The Use of Handheld Ultrasound Devices in Emergency Medicine

An Assessment of the Imaging Performance of Hand-Held Ultrasound Scanners Using the Edinburgh Pipe Phantom

OBJECTIVE

Although hand-held ultrasound devices (HHUSDs) are currently used for a diverse range of diagnostic and interventional applications the imaging performance of such scanners is rarely considered. The aim of this study was to assess the imaging performance of a wide-range of HHUSDs and compare their imaging performance to cart-based systems utilized for the same clinical applications.

METHODS

The grayscale imaging performances of 19 HHUSDs from eight different manufacturers, manufactured between 2016 and 2021, were measured using a figure-of-merit known as the resolution integral. The imaging performance of the HHUSDs were compared to 142 cart-based ultrasound scanners.

RESULTS

The HHUSD with the overall highest resolution integral (66) was a Butterfly (Burlington, MA, USA) wired phased array for small parts applications, followed by a Philips (Bothell, WA, USA) Lumify wired curvilinear transducer (57) for abdominal applications, a Butterfly wired phased array (56) for abdominal applications, a GE (Freiburg, Baden-Wurttemberg, Germany) VScan Air wireless linear array (56) for small parts applications, and a Healcerion (Seoul, Korea) Sonon 300L wireless linear array (56) for small parts applications. A GE VScan Extend wired phased array had the highest resolution integral (44) for cardiac applications.

CONCLUSIONS

The Butterfly phased array had the highest resolution integral of all the 19 HHUSDs, although this value is still less than the majority of cart-based cardiac and abdominal ultrasound scanners manufactured from 2010 to 2017. Clinical users of HHUSDs should be mindful of the limitations in imaging performance of hand-held ultrasound devices.

Point-of-Care Ultrasound in the Emergency Department: Training, Perceptions, Applications, and Barriers from Different Healthcare Professionals

Background

Point-of-care ultrasound (POCUS) is a valuable tool that assists in diagnosis and management of patients in the emergency department (ED) while being cost-efficient and without the use of ionizing radiation. To discern the opinions and perceptions of ED staff about POCUS applications and barriers, we conducted a cross-sectional survey of employees of 12 EDs in North Texas.

Methods

Participants completed a 20-item online survey about POCUS with questions pertaining to four domains: (1) employee and training information, (2) perceived benefits, (3) common applications, and (4) barriers to use. Out of 805 eligible ED employees, 103 completed the survey (16.1% response rate).

Results

The results indicated a generally positive perception of POCUS among all employee types. Physician had significant exposure and training of POCUS than non-physician group ( p < 0.001). Physicians tend to find cardiac assessments more useful for clinical management than non-physicians (47% vs. 23%, p = 0.01), while non-physicians find soft tissue/abscess assessments more useful (27% vs. 9%, p = 0.01).

Conclusion

The most significant barriers to POCUS use were time constraints for physicians and a lack of training for non-physician employees. Our study provides valuable insights into the perceptions of multiple ED professionals, serving as a foundation for promoting POCUS use in the ED.

Inter-System Variability of Eight Different Handheld Ultrasound (HHUS) Devices-A Prospective Comparison of B-Scan Quality and Clinical Significance in Intensive Care

BACKGROUND

the use of handheld ultrasonography (HHUS) devices is well established in prehospital emergency diagnostics, as well as in intensive care settings. This is based on several studies in which HHUS devices were compared to conventional high-end ultrasonography (HEUS) devices. Nonetheless, there is limited evidence regarding potential variations in B-scan quality among HHUS devices from various manufacturers, and regarding whether any such differences hold clinical significance in intensive care medicine settings.

METHODS

this study included the evaluation of eight HHUS devices sourced from diverse manufacturers. Ultrasound videos of five previously defined sonographic questions (volume status/inferior vena cava, pleural effusion, pulmonary B-lines, gallbladder, and needle tracking in situ) were recorded with all devices. The analogue recording of the same pathologies with a HEUS device served as gold standard. The corresponding findings (HHUS and HEUS) were then played side by side and evaluated by sixteen intensive care physicians experienced in sonography. The B-scan quality and the clinical significance of the HHUS were assessed using a five-point Likert scale (5 points = very good; 1 point = insufficient).

RESULTS

both in assessing the quality of B-scans and in their ability to answer clinical questions, the HHUS achieved convincing results-regardless of the manufacturer. For example, only 8.6% (B-scan quality) and 9.8% (clinical question) of all submitted assessments received an "insufficient" rating. One HHUS device showed a significantly higher (p < 0.01) average points score in the assessment of B-scan quality (3.9 ± 0.65 points) and in the evaluation of clinical significance (4.03 ± 0.73 points), compared to the other devices.

CONCLUSIONS

HHUS systems are able to reliably answer various clinical intensive care questions and are-while bearing their limitations in mind-an acceptable alternative to conventional HEUS devices. Irrespective of this, the present study was able to demonstrate relevant differences in the B-scan quality of HHUS devices from different manufacturers.

The Performance Characteristics of Handheld, Non-Piezoelectric Point-of-Care Ultrasound (POCUS) in the Emergency Department

The use of handheld point-of-care ultrasound (HH-POCUS) platforms is rapidly increasing, but the diagnostic performance of HH-POCUS in the emergency department (ED) has not been well-studied. For a period of one year, only a HH-POCUS system that uses a non-piezoelectric array (Butterfly iQ+™) was available for clinical POCUS examinations in our ED. We performed a retrospective observational study of patients who underwent cardiac, thoracic, renal, biliary, or lower extremity venous (DVT) examinations from November 2021-November 2022 and calculated performance characteristics of HH-POCUS relative to radiology imaging. A total of 381 HH-POCUS studies were evaluated. Cardiac image quality was significantly lower than lung (p = 0.002). Over half of the studies (213/381) had imaging available for comparison, and HH-POCUS identified 86.5% (32/37, (95%CI) 70.4-94.9) of prespecified emergent diagnoses, including acute cholecystitis, severely reduced left ventricular ejection fraction, pericardial effusion or tamponade, moderate or larger pleural effusion, pneumothorax, moderate or larger hydronephrosis, and DVT. For less emergent diagnoses, 84.3% (43/51, (95%CI) 70.9-92.5) were identified. Overall, HH-POCUS using a non-piezoelectric array showed modest real-world performance in the ED for cardiac, thoracic, renal, biliary, and DVT examinations. HH-POCUS may be inadequate to rule out some common ED diagnoses, but had good specificity for certain conditions such as pericardial effusion.

Efficacy of Handheld Ultrasound in Medical Education: A Comprehensive Systematic Review and Narrative Analysis

Miniaturization has made ultrasound (US) technology ultraportable and, in association with their relatively low cost, made handheld devices attractive for medical education training programs. However, performing an ultrasound requires complex skills, and it is unclear whether handheld devices are suitable for the training of novices. Our study aimed to identify to what extent handheld US devices can be employed in medical undergraduates' and residents' education. We selected studies that evaluate the results obtained by students and/or residents who have participated in ultrasound training programs using handheld devices. The studies were included if they reported post-test (pre-test optional) achievements or a comparison with a control group (a group of experts or novices who underwent a different intervention). Twenty-six studies were selected, and their characteristics were summarized. Handheld ultrasound devices were used in training programs to learn echocardiography, abdominal, and/or musculoskeletal ultrasound. Statistically significant progress was noted in the ability of naïve participants to capture and interpret ultrasound images, but training duration influenced the outcomes. While ultrasound training using handheld devices has proven to be feasible for various body regions and purposes (e.g., better understanding of anatomy, clinical applications, etc.), the long-term impacts of handheld education interventions must be considered in addition to the short-term results to outline guidelines for targeted educational needs.

Prospective Comparison of Handheld Ultrasound Devices from Different Manufacturers with Respect to B-Scan Quality and Clinical Significance for Various Abdominal Sonography Questions

BACKGROUND

Handheld ultrasound (HHUS) devices have chiefly been deployed in emergency medicine, where they are considered a valid tool. The data situation is less clear in the case of internal questions in abdominal sonography. In our study, we investigate whether HHUS devices from different manufacturers differ in their B-scan quality, and whether any differences are relevant for the significance of an internal ultrasound examination.

METHOD

The study incorporated eight HHUS devices from different manufacturers. Ultrasound videos of seven defined sonographic questions were recorded with all of the devices. The analogue recording of the same findings with a conventional high-end ultrasound (HEUS) device served as an evaluation criterion. Then, the corresponding findings were played side by side and evaluated by fourteen ultrasound experts using a point scale (5 points = very good; 1 point = insufficient).

RESULTS

The HHUS devices achieved relatively good results in terms of both the B-scan quality assessment and the ability to answer the clinical question, regardless of the manufacturer. One of the tested HHUS devices even achieved a significantly (p < 0.05) higher average points score in both the evaluation of B-scan quality and in the evaluation of clinical significance than the other devices. Regardless of the manufacturer, the HHUS devices performed best when determining the status/inferior vena cava volume and in the representation of ascites/free fluid.

CONCLUSION

In various clinical abdominal sonography questions, HHUS systems can reliably reproduce findings, and are-while bearing their limitations in mind-an acceptable alternative to conventional HEUS systems. Irrespective of this, the present study demonstrated relevant differences in the B-scan quality of HHUS devices from different manufacturers.

Artificial intelligence in emergency medicine. A systematic literature review

Motivation and objective: Emergency medicine is becoming a popular application area for artificial intelligence methods but remains less investigated than other healthcare branches. The need for time-sensitive decision-making on the basis of high data volumes makes the use of quantitative technologies inevitable. However, the specifics of healthcare regulations impose strict requirements for such applications. Published contributions cover separate parts of emergency medicine and use disparate data and algorithms. This study aims to systematize the relevant contributions, investigate the main obstacles to artificial intelligence applications in emergency medicine, and propose directions for further studies.

METHODS

The contributions selection process was conducted with systematic electronic databases querying and filtering with respect to established exclusion criteria. Among the 380 papers gathered from IEEE Xplore, ACM Digital Library, Springer Library, ScienceDirect, and Nature databases 116 were considered to be a part of the survey. The main features of the selected papers are the focus on emergency medicine and the use of machine learning or deep learning algorithms.

FINDINGS AND DISCUSSION

The selected papers were classified into two branches: diagnostics-specific and triage-specific. The former ones are focused on either diagnosis prediction or decision support. The latter covers such applications as mortality, outcome, admission prediction, condition severity estimation, and urgent care prediction. The observed contributions are highly specialized within a single disease or medical operation and often use privately collected retrospective data, making them incomparable. These and other issues can be addressed by creating an end-to-end solution based on human-machine interaction.

CONCLUSION

Artificial intelligence applications are finding their place in emergency medicine, while most of the corresponding studies remain isolated and lack higher generalization and more sophisticated methodology, which can be a matter of forthcoming improvements.

[Ultrasound systems for abdominal diagnostics - current methods, clinical applications and new technologies]

Abdominal ultrasound is the method of first choice in many clinical situations. Gray scale imaging (B-mode) and conventional Doppler techniques are nowadays complemented by contrast-enhanced ultrasound (CEUS), elastography, fat quantification and further technologies which allow multimodal characterization of organs and tissue structure using panoramic imaging, 3D-techniques and image fusion. The development of small portable devices augments the spectrum for sonographic diagnostics. In this review, we describe the current status of ultrasound technology based on published evidence. In addition, we provide guidance for quality assurance.

Postoperative Handheld Gastric Point-of-Care Ultrasound and Delayed Bowel Function

BACKGROUND

Delayed bowel function (DBF) following intra-abdominal surgery is a common problem that contributes to postoperative complications and prolonged length of stay. Use of a handheld gastric point-of-care ultrasound (GPOCUS) can identify a full vs empty stomach in the postoperative period. We hypothesized that the findings of a full stomach identified on a postoperative day 1 (POD1) GPOCUS exam would predict an increased risk of delayed bowel function.

STUDY DESIGN

A blinded, prospective cohort study was performed. Postoperative colorectal surgery patients were identified as having either a full or empty stomach based on previously published definitions. GPOCUS examinations were performed on POD1 using a handheld ultrasound device, and the clinicians were blinded to the results. Demographic and perioperative data were collected. The primary outcome variable was gastrointestinal-3 (GI-3) recovery, defined as time to tolerance of diet and either flatus or bowel movement.

RESULTS

Fifty-six patients agreed to participate in the study; fifty were eligible and included. Eighteen patients' stomachs were identified as full on POD1 GPOCUS examination, and thirty-two were identified as empty. No significant demographic or perioperative differences existed between groups. Patients with full stomachs had significantly delayed GI-3 recovery (4 vs 1 days, p < 0.0001) and longer length of stay (5 vs 3 days, p < 0.0001). Full-stomach patients also had significantly more emesis and nasogastric tube (NGT) placement (both p < 0.05).

CONCLUSIONS

GPOCUS performed on POD1 can predict DBF, length of stay, likelihood of emesis, and NGT placement. Use of handheld devices for GPOCUS showed promise for the identification of patients at high risk for DBF and could provide an opportunity for pre-emptive intervention.

Comparison of four handheld point-of-care ultrasound devices by expert users

Background

Point-of-care ultrasound (POCUS) is rapidly becoming ubiquitous across healthcare specialties. This is due to several factors including its portability, immediacy of results to guide clinical decision-making, and lack of radiation exposure to patients. The recent growth of handheld ultrasound devices has improved access to ultrasound for many clinicians. Few studies have directly compared different handheld ultrasound devices among themselves or to cart-based ultrasound machines. We conducted a prospective observational study comparing four common handheld ultrasound devices for ease of use, image quality, and overall satisfaction. Twenty-four POCUS experts utilized four handheld devices (Butterfly iQ+™ by Butterfly Network Inc., Kosmos™ by EchoNous, Vscan Air™ by General Electric, and Lumify™ by Philips Healthcare) to obtain three ultrasound views on the same standardized patients using high- and low-frequency probes.

Results

Data were collected from 24 POCUS experts using all 4 handheld devices. No single ultrasound device was superior in all categories. For overall ease of use, the Vscan Air™ was rated highest, followed by the Lumify™. For overall image quality, Lumify™ was rated highest, followed by Kosmos™. The Lumify™ device was rated highest for overall satisfaction, while the Vscan Air™ was rated as the most likely to be purchased personally and carried in one’s coat pocket. The top 5 characteristics of handheld ultrasound devices rated as being “very important” were image quality, ease of use, portability, total costs, and availability of different probes.

Conclusions

In a comparison of four common handheld ultrasound devices in the United States, no single handheld ultrasound device was perceived to have all desired characteristics. POCUS experts rated the Lumify™ highest for image quality and Vscan Air™ highest for ease of use. Overall satisfaction was highest with the Lumify™ device, while the most likely to be purchased as a pocket device was the Vscan Air™. Image quality was felt to be the most important characteristic in evaluating handheld ultrasound devices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-022-00274-6.

Evaluation of a Required Vertical Point-of-Care Ultrasound Curriculum for Undergraduate Medical Students

Introduction Point-of-care ultrasound training beginning in undergraduate medical education reinforces anatomy and physical examination skills and enhances clinical care. Implementation in an overcrowded curriculum requires strategic planning to overcome barriers including lack of faculty and equipment. Using Kern's six-step model as a framework, our study question was whether a longitudinal point-of-care ultrasound curriculum threaded through four years of medical school and using a novel combination of evidence-based strategies was feasible, acceptable, and resulted in students achieving ultrasound competencies by graduation. Materials and methods From 2016 to 2020, a required, vertical point-of-care ultrasound curriculum was created across all four undergraduate medical education class years, spearheaded by a single ultrasound fellowship-trained emergency physician with support from two basic anatomy faculty. We utilized strategies including handheld ultrasound devices, near-peer teaching, flipped classroom with virtual learning modules, staggered station rotations, and gamification to optimize student-instructor ratios and faculty time. Surveys and timed objective structured clinical assessments evaluated the curriculum. Results Students from the class of 2022 (n=99, 100% of class) participated in all curricular elements. Senior students answered more survey knowledge questions correctly when compared to pretest questions answered by first- and second-year students. Among 84 students who completed the survey, 75 (89%) rated their ultrasound curriculum as superior or above average. Objective structured clinical examination scores recorded for 53 students (54% of the class) demonstrated students correctly identified a median of 11-18 structures (interquartile range: 9.5-13) using point-of-care ultrasound. Conclusion Evidence-based strategies allowed faculty to develop a four-year required ultrasound curriculum that was highly acceptable by students and improved their knowledge and skills at graduation. At low cost and with few faculty, this program has been sustained for over six years.

[Perspectives and Challenges of hand-held Ultrasound]

The use of handheld ultrasound devices from a technical and data protection point of view, device properties, functionality, documentation, indications, delegation of performance, applications by doctors, students and non-medical staff is examined and discussed.

Point-of-care ultrasound in pediatric nephrology

Point-of-care ultrasound (POCUS) has evolved in recent years in clinical practice, helping in early bedside diagnosis of important etiologies. Many medical schools and training programs are integrating POCUS into their curriculum. Especially with the technological advances of newer handheld ultrasound devices, POCUS has now become a component adjunct to clinical examination, in the clinic and bedside in critical care units. The diagnostic utility of POCUS lies both in early identification of critical kidney disease, and also extra-renal pathologies from a focused cardiac ultrasound, lung ultrasound, and integrated fluid assessment. There is a need to incorporate POCUS in training in pediatric nephrology and establish competency standard criteria. This review shall cover how POCUS helps in enhancing patient care in pediatric kidney disorders and critical children, and the recent advances.

Pain After Preoperative Ultrasound Guided Hip Injections for Total Hip Arthroplasty: A Pilot Randomized Controlled Trial

Introduction. Hip replacement is a frequently performed and highly successful treatment for patients with end stage osteoarthritis. Advances in technique and pain management have allowed for rapid mobilization and early discharge after surgery. We hypothesize that pre-incision intra-articular injection of local anesthetic with epinephrine under image guidance combined with post incision peri-articular injection (PAI) may be more effective than PAI alone. Methods. A prospective, randomized, controlled, comparative investigation at a single institution of 41 patients undergoing THA who received standard 30 mL post-arthrotomy, PAI of ropivacaine with epinephrine under direct visualization after prosthesis implantation before closure or an equivalent dose divided into a 10 mL pre-incision, ultrasound guided intra-articular injection and a 20 mL post-arthrotomy PAI. Results. 42 patients were included in this study before its early conclusion with 22 patients in the treatment group and 20 in the control group. There were no significant differences in age, BMI or ASA scores. Additionally, there were no significant differences noted when comparing groups by postoperative outcome measures including OMME, EBL, OR time, PACU minutes, and first and last PACU pain score. Furthermore, there were no significant differences in the PROMs evaluated. Discussion. The addition of ultrasound guided pre-incision intra-articular injection to the standard PAI had no benefit when compared with standard PAI during a THA. Portable mobile phone based ultrasound devices provide a cost effective way to perform musculoskeletal blocks, and further studies on their use and comparative accuracy is warranted. A novel technique for confirmation of injection location is described.

Establishing an Ultrasound Screening Protocol for Chronic Liver Disease with a Handheld Device: A Pilot Project in Southern Ethiopia

Chronic liver disease (CLD) poses significant challenges in the developing world. The prevalence of this problem and the health burden on local health services are not well understood. The diagnosis and monitoring of CLD are difficult in these settings because of limited access to expensive imaging with limited mobility and/or liver biopsy. The aim of this project was to develop and implement an efficient evidence-based robust ultrasound protocol for the assessment of chronic liver disease using a hand-held ultrasound device that could be effectively used in the developing world. A protocol was established using scoring systems that have established accuracy for the diagnosis of hepatic fibrosis/cirrhosis and hepatic steatosis. Included in the protocol was the identification of hepatic masses, portal venous enlargement, hepatic size and splenic size. Hepatic steatosis was common, identified in 46 of 94 participants (49%). Hepatic fibrosis was observed in only 13 of 94 participants (14%). A significant limitation of the methodology was the inability to validate the results with biopsy or other forms of cross-sectional imaging. The protocol was successfully implemented in a community in a rural setting in South Ethiopia with a mean examination time of around 6 min. It is feasible to use handheld ultrasound for the screening of CLD in remote settings. This project provides an evidence-based framework for further studies in this area.

Association of traditional risk factors with carotid intima-media thickness and carotid plaque in asymptomatic individuals with a family history of premature cardiovascular disease

The use of imaging to detect subclinical atherosclerosis helps to inform decision-making in people classified as having intermediate risk for cardiovascular disease (CVD). This study sought to use carotid plaque as an alternative to carotid intima media thickness (cIMT). Carotid ultrasound for assessment of cIMT and plaque was obtained in 1031 people (53 years, 61% female) with a family history of atherosclerotic CVD. The association of baseline characteristics and standard atherosclerotic risk factors (RFs) were sought with abnormal cIMT and plaque. The strongest association of plaque was a history of hypertension (odds ratio [OR] 1.87 (1.02-3.42), followed by age (OR 1.08 [95% CI 1.02-1.13]). For cIMT, the strongest association was smoking history (OR 1.57 [1.13-2.19]). The area under the receiver operator curve for the presence of plaque was 0.74 (95% CI 0.68-0.81, p < 0.001) and 0.65 (95% CI 0.61-0.70, p < 0.001) for cIMT elevation. Isolated elevation of cIMT (n = 178) was associated with increased total cholesterol, body mass index (BMI) and systolic blood pressure (SBP). Plaque only (n = 29) was associated with hypertension, male sex and older age. The presence of both markers abnormal (n = 22) was associated with a history of smoking. The absence of either abnormal cIMT or plaque (n = 773), was inversely associated with current or past smoking, SBP and BMI. Abnormalities in carotid vessels are present in a minority of intermediate risk patients with familial premature disease. The associations with RFs differ and are more closely associated with plaque.

Development and Remodeling of Point-of-Care Ultrasound Education for Emergency Medicine Residents in Resource Limited Countries during the COVID-19 Pandemic

The administration of an accurate and effective POCUS course is a crucial tool in improving health education and thus the health care system in low- to middle-income countries. The development of the ultrasound curriculum in these countries during the pandemic era is a major challenge for medical educators. Therefore, this study aims to survey the learner experience after implementing the POCUS curriculum for first-year emergency medicine residents. All learners responded to the survey. Our results demonstrated that the ultrasound rotation and our ultra-sound learning materials were useful tools which showed a positive impact on POCUS knowledge for our learners. However, some obstacles of POCUS learning were identified to assist in closing faculty development gaps, including the availability of handheld devices, as well as the re-modeling of the ultrasound rotation course, which should be managed according to the feedback we received. This study demonstrated a clear need for constant updates in higher education, medical program development, accuracy of local learning materials, and the explosion of virtual and online learning platforms during this decade.

A Blueprint for an Integrated Point-of-Care Ultrasound Curriculum for Nephrology Trainees

Point-of-care ultrasonography (POCUS) is a limited ultrasound study performed by the clinician at the bedside as a component or an adjunct to physical examination. POCUS has multiple applications in nephrology practice, including evaluation of obstructive uropathy, objective assessment of volume status, arteriovenous access assessment, and procedural guidance. However, unlike specialties such as emergency medicine, POCUS training is not yet integrated into most nephrology fellowship curricula, and the sonographic applications taught vary widely among fellowship programs. In this article, we have used our institutional experience to provide a roadmap or blueprint for nephrology programs looking to create a POCUS program. We provide an overview of the curriculum, including the basic organization, applications taught, online resources, milestone development, and quality assessment. We also discuss the nuances of POCUS workflow and perspectives on billing for these limited studies. In addition, we share the evaluation forms and sample documentation we use in our program. Future support, in the form of endorsed nephrology society guidelines, is needed before POCUS training is universally incorporated across nephrology fellowship programs.