Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians

Point-of-care ultrasound: Closing guideline gaps in screening for valvular heart disease

BACKGROUND

A linear increase in the number of valvular heart disease is expected due to the aging population, yet most patients with severe valvular heart disease remain undiagnosed.

HYPOTHESIS

POCUS can serve as a screening tool for valvular heart disease.

METHODS

We reviewed the literature to assess the strengths and limitations of POCUS in screening and diagnosing valvular heart disease.

RESULTS

POCUS is an accurate, affordable, accessible, and comprehensive tool. It has a fast learning curve and can prevent unnecessary and more expensive imaging. Challenges include training availability, lack of simplified screening protocols, and reimbursement. Large scale valvular screening data utilizing POCUS is not available.

CONCLUSION

POCUS can serve as a screening tool and guide the management of patients with valvular heart disease. More data is needed about its efficacy and cost-effectiveness in the screening of patients with valvular heart disease.

The long-term effect of short point of care ultrasound course on physicians' daily practice

Background

The benefits of Point of Care Ultrasound (POCUS) are well established in the literature. As it is an operator-dependent modality, the operator is required to be skilled in obtaining and interpreting images. Physicians who are not trained in POCUS attend courses to acquire the basics in this field. The effectiveness of such short POCUS courses on daily POCUS utilization is unknown. We sought to measure the change in POCUS utilization after practicing physicians attended short POCUS courses.

Methods

A 13-statements questionnaire was sent to physicians who attended POCUS courses conducted at the Soroka University Medical Center between the years 2014–2018. Our primary objective was to compare pre-course and post-course POCUS utilization. Secondary objectives included understanding the course graduates’ perceived effect of POCUS on diagnosis, the frequency of ultrasound utilization and time to effective therapy.

Results

212 residents and specialists received the questionnaire between 2014–2018; 116 responded (response rate of 54.7%). 72 (62.1%) participants were male, 64 (55.2%) were residents, 49 (42.3%) were specialists, 3 (2.5%) participants did not state their career status. 90 (77.6%) participants declared moderate use or multiple ultrasound use six months to four years from the POCUS course, compared to a rate of ‘no use at all’ and ‘minimal use of 84.9% before the course. 98 participants [84.4% CI 77.8%, 91.0%] agree and strongly agree that a short POCUS course may improve diagnostic skills and 76.7% [CI 69.0%, 84.3%] agree and strongly agree that the POCUS course may shorten time to diagnosis and reduce morbidity.

Conclusions

Our short POCUS course significantly increases bedside ultrasound utilization by physicians from different fields even 4 years from course completion. Course graduates strongly agreed that incorporating POCUS into their clinical practice improves patient care. Such courses should be offered to residents and senior physicians to close the existing gap in POCUS knowledge among practicing physicians.

Remote Real-Time Ultrasound Supervision via Commercially Available and Low-Cost Tele-Ultrasound: a Mixed Methods Study of the Practical Feasibility and Users' Acceptability in an Emergency Department

Minor emergency departments (ED) struggle to access sufficient expertise to supervise learners of lung and cardiac point-of-care ultrasound (POCUS). Using tele-ultrasound (tele-US) for remote supervision may remedy this situation. We aimed to evaluate the feasibility of real-time supervision via tele-US when applied to an everyday ED clinic. We conducted a mixed methods study that assessed practical feasibility, determined performance, and explored users' acceptability of supervision via tele-US. Technical performance was assessed quantitatively by the ratio in mean gray value between images on site and as received by the supervisor, and by after-compression frame rate. Qualitatively, 12 exploratory semi-structured interviews were conducted with exposed junior doctors and supervisors. Remote supervision via tele-US was performed with 10 junior doctors scanning 45 included patients. During performance assessment, neither alternating internet connection nor software significantly changed the mean gray value ratio. The lowest median frame rate of 4.6 (interquartile range [IQR]: 3.1-5.0) was found by using a 4G internet connection; the highest of 28.5 (IQR: 28.5-29.0) was found with alternative computer and local area network internet connection. In interviews, supervisors stressed the importance of preserving frame rate, and junior doctors emphasized a need for shared ultrasound terminology. In the qualitative analysis, setup mobility, accessibility, and time consumption were emphasized as being of key importance for future clinical implementations. Remote supervision via a commercially available and low-cost tele-US setup is operational for both junior doctors and supervisors when applied to lung and cardiac POCUS scans of hospitalized patients.

Rapid, Single-View Speckle-Tracking-Based Method for Examining Left Ventricular Systolic and Diastolic Function in Point of Care Ultrasound

OBJECTIVES

A rapid, reliable quantitative assessment of left ventricular systolic and diastolic function is important for patient treatment in urgent and dynamic settings. Quantification of annular velocities based on a single 2-dimensional image loop, rather than on Doppler velocities, could be useful in point-of-care or focused cardiac ultrasound. We hypothesized that novel speckle-tracking-based mitral annular velocities would correlate with reference standard tissue Doppler imaging (TDI) velocities in a focused cardiac ultrasound-esque setting.

METHODS

Two echocardiographers each performed transthoracic echocardiographic measurements before and after induction of anesthesia in supine patients undergoing cardiac surgery. Speckle-tracking echocardiography (STE)-based systolic (S'_STE ) and diastolic (E'_STE and A'_STE ) velocities were compared to TDI and global longitudinal strain/strain rate. We also compared mitral annular displacement by speckle tracking with M-mode imaging.

RESULTS

Twenty-five patients were included and examined in both preinduction and postinduction states. Speckle-tracking-based velocities correlated with TDI measurements in both states (S', r = 0.73 and 0.76; E', r = 0.87 and 0.65; and A', r = 0.65 and 0.73), showing a mean bias of 25% to 30% of the reference standard measurement. The correlation of S'_STE with strain and the strain rate (S-wave) and E'_STE with the strain rate (E-wave) was good in awake, spontaneously breathing patients but was less strong in the ventilated state. Similarly, displacement by speckle tracking correlated with M-mode measurements in both states (r = 0.91 and 0.84). Measurements required medians of 31 and 34 seconds; reproducibility was acceptable for S'_STE and E'_STE .

CONCLUSIONS

Speckle-tracking-based mitral annular velocities and displacement correlate well with conventional measures as well as with deformation imaging. They may be clinically useful in rapidly assessing both systolic and diastolic function from a single 2-dimensional image loop.

Évaluation hémodynamique précoce par échocardiographie ciblée des patients en sepsis ou choc septique (Sepsis-3) au service d’urgence

Introduction : L’identification du profil hémodynamique des patients septiques au service d’urgence (SU) pourrait permettre d’adapter individuellement les recommandations de la Surviving Sepsis Campaign (SSC). L’objectif de cette étude était de décrire le profil hémodynamique précoce par échocardiographie ciblée chez les patients en sepsis et leur impact thérapeutique.

Méthode : Étude prospective monocentrique incluant les patients septiques (score qSOFA [quick Sepsis-related Organ Failure Assessment] ≥ 2) sur une période de 30 mois. L’échocardiographie était réalisée par des médecins urgentistes de niveau échographie clinique en médecine d’urgence 1 afin de déterminer le profil hémodynamique (hypovolémie, vasoplégie avec hyperkinésie, insuffisance ventriculaire ou profil « normal ») dès le sepsis identifié au SU. L’impact thérapeutique était défini par le nombre de patients pour lesquels l’échocardiographie modifiait le traitement de la SSC.

Résultats : Quatre-vingt-un patients (44 sepsis, 37 chocs septiques) ont été étudiés (âge moyen : 70 ± 15 ans ; hommes [n = 47, 58 %] ; SOFA = 5,3 ± 2,9 ; lactates = 4,6 ± 4,2 mmol/l ; admission en réanimation [n = 30, 37 %] ; mortalité j28 [n = 28, 35 %]) après un remplissage vasculaire médian de 500 ml (écart interquartile : 250–1 500 ml). Les profils hémodynamiques dominants étaient l’hypovolémie (n = 54, 66 %), parfois associée à une vasoplégie (n = 26, 32 %) et l’insuffisance ventriculaire (n = 21, 26 %). L’impact thérapeutique concernait 21 patients (26 %), dont un arrêt précoce du remplissage vasculaire après un volume de 850 ± 740 ml chez huit patients.

Conclusion : La dysfonction ventriculaire précoce est présente chez plus de 20 % des patients septiques. L’impact pronostique d’une évaluation échocardiographique dès l’identification du sepsis au SU reste à déterminer.

Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes

AIMS

The diagnosis of acute aortic syndromes (AASs) is challenging and requires integrated strategies. Transthoracic focused cardiac ultrasound (FoCUS) is endorsed by guidelines as a first-line/triage tool allowing rapid bedside assessment of the aorta. However, the performance of FoCUS in the European Society of Cardiology-recommended workup of AASs awaits validation.

METHODS AND RESULTS

This was a prespecified subanalysis of the ADvISED multicentre prospective study. Patients with suspected AAS underwent FoCUS for detection of direct/indirect signs of AAS. Clinical probability assessment was performed with the aortic dissection detection risk score (ADD-RS). Case adjudication was based on advanced imaging, surgery, autopsy, or 14-day follow-up. An AAS was diagnosed in 146 (17.4%) of 839 patients. Presence of direct FoCUS signs had a sensitivity and specificity of 45.2% [95% confidence interval (CI) 37-53.6%] and 97.4% (95% CI 95.9-98.4%), while presence of any FoCUS sign had a sensitivity and specificity of 89% (95% CI 82.8-93.6%) and 74.5% (95% CI 71-77.7%) for AAS. The additive value of FoCUS was most evident within low clinical probability (ADD-RS ≤1). Herein, direct FoCUS signs were identified in 40 (4.8%) patients (P < 0.001), including 29 with AAS. ADD-RS ≤1 plus negative FoCUS for AAS rule-out had a sensitivity of 93.8% (95% CI 88.6-97.1%) and a failure rate of 1.9% (95% CI 0.9-3.6%). Addition of negative D-dimer led to a failure rate of 0% (95% CI 0-1.2%).

CONCLUSION

FoCUS has additive value in the workup of AASs. Direct FoCUS signs can rapidly identify patients requiring advanced imaging despite low clinical probability. In integrated bundles, negative FoCUS is useful for rule-out of AASs.

Transthoracic Doppler echocardiography during a military mission in a French role II in Mali: is it useful to learn this practice?

Introduction

Ultrasound is now recognized as a key tool in the practice of medicine in isolated situations. This study aims to evaluate the impact of transthoracic echocardiography (TTE) in a military mission when performed by a trained military practitioner (MP).

Materials and Methods

We conducted a 2-month retrospective observational study on the use of TTE in a French medical complex in Mali with a mission that included providing a medical aid to the population. All patients were included. Every ultrasound performed by the MP was listed, and the epidemiologic data, indication for the exam and results were collected for each TTE.

Results

A total of 349 patients were included, 16 were war-wounded patients and 333 came for a general medical consultation. In all, 153 ultrasounds were performed, including 48 TTEs. Sixteen TTEs were performed to evaluate injuries in war-wounded patients. During the 333 medical consultations, 32 TTEs were realized. The indications were dyspnoea (10), heart murmur (7), acute chest pain (5) and assessment of heart disease (10). TTE permitted a direct positive diagnosis for 18 patients: 7 with acute heart failure and 11 with morphologic problems. The normality of the exam was a supplementary argument to exclude a cardiac implication for eight patients.

Conclusions

TTE can provide important information with a direct impact on the management of patients. Faced with cardiac emergencies, an adapted training can be proposed for the MP. Thereby, the transfer of conventional cardiac views could facilitate the advice of a cardiologist.

Contribution of caval index and ejection fraction estimated by e-point septal separation measured by emergency physicians in the clinical diagnosis of acute heart failure

OBJECTIVES

Although the reliability of e-point septal separation (EPSS) and caval index (CI) is proven in the diagnosis of acute heart failure (AHF), how much they contribute to the initial clinical impression is unclear. This study aimed to determine the diagnostic contribution of EPSS and CI to the initial clinical impression of AHF.

METHODS

This is a prospective observational study conducted in an academic emergency department (ED). The patients admitted to the ED with acute undifferentiated dyspnea were included. Primary diagnosis was made after an initial clinical evaluation, and a secondary diagnosis was made after EPSS and CI measurements. Independent cardiologists made the final diagnosis. The primary outcome was the diagnostic contribution of EPSS and CI to the primary diagnosis.

RESULTS

A total of 182 patients were included in the study. The primary diagnosis was found with a sensitivity of 0.55 and specificity of 0.84 and the secondary diagnosis was determined with a sensitivity of 0.78 and specificity of 0.83 in predicting the final diagnosis. The agreement coefficient between the primary and final diagnosis was 0.44 and between the secondary diagnosis and the final diagnosis was 0.61. When the primary diagnosis was coherent with secondary diagnosis, sensitivity and specificity were found to be 0.74 and 0.90, respectively.

CONCLUSION

Although a detailed history and physical examination are the essential factors in shaping clinical perception, CI and EPSS combined significantly contribute to the initial clinical impression.

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

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

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 Shifting Paradigm: The Role of Focused Cardiac Ultrasound in Bedside Patient Assessment

Transthoracic echocardiography is the standard of care in anatomic and functional cardiovascular assessment; however, focused cardiac ultrasound (FoCUS) performed with portable ultrasound equipment is increasingly being used as an adjunct to comprehensive history and physical examination. FoCUS assessments, unlike formal echocardiography, are intended to assist physicians in answering explicit clinical questions with a narrow differential diagnosis in real time. Over the past decade, a growing body of literature has repeatedly shown the value that FoCUS adds to clinical evaluation. Specifically, FoCUS improves point-of-care diagnostic accuracy, which in turn modifies treatment plans, decreases time to diagnosis, and reduces resource utilization. Although less robust, there is also evidence showing improvement in clinical outcomes. Based on this evidence, clinicians, training programs, and clinical societies have embraced FoCUS as a tool to complement bedside patient evaluation. Herein, we review the evidence for FoCUS in clinical practice, specifically evaluating the diagnostic accuracy, the impact on clinical decision-making, and the effect on clinical outcomes.

Development of a Focused Cardiac Ultrasound Image Acquisition Assessment Tool

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

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

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

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

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

Focused cardiac ultrasound and point-of-care NT-proBNP assay in the emergency room for differentiation of cardiac and noncardiac causes of respiratory distress in cats

OBJECTIVE

To assess the accuracy of focused cardiac ultrasound (FOCUS) and point-of-care N-terminal proBNP assay in the emergency setting for differentiation of cardiac from noncardiac causes of respiratory distress in cats.

DESIGN

Prospective diagnostic accuracy study between 2014 and 2016.

SETTING

Emergency room at an urban university teaching hospital.

ANIMALS

Forty-one client-owned cats presenting for evaluation of respiratory distress.

INTERVENTIONS

Emergency clinicians made an initial diagnosis of noncardiac or cardiac cause of respiratory distress based on physical examination (PE) findings and history. The diagnoses were updated after performing FOCUS and point-of-care N-terminal B-type natriuretic peptide (POC-BNP). Reference standard diagnosis was determined by agreement of a board-certified cardiologist and critical care specialist with access to subsequent radiographs and echocardiograms.

MEASUREMENTS AND MAIN RESULTS

Forty-one cats were enrolled. Three cats with incomplete data and 1 cat with an uncertain reference standard diagnosis were excluded. The remaining 37 cats were used for analysis: 21 cardiac and 16 noncardiac cases. The ratio of left atrial to aortic root diameter (LA:Ao) measured by FOCUS was significantly correlated with LA:Ao measured by echocardiography (R = 0.646, P < 0.0001). Emergency clinicians correctly diagnosed 27 of 37 (73.0%), yielding a PE positive percent agreement = 76.2% (95% CI, 52.8-91.8%) and negative percent agreement = 68.8% (95% CI, 41.3-89.0%). Five noncardiac and 5 cardiac cats were misdiagnosed. Post FOCUS, overall percent agreement improved to 34 of 37 (91.9%), with positive percent agreement = 95.2% (95% CI, 76.2-99.9%) and negative percent agreement = 87.5% (95% CI, 61.7-98.5%). The POC-BNP yielded an overall percent agreement = 32/34 (94.1%), positive percent agreement = 100% (95% CI, 82.4-100.0%), and negative percent agreement = 86.7% (95% CI, 59.5-98.3%) in differentiating cardiac versus noncardiac cases.

CONCLUSIONS

FOCUS evaluation of basic cardiac structure and LA:Ao by trained emergency clinicians improved accuracy of diagnosis compared to PE in cats with respiratory distress. FOCUS and POC-BNP are useful diagnostics in the emergent setting.

Point-of-care ultrasound (POCUS) as the keystone investigation in undifferentiated dyspnoea

Dyspnoea is defined as a subjective perception of laboured breathing. It is a common cause of access to the emergency department (ED), it has a high rate of intensive care unit admission and a high mortality. The most common causes of dyspnoea in the adult include pneumonia, heart failure, chronic obstructive pulmonary disease, pulmonary embolism and asthma. Due to the high variety of dyspnoea's causes, the need for a rapid and accurate diagnosis puts the emergency physician in trouble. Moreover, standard tests such as chest radiography, B-type natriuretic peptide and d-dimer require time and may be less useful in patients with respiratory failure who require urgent therapy. Point-of-care ultrasound (POCUS) is rapid, non-invasive, repeatable and a useful tool in evaluating patients with acute and severe dyspnoea. This case report demonstrates the usefulness of POCUS in a patient with undifferentiated respiratory failure presenting to the ED.

Special Considerations in Pulmonary Embolism: Clot-in-Transit and Incidental Pulmonary Embolism

This article describes 2 relatively rare, but complex situations in pulmonary embolism (PE): clot-in-transit (CIT), incidental PE (IPE). CIT describes a venous thromboembolism that has become lodged in the right heart. CIT is associated with high mortality and presents unique challenges in management. Incidental PE (IPE) describes PE diagnosed on imaging performed for another indication. The treatment is complex because there is often a disconnect between the PE severity on imaging and lack of severity of the clinical presentation. We summarize the available literature and aid clinicians as they manage patients with PE across the clinical severity spectrum.

ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome

Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series

Sympathetic crashing acute pulmonary edema (SCAPE) describes the most severe presentation of acute heart failure (AHF). Immediate intervention is required to prevent hemodynamic decompensation and endotracheal intubation. Although high-dose nitroglycerin (>100 μg/min) has been described for this clinical scenario in limited case reports, the concern for adverse effects such as hypotension and syncope limit providers comfortability in initiating nitroglycerin at these doses. Described here is a case series of four patients who safely and effectively received high-dose nitroglycerin infusions for the management of SCAPE.

MitraClip-Associated Endocarditis: Emergency Department Diagnosis With Point of Care Ultrasound

BACKGROUND

Management of mitral valve regurgitation in patients with multiple comorbidities is complicated because of poor surgical candidacy. Less invasive techniques for these patients include the MitraClip device, an endovascular repair option used to reduce mitral valve regurgitation symptoms. However, complications include leaflet damage, stenosis, and infectious endocarditis.

CASE REPORT

Four years after MitraClip placement, an 80-year-old man presented to the emergency department with progressive dyspnea. He was diagnosed with MitraClip-associated infectious endocarditis by the emergency physician using point-of-care ultrasound. There are 6 reported cases of infective endocarditis in patients with MitraClip devices, with this being the first case identified using point-of-care ultrasound. This is also the first reported case of MitraClip-associated Corynebacterium endocarditis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The use of the MitraClip device and its echocardiographic appearance is not widely described in the published emergency medicine literature. Knowledge of this device, its appearance, and the potential complications is essential for emergency physicians caring for these patients. Rapid diagnosis may lead to earlier initiation of treatment and optimal disposition for these complex patients.

Emergency Medicine Advanced Ultrasound Service: A new paradigm

OBJECTIVE

Point-of-care ultrasound (POCUS) is now ubiquitous in emergency medicine. Increased accessibility does not, however, ensure expertise in its use. We present a unique model of an Emergency Medicine Advanced Ultrasound Service (EMAUS). In our model specialist emergency physicians with advanced ultrasound (US) qualifications (emergency sonologists), provide images and reports for the entire department. The service is considered an extension of the traditional radiology model. It is consultative, diagnostic and procedural, and includes full US examinations as well as POCUS examinations.

METHODS

A 4-month prospective descriptive observational study was conducted at a tertiary hospital during which data was recorded about emergency medicine US use and its outcomes.

RESULTS

A total of 1336 US scans were recorded. Emergency sonologists conducted the majority of examinations, 69.8%. Half the consultative USs demonstrated positive findings. Follow-up computed tomography (CT) was recommended in 8.8% of consultative US studies and 12.4% of POCUS studies. Concerning incidental findings requiring further investigation (usually CT/magnetic resonance imaging) were infrequent at 1.6%.

CONCLUSION

Globally POCUS has proliferated with varying expertise and data to support its use. The EMAUS provides a trusted and accountable service with the advantages of simultaneously integrating consultative US into the clinical context by an emergency physician. A diverse range of indications, scan types and pathology was recorded over the period demonstrating the utility of combining the roles of senior clinician, sonographer and radiologist and the benefits of advanced training and credentialing.

General Pediatric Clinical Applications of POCUS: Part 2

The use of point-of-care ultrasound (POCUS) performed by non-radiologists has become more widespread and is entering new arenas of clinical care, particularly in the world of pediatrics. Children are prime candidates for ultrasound because they are more at risk to the harmful effects of ionizing radiation than adults. This is the second part of a two-part article reviewing 10 uses of POCUS that pediatricians can apply to their practice in both inpatient and outpatient settings. [Pediatr Ann. 2020;49(4):e196-e200.].

Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine

Point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. It has many uses in daily clinical practice, including improved diagnostic timeliness and accuracy, and providing information about a patient's prognosis and follow-up. It has been integrated into numerous specialities, but remains relatively undefined in internal medicine training programs. Ultrasonography is a useful tool in the standard clinical practice of internists in numerous clinical scenarios (Emergency Department, hospital ward, general and specific consultations, and home care). Although POCUS has been recently included in the European curriculum of internal medicine, there are differences between European internists in its use, ranging from not at all to well structured educational programs. The use of POCUS needs to be widespread in internal medicine departments, and to accomplish this we must encourage structured training. This document details the consensus-based recommendations by the European Federation of Internal Medicine (EFIM) Ultrasound working group. We establish POCUS core competencies and clinical settings for internists in a symptom-based approach. We also propose training requirements, providing a framework for training programs at a national level.

Ruptured Coronary Sinus of Valsalva in the Setting of a Supracristal Ventricular Septal Defect

A sinus of Valsalva aneurysm (SOVA) is usually a silent entity until one of its complications arises, such as heart failure. SOVA itself is uncommon, but it is more frequently associated with a supracristal ventricular septal defect (SVSD). We present a 67-year-old man with a history of an asymptomatic SVSD who presented to the emergency department with signs and symptoms of heart failure. He was subsequently found to have a ruptured SOVA and underwent urgent surgical repair.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Investigation of focused cardiac ultrasound in the emergency room for differentiation of respiratory and cardiac causes of respiratory distress in dogs

OBJECTIVE

To determine whether focused cardiac ultrasound (FOCUS) performed by emergency and critical care (ECC) specialists or residents in training improves differentiation of cardiac (C) versus non-cardiac (NC) causes of respiratory distress in dogs compared to medical history and physical examination alone.

DESIGN

Prospective cohort study (May 2014 to February 2016).

SETTING

University hospital.

ANIMALS

Thirty-eight dogs presenting with respiratory distress.

INTERVENTIONS

FOCUS.

MEASUREMENTS AND MAIN RESULTS

Medical history, physical examination, and FOCUS were obtained at presentation. Emergency and critical care clinicians, blinded to any radiographic or echocardiographic data, categorized each patient (C vs NC) before and after FOCUS. Thoracic radiography (within 3 h) and echocardiography (within 24 h) were performed. Percent agreement was calculated against a reference diagnosis that relied on agreement of a board-certified cardiologist and ECC specialist with access to all diagnostic test results. Reference diagnosis included 22 dogs with cardiac and 13 dogs with noncardiac causes of respiratory distress. In 3 dogs a reference diagnosis was not established. Prior to FOCUS, positive and negative percent agreement to detect cardiac causes was 90.9% (95% CI, 70.8-98.9) and 53.9% (25.1-80.8), respectively. Overall agreement occurred in 27 of 35 dogs (77.1%). Two C and 6 NC cases were incorrectly categorized. Following FOCUS, positive and negative percent agreement to detect cardiac causes was 95.5% (77.2-99.9) and 69.2% (38.6-90.9), respectively. Overall agreement occurred in 30 of 35 dogs (85.7%). Three dogs with discrepant pre-FOCUS diagnoses were correctly re-categorized post-FOCUS. One C and 4 NC cases remained incorrectly categorized. No correctly categorized dogs were incorrectly re-categorized following FOCUS. The proportions of dogs correctly classified pre- versus post-FOCUS were not significantly different (P = 0.25).

CONCLUSIONS

FOCUS did not significantly improve differentiation of C vs NC causes of respiratory distress compared to medical history and physical examination alone.

Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial

BACKGROUND

Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage.

OBJECTIVE

This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS.

METHODS

Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures.

RESULTS

Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores.

CONCLUSIONS

Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.

Effect of Changes in Intravascular Volume on Inferior Vena Cava and Aorta Diameters and the Caval/Aorta Index in Healthy Volunteers

OBJECTIVES

Although inferior vena cava diameter (IVCD) measurement can be useful as a noninvasive method for monitoring the volume status, the benefit of abdominal aorta diameter (AAD) measurement is unclear. The purpose of this study was to determine the value of the combined use of the IVCD and AAD in blood loss monitoring.

METHODS

This prospective observational study was conducted at the blood donor center of a training and research hospital. Standard blood donation criteria were followed during volunteer enrollment. Vital signs and ultrasound IVCD and AAD measurements were obtained before and after blood donation and after fluid resuscitation with 500 mL of 0.9% sodium chloride. Measurements before and after blood donation and after fluid resuscitation were compared by the paired t and Wilcoxon matched-pair tests.

RESULTS

Thirty-nine volunteers were included in the study. With 500 mL of blood loss, percent changes in the shock index (SI; mean ± SD, 7% ± 6%), IVCD (6% ± 2%), and caval/aorta index (IVCD/AAD; 6.1% ± 3%) were similar and were higher (P < .001 for all parameters) than the changes in the pulse rate (3% ± 4%), AAD (0.5% ± 1.5%), systolic blood pressure (3% ± 4%), and diastolic blood pressure (2% ± 7%). Although IVCD and SI values changed significantly (P < .001 for both) after 500 mL of 0.9% sodium chloride resuscitation, no significant change was observed in the IVCD/AAD (P = .059).

CONCLUSIONS

The IVCD/AAD, SI, and IVCD may have similar success rates in diagnosing early blood loss. Additionally, the SI and IVCD may be superior to the IVCD/AAD in bleeding patients requiring simultaneous fluid resuscitation.

Pocket-sized echocardiography for screening structural heart disease: diagnostic accuracy and cost-effectiveness for population-based studies

BACKGROUND

The standard transthoracic echocardiography has some limitations in emergent and community-based situations. The emergence of pocket-sized ultrasound has led to influential advancements.

METHODS

In this prospective study, in the hospital-based phase, children with suspected structural heart diseases were enrolled. In the school-based phase, healthy children were randomly selected from six schools. All individuals were examined by experienced operators using both the standard and the pocket-sized echocardiography.

RESULTS

A total of 73 individuals with a mean age of 9.9 ± 3.2 years in the hospital-based cohort and 143 individuals with a mean age of 12.8 ± 2.9 years in the school-based cohort were examined. The agreements between the standard and the pocket-sized echocardiography were good or excellent for major CHDs in both cohorts (κ statistics > 0.61). Among valvular pathologies, agreements for tricuspid and pulmonary valves' regurgitation were moderate among school-based cohorts (0.56 [95% confidence interval 0.12-1] and 0.6 [95% confidence interval 0.28-0.91], respectively). The agreements for tricuspid and pulmonary valves' regurgitation were excellent (>0.9) among hospital-based population. Other values for valvular findings were good or excellent. The overall sensitivity and specificity were 87.5% (95% confidence interval 47.3-99.7) and 93.8% (95% confidence interval 85-98.3) among the hospital-based individuals, respectively, and those were 88% (95% confidence interval 77.8-94.7) and 68.4% (95% confidence interval 56.7-78.6) among the school-based individuals, respectively. The cost of examination was reduced by approximately 70% for an individual using the pocket-sized device.

CONCLUSIONS

When interpreted by experienced operators, the pocket-sized echocardiography can be used as screening tool among school-aged population.

The Use of Point-of-Care Ultrasound to Accurately Measure Cardiac Output in Flight

Cardiac point-of-care ultrasound (POCUS) is a quick and accurate tool to assess a patient's cardiovascular and hemodynamic status by measuring the E-point septal separation (EPSS) and left ventricular ejection fraction. The case presented here highlights the potential for increased use of POCUS to guide resuscitation in the prehospital setting and during critical care transport. A 56-year-old male presented to a rural emergency department with chest pain and was found to have an inferior STelevation myocardial infarction (STEMI). Local helicopter air ambulance was called to transport the patient to a facility capable of cardiac catheterization. In route, the flight physician performed a cardiac POCUS exam which revealed decreased cardiac perfusion, a hypokinetic inferior wall, and overall decreased contractility. EPSS was measured at 0.77cm, indicating moderate left ventricular ejection fraction (LVEF) reduction. A cardiac left ventriculogram later confirmed a 40% ejection fraction as well as wall motion abnormalities of the inferior wall. The patient was found to have 100% occlusion of the right coronary artery that was revascularized with balloon angioplasty and a drug-eluting stent. He ultimately did well and was discharged home.

Bedside ultrasound in cardiac standstill: a clinical review

Patients with cardiac arrest present as a relatively frequent occurrence in the Emergency Department. Despite the advances in our understanding of the pathophysiology of cardiac arrest, managing the condition remains a stressful endeavor and currently implemented interventions, while beneficial, are still associated with a disappointingly low survivability. The majority of modern Advanced Life Support algorithms employ a standardized approach to best resuscitate the 'crashed' patient. However, management during resuscitation often encourages a 'one-size-fits-all' policy for most patients, with lesser attention drawn towards causality of the disease and factors that could alter resuscitative care. Life support providers are also often challenged by the limited bedside predictors of survival to guide the course and duration of resuscitation. Over the recent decades, point-of-care ultrasonography (PoCUS) has been gradually proving itself as a useful adjunct that could potentially bridge the gap in the recognition and evaluation of precipitants and end-points in resuscitation, thereby facilitating an improved approach to resuscitation of the arrested patient. Point-of-care ultrasound applications in the critical care field have tremendously evolved over the past four decades. Today, bedside ultrasound is a fundamental tool that is quick, safe, inexpensive and reproducible. Not only can it provide the physician with critical information on reversible causes of arrest, but it can also be used to predict survival. Of note is its utility in predicting worse survival outcomes in patients with cardiac standstill, i.e., no cardiac activity witnessed with ultrasound. Unfortunately, despite the increasing evidence surrounding ultrasound use in arrest, bedside ultrasound is still largely underutilized during the resuscitation process. This article reviews the current literature on cardiac standstill and the application of bedside ultrasound in cardiac arrests.

Smartphone interfaced handheld echocardiography for focused assessment of ventricular function and structure in children: A pilot study

INTRODUCTION

Miniaturized echocardiographic machines improve availability and portability and can be particularly useful for underserved and resource-limited settings. The goal of this study was to compare left ventricular fractional shortening (FS) and left ventricular ejection fraction (LVEF) obtained by a newer handheld echo (HHE) machine to standard transthoracic echocardiogram (TTE) in children.

METHODS

Pediatric outpatients (Birth-18 years) undergoing TTE were prospectively enrolled. HHE protocol included 2D and M-mode images from the parasternal long, short, and apical-4 chamber views. HHE and TTE measurements were reviewed for agreement. Kappa statistic was used to analyze qualitative indices while FS and LVEF were analyzed with Lin's concordance correlation coefficient (CCC) and Bland-Altman limits of agreement (loa).

RESULTS

Sixty children were enrolled; 55 were included in the quantitative analysis. Mean age was 7.5 ± 5.5 years; 67% males; median HHE image acquisition duration was 2.3(1-5) minutes. Fractional shortening and EF by HHE showed good agreement with TTE [CCC = 0.82, 95%CI (0.73,0.90), mean bias -3.18%, loa (-7.00,6.44%) vs CCC = 0.81 (0.72,0.90), mean bias -0.87%, loa (-6.94,5.17%], respectively. In children ≤5 years, HHE FS (n = 20) and EF (n = 21) agreed with TTE measurement [0.59 (0.31, 0.88), mean bias 0.30%, loa (-8.5, 9.1%); 0.79 (0.63, 0.96), mean bias 0.10%, loa (-5.99, 6.14)]. Kappa values for RV size, function, and LV function were 1.00 (P < .05); 0.75 for LV size (P < .05) and 0.66 for pericardial effusion (P < .05).

CONCLUSION

Handheld echo demonstrates good correlation with standard TTE for focused assessment of ventricular chamber sizes and function in children.

Feasibility of a Critical Care Ultrasound Curriculum Delivered Through Facebook

Purpose

To investigate the feasibility of adjunct critical care ultrasound (CCUS) curriculum via Facebook, and evaluate its impact on fellow’s interest and knowledge acquisition.

Materials and methods

All University of Southern California (USC), Pulmonary, Critical Care and Sleep Medicine (PCCM) fellows were provided the usual CCUS curriculum. The intervention group provided access to an adjunct CCUS curriculum delivered via Facebook.

Results

Out of a total of 21 fellows, 10 (47.6%) participated in the Facebook group. The mean number of posts viewed was 24 with a range of 8 to 36 (total 41). Of those who responded, 56% responded Facebook was effective, 89% felt the content was moderate to very useful, 56% responded it enhanced their CCUS education, and 44% stated it motivated them to learn. Pre- and post-testing was done using paired t-tests; the average pre and post-intervention raw score means (of a total of 41 questions) for controls were 35.4±2.9 and 38.2±1.75 (p=0.005). Intervention scores were 37.56±1.94 and 38.0±1.50 (=0.602). 

Conclusions

Evaluating the feasibility of the adjunct CCUS curriculum using social media, we found that Facebook may be acceptable to fellows, however, there was no significant improvement in knowledge. For learners, social media is easily accessible, widely available, and may motivate increased interest in learning and its potential uses warrants further study. 

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Value of Focused Echocardiography During Cardiac Arrest

Cardiac arrest is the absence of a centrally palpable pulse and no respiratory effort in an unresponsive patient. This often-lethal medical condition affects hundreds of thousands of people in the United States alone every year. Immediate intervention is crucial to provide the patient with any chance of survival. Advanced cardiac life support (ACLS) is the cornerstone therapy for cardiac arrest. Increased awareness and proper identification of life-threatening arrhythmias is critical, as it may lead to prompt medical treatment and improved mortality. The use of focused echocardiography, during a cardiac arrest, has been a developing area of interest over the past several years. The specific aim of this literature review was to emphasize the role of a focused echocardiogram and the valuable information that can be provided during a cardiac arrest.

Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice

Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.

Point-of-care ultrasound with pocket-size devices in emergency department

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.

Point-of-Care Ultrasound for Targeted Assessment of Shock: Remember HIPP in Children

The differential diagnosis for patients presenting in shock can be broad, making rapid diagnosis and management challenging. We present a case of a medically complex patient with presumed septic shock, diagnosed with a large pericardial effusion with evidence of tamponade using the rapid ultrasound in shock and hypotension protocol. The point-of-care ultrasound examination allowed for more timely and definitive management.