Role of point-of-care ultrasound study in early disposition of patients with undifferentiated acute dyspnea in emergency department: a multi-center prospective study

Effect of a Point-of-Care Ultrasound-Driven vs Standard Diagnostic Pathway on 24-Hour Hospital Stay in Emergency Department Patients with Dyspnea-Protocol for A Randomized Controlled Trial

Purpose

Point-of-care ultrasound (POCUS) helps emergency department (ED) physicians make prompt and appropriate decisions, but the optimal diagnostic integration and potential clinical benefits remain unclear. We describe the protocol and statistical analysis plan for a randomized controlled trial. The objective is to determine the effect of a POCUS-driven diagnostic pathway in adult dyspneic ED patients on the proportion of patients having a hospital stay of less than 24 hours when compared to the standard diagnostic pathway.

Patients and Methods

This is a multicenter, randomized, investigator-initiated, open-labeled, pragmatic, controlled trial. Adult ED patients with chief complaint dyspnea are eligible. Patients are randomized (1:1) to the POCUS-driven diagnostic pathway or standard diagnostic pathway, with 337 patients in each group. The primary outcome is the proportion of patients having a hospital stay (from ED arrival to hospital discharge) of less than 24 hours. Key secondary outcomes include hospital length-of-stay, 72-hour revisits, and 30-day hospital-free days.

Conclusion

Sparse evidence exists for any clinical benefit from a POCUS-integrated diagnostic pathway. The results from this trial will help clarify the promising signals for POCUS to influence patient care among ED patients with dyspnea.

The Role of Pocus in Acute Respiratory Failure: A Narrative Review on Airway and Breathing Assessment

Acute respiratory failure (ARF) is a challenging condition that clinicians, especially in emergency settings, have to face frequently. Especially in emergency settings, many underlying diseases can lead to ARF and life-threatening conditions have to be promptly assessed and correctly treated to avoid unfavorable outcomes. In recent years, point-of-care ultrasound (POCUS) gained growing consideration due to its bedside utilization, reliability and reproducibility even in emergency settings especially in unstable patients. Research on POCUS application to assess ARF has been largely reported mainly with observational studies showing heterogeneous results from many different applications. This narrative review describes the wide potentiality of POCUS to face airways and breathing life-threatening conditions such as upper airway management, pulmonary and pleural pathologies and diaphragm impairment. We conducted extensive research of the literature to report from major studies to case reports deemed useful in practical clinical utilization of POCUS in ARF. Due to the huge amount of the literature found, we focused on airways and breathing assessment trying to systematize the evidence according to clinical care of ARF in emergency settings. Further studies, possibly trials, should determine how POCUS is crucial in clinical practice in terms of standard of care improvements, patient safety and cost-benefit analysis.

POCUS in dyspnea, nontraumatic hypotension, and shock; a systematic review of existing evidence

BACKGROUND

Point-of-care ultrasound (POCUS) has been adopted as a powerful tool in acute medicine. This systematic review aims to critically appraise the existing literature on point-of-care ultrasound in respiratory or circulatory deterioration.

METHODS

Original studies on POCUS and dyspnea, nontraumatic hypotension, and shock from March 2002 until March 2022 were assessed in the PubMed and Embase Databases. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist.

RESULTS

We included 89 articles in this review. Point-of-care ultrasound in the initial workup increases the diagnostic accuracy in patients with dyspnea, nontraumatic hypotension and shock in the ED, ICU and medical ward setting. No improvement is found in patients with severe sepsis in the ICU setting. POCUS is capable of narrowing the differential diagnoses and is faster, and more feasible in the acute setting than other diagnostics available. Results on outcome measures are heterogenous. The quality of the included studies is considered low most of the times, mainly because of performance and selection bias and absence of a gold standard as the reference test.

CONCLUSION

We conclude that POCUS contributes to a higher diagnostic accuracy in dyspnea, nontraumatic hypotension, and shock. It aides in narrowing the differential diagnoses and shortening the time to correct diagnosis and effective treatment.

TRIAL REGISTRY

INPLASY; Registration number: INPLASY202220020; URL: https://inplasy.com/.

A REVIEW OF LAWSUITS RELATED TO POINT-OF-CARE EMERGENCY ULTRASOUND APPLICATIONS

BACKGROUND

Previous investigators have assessed United States Case Law to evaluate the medicolegal risk surrounding point-of-care ultrasound applications. These studies have suggested that nonperformance is the primary source of an allegation of medical malpractice.

OBJECTIVES

The objective of this study is to update the literature regarding medical malpractice cases involving ultrasound applications that could be used at the point of care, and assess the risk conveyed to advanced practice providers and by application of emerging applications of ultrasound.

METHODS

Authors reviewed the Westlaw database for medical malpractice cases involving point-of-care ultrasound applications between December 2012 and January 2021. Cases were included if there was an allegation of misconduct by an emergency provider and if an ultrasound included in the American College of Emergency Physicians investigators core, extended, emerging, or adjunct applications was discussed to any degree. Investigators independently reviewed the cases for inclusion. Authors abstracted the case information, type of ultrasound performed, and the specific allegation of misconduct.

RESULTS

Nineteen cases met inclusion criteria. Seven cases involved core applications of emergency ultrasound and 13 involved extended, emerging, or adjunct applications. One case was included in both categories as it included elements of both core and extended applications. The most common primary allegation was failure to perform an ultrasound. No cases clearly alleged misinterpretation of a point-of-care ultrasound.

CONCLUSION

As previous studies have suggested, nonperformance of ultrasound seems to convey the greatest medicolegal risk. Extended, emerging, or adjunct applications of ultrasound may convey a slightly higher risk.

Point-of-Care Ultrasonography as an Extension of the Physical Examination for Abdominal Pain in the Emergency Department: The Diagnosis of Small-Bowel Volvulus as a Rare Complication after Changing the Feeding Jejunostomy Tube

Point-of-care ultrasonography (POCUS) has become the most popular modality of testing for physicians in recent years and is used for improving the quality of care and increasing patient safety. However, POCUS is not always acceptable to all physicians. To address the benefits and importance of POCUS, numerous studies have examined the use of POCUS in clinical practice and even medical education. This article aims to highlight the effects of POCUS as an extension of the physical examination, and we present a case to address the reasons it should be performed. For a man experiencing abdominal pain immediately after his feeding jejunostomy tube was changed, there was high suspicion of small-bowel volvulus after a “whirlpool sign” was observed during the POCUS, whereby mesenteric vessels presented in a whirling or spiral shape. This impression was subsequently confirmed by computed tomography. Small-bowel volvulus is a rare complication of changing a feeding jejunostomy tube. The images submitted here add to the sparse evidence from the literature on the use of POCUS as an extension of the physical examination for evaluating abdominal pain. POCUS can be used after taking the patient’s history and conducting a physical examination. The observation of a whirlpool sign may indicate the presence of a volvulus that is life-threatening.

Usefulness of Multi-Organ Point-of-Care Ultrasound as a Complement to the Decision-Making Process in Internal Medicine

Accumulated data show the utility of diagnostic multi-organ point-of-care ultrasound (PoCUS) in the assessment of patients admitted to an internal medicine ward. We assessed whether multi-organ PoCUS (lung, cardiac, and abdomen) provides relevant diagnostic and/or therapeutic information in patients admitted for any reason to an internal medicine ward. We conducted a prospective, observational, and single-center study, at a secondary hospital. Multi-organ PoCUS was performed during the first 24 h of admission. The sonographer had access to the patients’ medical history, physical examination, and basic complementary tests performed in the Emergency Department (laboratory, X-ray, electrocardiogram). We considered a relevant ultrasound finding if it implied a significant diagnostic and/or therapeutic change. In the second semester of 2019, we enrolled 310 patients, 48.7% were male and the mean age was 70.5 years. Relevant ultrasound findings were detected in 86 patients (27.7%) and in 60 (19.3%) triggered a therapeutic change. These findings were associated with an older age (Mantel−Haenszel χ2 = 25.6; p < 0.001) and higher degree of dependency (Mantel−Haenszel χ2 = 5.7; p = 0.017). Multi-organ PoCUS provides relevant diagnostic information, complementing traditional physical examination, and facilitates therapy adjustment, regardless of the cause of admission. Multi-organ PoCUS to be useful need to be systematically integrated into the decision-making process in internal medicine.