The utility of transvaginal ultrasound in the ED evaluation of complications of first trimester pregnancy

Incidental Renal Cysts Found by Point-of-Care Ultrasound: A Retrospective Chart Review

BACKGROUND

Incidental findings are unrelated to a patient's complaint, found on diagnostic imaging, such as point-of-care ultrasound (POCUS). Incidental findings represent potential harms to patients and may lead to increased patient anxiety and health care costs related to downstream testing and surveillance.

STUDY OBJECTIVES

In this study, we aimed to calculate the rate of incidental renal cysts found by POCUS. Further, we hoped to describe how emergency physicians relay the findings to patients. Lastly, we hoped to examine if patients suffered harms in the 12 months following identification of an incidental renal cyst.

METHODS

From our single-center, academic emergency department (ED), we reviewed renal POCUS images from 1000 consecutive adult ED patients to determine if there was a renal cyst. Next, we performed manual chart review to determine if patients were informed of the incidental renal cyst or suffered any patient harms.

RESULTS

We found the prevalence of renal cysts to be 6.5% (95% confidence interval: 4.9%-8.4%). Those with cysts were more likely to be older compared to those without (63 ± 14 vs. 49 ± 15 years of age). Only 8% of patients had evidence that they were informed of their incidental renal cyst. No patients received a biopsy or were diagnosed with renal cell carcinoma or polycystic kidney disease.

CONCLUSION

Incidental renal cysts are common and are more likely to be found in older adults. In our study, physicians infrequently informed patients of their incidental finding.

High-Fidelity Simulation with Transvaginal Ultrasound in the Emergency Department

Audience

Intern and junior emergency medicine residents.

Introduction

Abdominal pain and vaginal bleeding in the first trimester of pregnancy are common presentations to the emergency department (ED).1 Formal transvaginal ultrasound (TVUS) is considered the test of choice for evaluation of first trimester pregnancy due to its high sensitivity and specificity for identifying intrauterine and ectopic pregnancies.1 Additionally, TVUS can evaluate for various uterine and ovarian pathology as well as identify other non-gynecologic conditions and is within the scope of practice for the emergency physician.2 Given the emergent and time sensitive nature of certain obstetric and gynecologic conditions, formal transvaginal ultrasound imaging may not be feasible. A rapid assessment with transvaginal point-of-care ultrasound (TVPOCUS) can be utilized by emergency medicine physicians (EMP) to confirm intrauterine pregnancies (IUP) and identify any associated complications. There are multiple advantages to TVPOCUS including reduced cost and length of stay, patient satisfaction, and improved resource utilization.1,3 Additionally, multiple studies demonstrate that EMPs can learn this skill and perform TVPOCUS accurately and safely.1,3 Developing the skills and comfort with TVPOCUS in a simulation setting during residency is beneficial and can have important implications in future practice.

Educational Objectives

By the end of the session, learners should be able to 1) recognize the clinical indications for transvaginal ultrasound in the ED, 2) practice the insertion, orientation, and sweeping motions used to perform a TVPOCUS study, 3) interpret transvaginal ultrasound images showing an IUP or alternative pathologies, and 4) understand proper barrier, disinfection, and storage techniques for endocavitary probes.

Educational Methods

This session included three high-fidelity simulation cases that allowed participants to utilize TVPOCUS in a safe and conducive environment. There was a total of 32 emergency medicine (EM) residents who participated. The simulation sessions were divided into two separate rooms and included four learners for each session that actively managed the patient, for a total of 12 active participants. The 20 remaining residents were observers. Participants learned evidence-based indications, performance, and interpretation of transvaginal ultrasound. Three cases were reviewed and included IUP, ruptured ectopic pregnancy with hemorrhagic shock, and appendicitis in pregnancy. The cases were followed by a debriefing session and discussion regarding the evidence behind bedside transvaginal ultrasound, its incorporation into EM workflow, and practice-based learning.

Research Methods

The educational content and efficacy were evaluated by oral feedback in a debriefing session after the workshop. Additionally, pre-simulation and post-simulation surveys were sent to participants to assess prior ultrasound experience and confidence on the indications, performance, and interpretation of transvaginal ultrasound. Responses were collected using a Likert scale of 1 to 5, with 1 being "not at all confident" and 5 being "very confident."

Results

Ten learners responded to the survey consisting of EM residents in a three-year EM residency program. Prior to the workshop, the median reported confidence level across all questions was "1- not at all confident" for the PGY-1 class, and "3-neutral" for the PGY-2 and PGY-3 classes. Following the workshop, all median scores across all classes were "4-confident," demonstrating an increase in confidence scoring across all measurements and participants. Incorporating transvaginal ultrasound into clinical workflow demonstrated the largest increase in confidence score (median 1.5 to 4), followed by insertion/orientation of the endocavitary probe (median 2.5 to 5).

Discussion

This high-fidelity simulation familiarized learners with transvaginal ultrasound and how it can be appropriately utilized for a variety of high-yield clinical scenarios that present regularly to the ED. Given the variation in ultrasound training among residency programs, and the lack of specific simulation content addressing this modality, it is important to implement scenarios that improve learner comfort with TVPOCUS. Overall, this workshop resulted in an increase in confidence scores of participants in the indication, performance, and interpretation of TVPOCUS in the ED.

Topics

Transvaginal ultrasound, POCUS, intrauterine pregnancy, ectopic pregnancy, hemorrhagic shock, appendicitis in pregnancy, abdominal pain, emergency medicine.

Comparison of transvaginal ultrasound utilization between radiology and point of care ultrasound in first trimester pregnancy

BACKGROUND

Transvaginal (TVUS) and transabdominal ultrasound (TAUS) are both utilized in the evaluation of early pregnancy patients. While many practitioners using point of care ultrasound (POCUS) will generally not pursue TVUS in cases where an intrauterine pregnancy (IUP) is visualized on TAUS, this may not be true in Radiology performed ultrasound.

OBJECTIVES

To evaluate for differences in transvaginal ultrasound (TVUS) utilization between Radiology performed (RP) ultrasound and point of care ultrasound (POCUS) by Emergency Department (ED) physicians in early pregnancy patients. Secondarily, to assess length of stay (LOS) differences and the impact of specialized emergency ultrasound training on TVUS utilization.

METHODS

This was a retrospective study at a single academic ED. Study population was all ED patients who underwent first trimester ultrasound during the one year period of March 1, 2021 to February 28, 2022. Variables evaluated were chief complaint, gestational age, LOS, TAUS and TVUS utilization, ultrasound findings, and ultrasound specialty training of the ED physician.

RESULTS

There were 133 cases of POCUS ultrasound and 254 cases of RP ultrasound. All cases had TAUS imaging performed. Median LOS for patients when POCUS was utilized was 207 min (IQR 151-294) and 258 min (IQR 208-328) for those only using RP ultrasound, p ≤ 0.001. In the POCUS cohort, 38% (95% CI 30%-46%) received TVUS, while 94% received TVUS in the RP cohort (95% CI 90%-96%), p ≤ 0.001. Patients seen by ED faculty with ultrasound specialty training had TVUS 53% of the time (95% CI 41%-65%), while those seen by other ED faculty had TVUS 79% (95% CI 74%-83%) of the time, p = 0.035.

CONCLUSION

POCUS in early pregnancy is associated with a significant reduction in TVUS usage. We suspect that POCUS users elect not to pursue TVUS after an IUP is identified on TAUS, while technicians perform protocol-based TVUS irrespective of TAUS findings. Patients seen by ultrasound trained ED physicians are less likely to receive TVUS.

The Utility of Transvaginal Ultrasound After Intrauterine Pregnancy Identification on Transabdominal Ultrasound in Emergency Department Patients

Introduction

Ultrasonography has an important role in the evaluation of Emergency Department (ED) patients presenting with early pregnancy complaints. Both transabdominal (TAUS) and transvaginal ultrasound (TVUS) can be utilized. While TVUS generally allows for greater detail, it is unclear how much added benefit exists in performing TVUS once an intrauterine pregnancy (IUP) has been identified on TAUS.

Methods

This was a retrospective study utilizing Radiology Department ultrasound examinations obtained in first trimester pregnancy ED patients during a consecutive four month period in 2019. Studies wherein both TAUS and TVUS were both performed were included. Two ED physicians with specialized training in point of care ultrasound reviewed only the TAUS images from these studies. Their findings were compared to the Radiologist interpretation, which was inclusive of both TAUS and TVUS components of the study.

Results

108 studies met inclusion criteria. Amongst these, 82 had IUP's identified on the radiologist report. 69 studies had an IUP identified by ED physician review of the TAUS images, with 1 false positive. Each case of intrauterine fetal demise (IUFD) was identified on ED physician review of TAUS. Two ectopic pregnancies were present, neither of which was mistaken for IUP on ED physician TAUS review. There were 15 studies with subchorionic hemorrhage and 3 studies with an ovarian cyst noted on the radiologist report.

Conclusion

Following the identification of an IUP on TAUS, the added diagnostic value of TVUS amongst this cohort of ED patients was low. Given the added time and cost of TVUS, selective instead of routine usage should be encouraged.

Ultrasound in Pregnancy

This article reviews the use of ultrasound in pregnancy pertinent to the emergency physician. The techniques for transabdominal and transvaginal studies are detailed including approaches to gestational dating. Diagnosis of ectopic pregnancy is reviewed focusing on the potential pitfalls: reliance on beta-human chorionic gonadotropin, pseudogestational sac, interstitial pregnancy, and heterotopic pregnancy. Techniques for the identification of placental issues and presenting parts during the second and third trimesters are reviewed. Ultrasound is a safe and effective tool for the experienced emergency physician and is integral to providing high-quality care to pregnant women.

External validation of the POP score for predicting obstetric and gynecological diseases in the emergency department

BACKGROUND

The POP score was developed as an easy screening tool for predicting obstetrics and gynecological (OBGYN) diseases in the emergency department (ED), and consists of three predictors, each representing one point: past history of OBGYN diseases, no fever or digestive symptoms, and peritoneal irritation signs). However, its external validity has not yet been evaluated. We aimed to perform the external validation of the POP score.

METHODS

This is a multi-center, retrospective cohort study using ED data of three tertiary care hospitals in Japan between Jan 2017 and October 2020. Young adult women aged 16-49 years with abdominal pain were included in the analysis. The probability of OBGYN diseases was calculated using a logistic regression model of the POP score. Predictions were compared with observations to evaluate the calibration of the model. Further, the diagnostic ability (sensitivity, specificity, and likelihood ratio) of the POP score was evaluated.

RESULTS

Of 66,599 ED visits, 1026 young adult women (median age [interquartile range]: 31 [23-41] years) were included for the analysis. The c-statistic was 0.645 [95% confidence interval (CI): 0.603-0.687]. The predicted probabilities of OBGYN diseases was generally well-calibrated to the observations. When the cut-off was set between 2 and 3 points for the ruling in of OBGYN diseases, the positive likelihood ratio was 9.72 [95% CI: 3.33-28.4]. When the cut-off was set between 0 and 1 points for ruling out of OBGYN diseases, negative likelihood ratio was 0.181 [95% CI: 0.059-0.558].

CONCLUSIONS

Using ED data of three tertiary care hospitals, we externally validated the POP score for prediction of OBGYN diseases in the ED. The POP score likely has clinical value for screening OBGYN diseases in young adult women with abdominal pain in the ED.

Comparing Time to Diagnosis and Treatment of Patients with Ruptured Ectopic Pregnancy Based on Type of Ultrasound Performed: A Retrospective Inquiry

BACKGROUND

Hemorrhage from ruptured ectopic pregnancy is the leading cause of first trimester mortality in North America.

OBJECTIVES

Our objective was to compare patients with a ruptured ectopic pregnancy who had an emergency department (ED) point-of-care ultrasound (PoCUS) with those who received a radiology department-performed ultrasound (RADUS). Four time intervals were measured: ED arrival to ultrasound interpretation, obstetric consultation, operating room (OR) arrival, and ultrasound interpretation to OR arrival.

METHODS

This was a retrospective cohort study of patients with ruptured ectopic pregnancy seen between February 2012 and September 2018 at an urban tertiary care hospital. Patients who received an ultrasound in the ED, went directly to the OR, and had confirmed rupture were included.

RESULTS

Of 262 patients diagnosed with ectopic pregnancy during the study period, 36 (14%) were ruptured and 32 were enrolled. Comparing times between PoCUS (n = 10) and RADUS (n = 22) groups, the mean time from ED arrival to ultrasound interpretation was 15 vs. 138 min (difference 123, 95% confidence interval [CI] 88-158), from ED arrival to obstetric consultation was 35 vs. 150 min (difference 115, 95% CI 59-171), from ED arrival to OR arrival was 160 vs. 381 min (difference 222, 95% CI 124-320), and from ultrasound interpretation to OR arrival was 145 vs. 243 min (difference 98, 95% CI 12-184).

CONCLUSION

ED patients with a ruptured ectopic pregnancy who received a PoCUS first had shorter times to diagnosis, obstetric consultation, and OR arrival compared with those who received RADUS.

Experiences and outcomes of women with bleeding in early pregnancy presenting to the Emergency Department: An integrative review

BACKGROUND

Bleeding in early pregnancy occurs in approximately a quarter of all pregnancies and is a common reason for presentation to the Emergency Department (ED). This review combined current knowledge about experiences, interventions, outcomes and frequency of women presenting to the ED with per vaginal (PV) bleeding in the first 20 weeks of pregnancy.

METHODS

This integrative literature review was conducted using electronic database and hand searching methods for primary research published from 2000; followed by screening and appraisal. Articles were compared and grouped to identify characteristics and patterns that guided the synthesis of categories.

RESULTS

Forty-two primary research articles met inclusion criteria. Four main categories related to experiences and outcomes of women with bleeding in early pregnancy presenting to the ED were identified: presentation frequency and characteristics; women and their partners' experiences in the ED; interventions and treatments; patient and health service outcomes.

CONCLUSIONS

Negative and often frustrating experiences are reported by women experiencing PV bleeding, their partners and ED healthcare providers. While strategies such as early pregnancy assessment services contribute to improved outcomes, the availability of these services vary. Further research is needed to identify specific needs of this group of women and their partners, and the staff providing their care in the ED, to inform strategies for improved quality of care.

Point of Care Ultrasound First: An Opportunity to Improve Efficiency for Uncomplicated Pregnancy in the Emergency Department

Introduction: Research suggests emergency providers using point-of-care ultrasound (POCUS) to confirm an uncomplicated intrauterine pregnancy (IUP) can decrease emergency department (ED) length of stay (LOS) compared to a radiology department ultrasound (RADUS). The objective of this study was to compare the time to diagnosis and LOS between POCUS and RADUS patients. Methods: This was a retrospective study at one urban medical center. A standardized tool was used to abstract data from a random sample of pregnant patients diagnosed with uncomplicated IUP between January 2016 and December 2017 at a single tertiary care medical center. Microsoft Excel 2010 software was used to measure time intervals, prepare descriptive statistics, and perform Mann-Whitney U tests to compare differences. Results: A random sample of 836 (36%) of the 2,346 emergency department patients diagnosed with an IUP between 8-20 weeks' gestation during the study period was evaluated for inclusion. Three hundred sixty-six met inclusion criteria and were included in the final analysis. Patients were divided into 2 groups based on which type of ultrasound scan they received first: POCUS (n=165) and RADUS (n=201). Patients who received POCUS were found to have an IUP identified in an average of 48 minutes (95% CI, 43 to 53), while the RADUS group's mean time to diagnosis was 120 minutes (95% CI 113 to 127) with a difference of 72 minutes (95% CI, 63 to 80; p<0.001). The mean LOS for patients who received POCUS was 132 minutes (95% CI, 122 to 142), while that of the RADUS group was 177 minutes (95% CI 170 to 184) with a difference of 45 minutes (95% CI 32 to 56; p<0.001). The study is limited by its single-center, retrospective design and by lack of blinding of data abstractors. Conclusion: Pregnant emergency department patients diagnosed with an uncomplicated IUP between 8-weeks and 20-weeks' gestation had statistically significant reduction in time to diagnosis and disposition from the ED if assessed with POCUS as compared to RADUS.

The feasibility of bedside transvaginal ultrasonography in non-pregnant women in the emergency department

STUDY OBJECTIVE

We recorded data on the routine use of point-of-care transvaginal ultrasound (POC TVUS) for the evaluation of non-pregnant women with pelvic complaints in the Emergency Department (ED), and sought to determine how it altered the diagnostic impression and management.

METHODS

This was a prospective observational study. Adult non-pregnant women with pelvic complaints undergoing POC TVUS were enrolled. Pre and post ultrasound, the treating physician completed a data collection form indicating the most likely cause of the patient's pain, current treatment plan, and expected ultrasound findings. Immediately after the ultrasound, the treating physician completed another form to indicate details about the sonographic process and findings, and whether a radiologyperformed TVUS was planned.

RESULTS

Of 113 women enrolled, 79% had both ovaries visualized and the POC TVUS led to changes in plan in 43% of patients, including 3 emergent/urgent interventions; 48% of patients had unexpected findings. Of the 25% who had an additional radiology exam, there were no instances of discordant findings when both ovaries were assessed to be normal on ED Ultrasound. The ultrasound added <10 minutes in 92% of patients. With an ED ultrasound only (n = 85), the median length of stay (LOS) was 282 (IQR 197-323) minutes, compared to 437 (IQR 367-500) minutes when a radiology ultrasound was required (n = 28) (median difference,170 minutes [95% CI 122-212 min]).

CONCLUSION

In this study, emergency physicians were able to efficiently obtain and interpret POC TVUS images that changed assessment of non-pregnant women with pelvic pain without significantly increasing the ED length of stay.

Diagnostic Ultrasound Safety Review for Point-of-Care Ultrasound Practitioners

Potential ultrasound exposure safety issues are reviewed, with guidance for prudent use of point-of-care ultrasound (POCUS). Safety assurance begins with the training of POCUS practitioners in the generation and interpretation of diagnostically valid and clinically relevant images. Sonographers themselves should minimize patient exposure in accordance with the as-low-as-reasonably-achievable principle, particularly for the safety of the eye, lung, and fetus. This practice entails the reduction of output indices or the exposure duration, consistent with the acquisition of diagnostically definitive images. Informed adoption of POCUS worldwide promises a reduction of ionizing radiation risks, enhanced cost-effectiveness, and prompt diagnoses for optimal patient care.

Point of care ultrasound is associated with decreased ED length of stay for symptomatic early pregnancy

INTRODUCTION

Emergency physicians (EP) can accurately rule out ectopic pregnancy with pelvic point of care ultrasound (PPOCUS). Multiple studies have suggested that PPOCUS may decrease length of stay (LOS) for emergency department (ED) patients presenting with early symptomatic pregnancy compared to comprehensive ultrasound (CUS). This systematic review and meta-analysis examines the association between the use of PPOCUS vs CUS and ED LOS.

METHODS

A systematic review of the literature was performed. Patients with symptomatic early pregnancy receiving EP-performed PPOCUS were compared to patients receiving CUS without PPOCUS. Keywords and search terms were generated for PPOCUS, ED LOS and CUS. Two independent reviewers screened abstracts for inclusion. A third reviewer was used when conflicts arose to gain consensus. Formal bias assessment was performed on included studies. Meta-analysis was carried out, pooling the mean differences between studies using a random-effects model.

RESULTS

2980 initial articles were screened, 32 articles underwent detailed review, 8 underwent bias assessment, and 6 were included in the final meta-analysis. There were 836 patients in the study group and 1514 in the control group. All studies showed a decreased LOS in the PPOCUS group with a mean decrease of 73.8 min (95% CI 49.1, 98.6). Two studies not included in the meta-analysis also showed significantly decreased LOS with PPOCUS.

CONCLUSION

Use of PPOCUS in the evaluation of patients with symptomatic early pregnancy is associated with decreased LOS in patients ultimately diagnosed with intrauterine pregnancy. This review suggests that this finding is generalizable to a variety of practice settings.

Emergency Department Patient Perceptions of Transvaginal Ultrasound for Complications of First-Trimester Pregnancy

OBJECTIVES

Emergency department (ED) transvaginal ultrasound (US) is underused in clinical practice. This study assessed pregnant women's perceptions of ED transvaginal US in terms of pain, embarrassment, anxiety, and willingness to receive the procedure. Secondary variables include physicians' perceptions of patients' experiences.

METHODS

Women undergoing US examinations for complications of first-trimester pregnancy were prospectively surveyed before any US and after ED and/or radiology transvaginal US. Patients' and physicians' assessments of pain, embarrassment, and anxiety were measured with visual analog scales (0-100).

RESULTS

A total of 398 women were enrolled. In the pre-US survey, the median anxiety score was 14 (interquartile range, 3-51), and 96% of patients were willing to have an ED transvaginal US if necessary. Of those who had ED transvaginal US, 96% would agree to have another examination. Patients reported minimal pain/embarrassment, and there was no difference if performed in the ED versus radiology (median pain, 11.5 versus 13; P = .433; median embarrassment, 7 versus 4; P = .345). Of the 48 who had both ED and radiology transvaginal US, 85% thought the ED transvaginal US was worthwhile. Physicians accurately assessed patient's embarrassment and pain (mean differences, 3.5 and -1.9, respectively; P > .25 for both); however, they overestimated them relative to the pelvic examination (mean difference for embarrassment, 12.8; P < .0001; pain, 8.0; P = .01).

CONCLUSIONS

Pregnant ED patients report low levels of anxiety, pain, and embarrassment, and after ED transvaginal US, 96% would agree to have the examination again. There is no difference in pain/embarrassment between ED and radiology transvaginal US. Emergency department physicians accurately assessed patients' pain and embarrassment with ED transvaginal US but overestimated them compared to the pelvic examination.

Women's experiences with early pregnancy loss in the emergency room: A qualitative study

OBJECTIVES

To understand the reasons why women present to the Emergency Room (ER) for Early Pregnancy Loss (EPL)-related care, how they perceive care and counseling there, and their overall experience during and after their visit.

STUDY DESIGN

This qualitative study utilized semi-structured telephone interviews. Participants were recruited in a large urban ER; women who experienced EPL were interviewed by telephone about their experiences 1-3 weeks after their visit. Audio recordings were transcribed and coded by two independent coders.

MAIN OUTCOME MEASURES

This qualitative study utilized semi-structured interviews without the use of formal outcome measurement tools.

RESULTS

Of the sixty-seven women recruited, ten completed the full telephone interview. Interview participants' responses were grouped into four categories: Feelings about EPL, reasons for going to the ER, experience in the ER, and experience after leaving the ER. Women had mixed feelings about their ER experiences; many reported chaos, lack of information or lack of emotional support, while a few felt informed and supported. Many did not know much about EPL before their experience.

CONCLUSIONS

ER care for women experiencing suspected or confirmed EPL may not be addressing the emotional needs and knowledge gaps of women. Patient education, emotional support, and clear plans for outpatient follow up are critical. Further research is needed to guide interventions to improve care.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Ultrasonography in the emergency department

Point-of-care ultrasonography (POCUS) is a useful imaging technique for the emergency medicine (EM) physician. Because of its growing use in EM, this article will summarize the historical development, the scope of practice, and some evidence supporting the current applications of POCUS in the adult emergency department. Bedside ultrasonography in the emergency department shares clinical applications with critical care ultrasonography, including goal-directed echocardiography, echocardiography during cardiac arrest, thoracic ultrasonography, evaluation for deep vein thrombosis and pulmonary embolism, screening abdominal ultrasonography, ultrasonography in trauma, and guidance of procedures with ultrasonography. Some applications of POCUS unique to the emergency department include abdominal ultrasonography of the right upper quadrant and appendix, obstetric, testicular, soft tissue/musculoskeletal, and ocular ultrasonography. Ultrasonography has become an integral part of EM over the past two decades, and it is an important skill which positively influences patient outcomes.