Tricuspid annular plane of systolic excursion to prognosticate acute pulmonary symptomatic embolism (TAPSEPAPSE study)

The 2023 Core Content of advanced emergency medicine ultrasonography

In February 2023, the American Board of Emergency Medicine (ABEM) approved modifications to the Advanced Emergency Medicine Ultrasonography (AEMUS) Core Content, which defines the areas of knowledge considered essential for the practice of AEMUS. This manuscript serves as a revision of the AEMUS Core Content originally published in 2014. The revision of the Core Content for AEMUS training aims to establish standardized education and qualifications necessary for AEMUS fellowship program leadership, clinical application, administration, quality improvement, and research. The Core Content provides the organizational framework and serves as the basis for the development of content for the Focused Practice Examination (FPE) administered by ABEM. AEMUS fellowship directors may reference the Core Content when designing AEMUS fellowship curricula to help prepare graduates for the autonomous practice of AEMUS and the FPE. In this article, an updated revision of the previously published AEMUS Core Content is detailed, and the entire development of the Core Content is presented.

Analysis of echocardiographic criteria for pulmonary embolism

To date, the search for the most informative diagnostic and prognostic echocardiographic criteria for pulmonary embolism is relevant. Aims. To conduct a critical analysis of the generally accepted echocardiographic criteria for pulmonary embolism in order to establish the most significant of them in determining the severity and outcomes of the disease. Materials and methods. The study included 42 patients with fatal pulmonary embolism, 51 patients with hemodynamically unstable and 193 with hemodynamically stable course of the disease. The prevalence of generally accepted echocardiographic criteria for overload of the right heart was assessed, followed by their significance for determining the severity of the disease and predicting its outcomes. Results. It was found that among the generally recognized echocardiographic criteria, the most significant for determining the severity of pulmonary embolism and its outcomes are: an increase in the ratio of basal sizes of the right and left ventricles more than 1.1, an increase in systolic pressure in the pulmonary artery more than 55 mm Hg, dyskinesia of the free wall of the right ventricle, flattening of the interventricular septum, a decrease in systolic excursion the plane of the tricuspid valve is less than 1.6 cm. However, all of them, except the last one, do not have high sensitivity and specificity. The significance of the currently underestimated cardiac stroke volume as a prognostic indicator of echocardiography has been established. It was determined that its decrease of less than 45 ml correlated with hemodynamic instability of the course of the disease, and less than 35 ml was associated with a fatal outcome. This indicator had high diagnostic characteristics. Conclusion. A decrease in the systolic excursion of the tricuspid valve plane of less than 1.6 cm and a decrease in the stroke volume of the heart of less than 45 ml are the most significant indicators of echocardiography in assessing the severity and prognosis of pulmonary embolism.

Point of care ultrasound detection of thrombus straddling a patent foramen ovale in a patient with acute chest syndrome

Patients with sickle cell disease can develop acute chest syndrome and are at high risk of developing pulmonary thrombosis. We report a case of a young woman with sickle cell disease who was hospitalized for vaso-occlusive crisis and subsequently developed worsening acute chest syndrome and stroke, discovered on point of care ultrasound to have right heart failure and a thrombus straddling a patent foramen oval. POCUS is highly specific for the detection of right heart dilation/dysfunction and should be a routine component of the assessment of acutely decompensating patients.

Diagnostic accuracy of focused deep venous, lung, cardiac and multiorgan ultrasound in suspected pulmonary embolism: a systematic review and meta-analysis

OBJECTIVE

To determine the diagnostic accuracy of point-of-care ultrasound in suspected pulmonary embolism.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase, CINAHL and Cochrane library were searched on 2 July 2020 with no restrictions on the date of publication. Subject headings or subheadings combined with text words for the concepts of pulmonary embolism, ultrasound and diagnosis were used.

ELIGIBILITY CRITERIA AND DATA ANALYSIS

Eligible studies reported sensitivity and specificity of deep venous, lung, cardiac or multiorgan ultrasound in patients with suspected pulmonary embolism, using an adequate reference-test. Prospective, cross-sectional and retrospective studies were considered for eligibility. No restrictions were made on language. Studies were excluded if a control group consisted of healthy volunteers or if transesophageal or endobronchial ultrasound was used. Risk of bias was assessed using quality assessment of diagnostic accuracy studies-2. Meta-analysis of sensitivity and specificity was performed by construction of hierarchical summary receiver operator curves. I² was used to assess the study heterogeneity.

MAIN OUTCOME MEASURES

The primary outcome was overall sensitivity and specificity of reported ultrasound signs, stratified by organ approach (deep venous, lung, cardiac and multiorgan). Secondary outcomes were stratum-specific sensitivity and specificity within subgroups defined by pretest probability of pulmonary embolism.

RESULTS

6378 references were identified, and 70 studies included. The study population comprised 9664 patients with a prevalence of pulmonary embolism of 39.9% (3852/9664). Risk of bias in at least one domain was found in 98.6% (69/70) of included studies. Most frequently, 72.8% (51/70) of studies reported >24 hours between ultrasound examination and reference test or did not disclose time interval at all. Level of heterogeneity ranged from 0% to 100%. Most notable ultrasound signs were bilateral compression of femoral and popliteal veins (22 studies; 4708 patients; sensitivity 43.7% (36.3% to 51.4%); specificity 96.7% (95.4% to 97.6%)), presence of at least one hypoechoic pleural-based lesion (19 studies; 2134 patients; sensitivity 81.4% (73.2% to 87.5%); specificity 87.4% (80.9% to 91.9%)), D-sign (13 studies; 1579 patients; sensitivity 29.7% (24.6% to 35.4%); specificity 96.2% (93.1% to 98.0%)), visible right ventricular thrombus (5 studies; 995 patients; sensitivity 4.7% (2.7% to 8.1%); specificity 100% (99.0% to 100%)) and McConnell's sign (11 studies; 1480 patients; sensitivity 29.1% (20.0% to 40.1%); specificity 98.6% (96.7% to 99.4%)).

CONCLUSION

Several ultrasound signs exhibit a high specificity for pulmonary embolism, suggesting that implementation of ultrasound in the initial assessment of patients with suspected pulmonary embolism may improve the selection of patients for radiation imaging.

PROSPERO REGISTRATION NUMBER

CRD42020184313.

Point-of-Care Ultrasonography in Patients With Acute Dyspnea: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians

BACKGROUND

Dyspnea is a common and often debilitating symptom with a complex diagnostic work-up.

PURPOSE

To evaluate the benefits, harms, and diagnostic test accuracy of point-of-care ultrasonography (POCUS) in patients with acute dyspnea. (PROSPERO: CRD42019126419).

DATA SOURCES

Searches of multiple electronic databases without language limitations (January 2004 to August 2020) and reference lists of pertinent articles and reviews.

STUDY SELECTION

Five randomized controlled trials (RCTs) and 44 prospective cohort-type studies in patients with acute dyspnea evaluated POCUS as a diagnostic tool to determine the underlying cause of dyspnea. Two investigators independently screened the literature for inclusion.

DATA EXTRACTION

Data abstraction by a single investigator was confirmed by a second investigator; 2 investigators independently rated risk of bias and determined certainty of evidence.

DATA SYNTHESIS

Point-of-care ultrasonography, when added to a standard diagnostic pathway, led to statistically significantly more correct diagnoses in patients with dyspnea than the standard diagnostic pathway alone. In-hospital mortality and length of hospital stay did not differ significantly between patients who did or did not receive POCUS in addition to standard diagnostic tests. Finally, POCUS consistently improved the sensitivities of standard diagnostic pathways to detect congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax; specificities increased in most but not all studies.

LIMITATIONS

Most studies assessed diagnostic test accuracy, which has limited utility for clinical decision making. Studies rarely reported on the proportion of indeterminate sonography results, and no evidence is available on adverse health outcomes of false-positive or false-negative POCUS results.

CONCLUSION

Point-of-care ultrasonography can improve the correctness of diagnosis in patients with acute dyspnea.

PRIMARY FUNDING SOURCE

American College of Physicians.

Right ventricular echocardiographic parameters associated with prothrombotic abnormalities in normotensive patients with acute pulmonary embolism

BACKGROUND

In acute pulmonary embolism (PE) right ventricular (RV) pressure overload negatively affects prognosis. Recently we have shown that RV dilatation is associated with a prothrombotic state in PE. We investigated which RV echocardiographic parameters best indicate prothrombotic alterations in acute PE.

METHODS

In 121 normotensive, noncancer PE patients, markers of RV dilatation and dysfunction were evaluated on admission using transthoracic echocardiography, along with prothrombotic state markers, i.e. increased endogenous thrombin generation (ETP), low fibrin clot permeability (K_s, a measure of clot density), and prolonged clot lysis time (CLT).

RESULTS

RV parasternal long axis (RVOT PLAX) >30 mm was associated with ETP (OR 3.86; 95% CI 1.55-9.62; p = 0.004) and CLT (OR 4.08; 95% CI 1.58-10.54; p = 0.004) in the top quartiles, but not with K_s. RV short parasternal axis (RVOT PSAX) >27 mm showed similar associations with higher ETP (OR 3.54; 95% CI 1.50-8.37; p = 0.004) and prolonged CLT (OR 2.78; 95% CI 1.17-6.62; p = 0.021). RV basal diameter >41 mm solely predicted prolonged CLT (OR 2.93; 95% CI 1.23-6.99; p = 0.016). The right atrium area, pulmonary trunk diameter, and tricuspid regurgitation maximum velocity were not related to prothrombotic markers, except for tricuspid annular plane systolic excursion weakly associated with ETP. Multivariable analysis showed that RVOT PSAX is independently associated with prolonged CLT (OR 1.16; 95% CI 1.04-1.30; p = 0.007), low K_s (OR 1.21; 95% CI 1.02-1.44; p = 0.029), and higher ETP (OR 1.14; 95% CI 1.03-1.26; p = 0.009).

CONCLUSIONS

Among RV echocardiographic parameters, the RVOT dilatation measured in PSAX best predicts prothrombotic alterations in PE patients.

Serial Point-of-care Echocardiography Performed by an Emergency Physician to Guide Thrombolytic Management of Massive Pulmonary Embolism

Massive pulmonary embolism (PE) is a life-threatening condition with a high mortality burden. The rapid diagnosis of PE can be supported with focused cardiac ultrasound (FOCUS) by identifying signs of right ventricular dysfunction (RVD). This case report describes a patient with hemodynamically unstable massive PE who received systemic thrombolytic therapy. Emergency physicians performed serial FOCUS examinations to assess the resolution of RVD in guidance of clinical management.

Tricuspid Annular Plane of Systolic Excursion (TAPSE) for the Evaluation of Patients with Severe Sepsis and Septic Shock

Introduction

Sepsis is a systemic infection that can rapidly progress into multi organ failure and shock if left untreated. Previous studies have demonstrated the utility of point of care ultrasound (POCUS) in the evaluation of patients with sepsis. However, limited data exists on the evaluation of the tricuspid annular plane of systolic excursion (TAPSE) in patients with sepsis.

Methods

We prospectively enrolled patients who presented to the emergency department (ED) with concern for severe sepsis or septic shock in a pilot study. In patients that screened positive, the treating physician then performed POCUS to measure the TAPSE value. We compared the intensive care unit (ICU) admission rate, hospital length of stay, and morbidity with their respective TAPSE values.

Results

We enrolled 24 patients in the study. Eight patients had TAPSE values less than 16 millimeters (mm), two patients had TAPSE values between 16mm–20mm, and fourteen patients had TAPSE values greater than 20mm. There was no statistically significant association between TAPSE levels and ICU admission (p=0.16), or death (p=0.14). The difference of length of stay (LOS) was not statistically significant in case of hospital LOS (p= 0.72) or ICU LOS.

Conclusion

Our pilot data did not demonstrate a correlation between severe sepsis or septic shock and TAPSE values. This may be due to several factors including patient comorbidities, strict definitions of sepsis and septic shock, as well as the absence of septic cardiomyopathy (SCM) in patients with sepsis and septic shock. Future large-scale studies are needed to determine if TAPSE can be beneficial in the ED evaluation of patients with concern for SCM.