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Allen R, Paz-Soldan G, Wilson M, Huang J, Omer T, Mailhot T, Sajed D. Incidental Renal Cysts Found by Point-of-Care Ultrasound: A Retrospective Chart Review. J Emerg Med 2024; 67:e209-e216. [PMID: 38816260 DOI: 10.1016/j.jemermed.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/09/2024] [Accepted: 03/06/2024] [Indexed: 06/01/2024]
Abstract
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.
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Affiliation(s)
- Robert Allen
- Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, California.
| | - Gonzalo Paz-Soldan
- Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, California
| | - Melissa Wilson
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles General Medical Center, Los Angeles, California
| | - Jennifer Huang
- Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, California
| | - Talib Omer
- Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, California
| | - Thomas Mailhot
- Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, California
| | - Dana Sajed
- Department of Emergency Medicine, Los Angeles General Medical Center, Los Angeles, California
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Filler L, Lettang K. High-Fidelity Simulation with Transvaginal Ultrasound in the Emergency Department. JOURNAL OF EDUCATION & TEACHING IN EMERGENCY MEDICINE 2024; 9:S65-S135. [PMID: 39129726 PMCID: PMC11312878 DOI: 10.21980/j8606q] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 07/11/2024] [Indexed: 08/13/2024]
Abstract
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.
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Affiliation(s)
- Levi Filler
- Creighton University School of Medicine Phoenix Program, Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ
| | - Katrina Lettang
- Creighton University School of Medicine Phoenix Program, Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ
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Thom C, Livingstone K, Ottenhoff J, Han D, Martindale J, Moak J. Comparison of transvaginal ultrasound utilization between radiology and point of care ultrasound in first trimester pregnancy. Am J Emerg Med 2024; 80:143-148. [PMID: 38604108 DOI: 10.1016/j.ajem.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/12/2024] [Accepted: 03/31/2024] [Indexed: 04/13/2024] Open
Abstract
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.
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Affiliation(s)
| | | | | | - David Han
- University of Virginia Health System, USA
| | | | - James Moak
- University of Virginia Health System, USA
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Salerno A, Lewiss RE. Rekindling the Relevance of Obstetrical Transvaginal POCUS: Overcoming Barriers to Ensure Patient-Centered Care. POCUS JOURNAL 2023; 8:106-108. [PMID: 38099157 PMCID: PMC10721291 DOI: 10.24908/pocus.v8i2.16855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Alexis Salerno
- Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of Maryland School of Medicine
| | - Resa E Lewiss
- Professor of Emergency Medicine, The University of Alabama at Birmingham
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Thom C, Kongkatong M, Moak J. The Utility of Transvaginal Ultrasound After Intrauterine Pregnancy Identification on Transabdominal Ultrasound in Emergency Department Patients. Open Access Emerg Med 2023; 15:207-216. [PMID: 37274422 PMCID: PMC10237201 DOI: 10.2147/oaem.s409920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/20/2023] [Indexed: 06/06/2023] Open
Abstract
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.
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Affiliation(s)
- Christopher Thom
- Emergency Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Matthew Kongkatong
- Emergency Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - James Moak
- Emergency Medicine, University of Virginia Health System, Charlottesville, VA, USA
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King SA, Salerno A, Sommerkamp S. Ultrasound in Pregnancy. Emerg Med Clin North Am 2023; 41:337-353. [PMID: 37024168 DOI: 10.1016/j.emc.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
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.
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Çelik A, Yazıcı MM, Oktay M. The impact of high-frequency linear transducer on the accuracy of pelvic ultrasound in early pregnancy pelvic pain and bleeding. Am J Emerg Med 2022; 61:105-110. [DOI: 10.1016/j.ajem.2022.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 10/31/2022] Open
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External validation of the POP score for predicting obstetric and gynecological diseases in the emergency department. Am J Emerg Med 2021; 51:348-353. [PMID: 34808457 DOI: 10.1016/j.ajem.2021.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- José L Díaz-Gómez
- From the Baylor College of Medicine, Houston (J.L.D.-G.); and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead (P.H.M.), and the Albert Einstein College of Medicine, New York (S.J.K.) - both in New York
| | - Paul H Mayo
- From the Baylor College of Medicine, Houston (J.L.D.-G.); and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead (P.H.M.), and the Albert Einstein College of Medicine, New York (S.J.K.) - both in New York
| | - Seth J Koenig
- From the Baylor College of Medicine, Houston (J.L.D.-G.); and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead (P.H.M.), and the Albert Einstein College of Medicine, New York (S.J.K.) - both in New York
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10
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Urquhart S, Barnes M, Flannigan M. Comparing Time to Diagnosis and Treatment of Patients with Ruptured Ectopic Pregnancy Based on Type of Ultrasound Performed: A Retrospective Inquiry. J Emerg Med 2021; 62:200-206. [PMID: 34538680 DOI: 10.1016/j.jemermed.2021.07.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/30/2021] [Accepted: 07/31/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Sara Urquhart
- Michigan State University College of Human Medicine, Grand Rapids, Michigan.
| | - Mariah Barnes
- Department of Emergency Medicine, Spectrum Health, Grand Rapids, Michigan
| | - Matthew Flannigan
- Department of Emergency Medicine, Spectrum Health, Grand Rapids, Michigan
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Trostian B, Curtis K, McCloughen A, Shepherd B, Munroe B, Davis W, Hirst E, Tracy SK. Experiences and outcomes of women with bleeding in early pregnancy presenting to the Emergency Department: An integrative review. Australas Emerg Care 2021; 25:55-83. [PMID: 34083158 DOI: 10.1016/j.auec.2021.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/26/2021] [Accepted: 04/26/2021] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Baylie Trostian
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, Australia; Emergency Department, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Australia; Department of Obstetrics and Gynaecology, Illawarra Shoalhaven Local Health District, Wollongong, Australia.
| | - Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Emergency Department, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Australia
| | - Andrea McCloughen
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia
| | - Ben Shepherd
- Emergency Department, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Australia
| | - Belinda Munroe
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, Australia; Emergency Services, Critical Care Division, Illawarra Shoalhaven Local Health District, Australia
| | - Warren Davis
- Department of Obstetrics and Gynaecology, Illawarra Shoalhaven Local Health District, Wollongong, Australia
| | - Elizabeth Hirst
- Department of Obstetrics and Gynaecology, Illawarra Shoalhaven Local Health District, Wollongong, Australia
| | - Sally K Tracy
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia; Molly Wardaguga Research Centre, CDU, Darwin, Australia
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Urquhart S, Stevens K, Barnes M, Flannigan M. Point of Care Ultrasound First: An Opportunity to Improve Efficiency for Uncomplicated Pregnancy in the Emergency Department. POCUS JOURNAL 2021; 6:42-44. [PMID: 36895504 PMCID: PMC9979936 DOI: 10.24908/pocus.v6i1.14762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Sara Urquhart
- Spectrum Health -Michigan State University College of Human Medicine Grand Rapids, MI
| | - Kendall Stevens
- Spectrum Health -Michigan State University College of Human Medicine Grand Rapids, MI
| | - Mariah Barnes
- Spectrum Health -Michigan State University College of Human Medicine Grand Rapids, MI
| | - Matthew Flannigan
- Spectrum Health -Michigan State University College of Human Medicine Grand Rapids, MI
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Gelin A, Driver BE, Whitson KL, Carlson KR, Wagner B, Klein L, Smith SW, Reardon RF. The feasibility of bedside transvaginal ultrasonography in non-pregnant women in the emergency department. Am J Emerg Med 2020; 46:398-403. [PMID: 33131753 DOI: 10.1016/j.ajem.2020.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 10/23/2022] Open
Abstract
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.
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Affiliation(s)
- Anst Gelin
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kayla L Whitson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Krista R Carlson
- Brooke Army Medical Center, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA
| | - Barrett Wagner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA; University of Minnesota Medical School, Minneapolis, MN, USA
| | - Lauren Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; University of Minnesota Medical School, Minneapolis, MN, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; University of Minnesota Medical School, Minneapolis, MN, USA
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; University of Minnesota Medical School, Minneapolis, MN, USA
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Miller DL, Abo A, Abramowicz JS, Bigelow TA, Dalecki D, Dickman E, Donlon J, Harris G, Nomura J. Diagnostic Ultrasound Safety Review for Point-of-Care Ultrasound Practitioners. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1069-1084. [PMID: 31868252 DOI: 10.1002/jum.15202] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 11/14/2019] [Accepted: 11/29/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
| | - Alyssa Abo
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Jacques S Abramowicz
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois, USA
| | - Timothy A Bigelow
- Center for Nondestructive Evaluation, Iowa State University, Ames, Iowa, USA
| | - Diane Dalecki
- Department of Biomedical Engineering, University of Rochester, Rochester, New York, USA
| | - Eitan Dickman
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York, USA
| | - John Donlon
- Acoustic Measurements, Philips Healthcare, Bothell, Washington, USA
| | - Gerald Harris
- Center for Devices and Radiological Health, United States Food and Drug Administration (retired), Silver Spring, Maryland, USA
| | - Jason Nomura
- Department of Emergency Medicine, Christiana Hospital, Newark, Delaware, USA
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15
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Pek JH, Simpson WL, Owen J, Nelson B. Live Twin Ectopic Pregnancy. J Emerg Med 2020; 59:e77-e79. [PMID: 32451187 DOI: 10.1016/j.jemermed.2020.04.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/25/2020] [Accepted: 04/08/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Jen Heng Pek
- Department of Emergency Medicine, The Mount Sinai Hospital, New York, New York
| | - William L Simpson
- Department of Radiology, The Mount Sinai Hospital, New York, New York
| | - Jane Owen
- Department of Obstetrics and Gynecology, The Mount Sinai Hospital, New York, New York
| | - Bret Nelson
- Department of Emergency Medicine, The Mount Sinai Hospital, New York, New York
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16
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Beals T, Naraghi L, Grossestreuer A, Schafer J, Balk D, Hoffmann B. Point of care ultrasound is associated with decreased ED length of stay for symptomatic early pregnancy. Am J Emerg Med 2019; 37:1165-1168. [PMID: 30948256 DOI: 10.1016/j.ajem.2019.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Tyler Beals
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
| | - Leily Naraghi
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
| | - Anne Grossestreuer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
| | - Jesse Schafer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
| | - Dan Balk
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
| | - Beatrice Hoffmann
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 1 Deaconess Rd, Rosenberg 2, Boston, MA 0215, USA.
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17
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Panebianco N, Shofer F, O'Conor K, Wihbey T, Mulugeta L, Baston CM, Suzuki E, Alghamdi A, Dean A. Emergency Department Patient Perceptions of Transvaginal Ultrasound for Complications of First-Trimester Pregnancy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1965-1975. [PMID: 29380893 DOI: 10.1002/jum.14546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/10/2017] [Accepted: 11/04/2017] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Nova Panebianco
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Frances Shofer
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Katie O'Conor
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Tristan Wihbey
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Lakeisha Mulugeta
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Cameron M Baston
- the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Evan Suzuki
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Adel Alghamdi
- Department of Emergency Medicine, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Anthony Dean
- Department of Emergency Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
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18
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Baird S, Gagnon MD, deFiebre G, Briglia E, Crowder R, Prine L. Women's experiences with early pregnancy loss in the emergency room: A qualitative study. SEXUAL & REPRODUCTIVE HEALTHCARE 2018; 16:113-117. [PMID: 29804754 DOI: 10.1016/j.srhc.2018.03.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 02/19/2018] [Accepted: 03/06/2018] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Sara Baird
- The Institute for Family Health, 1824 Madison Ave, New York, NY 10035, USA; Mount Sinai School of Medicine, 1 Gustave Levy Place, New York, NY 10029, USA.
| | - Monica D Gagnon
- The Institute for Family Health, 1824 Madison Ave, New York, NY 10035, USA.
| | - Gabrielle deFiebre
- The Institute for Family Health, 1824 Madison Ave, New York, NY 10035, USA; CUNY Graduate School of Public Health and Health Policy, 55 W 125th St, New York, NY 10027, USA.
| | - Emily Briglia
- CUNY Graduate School of Public Health and Health Policy, 55 W 125th St, New York, NY 10027, USA.
| | - Rebecca Crowder
- The Institute for Family Health, 1824 Madison Ave, New York, NY 10035, USA; Mount Sinai School of Medicine, 1 Gustave Levy Place, New York, NY 10029, USA.
| | - Linda Prine
- The Institute for Family Health, 1824 Madison Ave, New York, NY 10035, USA; Mount Sinai School of Medicine, 1 Gustave Levy Place, New York, NY 10029, USA.
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19
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Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med 2017; 69:e27-e54. [PMID: 28442101 DOI: 10.1016/j.annemergmed.2016.08.457] [Citation(s) in RCA: 402] [Impact Index Per Article: 57.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Indexed: 02/06/2023]
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20
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Scherer L, Zappolo K. Pregnancy Disasters in the First Trimester. PHYSICIAN ASSISTANT CLINICS 2017. [DOI: 10.1016/j.cpha.2017.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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21
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Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
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22
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Whitson MR, Mayo PH. Ultrasonography in the emergency department. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:227. [PMID: 27523885 PMCID: PMC4983783 DOI: 10.1186/s13054-016-1399-x] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Micah R Whitson
- Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA.
| | - Paul H Mayo
- Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA
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