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Schwid M, Harris O, Landry A, Eyre A, Henwood P, Kimberly H. Use of a Refresher Course Increases Confidence in Point-of-Care Ultrasound Skills in Emergency Medicine Faculty. Cureus 2019; 11:e5413. [PMID: 31632866 PMCID: PMC6795372 DOI: 10.7759/cureus.5413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction All practicing emergency medicine (EM) physicians need to maintain a skillset in emergency ultrasound (US) after their initial training. EM physicians in academic practice may be supervising trainees performing ultrasound applications that they aren't comfortable with. This study investigates the effectiveness of a US refresher course. The hypothesis was that a series of short courses would increase confidence in performing and supervising US applications. Methods Nine basic emergency ultrasound applications were taught over the course of one year by ultrasound fellowship-trained EM faculty in a simulation center at a single academic institution. Each session included 30-minutes of didactics/image review and 30-minutes of hands-on practice on normal volunteers and was followed by an anonymous questionnaire evaluating comfort level performing and supervising the ultrasound application before and after the course using a Likert scale from 1 "not at all confident" to 5 "very confident". Results Thirty-six of 60 EM physicians participated in at least 1 of the 9 sessions (median 3, interquartile range 2-4). Faculty who attended had a median of 10 (interquartile range 7-15) years in practice and 61% work at both academic and community sites. For all sessions combined, confidence in performing US increased from a mean score on the Likert scale of 3.3 to 4.4 (difference 1.1, confidence interval (CI) (0.94, 1.29), p < 0.001) and confidence in supervising trainees increased from a mean of 3.4 to 4.5 (difference 1.1, CI (0.88, 1.23), p < 0.001). The largest increases were seen in musculoskeletal (MSK), nerve, and pelvic applications and the least increase was seen with the session focused on intravenous access, but confidence was increased in all sessions. Physicians in practice ≥10 years increased in confidence in performing and supervising the applications by 1.4 (CI (1.11, 1.60), p < 0.001) and 1.3, (CI (1.01, 1.49), p < 0.001), respectively. Physicians in practice <10 years increased 0.8 (CI (0.57, 1.03), p < 0.001) and 0.8 (CI (0.55, 1.05), p < 0.001), respectively. Conclusion An emergency ultrasound refresher course for EM physicians at a single institution improved self-reported confidence in both performing and supervising trainees in all applications reviewed. Those in practice ≥10 years showed the largest increases.
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Affiliation(s)
- Madeline Schwid
- Emergency Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, USA
| | - Owen Harris
- Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Adaira Landry
- Emergency Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, USA
| | - Andrew Eyre
- Emergency Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, USA
| | - Patricia Henwood
- Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Heidi Kimberly
- Emergency Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, USA
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102
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Mancusi C, Carlino MV, Sforza A. Point-of-care ultrasound with pocket-size devices in emergency department. Echocardiography 2019; 36:1755-1764. [PMID: 31393640 DOI: 10.1111/echo.14451] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 07/16/2019] [Accepted: 07/18/2019] [Indexed: 12/17/2022] Open
Abstract
Point-of-care ultrasound is a useful tool for clinicians in the management of patients. Particularly in emergency department, the role of point-of-care ultrasound is strongly increasing due to the need for a rapid assessment of critically ill patients and to speed up the diagnostic process. Hand-carried ultrasound devices are particularly useful in emergency setting and allow rapid assessment of patient even in prehospital setting. This article will review the role of point-of-care ultrasonography, performed with pocket-size devices, in the management of patients presenting with acute onset of undifferentiating dyspnea, chest pain, and shock in emergency department.
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Affiliation(s)
- Costantino Mancusi
- Hypertension Research Center, Department of Advanced Biomedical Science, Federico II University Hospital, Naples, Italy
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103
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Shokoohi H, LeSaux MA, Roohani YH, Liteplo A, Huang C, Blaivas M. Enhanced Point-of-Care Ultrasound Applications by Integrating Automated Feature-Learning Systems Using Deep Learning. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1887-1897. [PMID: 30426536 DOI: 10.1002/jum.14860] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 09/30/2018] [Indexed: 06/09/2023]
Abstract
Recent applications of artificial intelligence (AI) and deep learning (DL) in health care include enhanced diagnostic imaging modalities to support clinical decisions and improve patients' outcomes. Focused on using automated DL-based systems to improve point-of-care ultrasound (POCUS), we look at DL-based automation as a key field in expanding and improving POCUS applications in various clinical settings. A promising additional value would be the ability to automate training model selections for teaching POCUS to medical trainees and novice sonologists. The diversity of POCUS applications and ultrasound equipment, each requiring specialized AI models and domain expertise, limits the use of DL as a generic solution. In this article, we highlight the most advanced potential applications of AI in POCUS tailored to high-yield models in automated image interpretations, with the premise of improving the accuracy and efficacy of POCUS scans.
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Affiliation(s)
- Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maxine A LeSaux
- Department of Emergency Medicine, (George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Yusuf H Roohani
- Platform Technology and Science, GlaxoSmithKline, Cambridge, Massachusetts, USA
| | - Andrew Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Calvin Huang
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Blaivas
- Department of Emergency Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
- St Francis Hospital, Columbus, Georgia, USA
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Role of Parathyroid Hormone Assay and Bedside Ultrasound in the Emergency Department in Differentiating Acute Kidney Injury from Chronic Kidney Disease: A Systematic Review. Emerg Med Int 2019; 2019:2102390. [PMID: 30993021 PMCID: PMC6434274 DOI: 10.1155/2019/2102390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/28/2019] [Accepted: 02/21/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction It is not uncommon for patients without preceding history of kidney disease to present to the Emergency department with renal failure. The absence of prior medical records or renal imaging presents a diagnostic challenge. Elevated parathyroid hormone levels or echogenic contracted kidneys on ultrasound are known to point to a diagnosis of chronic kidney disease. The literature in this regard is surprisingly limited. The objective of this study is to assess the role of intact parathyroid (iPTH) blood level and bedside ultrasound in differentiating acute kidney injury from chronic kidney disease. Methods A systematic review which included a literature search of 3 databases, PubMed, Embase, and Cinahl (R) as also secondary sources, was done. The inclusion criteria evaluated studies which evaluated iPTH or bedside ultrasound in differentiating acute kidney injury from chronic kidney disease. We excluded studies which used other laboratory biomarkers like neutrophil gelatin associated lipocalin (NGAL) or carbamylated haemoglobin. A total of 2256 articles were identified. After screening, the relevant articles were reviewed, and an assessment of their methodological quality was made based on the CASP: Critical Appraisals Skill Programme. Results Of the 2256 articles identified, after screening, only 5 were identified as relevant. Conclusions An elevated parathyroid hormone level and echogenic contracted kidneys on bedside ultrasound in the Emergency department can help differentiate acute kidney injury from chronic kidney disease. This differentiation helps decide need for admission as well as further management. Although iPTH level may also rise in acute kidney injury, the value (2.5 times normal) can discriminate it from chronic kidney disease.
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105
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Shi D, Liu J, Xu J, Zhu H, Yu X. Evaluation of a new goal-directed training curriculum for point-of-care ultrasound in the emergency department: impact on physician self-confidence and ultrasound skills. Eur J Trauma Emerg Surg 2019; 47:435-444. [PMID: 30963185 PMCID: PMC8016812 DOI: 10.1007/s00068-019-01126-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/29/2019] [Indexed: 02/05/2023]
Abstract
Purpose Developing countries need effective and efficient training curriculum for the point-of-care ultrasound (POCUS) in the emergency department (ED). We have developed a new goal-directed training curriculum focusing on critical POCUS procedures used in ED. Methods To evaluate the impact of the new POCUS curriculum on ED physicians’ performance/self-confidence, we carried out a quasi-experimental trial at ED training center of Peking Union Medical College Hospital, in which we trained two groups of physicians using either traditional curriculum or the new goal-directed curriculum. We measured the confidence in performing Focused Assessment with Sonography in Trauma, thoracic, vascular, ultrasound-guided puncture, echocardiography and undifferentiated shock diagnostic ultrasound at baseline, training completion and 1 month after training. We also measured the performance skills at the time of training completion. The relative value of the new curriculum was evaluated by differences in the confidence and performance measurements, with control for baseline measurements and confounding characteristics in univariate analyses and multivariate linear regression models. Results After training, both groups of trainees reported significantly increased self-confidence in performing POCUS as compared with baseline. Trainees with the new curriculum had statistically significant higher self-confidence increase and performance scores (p < 0.05), e.g., increase in confidence for diagnosis of undifferentiated shock at training completion = 3.14 vs. 1.85, 1 month after training = 2.22 vs. 1.56, for new and traditional curriculum, respectively. The new curriculum also resulted in a higher number of shock POCUS done within 1 month after training: 1.73 vs. 0, and higher overall performance scores: 165 vs. 113. The findings were robust when controlling for imbalanced baseline characteristics in multivariate regression models. Conclusion We conclude that a goal-directed, intensive but brief ED POCUS curriculum significantly increases trainee self-confidence, performance, and promote trainees to perform more procedures.
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Affiliation(s)
- Di Shi
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Jihai Liu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
| | - Jun Xu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Huadong Zhu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Xuezhong Yu
- Department of Emergency Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
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106
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Ojaghihaghighi S, Lombardi KM, Davis S, Vahdati SS, Sorkhabi R, Pourmand A. Diagnosis of Traumatic Eye Injuries With Point-of-Care Ocular Ultrasonography in the Emergency Department. Ann Emerg Med 2019; 74:365-371. [PMID: 30905470 DOI: 10.1016/j.annemergmed.2019.02.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 01/28/2019] [Accepted: 02/01/2019] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE Traumatic eye injuries are common emergency department presentations worldwide, and diagnosis may be delayed because of concurrent injuries and lack of guidelines in regard to the utility of clinical examination, computed tomography (CT), and point-of-care ultrasonography. In this study, we compare point-of-care ultrasonography with ophthalmologist clinical examination and CT for 6 types of traumatic eye injury. METHODS We conducted a prospective cohort study evaluating patients with suspected traumatic eye injury who were recruited at an academic medical center in Tabriz, Iran. Each patient was evaluated by an emergency physician with point-of-care ultrasonography using a 7- to 15-MHz linear transducer, by a radiologist with orbital CT imaging, and by an ophthalmologist with a complete bedside ocular examination. Obtained results were tabulated. Sensitivity, specificity, and likelihood ratios were subsequently calculated. Cohen's κ was assessed to evaluate the agreement between ocular point-of-care ultrasonography with orbital CT and point-of-care ultrasonography with complete bedside ocular examination. RESULTS Two hundred thirty-two patients (351 eyes) with suspected traumatic eye injury were included. In all measures of accuracy, diagnosis by point-of-care ultrasonography compared favorably with CT and a complete bedside ocular examination by an ophthalmologist in the 6 ocular injury patterns included in this study. Compared with CT imaging, point-of-care ultrasonography provided a specificity of 99.4% (95% confidence interval [CI] 97.8% to 99.9%) and a sensitivity of 96.8% (95% CI 83.3% to 99.9%) in the diagnosis of lens dislocation, and a specificity of 99.7% (95% CI 98.3% to 100.0%) and sensitivity of 95.7% (95% CI 78.1% to 99.9%) in the diagnosis of retrobulbar hematoma. Compared with complete bedside ocular examination by an ophthalmologist, point-of-care ultrasonography provided a specificity of 98.7% (95% CI 96.7% to 99.6%) and sensitivity of 97.8% (95% CI 88.2% to 99.9%) in the diagnosis of vitreous hemorrhage. In all injury types, positive likelihood ratios were high and negative ones were low. CONCLUSION Point-of-care ultrasonography demonstrates high sensitivity and specificity in the diagnosis of traumatic eye injury, and represents a valuable diagnostic tool in addition to orbital CT and complete beside ocular examination by an ophthalmologist in the diagnosis of traumatic eye injury.
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Affiliation(s)
| | - Kevin M Lombardi
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Steven Davis
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Samad S Vahdati
- Department of Emergency Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rana Sorkhabi
- Department of Emergency Medicine, Tabriz University of Medical Sciences, Tabriz, Iran; Department of Ophthalmology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC.
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107
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Leschyna M, Hatam E, Britton S, Myslik F, Thompson D, Sedran R, VanAarsen K, Detombe S. Current State of Point-of-care Ultrasound Usage in Canadian Emergency Departments. Cureus 2019; 11:e4246. [PMID: 31131169 PMCID: PMC6516619 DOI: 10.7759/cureus.4246] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/13/2019] [Indexed: 01/10/2023] Open
Abstract
Background Point-of-care ultrasound (POCUS) has many applications in emergency medicine, which have been proven to improve patient outcomes. Training programs and well-established guidelines for its use are available, but Canadian adoption rates and attitudes toward this technology have not been recently assessed. Objectives This study aimed to provide a national assessment of the current use of POCUS in Canadian emergency departments (ED) including patterns of use, attitudes towards its role, descriptors of training experience, as well as barriers to increased utilization. Methods An electronic survey was sent to physician members of the Canadian Association of Emergency Physicians. The survey included questions related to demographics, attitudes towards POCUS, POCUS utilization, and barriers to POCUS use. Responses were statistically analyzed to identify significant associations. Results Responses demonstrated a strong association between POCUS training and amount of POCUS usage. Neither hospital type nor community type was associated with the degree of POCUS usage. POCUS was most widely adopted for Canadian Point of Care Ultrasound Society (CPOCUS) core applications and has increased since the last national survey. The most commonly reported barrier to increased POCUS adoption was the lack of training. Most physicians have formal POCUS training in core applications, and approximately one third have advanced training. Conclusions POCUS training and utilization appear to have increased since the last national assessment. This provides a foundation for future POCUS research.
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Affiliation(s)
- Mason Leschyna
- Family Medicine, London Health Sciences Centre, University of Western Ontario, London, CAN
| | - Erfun Hatam
- Emergency Medicine, London Health Sciences Centre, University of Western Ontario, London, CAN
| | | | - Frank Myslik
- Emergency Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, CAN
| | - Drew Thompson
- Emergency Medicine, London Health Sciences Centre, University of Western Ontario, London, CAN
| | - Robert Sedran
- Emergency Medicine, London Health Sciences Centre, University of Western Ontario, London, CAN
| | - Kristine VanAarsen
- Emergency Medicine, London Health Sciences Centre, University of Western Ontario, London, CAN
| | - Sarah Detombe
- Emergency Medicine, London Health Sciences Centre, University of Western Ontario, London, CAN
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108
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Prats MI, Nelson BP, Gold DL, Branditz LD, Boulger CT, Bahner DP. CLEAR: A Novel Approach to Ultrasound Equipment Homeostasis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:767-773. [PMID: 30121948 DOI: 10.1002/jum.14757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 06/20/2018] [Accepted: 06/20/2018] [Indexed: 06/08/2023]
Abstract
Protocols for the sanitation and maintenance of point-of-care ultrasound (US) equipment are lacking. This study introduces the CLEAR protocol (clean, locate, energize, augment supplies, and remove patient identifiers) as a tool to improve the readiness of US equipment, termed US equipment homeostasis. The state of US equipment homeostasis in the emergency department of a single academic center was investigated before and after implementing this protocol, with an improvement in outcomes. These findings demonstrate that the CLEAR protocol can improve US homeostasis. CLEAR can function as a teaching tool to promote homeostasis as well as a checklist to assess compliance.
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Affiliation(s)
- Michael I Prats
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bret P Nelson
- Department of Emergency Medicine, Division of Emergency Ultrasound, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Delia L Gold
- Department of Pediatrics, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lauren D Branditz
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Creagh T Boulger
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David P Bahner
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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109
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Phillips L, Hiew M. Point of care ultrasound: Breaking the sound barrier in the emergency department. Australas J Ultrasound Med 2019; 22:3-5. [PMID: 34760529 PMCID: PMC8411775 DOI: 10.1002/ajum.12129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Luke Phillips
- Emergency & Trauma CentreThe Alfred HospitalCommercial RoadMelbourneVictoria3004Australia
- Emergency Medicine Ultrasound Group (EMUGs)Virtual OfficeMelbourneVictoria3000Australia
| | - Melody Hiew
- Emergency Medicine Ultrasound Group (EMUGs)Virtual OfficeMelbourneVictoria3000Australia
- Emergency DepartmentCasey HospitalMonash Health62‐70 Kangan DriveBerwickVictoria3806Australia
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110
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Collins K, Collins C, Kothari A. Point-of-care ultrasound in obstetrics. Australas J Ultrasound Med 2019; 22:32-39. [PMID: 34760534 PMCID: PMC8411729 DOI: 10.1002/ajum.12133] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Point-of-care ultrasound, or PoCUS, where imaging is undertaken at the bedside, clinic or emergency department (ED) by the clinician overseeing treatment, is a rapid form of assessment that may be undertaken alongside or as an alternative to traditional, formal ultrasound performed by a radiology service. PoCUS reduces the time to diagnosis, thus allowing lifesaving treatment to be initiated. This is particularly relevant in Obstetrics and Gynaecology (OBGYN), where delayed diagnosis of pregnancy complications is often fatal or highly debilitating to the mother or fetus. The literature suggests that PoCUS is particularly useful in areas that are inadequately resourced, as it is relatively cheap and accessible. High-quality training is essential to ensure that the staff performing the scans are adequately qualified to deliver the service. Clinicians who perform PoCUS in their practice should be aware of the appropriate indications, as well as when to refer for formal imaging.
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Affiliation(s)
- Kelly Collins
- Northwest Private Hospital137 Flockton streetEverton ParkQueensland4053Australia
| | - Craig Collins
- Redcliffe HospitalAnzac AvenueRedcliffeQueensland4020Australia
| | - Alka Kothari
- Redcliffe HospitalAnzac AvenueRedcliffeQueensland4020Australia
- University of QueenslandSt LuciaQueensland4072Australia
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111
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Baron A, Beirne G, Wald A. Paramedic point of care ultrasound at Australian mass gatherings. Australas J Ultrasound Med 2019; 22:56-60. [PMID: 34760538 PMCID: PMC8411800 DOI: 10.1002/ajum.12132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Point of care ultrasound (POCUS) is not traditionally performed by paramedics, and where it is used, is generally limited to resuscitative-type ultrasound examinations. We describe a select series of patient care cases collected between August 2017 and February 2018 which are the first known examples of expanded POCUS performed by a paramedic in this context. These point of care scans were performed for both high and lower acuity patient presentations and are felt to have contributed to improved decision-making in the treatment and onward referral of patients in the Australian festival and event medicine.
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Affiliation(s)
- Aidan Baron
- Paramedic Ultrasound Research GroupSydneyAustralia
- Emergency Cardiovascular and Critical Care Research GroupCentre for Health and Social Care ResearchKingston University and St George's University of LondonLondonUK
- Discipline of ParamedicineSchool of Biomedical SciencesFaculty of ScienceCharles Sturt UniversityAlburyNew South WalesAustralia
| | | | - Anthony Wald
- Paramedic Ultrasound Research GroupSydneyAustralia
- Monash Cardiovascular Research CentreMonashHeartMonash Medical CentreMelbourneVictoriaAustralia
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113
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Battle C, Hayward S, Eggert S, Evans PA. Comparison of the use of lung ultrasound and chest radiography in the diagnosis of rib fractures: a systematic review. Emerg Med J 2018; 36:185-190. [PMID: 30470688 DOI: 10.1136/emermed-2017-207416] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 09/30/2018] [Accepted: 11/13/2018] [Indexed: 11/03/2022]
Abstract
INTRODUCTION It is well-recognised that the detection of rib fractures is unreliable using chest radiograph. The aim of this systematic review was to investigate whether the use of lung ultrasound is superior in accuracy to chest radiography, in the diagnosis of rib fractures following blunt chest wall trauma. METHODS The search filter was used for international online electronic databases including MEDLINE, EMBASE, Cochrane and ScienceDirect, with no imposed time or language limitations. Grey literature was searched. Two review authors completed study selection, data extraction and data synthesis/analysis process. Quality assessment using the Quality Assessment of Diagnostic Accuracy Studies Tool (QUADAS-2) was completed. RESULTS 13 studies were included. Overall, study results demonstrated that the use of lung ultrasound in the diagnosis of rib fractures in blunt chest wall trauma patients appears superior compared with chest radiograph. All studies were small, single centre and considered to be at risk of bias on quality assessment. Meta-analysis was not possible due to high levels of heterogeneity, lack of appropriate reference standard and poor study quality. DISCUSSION The results demonstrate that lung ultrasound may be superior to chest radiography, but the low quality of the studies means that no definitive statement can be made.
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Affiliation(s)
- Ceri Battle
- Welsh Centre in Emergency Medicine Research, Morriston Hospital, Swansea, UK
| | - Simon Hayward
- Physiotherapy Department, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Sabine Eggert
- Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK
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114
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Varndell W, Topacio M, Hagness C, Lemon H, Tracy D. Nurse-performed focused ultrasound in the emergency department: A systematic review. Australas Emerg Care 2018; 21:121-130. [DOI: 10.1016/j.auec.2018.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 08/22/2018] [Accepted: 09/30/2018] [Indexed: 01/12/2023]
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115
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Waring L, Miller PK, Sloane C, Bolton G. Charting the practical dimensions of understaffing from a managerial perspective: The everyday shape of the UK's sonographer shortage. ULTRASOUND (LEEDS, ENGLAND) 2018; 26:206-213. [PMID: 30479635 PMCID: PMC6243452 DOI: 10.1177/1742271x18772606] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/30/2018] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Across the last two decades, ultrasound services in many healthcare sectors have become increasingly pressurised as a consequence of upsurging demand and difficulties in recruiting viable clinicians. Indeed by 2013, the UK government's Migration Advisory Committee had listed sonography as an official 'shortage specialty'. Comparatively little research has to date, however, explored the impacts of this situation upon the departments themselves, and the individuals working therein. The core purpose of this study is, thus, to lend qualitative depth to current understandings of the frontline situation in the UK's ultrasound units, many of which are understaffed, from the perspective of their managers. METHODS Using a thematic analysis informed by a Straussian model of Grounded Theory, N = 20 extended accounts provided by ultrasound department leads in public (n = 18) and private (n = 2) units were explored. RESULTS Four global themes emerged from the analysis of which the first two (the broadly sociological matters) are described in this paper. Theme 1 addresses how a lack of staff in the broader ultrasound economy has created a troublesome migratory system in contemporary UK ultrasound. Theme 2 addresses how this economy works chiefly to the advantage of the most junior and the most senior clinicians, often leaving mid-career professionals in the borderline impossible situation of having to concurrently occupy both junior and senior roles. CONCLUSIONS The findings ideally open up debate on some key practical contingencies of the UK's sonographer shortage, and reflect upon literature regarding the nuanced aspects of a shifting healthcare workplace constitution.
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Affiliation(s)
- Lorelei Waring
- Department of Medical and Sport Sciences, University of Cumbria, Lancaster, UK
| | - Paul K Miller
- Department of Medical and Sport Sciences, University of Cumbria, Lancaster, UK
| | - Charles Sloane
- Department of Medical and Sport Sciences, University of Cumbria, Lancaster, UK
| | - Gareth Bolton
- Department of Medical and Sport Sciences, University of Cumbria, Lancaster, UK
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The Benefit of Ultrasound in Deciding Between Tube Thoracostomy and Observative Management in Hemothorax Resulting from Blunt Chest Trauma. World J Surg 2018; 42:2054-2060. [PMID: 29305713 DOI: 10.1007/s00268-017-4417-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hemothorax is most commonly resulted from a closed chest trauma, while a tube thoracostomy (TT) is usually the first procedure attempted to treat it. However, TT may lead to unexpected results and complications in some cases. The advantage of thoracic ultrasound (TUS) over a physical examination combined with chest radiograph (CXR) for diagnosing hemothorax1 has been proposed previously. However, its benefits in terms of avoiding non-therapeutic TT have not yet been confirmed. Therefore, this study is aimed to evaluate the severity of hemothorax in blunt chest trauma patients by using TUS in order to avoid non-therapeutic TT in stable cases. METHODS The data from 46,036 consecutive patient visits to our trauma center over a four-year period were collected, and those with blunt chest trauma were identified. Patients who met any of the following criteria were excluded: transferred from another facility, with an abbreviated injury scale (AIS) score ≥ 2 for any region except the chest region, with a documented finding of tension pneumothorax or pneumothorax >10%, younger than 16 years old and with indications requiring any non-thoracic major operation. The decision to perform TT for those patients in the non-TUS group was made on the basis of CXR findings and clinical symptoms. The continuous data were analyzed by using the two-tailed Student's t test, and the discrete data were analyzed by Chi-square test. RESULTS A total of 84 patients met the criteria for inclusion in the final analysis, with TT having been performed on 42 (50%) of those patients. The mean volume of the drainage amount was 860 ml after TT. The TT drainage was less than 500 ml in 12 patients in the non-TUS group (40%), while none was less than 500 ml in the TUS group (p = 0.036, Fisher's exact test). In terms of the positive rate of subsequent effective TT, the sensitivity of TUS was 90% and the specificity was 100%. There were 3 patients with delayed hemothorax: 2 of the 58 (3.6%) in the non-TUS group and 1 of 26 (4.5%) in the TUS group (p > 0.05, Fisher's exact test). The hospital length of stay in the non-TUS group with non-therapeutic TT was significantly longer than in the TUS group without TT (8.2 vs. 5.4 days, p = 0.018). There were no other major complications or deaths in either group during the 90-day follow-up period. CONCLUSION In the case of blunt trauma, TUS can rapidly and accurately evaluate hemothorax to avoid TT in patients who may not benefit much from it. As a result, the rate of non-therapeutic TT can be decreased, and the influence on shortening hospital length of stay may be further evaluated with prospective controlled study.
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Prospective Evaluation of Point-of-Care Ultrasound at a Remote, Multi-Day Music Festival. Prehosp Disaster Med 2018; 33:484-489. [DOI: 10.1017/s1049023x18000821] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
AbstractIntroductionPoint-of-Care Ultrasound (POCUS) has become an important diagnostic tool for hospital-based clinicians. This study assesses the role of POCUS at Pemberton Music Festival 2016 (Pemberton, British Columbia [BC], Canada), a remote mass gathering where physicians face limited resources, complex disposition decisions, and a dynamic clinical environment.ObjectivesThis study prospectively evaluated the impact of POCUS on patient diagnosis, management, and disposition based on the self-report of the study physicians. The authors hypothesized that having ultrasound available for use would aid in diagnostic and management decisions and would reduce the need to transfer patients off-site to other health care facilities, reducing impact on the acute health services in the host community.MethodsA handheld ultrasound was available for use by physicians in the main medical tent. All participating physicians self-reported their training and comfort using POCUS. After each POCUS scan, physicians completed a survey and recorded the indication for use, scans performed, and impact on patient diagnosis, management, and disposition.ResultsIn total, POCUS was used on 28 of the 686 patients treated in the main medical tent; POCUS was reported to narrow the differential diagnosis in 64% of cases and altered the working diagnosis in 21% of cases. Its use changed the management plan in 39% of patients. Its use was reported to reduce the burden on broader health care resource utilization in 46% of cases and prevented ambulance transport off-site in 32% of cases (nine cases in total). This corresponded to an absolute risk reduction of 1.3% for the percentage of patients transferred to hospital (PPTH; relative risk reduction of 53%).Conclusion:Physicians reported that POCUS improved the diagnosis, management, and disposition of select patients at a remote, multi-day music festival. Also, POCUS reduced ambulance transfers off-site and reduced the perceived burden on broader health care utilization.PragerR, SedgwickC, LundA, KimD, HoB, StachuraM, GutmanS. Prospective evaluation of point-of-care ultrasound at a remote, multi-day music festival. Prehosp Disaster Med. 2018;33(5):484–489.
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Iqhbal M, Noor JM, Karim NA, Ismail I, Sanib H, Mokhtar MA, Salim SSF. Point-of-Care Airway Ultrasonography Prior to an Emergency Cricothyroidotomy: Case Report. Sultan Qaboos Univ Med J 2018; 18:e219-e222. [PMID: 30210855 DOI: 10.18295/squmj.2018.18.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/08/2018] [Accepted: 02/01/2018] [Indexed: 01/12/2023] Open
Abstract
The use of ultrasonography in acute and critical care medicine is becoming increasingly common. However, use of an airway ultrasound as an adjunct to determine the type of intervention needed and assess complications is not common practice. We report a 56-year-old male who presented to the Emergency Department of the Sungai Buloh Hospital, Selangor, Malaysia, in 2015 with hoarseness, stridor and impending respiratory failure. A point-of-care ultrasound performed to assess the neck and vocal cords indicated a heterogeneous echogenic mass in the larynx, thus ruling out a cricothyroidotomy. The patient was therefore referred for an emergency tracheostomy. This case highlights the importance of point-of-care airway ultrasonography in the assessment of patients with stridor. This imaging technique not only helps to detect the cause of the stridor, but also to determine the feasibility of a cricothyroidotomy in emergency cases.
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Affiliation(s)
- Mohamad Iqhbal
- Department of Emergency Medicine, Faculty of Medicine, MARA University of Technology, Selangor, Malaysia
| | - Julina M Noor
- Department of Emergency Medicine, Faculty of Medicine, MARA University of Technology, Selangor, Malaysia
| | - Nur A Karim
- Department of Emergency Medicine, Faculty of Medicine, MARA University of Technology, Selangor, Malaysia
| | - Izzat Ismail
- Department of Emergency Medicine, Faculty of Medicine, MARA University of Technology, Selangor, Malaysia
| | - Halim Sanib
- Department of Emergency Medicine, Faculty of Medicine, MARA University of Technology, Selangor, Malaysia
| | - Mohd A Mokhtar
- Department of Emergency Medicine, Faculty of Medicine, MARA University of Technology, Selangor, Malaysia
| | - Safreeda S F Salim
- Department of Emergency Medicine, Faculty of Medicine, MARA University of Technology, Selangor, Malaysia
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Jensen JK, Dyre L, Jørgensen ME, Andreasen LA, Tolsgaard MG. Simulation-based point-of-care ultrasound training: a matter of competency rather than volume. Acta Anaesthesiol Scand 2018; 62:811-819. [PMID: 29392718 DOI: 10.1111/aas.13083] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/04/2018] [Accepted: 01/10/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Point-of-care ultrasonography plays an increasingly important role in the initial resuscitation of critically ill patients but acquisition of the skill is associated with long learning curves. The skills required to perform ultrasound examinations can be practiced in a simulated setting before being performed on actual patients. The aim of this study was to investigate the learning curves for novices training the FAST protocol on a virtual-reality simulator. METHODS Ultrasound novices (N = 25) were instructed to complete a FAST training program on a virtual-reality ultrasound simulator. Participants were instructed to continue training until they reached a previously established mastery learning level, which corresponds to the performance level of a group of ultrasound experts. Performance scores and time used during each FAST examination were used to determine participants' learning curves. RESULTS The participants attained the mastery learning level within a median of three (range two to four) attempts corresponding to a median of 1 h 46 min (range 1 h 2 min to 3 h 37 min) of simulation training. The ultrasound novices' examination speed improved significantly with training, and continued to improve even after they attained the mastery learning level (P = 0.011). Twenty-three participants attained the mastery learning level. CONCLUSION Novices can attain mastery learning levels using simulation-based ultrasound training with less than, on average, 2 h of practice. However, we found large variations in the amount of training needed, which raises questions about the adequacy of current volume-based models for determining ultrasound competency.
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Affiliation(s)
- J. K. Jensen
- Department of Anaesthesiology; Odense Universitetshospital; Odense Denmark
| | - L. Dyre
- Copenhagen Academy for Medical Education and Simulation (CAMES); Rigshospitalet; København Denmark
- Department of Obstetrics; Rigshospitalet; Juliane Marie Centre; København Denmark
| | | | - L. A. Andreasen
- Copenhagen Academy for Medical Education and Simulation (CAMES); Rigshospitalet; København Denmark
| | - M. G. Tolsgaard
- Copenhagen Academy for Medical Education and Simulation (CAMES); Rigshospitalet; København Denmark
- Department of Obstetrics; Rigshospitalet; Juliane Marie Centre; København Denmark
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Michels G, Zinke H, Möckel M, Hempel D, Busche C, Janssens U, Kluge S, Riessen R, Buerke M, Kelm M, von Bardeleben RS, Knebel F, Busch HJ. [Recommendations for education in ultrasound in medical intensive care and emergency medicine: position paper of DGIIN, DEGUM and DGK]. Med Klin Intensivmed Notfmed 2018; 112:314-319. [PMID: 28447145 DOI: 10.1007/s00063-017-0285-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Point-of-care ultrasound in acute care medicine is a prerequisite for diagnosis and therapy monitoring of critically ill patients. There is currently no uniform education strategy for medical intensive care and emergency medicine. As part of the basic level, the trainee takes theoretical and clinical training covering abdominal and thoracic ultrasonography and focused cardiovascular ultrasound. In a second step, special knowledge and skills can be acquired at an expert level. This two-stage concept is intended to guarantee quality assurance in ultrasound education in medical intensive care and emergency medicine.
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Affiliation(s)
- G Michels
- Klinik III für Innere Medizin, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - H Zinke
- Klinik für konservative Intensivmedizin, Dietrich-Bonhoeffer-Klinikum, Neubrandenburg, Deutschland
| | - M Möckel
- Notfallmedizin der Charité, Campus Virchow-Klinikum, Universitätsmedizin Berlin, Berlin, Deutschland
| | - D Hempel
- Klinik für Innere Medizin IV, Universitätsklinikum Jena, Jena, Deutschland
| | - C Busche
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - U Janssens
- Klinik für Innere Medizin und Intensivmedizin, St.-Antonius-Hospital, Eschweiler, Deutschland
| | - S Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - R Riessen
- Department für Innere Medizin, Internistische Intensivstation, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - M Buerke
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, St. Marien-Krankenhaus Siegen gem. GmbH, Siegen, Deutschland
| | - M Kelm
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - R S von Bardeleben
- Kardiologie I, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Mainz, Deutschland
| | - F Knebel
- Medizinische Klinik mit Schwerpunkt Kardiologie und Angiologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - H-J Busch
- Universitäts-Notfallzentrum, Universitätsklinikum Freiburg, Freiburg, Deutschland
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Abstract
PURPOSE OF REVIEW The objective was to define the role of ultrasound in the diagnosis and the management of circulatory shock by critical appraisal of the literature. RECENT FINDINGS Assessment of any patient's hemodynamic profile based on clinical examination can be sufficient in several cases, but many times unclarities remain. Arterial catheters and central venous lines are commonly used in critically ill patients for practical reasons, and offer an opportunity for advanced hemodynamic monitoring. Critical care ultrasonography may add to the understanding of the hemodynamic profile at hand. Improvements in ultrasound techniques, for example, smaller devices and improved image quality, may reduce limitations and increase its value as a complementary tool. Critical care ultrasonography has great potential to guide decisions in the management of shock, but operators should be aware of limitations and pitfalls as well. Current evidence comes from cohort studies with heterogeneous design and outcomes. SUMMARY Use of ultrasonography for hemodynamic monitoring in critical care expands, probably because of absence of procedure-related adverse events. Easy applicability and the capacity of distinguishing different types of shock add to its increasing role, further supported by consensus statements promoting ultrasound as the preferred tool for diagnostics in circulatory shock.
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Abstract
Ultrasound is an efficacious, versatile and affordable imaging technique in emergencies, but has limited utility without expert interpretation. Telesonography, in which experts may remotely support the use of ultrasound through a telecommunications link, may broaden access to ultrasound and improve patient outcomes, particularly in remote settings. This review assesses the literature regarding telesonography in emergency medicine, focussing on evidence of feasibility, diagnostic accuracy and clinical utility. A systematic search was performed for articles published from 1946 to February 2017 using the Cochrane, Medline, EMBASE, and CINAHL databases. Further searches utilising Scopus, Google Scholar, and citation lists were conducted. 4388 titles were identified and screened against inclusion criteria which resulted in the inclusion of 28 papers. These included feasibility, diagnostic accuracy and clinical pilot studies. Study design, methodology and quality were heterogeneous. There was good evidence of feasibility from multiple studies. Where sufficient bandwidth and high quality components were used, diagnostic accuracy was slightly reduced by image transmission. There was evidence of clinical utility in remote hospitals and low-resource settings, although reliability was infrequently reported. Further exploratory research is required to determine minimum requirements for image quality, bandwidth, frame rate and to assess diagnostic accuracy. Clinical trials in remote settings are justifiable. Telecommunication options will depend on local requirements; no one system conveys universal advantages. The methodological quality of research in this field must improve: studies should be designed to minimise bias, and must include details of their methods to allow replication. Analysis of cost effectiveness and sustainability should be provided.
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Affiliation(s)
| | - Leila Eadie
- Centre for Rural Health, University of Aberdeen, Inverness, Scotland, United Kingdom
| | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Inverness, Scotland, United Kingdom
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Morton A, Teasdale S. Review article: Investigations and the pregnant woman in the emergency department - part 2: Point-of-care ultrasound, electrocardiography, respiratory function tests and radiology. Emerg Med Australas 2018; 30:749-753. [PMID: 29577627 DOI: 10.1111/1742-6723.12956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 12/13/2022]
Abstract
Accurate assessment of the pregnant patient in the ED depends on knowledge of physiological changes in pregnancy, and how these changes may impact on pathology tests, appearance on point-of-care ultrasound, electrocardiography and respiratory function tests. In addition, the emergency physician needs to be cognisant of disorders that are unique to or more common during pregnancy. Part 2 of this review addresses the role of point-of-care ultrasound in pregnancy, physiological changes that may affect interpretation of point-of-care ultrasound, changes in electrocardiography and respiratory function tests, and the safety of radiological procedures in the pregnant patient. Part 1 addressed potential deviations in laboratory investigation reference intervals resulting from physiological alterations in pregnancy and the important causes of abnormal laboratory results in pregnancy.
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Affiliation(s)
- Adam Morton
- Mater Health and The University of Queensland, Brisbane, Queensland, Australia
| | - Stephanie Teasdale
- Mater Health and The University of Queensland, Brisbane, Queensland, Australia
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Di Pietro S, Falaschi F, Bruno A, Perrone T, Musella V, Perlini S. The learning curve of sonographic inferior vena cava evaluation by novice medical students: the Pavia experience. J Ultrasound 2018; 21:137-144. [PMID: 29564661 DOI: 10.1007/s40477-018-0292-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 02/28/2018] [Indexed: 12/17/2022] Open
Abstract
PURPOSE The sonographic evaluation of inferior vena cava diameters and its collapsibility-that is also defined as the caval index-has become a popular way to easily obtain a noninvasive estimate of central venous pressure. This is generally considered an easy sonographic task to perform, and according to the American College of Emergency Physicians (ACEP) Guidelines 25 repetitions of this procedure should be sufficient to reach proficiency. However, little is known about the learning process for this sonographic technique. Therefore, we designed this study to investigate the learning curve of inferior vena cava evaluation. METHODS We enrolled a sample of ten ultrasound-naïve medical students who received a preliminary training provided by two Junior Emergency Medicine Residents. Following training, each student performed the sonographic task on 25 different patients who were hospitalized in the internal medicine ward. The students' performance was compared with the results obtained by a consultant in internal medicine with extensive experience in point-of-care ultrasound, who repeated the procedure on the same patients (gold standard). In detail, we evaluated the time to complete the task, the quality of the obtained images, and the ability to visually estimate and measure the caval index. RESULTS Although most students (9/10) reached the pre-defined level of competence, their overall performance was inferior to the one achieved by the gold standard, with little improvement over time. However, repetition was associated with progressive shortening of the time needed to achieve readable images. CONCLUSIONS Overall, these findings suggest that, although allowing to obtain a pre-defined competence, 25 repetitions are not enough to reach a good level of proficiency for this technique, that needs a longer training to be achieved.
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Affiliation(s)
- Santi Di Pietro
- Clinica Medica 2, Department of Internal Medicine, Emergency Medicine Fellowship Program, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Francesco Falaschi
- Clinica Medica 2, Department of Internal Medicine, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alice Bruno
- Clinica Medica 2, Department of Internal Medicine, Emergency Medicine Fellowship Program, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Tiziano Perrone
- Clinica Medica 1, Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Valeria Musella
- Clinical Epidemiology and Biometric Unit, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Stefano Perlini
- Clinica Medica 2, Department of Internal Medicine, Emergency Medicine Fellowship Program, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
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Parulekar P, Neil-Gallacher E, Harrison A. Intensive care unit physician-delivered point of care renal tract ultrasound in acute kidney injury is feasible. J Intensive Care Soc 2018; 19:313-318. [PMID: 30505345 DOI: 10.1177/1751143718762685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Acute kidney injury is common in critically ill patients, with ultrasound recommended to exclude renal tract obstruction. Intensive care unit clinicians are skilled in acquiring and interpreting ultrasound examinations. Intensive Care Medicine Trainees wish to learn renal tract ultrasound. We sought to demonstrate that intensive care unit clinicians can competently perform renal tract ultrasound on critically ill patients. Thirty patients with acute kidney injury were scanned by two intensive care unit physicians using a standard intensive care unit ultrasound machine. The archived images were reviewed by a Radiologist for adequacy and diagnostic quality. In 28 of 30 patients both kidneys were identified. Adequate archived images of both kidneys each in two planes were possible in 23 of 30 patients. The commonest reason for failure was dressings and drains from abdominal surgery. Only one patient had hydronephrosis. Our results suggest that intensive care unit clinicians can provide focussed renal tract ultrasound. The low incidence of hydronephrosis has implications for delivering the Core Ultrasound in Intensive Care competencies.
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Affiliation(s)
| | | | - Alex Harrison
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Survival after Cardiac Arrest Secondary to Massive Pulmonary Embolism. Case Rep Emerg Med 2018; 2018:8076808. [PMID: 29666716 PMCID: PMC5830964 DOI: 10.1155/2018/8076808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/13/2017] [Accepted: 01/04/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction It is estimated that the diagnosis of pulmonary embolism (PE) is missed in as many as 84% of all cases of PE. Cardiac arrest following PE is generally associated with poor outcomes. Case Report A 43-year-old man presented to the Emergency Department (ED) in cardiac arrest. Swelling of his right lower limb was noted on arrival. Point of care ultrasound was performed during ongoing cardiopulmonary resuscitation (CPR) and showed a thrombus in the right iliofemoral vein as well as dilatation of the right ventricle. Fibrinolytic therapy was initiated immediately and a return of spontaneous circulation (ROSC) was achieved 30 minutes later. The diagnosis of PE was finally confirmed on computed tomography pulmonary angiography once haemodynamic stability was achieved. The patient was thereafter transferred to the intensive care unit for postresuscitation care and further management. Several days later, he was discharged home neurologically intact and fully recovered. Discussion Since outcomes after cardiac arrest following PE are generally dismal, available and potentially life-saving interventions to restore pulmonary circulation should be rapidly implemented when PE is the likely cause of cardiac arrest.
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Mengarelli M, Nepusz A, Kondrashova T. A Comparison of Point-of-Care Ultrasonography Use in Rural Versus Urban Emergency Departments Throughout Missouri. MISSOURI MEDICINE 2018; 115:56-60. [PMID: 30228684 PMCID: PMC6139795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
We surveyed emergency department directors at 56 Missouri hospitals about availability of ultrasound equipment, primary uses for ultrasonography, and factors that could increase ultrasonography use in the emergency departments. Results indicated large-sized hospitals, typically in urban areas, used ultrasonography more than medium-sized or small-sized hospitals. Lack of ultrasound equipment and appropriately trained physicians contributed to limited use of ultrasonography in small-sized hospitals, typically in rural areas.
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Affiliation(s)
- Michael Mengarelli
- Michael Mengarelli, BS Osteopathic Medical Student, at Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, Missouri
| | - Anthony Nepusz
- Anthony Nepusz, BS, Osteopathic Medical Student, at Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, Missouri
| | - Tatyana Kondrashova
- Tatyana Kondrashova, MD, PhD, Department of Family Medicine, Preventive Medicine, and Community Health, at Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, Missouri
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Long B, Alerhand S, Maliel K, Koyfman A. Echocardiography in cardiac arrest: An emergency medicine review. Am J Emerg Med 2017; 36:488-493. [PMID: 29269162 DOI: 10.1016/j.ajem.2017.12.031] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/12/2017] [Accepted: 12/12/2017] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Cardiac arrest management primarily focuses on optimal chest compressions and early defibrillation for shockable cardiac rhythms. Non-shockable rhythms such as pulseless electrical activity (PEA) and asystole present challenges in management. Point-of-care ultrasound (POCUS) in cardiac arrest is promising. OBJECTIVES This review provides a focused assessment of POCUS in cardiac arrest, with an overview of transthoracic (TTE) and transesophageal echocardiogram (TEE), uses in arrest, and literature support. DISCUSSION Cardiac arrest can be distinguished between shockable and non-shockable rhythms, with management varying based on the rhythm. POCUS provides a diagnostic and prognostic tool in the emergency department (ED), which may improve accuracy in clinical decision-making. Several protocols incorporate POCUS based on different cardiac views. TTE includes parasternal long axis, parasternal short axis, apical 4-chamber, and subxiphoid views, which may be used in cardiac arrest for diagnosis of underlying cause and potential prognostication. TEE is conducted by inserting the probe into the esophagus of intubated patients, with several studies evaluating its use in cardiac arrest. It is associated with few adverse effects, while allowing continued compressions (and evaluation of those compressions) and not interrupting resuscitation efforts. CONCLUSIONS POCUS is a valuable diagnostic and prognostic tool in cardiac arrest, with recent literature supporting its diagnostic ability. TTE can guide resuscitation efforts dependent on the rhythm, though TTE should not interrupt other resuscitation measures. TEE can be useful during arrest, but further studies based in the ED are needed.
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Affiliation(s)
- Brit Long
- San Antonio Military Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX, United States, 78234.
| | - Stephen Alerhand
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, United States.
| | - Kurian Maliel
- Wright Patterson Military Medical Center, Department of Cardiology, 4881 Sugar Maple Dr, Dayton, OH 45433, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
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Cormack CJ, Coombs PR, Guskich KE, Blecher GE, Goldie N, Ptasznik R. Collaborative model for training and credentialing point-of-care ultrasound: 6-year experience and quality outcomes. J Med Imaging Radiat Oncol 2017; 62:330-336. [DOI: 10.1111/1754-9485.12697] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/12/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - Peter R Coombs
- Department of Diagnostic Imaging; Monash Health; Victoria Australia
| | - Kate E Guskich
- Department of Diagnostic Imaging; Monash Health; Victoria Australia
| | | | - Neil Goldie
- Department of Emergency Medicine; Monash Health; Victoria Australia
| | - Ronnie Ptasznik
- Department of Diagnostic Imaging; Monash Health; Victoria Australia
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Fedor PJ, Burns B, Lauria M, Richmond C. Major Trauma Outside a Trauma Center: Prehospital, Emergency Department, and Retrieval Considerations. Emerg Med Clin North Am 2017; 36:203-218. [PMID: 29132578 DOI: 10.1016/j.emc.2017.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Care of the critically injured begins well before the patient arrives at a large academic trauma center. It is important to understand the continuum of care from the point of injury in the prehospital environment, through the local hospital and retrieval, until arrival at a trauma center capable of definitive care. This article highlights the important aspects of trauma assessment and management outside of tertiary or quaternary care hospitals. Key elements of each phase of care are reviewed, including management pearls and institutional strategies to facilitate effective and efficient treatment of trauma patients from the point of injury forward.
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Affiliation(s)
- Preston J Fedor
- Department of Emergency Medicine, Division of Prehospital, Austere and Disaster Medicine, University of New Mexico, 1 University of New Mexico, MSC11 6025, Albuquerque, NM 87131-0001, USA.
| | - Brian Burns
- Greater Sydney Area HEMS, NSW Ambulance, NSW 2200, Australia; Sydney University, Sydney, NSW, Australia
| | - Michael Lauria
- Dartmouth-Hitchcock Advanced Response Team (DHART), Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Clare Richmond
- Greater Sydney Area HEMS, NSW Ambulance, NSW 2200, Australia; Royal Prince Alfred Hospital, Sydney, Australia
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Blans MJ, Bosch FH. Ultrasound in acute internal medicine; time to set a European standard. Eur J Intern Med 2017; 45:51-53. [PMID: 28986154 DOI: 10.1016/j.ejim.2017.09.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 09/27/2017] [Accepted: 09/29/2017] [Indexed: 10/18/2022]
Abstract
Nowadays point-of-care ultrasound (POCUS) is considered indispensable for critical care and emergency physicians. POCUS is a noninvasive tool, can be done at the bedside, leads to instant diagnostic information and is safe in terms of radiation. POCUS could also be very suitable for internists in the field of acute internal medicine. There are differences between European internists in the use of POCUS from no use at all to more outlined educational programs. In literature there are examples of comprehensive POCUS guidelines which could serve as an example for the European Federation of Internal Medicine (EFIM). In this review some aspects of POCUS are highlighted and the authors encourage EFIM to set European standards for this important development.
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Affiliation(s)
- Michael Justinus Blans
- Department of Internal Medicine and Intensive Care, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands.
| | - Frank Hendrik Bosch
- Department of Internal Medicine and Intensive Care, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands.
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Cambournac M, Goy-Thollot I, Violé A, Boisvineau C, Pouzot-Nevoret C, Barthélemy A. Sonographic assessment of volaemia: development and validation of a new method in dogs. J Small Anim Pract 2017; 59:174-182. [PMID: 28960319 DOI: 10.1111/jsap.12759] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/11/2017] [Accepted: 06/20/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aims of this study were to describe a method for the sonographic assessment of volaemia, to determinate inter- and intra-operator variability and to assess the ability to detect blood loss after blood donation in healthy dogs. MATERIALS AND METHODS The left kidney was identified in a spleno-renal view, and transverse views of the caudal vena cava and aorta were obtained in 12 dogs. Vessel diameters were measured in B-mode, in duplicate by two operators, and the caudal vena cava:aorta ratio was calculated. Intra- and inter-operator variabilities were assessed using a Bland-Altman method by plotting the differences between the repeated measurements obtained from the same subject by the same operator and by the two operators against their means. Before and after blood donation measurements were compared using paired t-tests or one-sample t-tests, if appropriate. RESULTS Intra- and inter-operator variability was within the limit of agreement for the vast majority of measurements. After a blood donation of 9·8 ±2·2 mL/kg, the mean aorta measurements were not significantly different from those obtained before blood donation (1·11 versus 1·10, P=0·28), whereas the mean caudal vena cava measurements and caudal vena cava:aorta ratios were significantly lower (1·28 versus 1·01, P<0·0001; 1·17 versus 1·01, P=0·0001, respectively). CLINICAL SIGNIFICANCE The low intra- and inter-operator variabilities in the caudal vena cava, aorta and caudal vena cava:aorta ratio measurements support their reliability and operator independency. The sonographic assessment of volaemia appears to be a promising non-invasive, repeatable point-of-care ultrasound protocol for assessment and monitoring of blood loss. Further studies are needed to assess the sonographic assessment of volaemia protocol in spontaneously bleeding dogs.
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Affiliation(s)
- M Cambournac
- Intensive Care Unit (SIAMU), Université de Lyon, VetAgro Sup, APCSe, F-69280, Marcy l'Etoile, France
| | - I Goy-Thollot
- Intensive Care Unit (SIAMU), Université de Lyon, VetAgro Sup, APCSe, F-69280, Marcy l'Etoile, France
| | - A Violé
- Intensive Care Unit (SIAMU), Université de Lyon, VetAgro Sup, APCSe, F-69280, Marcy l'Etoile, France
| | - C Boisvineau
- Intensive Care Unit (SIAMU), Université de Lyon, VetAgro Sup, APCSe, F-69280, Marcy l'Etoile, France
| | - C Pouzot-Nevoret
- Intensive Care Unit (SIAMU), Université de Lyon, VetAgro Sup, APCSe, F-69280, Marcy l'Etoile, France
| | - A Barthélemy
- Intensive Care Unit (SIAMU), Université de Lyon, VetAgro Sup, APCSe, F-69280, Marcy l'Etoile, France
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Wortsman X. Sonography of Dermatologic Emergencies. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1905-1914. [PMID: 28470978 DOI: 10.1002/jum.14211] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/05/2016] [Indexed: 06/07/2023]
Abstract
Dermatologic conditions may be the subjects of potential emergency consultations, and the knowledge of their sonographic appearance can facilitate an early diagnosis and management. In this pictorial essay, the sonographic dermatologic anatomy, technique, and conditions that can be supported by a prompt sonographic diagnosis are reviewed. The sonographic signs that may help diagnose these entities are discussed with a practical approach.
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Affiliation(s)
- Ximena Wortsman
- Departments of Imaging and Dermatology, Institute for Diagnostic Imaging and Research of the Skin and Soft Tissues, Faculty of Medicine, University of Chile, Santiago, Chile
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135
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Snelling PJ, Tessaro M. Paediatric emergency medicine point-of-care ultrasound: Fundamental or fad? Emerg Med Australas 2017; 29:486-489. [PMID: 28845599 DOI: 10.1111/1742-6723.12848] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Peter J Snelling
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Department of Paediatrics, Greenslopes Private Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Mark Tessaro
- Emergency Department, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Weile J, Nielsen K, Primdahl SC, Frederiksen CA, Laursen CB, Sloth E, Kirkegaard H. Ultrasonography in trauma: a nation-wide cross-sectional investigation. Crit Ultrasound J 2017. [PMID: 28639253 PMCID: PMC5479771 DOI: 10.1186/s13089-017-0071-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Focused Assessment with Sonography in Trauma (FAST) protocol is considered beneficial in emergent evaluation of trauma patients with blunt or penetrating injury and has become integrated into the Advanced Trauma Life Support (ATLS) protocol. No guidelines exist as to the use of ultrasonography in trauma in Denmark. We aimed to determine the current use of ultrasonography for assessing trauma patients in Denmark. METHODS We conducted a nation-wide cross-sectional investigation of ultrasonography usage in trauma care. The first phase consisted of an Internet-based investigation of existing guidelines, and the second phase was a series of structured interviews of orthopedic surgeons, anesthesiologists, and radiologists on call in all hospitals receiving traumatized patients in Denmark. RESULTS Guidelines were obtained from all 22 hospitals receiving traumatized patients in Denmark. Twenty-one (95.5%) of the guidelines included and recommended FAST as part of trauma assessment. The recommended person to perform the examination was the radiologist in n = 11 (50.0%), the surgeon in n = 6 (27.3%), the anesthesiologist in n = 1 (4.5%), and unspecified in n = 3 (13.6%) facilities. FAST indications varied between circulatory instability n = 8 (36.4%), team leader's discretion n = 6 (27.3%), abdominal trauma n = 3 (13.6%), and not specified n = 6 (27.3%). Telephone interviews revealed that exams were always n = 8 (36.4%) or often n = 4 (18.2%) registered in the patients' charts. The remaining n = 10 (45.5%) facilities either never registered n = 2 (9.1%), it was not possible to register n = 1 (4.5%), or unknown by the trauma leaders n = 7 (31.8%). Images were often stored in n = 1 (4.5%), never stored in n = 10 (45.5%), not possible to store in n = 2 (9.1%), and unknown in n = 9 (40.9%) facilities. CONCLUSION Ultrasonography was used in a non-uniform fashion by multiple specialties in Danish trauma facilities. Very few images from FAST examinations were stored and documentation was scanty. National guidelines on application and documentation of ultrasonography in trauma are called for.
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Affiliation(s)
- Jesper Weile
- Emergency Department, Regional Hospital Herning, Herning, Denmark. .,Research Center for Emergency Medicine, Aarhus University Hospital, Nørrebrogade 44, Building 1B, 8000, Aarhus C, Denmark.
| | - Klaus Nielsen
- Department of Medicine, Section of Respiratory Medicine, University Hospital Hvidovre, Hvidovre, Denmark
| | | | | | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Erik Sloth
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
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Empfehlungen zur Ultraschallausbildung in der internistischen Intensiv- und Notfallmedizin: Positionspapier der DGIIN, DEGUM und DGK. DER KARDIOLOGE 2017. [DOI: 10.1007/s12181-017-0157-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Gungor F, Kilic T, Akyol KC, Ayaz G, Cakir UC, Akcimen M, Eken C. Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in the Emergency Department. Acad Emerg Med 2017; 24:578-586. [PMID: 28171688 DOI: 10.1111/acem.13169] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 01/28/2017] [Accepted: 01/29/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Early and accurate diagnosis of acute appendicitis (AA) with ultrasound (US) can minimize the morbidity and mortality of the patients. In this regard, US can help emergency physicians (EPs) in the diagnosing process and clinical decision making for AA. Therefore, we primarily aimed to evaluate the effectiveness of point-of-care US (POCUS) in clinical decision making of EPs for the diagnostic evaluation for AA in the emergency department (ED). METHODS The study sample consisted of patients aged > 18 years who presented to the ED with abdominal pain and underwent diagnostic evaluation for AA. All patients were examined initially with POCUS by EPs and then with radiology-performed US (RADUS) by radiologists. Pre- and post-POCUS median diagnostic certainty values (MDCVs) for AA were determined with visual analog scale (VAS) scores (0 = not present, 100 = certainly present) by POCUS performers. Definitive diagnoses were determined by surgery, pathologic evaluation of appendectomy specimens, or clinical follow-up results. The sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) for POCUS and RADUS together with pre- and post-POCUS VAS scores for MDCVs were compared. RESULTS A total of 264 patients were included into the final analysis and 169 (64%) had a diagnosis of AA. The sensitivity, specificity, PLR, and NLR of US examinations were 92.3% (95% confidence interval [CI] = 87.2%-95.8%), 95.8% (89.5%-98.8%), 21.9 (8.4-57.2), and 0.08 (0.05-0.1) for POCUS and 76.9% (69.8-83%), 97.8% (84.9-99.7%), 36.4 (9.25-144.3), and 0.24 (0.18-0.31) for RADUS, respectively. Pre-POCUS and post-POCUS VAS scores for MDCVs were 60 (interquartile range [IQR] = 50-65) and 95 (IQR = 20-98), respectively (p = 0.000). CONCLUSION Point-of-care ultrasonography, when performed in ED for the diagnosis of AA, has high sensitivity and specificity and had a positive impact on the clinical decision making of EPs.
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Affiliation(s)
- Faruk Gungor
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Taylan Kilic
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Kamil Can Akyol
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Gizem Ayaz
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Umut Cengiz Cakir
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Mehmet Akcimen
- Department of Emergency Medicine; Antalya Training and Research Hospital; Antalya Turkey
| | - Cenker Eken
- Department of Emergency Medicine; Akdeniz University Medical Faculty; Antalya Turkey
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