonary embolism and deep venous thrombosis diagnosed by point-of-care ultrasound, which resulted in a favorable outcome. In this article, we have also delineated bradycardia as an atypical sign of pulmonary embolism and explained the potential mechanism behind it.

Incidental Diagnosis of Honeycomb Gallbladder on Point-of-Care Ultrasound

Honeycomb gallbladder is a term that has been coined to describe a multiseptated gallbladder. In this case report, we describe a pregnant patient who had an extensive work-up of her abdominal pain and was found to have this incidental finding.

Incorporating personal-device-based point-of-care ultrasound into obstetric care: a validation study

BACKGROUND

Personal-device-based point-of-care-ultrasound (P-POCUS) probes plug directly into a cell phone or tablet to function as its display, creating the potential to increase access to obstetric ultrasonography in complex healthcare settings (COVID units, low resource settings); however, new technology must be proven to be reliable in the obstetric setting before integrating into practice.

OBJECTIVE

To evaluate the intraclass correlation (reliability) of personal-device-based-point-of-care-ultrasound devices as compared with standard ultrasound machines in obstetrics.

STUDY DESIGN

This was a prospective, observational study of patients between 19-39 weeks gestation in an urban, prenatal ultrasound diagnosis center. Each patient underwent assessment by an expert sonographer using standard ultrasound machines and personal-device-based-point-of-care-ultrasound devices to determine estimated fetal weight. The statistical reliability and agreement between the estimated fetal weights was assessed through intraclass correlation coefficients, Bland-Altman plots, and Pearson correlation coefficients.

RESULTS

100 paired sets of scans were performed from October 2020 to December 2020. For the estimated fetal weights, there was near-perfect agreement, with an intraclass correlation coefficient of 0.99 (P<.0001). Bland-Altman analysis showed an average difference of 53 grams, with 95% limit of agreement between -178 grams and 283 grams. Pearson correlation showed near-perfect correlation between the measurements (r=0.99, P<.0001).

CONCLUSION

personal-device-based point-of-care-ultrasound devices are reliable tools for performing basic obstetrical ultrasound and have the potential to increase access to obstetrical ultrasound worldwide.

Number Needed to Scan: Evidence-Based Point-of-Care Ultrasound (POCUS)

Interest and enthusiasm, regarding the use of point-of-care ultrasound (POCUS), continues to grow among clinicians in multiple medical specialties. Ultrasound machines technology has advanced to allow for smaller, even handheld machines. Integration of automated imaging technology has made these machines more user-friendly. However, one of the concerns with the widespread availability of POCUS is the overuse and misuse of this technology. In order to maximize the clinical impact of POCUS, this manuscript seeks to discuss a novel concept called the “Number needed to scan” (NNS). The NNS is an expression of the number of POCUS examinations needed to be performed to attain a benefit to the patient or to prevent an adverse outcome of a procedure. NNS serves a dual purpose: it can help clinicians understand the magnitude of clinical impact when they apply POCUS, and it can help clinicians explain this magnitude in layman terms to their patients. In this manuscript, we have focused our NNS calculations on landmark articles in three major categories: change in management; safety and accuracy; and catching a missed diagnosis. As clinicians seek to be good stewards of POCUS, NNS should be a concept used to consider which patients will be most likely to benefit from a clinician performed ultrasound.

Role of Point-of-Care Ultrasound in Diagnosing Cysticercosis

Soft-tissue swelling is common in clinical practice and few common causes are lipoma, sebaceous cyst, abscess, etc. Though rare, myocutaneous cysticercosis can also be a differential. Point-of-care ultrasound (POCUS) can help diagnose myocutaneous cysticercosis, which can predict neurocysticercosis among patients presenting with headaches and seizures. Myocutaneous cysticercosis is often seen as a cystic lesion with eccentric hyperechoic foci (scolex) in ultrasound. Here, we describe a case of multiple swellings in the neck and forearm associated with headache, which turned out to be myocutaneous cysticercosis and neurocysticercosis, diagnosed with the help of ultrasound.

McConnell in Shock

The ideal approach to hemodynamically unstable patients requires the quick identification of the type of shock and its etiology. This can be a challenge in critically ill patients due to the limited information, the wide number of differential diagnosis and the need for fast intervention. Point-of-care ultrasound (POCUS) is a non-invasive, low-cost, real-time and reliable tool used to rapidly and accurately assess hemodynamically unstable patients at the bedside. It can support diagnosis, tailor therapy and guide further workup, especially in patients deemed too unstable to undergo other imaging studies. The authors describe the case of a patient in obstructive shock due to pulmonary embolism, in which McConnell sign was identified by bedside echocardiography, before lab tests and pulmonary computerized tomography angiogram results were obtained

Ultrasound-Assisted Diagnosis of Embolic Cerebrovascular Accident From Left Atrial Myxoma in the Emergency Department

BACKGROUND

Acute-onset, unilateral weakness is an alarming presentation due to the possibility of a cerebrovascular accident. When considering cerebrovascular accidents in patients younger than 35 years, emergency physicians should evaluate embolic sources.

CASE REPORT

A 28-year-old man with no reported past medical history presented to the Emergency Department with a complaint of acute-onset left-sided hemiparesis and facial droop that started a day prior to arrival. He was stable, had unilateral weakness, hyperreflexia, and slightly slurred speech. He reported no sensory deficits. A computed tomography scan of the head demonstrated areas of ischemia. Patient demographics suggested an embolic source, so point-of-care-ultrasound (POCUS) was performed by emergency practitioners, leading to the discovery of a large, mobile, left atrial mass. After admission and confirmatory imaging, the mass was surgically removed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In young, otherwise healthy individuals, heart masses should be considered as a cause of unexplained stroke-like symptoms. POCUS can identify these masses and expedite care.

Perioperative Point-of-Care Ultrasound Use by Anesthesiologists

Point-of-Care ultrasound (POCUS) is the bedside utilization of ultrasound, in real-time, to aid in the diagnosis and treatment of patients. Image acquisition from POCUS utilization by anesthesiologists involves the assessment of multiple organs in different perioperative situations. POCUS can be utilized to enhance clinical decision-making in a variety of perioperative situations due to its ability to assess endotracheal tube placement, cardiac function, pulmonary function, aspiration risk, hemodynamics, vascular access, and nerve visualization for regional procedures. The mounting clinical evidence for the value of POCUS in perioperative settings, its growing affordability, and its low associated risks are responsible for the nationwide movement across many anesthesiology residency programs to increase the focus on perioperative ultrasound training. The purpose of this review is to present to current anesthesiologists and anesthesiology trainees, a broad discussion regarding the diverse utility and importance of POCUS in perioperative settings.

Images in Primary Care Medicine: Point-of-Care Ultrasound in Gout

Gout is the most common crystal arthropathy and is frequently diagnosed and managed by primary care physicians. Point-of-care ultrasound (POCUS) is a valuable tool to aid in the diagnosis of gout via the identification of the double contour sign, aggregates of crystals, tophi, and erosions. In addition, POCUS can aid in the management of gout by recognizing early signs of gout, monitoring the effectiveness of urate-lowering therapy, and guiding aspiration and corticosteroid injection.

Pneumothorax Following Acupuncture

Pneumothorax, the accumulation of air between the visceral and parietal pleurae, represents a potentially serious cause of chest pain in patients presenting to the emergency department. While there are known risk factors for spontaneous pneumothorax, in rare cases dry needling and acupuncture, forms of complementary and alternative medicine, have been known to result in pneumothorax.

We present a case of a 38-year-old healthy female who presented with acute onset of pleuritic chest pain to the Emergency Department. On further history, it was discovered that she had received dry needling acupuncture for unrelated back pain the day prior to presentation. She was initially investigated with an electrocardiogram (ECG), which was unremarkable, and point of care ultrasound (POCUS), which showed absent lung sliding and the presence of a lung point on the right side, indicative of pneumothorax. This case describes the key features of pneumothorax on POCUS and how POCUS can be a valuable tool in the diagnosis of lung pathologies and highlights the importance of considering the rare but potentially serious complications of complementary and alternative medicine practices which are typically regarded as safe.

A Step in the Right Direction: Point-of-Care Ultrasound as an Evaluation Tool of Achilles Tendon Injuries in the Emergency Department

This report describes the diagnosis of an Achilles tendon tear in a female patient with an inconclusive physical exam, which was limited by the patient’s body habitus. Expedient use of point-of-care ultrasound supported the diagnosis of an Achilles tear with findings of a tendinous defect, fibrous stranding, and surrounding anechoic fluid, suggestive of localized hemorrhage. The patient was splinted in plantar flexion and had prompt orthopedic referral with MRI that verified Achilles tear.

Training the Trainer: Faculty From Across Multiple Specialties Show Improved Confidence, Knowledge and Skill in Point of Care Ultrasound After a Short Intervention

Objectives  Lack of faculty skill and confidence in performing and teaching point-of-care ultrasound (POCUS) remains a significant barrier to implementation of a longitudinal ultrasound curriculum in undergraduate medical education. Our objective was to assess faculty comfort, knowledge and skill with performing and teaching POCUS before and after a focused workshop. Methods  This was a prospective study assessing faculty from multiple specialties. Faculty completed a pre- and post-workshop survey and ultrasound knowledge assessment, and a post-workshop objective structured clinical examination (OSCE) to assess ability to perform POCUS. Differences between pre- and post-workshop responses were analyzed using Fisher's Exact and Wilcoxon tests, and statistical significance was accepted for p<0.05. Results We analyzed data on 78 faculty from multiple disciplines. Faculty had a median of 7.5 years of experience with medical student teaching. Sixty-eight percent of faculty had performed <25 prior ultrasound (US) examinations. Comparing pre- to post-workshop responses, we found significant reductions in barriers to using US, and improved confidence with using, obtaining and interpreting POCUS (p<0.01). Faculty felt significantly more comfortable with the idea of teaching medical students POCUS (p<0.01). POCUS knowledge improved from 50% to 86% (p<0.01). On the post-workshop OSCE, 90% of anatomic structures were correctly identified with a median image quality of 4 out of 5. Conclusion After attending a six-hour workshop, faculty across multiple specialties had increased confidence with using and teaching POCUS, showed improved knowledge, and were able to correctly identify pertinent anatomic structures with ultrasound while obtaining good image quality.

Paddling Upstream With Point-of-Care Ultrasound to Diagnose Cardiac Ascites

Ascites has multiple etiologies, including cirrhosis and heart failure, which can be differentiated by point-of-care ultrasound (POCUS). One cause of cardiac ascites that can be difficult to identify is portopulmonary hypertension (PPH), a rare disorder caused by pulmonary artery vasoconstriction due to advanced liver disease. POCUS can readily identify right ventricular dysfunction which can accelerate a PPH diagnosis. This case report describes the use of POCUS to work-up new onset ascites and expedite diagnosis of cardiac ascites due to PPH.

Urinary Retention in a Patient With an Artificial Urinary Sphincter: A Case Report of a Rare Cause of Urinary Retention

Urinary retention is the inability to spontaneously void with lower abdominal or suprapubic pain caused by infection, trauma, obstruction, medications, or neurological etiologies. Acute urinary retention (AUR) is a urological emergency often seen in males presenting to the emergency department (ED). AUR is frequently seen in men over the age of 60 and approximately one-third of men over the age of 80. A 61-year-old Spanish-speaking male, with a history of prostate cancer and prostatectomy with the recent insertion of an artificial urethral sphincter two months prior, presented to the ED with urinary retention, complaining of malfunction in his artificial sphincter with worsening abdominal pain, distention, urinary urgency, and nausea. A bladder scan demonstrated 450 ml of urine. Bedside ultrasound (US) showed moderate bilateral hydronephrosis and hydroureter. After consultation with urology, they revealed that the patient did not understand how to properly use his implanted device. Urology experts have recommended minimal urethral instrumentation in patients with artificial urinary sphincters due to the risk of complications. Although we present a rare cause of urinary retention, emergency physicians should avoid catheterization in these patients. Bedside renal ultrasound is useful for the diagnosis of hydronephrosis and hydroureter and confirmation of pump and balloon placement. We recommend a prompt urology consultation. This case is an important example of appropriate postoperative education and close-ended communication. Certified interpreters should be used to avoid communication barriers and complications.

Right Heart Thrombus in Transit Diagnosed With Focused Cardiac Ultrasound in the Emergency Department

The diagnosis of a right heart thrombus (RHTh) in transit associated with pulmonary embolism (PE) is an uncommon phenomenon with a high mortality rate. Timely recognition of RHTh with focused cardiac ultrasound (FOCUS) in cases of suspected PE is necessary for critical decision making in the emergency department (ED). We present a case of RHTh with submassive PE in which the patient underwent successful catheter-directed thrombolysis. This case report illustrates the significance of an emergency physician (EP) implementing FOCUS during the initial ED evaluation to rapidly diagnose RHTh in transit and initiate PE therapy without delay.

A Case Report of Acute Heart Failure Due to Infective Aortic Endocarditis Diagnosed by Point-of-care Ultrasound

Introduction

Infective endocarditis (IE) is a life-threatening condition with significant morbidity and mortality, and can require surgical repair.

Case Report

A 36-year-old man presented to the emergency department for worsening dyspnea and chest pain. Point-of-care echocardiography demonstrated a mobile oscillating mass on the aortic valve with poor approximation of the valve leaflets, suggesting aortic valve insufficiency secondary to IE as the cause of acute heart failure. The patient underwent emergent aortic valve replacement within 24 hours.

Discussion

While point-of-care echocardiography has been well documented in identifying tricuspid vegetations, aortic valve involvement and subsequent heart failure is less well described. Earlier recognition of aortic valve vegetations and insufficiency can expedite surgical intervention, with decreased complication rates linked to earlier antimicrobial therapy.

Conclusion

This case report highlights the ability of point-of-care ultrasound to identify aortic vegetations, allowing for the earlier diagnosis and therapy.

Stakeholder Perceptions of Point-of-Care Ultrasound Implementation in Resource-Limited Settings

Background: Nearly half of the world lacks access to diagnostic imaging. Point of care ultrasound (POCUS) is a versatile and relatively affordable imaging modality that offers promise as a means of bridging the radiology gap and improving care in low resource settings. Methods: We performed semi-structured interviews of key stakeholders at two diverse hospitals where POCUS implementation programs had recently been conducted: one in a rural private hospital in Haiti and the other in a public referral hospital in Malawi. Questions regarding the clinical utility of POCUS, as well as barriers and facilitators of its implementation, were asked of study participants. Using the Framework Method, analysis of interview transcripts was guided by the WHO ASSURED criteria for point of care diagnostics. Results: Fifteen stakeholders with diverse roles in POCUS implementation were interviewed. Interviewees from both sites considered POCUS a valuable diagnostic tool that improved clinical decisions. They perceived barriers to adequate training as one of the most important remaining barriers to POCUS implementation. Conclusions: In spite of the increasing affordability and portability of ultrasounds devices, there are still important barriers to the implementation of POCUS in resource-limited settings.

Estimation of spleen size with hand-carried ultrasound

OBJECTIVES

Physical examination can identify palpable splenomegaly easily, but evaluating lesser degrees of splenomegaly is problematic. Hand-carried ultrasound allows rapid bedside assessment of patients. We conducted this study to determine whether hand-carried ultrasound can reliably assess spleen size.

METHODS

Patients with varying degrees of splenomegaly were studied. Two sonographers blindly measured spleen size in each patient using either a hand-carried or conventional ultrasound device in random order. Sonographers completed a data sheet indicating the adequacy of the image, clinical measurements of enlargement, and confidence in their observations.

RESULTS

Sixteen patients (10 male and 6 female; mean age ± SEM, 60 ± 4 years) were recruited. Image quality was adequate or better in all scans with conventional ultrasound and in 15 of 16 scans with hand-carried ultrasound. The greatest longitudinal measurement recorded was statistically equivalent across ultrasound techniques, with mean values of 16.4 cm (95% confidence interval, 14.8-18.0 cm) for conventional ultrasound and 15.8 cm (95% confidence interval, 14.1-17.4 cm) for hand-carried ultrasound. The correlation between measurement techniques was r = 0.89 (P < .0001). Sonographers were somewhat or very confident in the outcomes of all scans with conventional ultrasound and in 15 of 16 cases with hand-carried ultrasound. In general, it took longer for sonographers to obtain images with hand-carried ultrasound.

CONCLUSIONS

We have shown that hand-carried ultrasound can be used at the point of care by trained individuals to diagnose splenomegaly. However, hand-carried ultrasound images were less likely to be judged excellent, were accompanied by less diagnostic certainty, and took longer to obtain.