[Focused echocardiography in acute medicine]

Echoscopy in scanning cardiac diseases in critical care medicine

BACKGROUND AND AIMS

Targeted ultrasound examinations with a portable ultrasound device ("handheld ultrasound system"; HHUS) have been defined as "echoscopy" by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). Cardiac scanning with HHUS is feasible. Echoscopy could play a major role in emergency and intensive care medicine, but adequate data on its effectiveness are still lacking. Sonographic examinations in the field of emergency and intensive care medicine can often not be carried out under standardized examination conditions. Thus, the aim of this study is to show that the use of HHUS for echocardiography in emergency medicine is possible and that for this setting HHUS is not inferior to a high-end ultrasound system (HEUS) for detecting cardiac pathologies.

METHODS

The examinations were carried out with a Vscan™ (GE Medical Systems, Solingen, Germany) and a high-end ultrasound device (Acuson X‑300 or X‑700). The examinations were randomized and blinded to two examiners within 30 min. The examinations took place in the intensive care unit, the emergency room and the ambulance service. The results were recorded in an examination sheet.

RESULTS

In all, 93 patients (61 men and 32 women, age 69 ± 14.76 [33-95] years). In 32.6% (30/93) of examinations with HEUS the examination conditions were optimal and in 29.03% (27/93) when the HHUS was used. Of the examinations, 50.08% (31/61) were carried out by both examiners in the same patient position. Using HHUS, the following sensitivity and specificities (respectively) were found: pericardial effusion (73.68%; 96.97%), hemodynamically relevant effusion (50%; 97.67%), right heart strain (90,91%; 96,72%), arrest of the right ventricle (100%; 87,5%), limitation of left ventricular pump function (91.49%; 86.11%), wall movement disorders (WMD, 97.29%; 78.95%), aortic valve sclerosis (42.86%; 86.67%), aortic regurgitation (60%; 95%), mitral valve sclerosis (60%; 100%), mitral reguritation (66.67%; 82.86%), tricuspid valve regurgitation (48%; 81,48%). Measurements of the dimensions of pericardial effusion, the left ventricle, the left atrium and the left ventricular posterior wall each had a positive correlation between the examination with HHUS and HEUS (Κ = 0.45 to 0.91). The diameters determined by HHUS and HEUS for the septum and aortic root, however, correlated negatively (κ = -0.61 to -0.86).

CONCLUSIONS

The use of echoscopy in emergency and intensive care medicine is not inferior to HEUS for detecting defined cardiac pathologies.

Echoscopy in scanning abdominal diseases in a critical care setting

BACKGROUND AND AIMS

Targeted ultrasound examinations with portable ultrasound device (handheld ultrasound system [HHUS]) have been defined as "echoscopy" by the European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB). For abdominal diseases it has been shown that echoscopy is sensitive and specific. The aim of this study is to show that the use of HHUS for abdominal ultrasonography is possible under the conditions prevailing in emergency and intensive care medicine and that it is not inferior to high-end devices (high-end ultrasound systems [HEUS]).

METHODS

Examinations were carried out with a first-generation Vscan™ (GE Medical Systems, Solingen, Germany) and HEUS device (Siemens Acuson X‑300 or X‑700, Siemens Healthcare, Erlangen, Germany). The HEUS device was seen as standard. The examinations were randomized and blinded and carried out by two examiners within 30 min in order to avoid falsifications due to time delay. They took place in the intensive care unit, the emergency room and the emergency medical service. The results had to be recorded in an examination sheet.

RESULTS

In all, 86 patients (54 men and 32 women, aged 73 ± 14.58 [28-95] years) were included. In 45.35% (39/86) of the ultrasound examinations using HEUS and in 41.86% (36/89) of the cases using HHUS the examination conditions were optimal. Furthermore, 76.19% of the examinations were carried out by both examiners in the same scanning position. For the detection of liver tumours, HHUS shows a sensitivity of 70% and specificity of 100%. With regard to identifying signs of cholecystitis, i.e., evidence of surrounding inflammation (a) or hydrops (b), HHUS shows a sensitivity of 66.67% (a) and 60% (b) and a specificity of 97.06% (a) and 96.86% (b). The diagnosis of an ileus is successful with a sensitivity of 87.5% and a specificity of 60%. The respiratory variability of the inferior vena cava has a sensitivity of 100% and a specificity of 40% using HHUS. Ascites and pleural effusions can be diagnosed with a sensitivity of 89% and a specificity of 93.1%. When using the FAST (Focused Assessment with Sonography for Trauma) protocol, HHUS has a sensitivity of 80% and a specificity of 90.9%. With the exception of kidney cysts and inferior vena cava, the measurement of the diameter has a positive correlation.

CONCLUSION

Echoscopy of the abdomen in emergency and intensive care medicine is possible despite restrictive circumstances. The inferior vena cava can only be assessed to a limited extent with the first generation of Vscan™. In order to use sonography in emergency and intensive care medicine, a standardized procedure is to be aimed for and training in emergency sonography is necessary.

[Focused ultrasound in the emergency room]

Ultrasound is an important tool in diagnosis and treatment of critically ill patients. For trauma patients the eFAST (extended focused assessment with sonography for trauma) algorithm is already implemented in the diagnostic pathway. However, critically ill patients without trauma also need a structured approach including an early focused ultrasonographic exam. National and international guidelines regarding critical illnesses such as acute coronary syndrome, cardiogenic shock complicating myocardial infarction, pulmonary embolism or acute aortic syndromes recommend the use of ultrasound. We present pathways how ultrasound can be used in the diagnostic approach of common symptoms such as dyspnea, shock and abdominal pain. Using the ABCDE approach this article shows how ultrasound can be incorporated into the diagnostic pathway.

[Point-of-care ultrasonography of the abdomen in emergency and intensive care medicine]

Point-of-care ultrasound is a fundamental part of diagnostic and therapeutic management in emergency and intensive care medicine. The availability of high-resolution mobile ultrasound systems allows high-quality imaging at the bedside of the patient. Point-of-care ultrasound is not a comprehensive differential diagnostic abdominal ultrasound examination. Rather, the aim of the method is to integrate easily detectable sonographic findings into the clinical context. From this, the necessary diagnostic or therapeutic procedures are derived. This article shows opportunities and limitations of this method. The structure of the article is given by the leading clinical symptoms. The focus is on the ultrasound examination and the characteristic sonographic findings with illustrative ultrasound images. This is followed by a short differential diagnostic interpretation. Further diagnostic or therapeutic management is also briefly addressed.