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Núñez-Ramos JA, Duarte-Misol D, Petro MAB, Pérez KJS, Echeverry VPG, Malagón SV. Agreement of point of care ultrasound and final clinical diagnosis in patients with acute heart failure, acute coronary syndrome, and shock: POCUS not missing the target. Intern Emerg Med 2024; 19:1585-1592. [PMID: 38864971 PMCID: PMC11405453 DOI: 10.1007/s11739-024-03639-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/08/2024] [Indexed: 06/13/2024]
Abstract
Point-of-care ultrasound (POCUS) is an important tool for clinical diagnosis and decision-making in critical and non-critical scenarios. Dyspnea, chest pain, and shock are conditions susceptible to evaluation with ultrasound considering diagnostic accuracy and clinical impact already proven. There is scarce evidence in diagnosis agreement using ultrasound as an extension of physical examination. We aimed to evaluate ED patients in whom POCUS was performed, to analyze agreement between clinical initial diagnosis using ultrasound images and final diagnosis. Furthermore, we analyze failed diagnosis, inconclusive POCUS exams, and discuss details. A cross-sectional analytical study was conducted on adults who visited the emergency department with any of these three chief complaints: dyspnea, chest pain, and shock. All were evaluated with ultrasound at admission. Agreement between initial diagnosis using POCUS and final definite diagnosis was calculated. Failed diagnosis and inconclusive exams were analyzed. A total of 209 patients were analyzed. Populations: mostly males, mean age 64 years old, hypertensive. Agreement on patients with dyspnea and suspicion of acute decompensated heart failure was 0.98; agreement on chest pain suspicion of non-ST acute coronary syndrome was 0.96; agreement on type of shock was 0.90. Among the population, 12 patients had an inconclusive POCUS exam, and 16 patients had a failed diagnosis. The use of POCUS in the emergency department shows almost perfect agreement when compared with the final diagnosis in individuals experiencing acutely decompensated heart failure, acute coronary syndrome, and shock. Prospective studies are needed to evaluate the impact of this tool on mortality and prognosis when there are diagnostic errors.
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Affiliation(s)
- José Atilio Núñez-Ramos
- Health Science Division, Universidad del Norte, Barranquilla, Colombia.
- Emergency Department, Hospital Universidad del Norte, Soledad, Colombia.
| | | | | | | | | | - Sergio Velasco Malagón
- Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
- Grupo de Interés en Ultrasonido Enfocado UN-HUN., Bogotá, Colombia
- Department of Internal Medicine, Clínica Nueva El Lago, Bogotá, Colombia
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Kim DJ, Sheppard G, Lewis D, Buchanan IM, Jelic T, Thavanathan R, Myslik F, Lalande E, Bell CR, Chenkin J, Heslop CL, Olszynski P, Atkinson P, Burwash-Brennan T. POCUS literature primer: key papers on cardiac and lung POCUS. CAN J EMERG MED 2024:10.1007/s43678-024-00755-8. [PMID: 39183217 DOI: 10.1007/s43678-024-00755-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 07/26/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVE Although point of care ultrasound (POCUS) use has become prevalent in medicine, clinicians may not be familiar with the evidence supporting its utility in patient care. The objective of this study is to identify the top five most influential papers published on the use of cardiac POCUS and lung POCUS in adult patients. METHODS A 14-member expert panel from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative used a modified Delphi process. Panel members are ultrasound fellowship trained or equivalent, are engaged in POCUS scholarship, and are leaders in POCUS locally and nationally in Canada. The modified Delphi process consisted of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers on cardiac POCUS and lung POCUS. RESULTS A total of 66 relevant papers on cardiac POCUS and 68 relevant papers on lung POCUS were nominated by the panel. There was 100% participation by the panel members in all three rounds of the modified Delphi process. At the end of this process, we identified the top five most influential papers on cardiac POCUS and lung POCUS. Papers include studies supporting the use of POCUS for accurately assessing left ventricular systolic function, diagnosing pericardial effusion, clarifying its test characteristics for pulmonary embolism, identifying pulmonary edema and pneumonia, as well as consensus statements on the use of cardiac and lung POCUS in clinical practice. CONCLUSION We have created a list of the top five influential papers on cardiac POCUS and lung POCUS as an evidence-based resource for trainees, clinicians, and researchers. This will help trainees and clinicians better understand how to use POCUS when scanning the heart and lungs, and it will also help researchers better understand where to direct their scholarly efforts with future research.
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Affiliation(s)
- Daniel J Kim
- Department of Emergency Medicine, University of British Columbia and Vancouver General Hospital, Vancouver, BC, Canada.
| | - Gillian Sheppard
- Discipline of Emergency Medicine, Memorial University of Newfoundland, St. John's, NF, Canada
| | - David Lewis
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Saint John, NB, Canada
| | - Ian M Buchanan
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Rajiv Thavanathan
- Ottawa Hospital Research Institute and Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Frank Myslik
- Division of Emergency Medicine, Department of Medicine, Western University, London, ON, Canada
| | - Elizabeth Lalande
- Department of Emergency Medicine, Université Laval, Quebec City, QC, Canada
| | - Colin R Bell
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Jordan Chenkin
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Claire L Heslop
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Paul Olszynski
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Paul Atkinson
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Saint John, NB, Canada
| | - Talia Burwash-Brennan
- Department of Family and Emergency Medicine, Université de Montréal, Montreal, QC, Canada
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Cohen JL, Billstrom A, Myers M. Seeing Bradycardia: How Ultrasound Improves Medical Decision-Making. Cureus 2024; 16:e65951. [PMID: 39229413 PMCID: PMC11370700 DOI: 10.7759/cureus.65951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2024] [Indexed: 09/05/2024] Open
Abstract
There is a broad differential for new-onset cardiac dysrhythmia, and the rapid identification of the underlying cause of these cardiac emergencies can be lifesaving. Identifying wall motion abnormalities on point-of-care ultrasound (POCUS) is not a core echocardiography application for Emergency Medicine (EM) physicians. However, ruling in a regional wall motion abnormality can expedite patient-centered care and assist the busy EM physician in high-risk cases.
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Affiliation(s)
- Jared L Cohen
- Emergency Department, San Antonio Military Medical Center, San Antonio, USA
| | - Amie Billstrom
- Emergency Department, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Melissa Myers
- Emergency Department, Brooke Army Medical Center, Fort Sam Houston, USA
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Bima P, Agishev I, Fucile I, de Stefano G, Morello F, Mueller C, Nazerian P. Diagnostic accuracy of point-of-care cardiac ultrasound for acute coronary syndromes in patients presenting with chest pain to the emergency department: a single-center prospective study. Eur J Emerg Med 2024:00063110-990000000-00137. [PMID: 38985842 DOI: 10.1097/mej.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND AND IMPORTANCE The diagnostic accuracy of focused cardiac ultrasound (FoCUS) performed in patients presenting to the emergency department (ED) with chest pain is currently unknown. OBJECTIVE The objective of this study was to assess the diagnostic accuracy of regional wall motion abnormalities detected with FoCUS for non-ST-elevation acute coronary syndrome (NSTE-ACS) diagnosis. DESIGN A Single-center prospective observational study conducted in 2022 in the ED of the University Hospital Careggi, Italy. SETTING AND PARTICIPANTS Adult patients presenting to the ED with acute nontraumatic chest pain were enrolled, irrespective of the presence of previous regional wall motion abnormalities. Patients with ST-segment elevation myocardial infarctions and patients with hemodynamic instability were excluded. FoCUS was performed at presentation by a trained ED physician. OUTCOME MEASURES AND ANALYSIS The final diagnosis of NSTE-ACS vs. alternative diagnosis was adjudicated by an ED physician blinded to FoCUS results after a 30-day follow-up. To assess if regional wall motion abnormalities were an independent predictor of NSTE-ACS, a multivariable logistic regression model was built. Diagnostic performance measures were calculated. A sensitivity analysis considering only type-1 NSTEMIs (i.e. plaque rupture/thrombosis) was conducted. MAIN RESULTS Among 686 patients, NSTE-ACS was adjudicated in 106 (15.5%) patients, 67 of which were NSTEMIs. A total of 87 (12.7%) patients had regional wall motion abnormalities detected by FoCUS, which were an independent predictor of NSTE-ACS in the multivariable logistic regression analysis. Regional wall motion abnormalities had a sensitivity of 42.5% (33.0-51.9), a specificity of 92.8% (90.6-94.9), a negative predictive value of 89.8% (87.4-92.2), and a positive predictive value of 51.7% (41.2-62.2), for NSTE-ACS. Results were consistent in the sensitivity analysis. CONCLUSIONS In ED patients with chest pain and no ST elevation, the detection of regional wall motion abnormalities was a predictor of NSTE-ACS. Despite a high specificity, which indicated a possible role of FoCUS in the rule-in of NSTE-ACS, sensitivity was too low to allow a safe rule-out using FoCUS results alone.
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Affiliation(s)
- Paolo Bima
- Department of Medical Sciences, University of Turin, Turin, Italy
- Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
- GREAT Network, Rome
| | - Ilya Agishev
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
| | - Ilaria Fucile
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
| | - Giuliano de Stefano
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
| | - Fulvio Morello
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
- GREAT Network, Rome
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
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Kameda T, Ishii H, Oya S, Katabami K, Kodama T, Sera M, Takei H, Taniguchi H, Nakao S, Funakoshi H, Yamaga S, Senoo S, Kimura A. Guidance for clinical practice using emergency and point-of-care ultrasonography. Acute Med Surg 2024; 11:e974. [PMID: 38933992 PMCID: PMC11201855 DOI: 10.1002/ams2.974] [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: 04/01/2024] [Revised: 05/11/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.
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Affiliation(s)
- Toru Kameda
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Clinical Laboratory MedicineJichi Medical UniversityShimotsukeJapan
| | - Hiromoto Ishii
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
| | - Seiro Oya
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineShizuoka Medical CenterShizuokaJapan
| | - Kenichi Katabami
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care CenterHokkaido University HospitalSapporoJapan
| | - Takamitsu Kodama
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and General Internal MedicineTajimi City HospitalTajimiJapan
| | - Makoto Sera
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineFukui Prefectural HospitalFukuiJapan
| | - Hirokazu Takei
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineHyogo Prefectural Kobe Children's HospitalKobeJapan
| | - Hayato Taniguchi
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Advanced Critical Care and Emergency CenterYokohama City University Medical CenterYokohamaJapan
| | - Shunichiro Nakao
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Hiraku Funakoshi
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineTokyo Bay Urayasu Ichikawa Medical CenterUrayasuJapan
| | - Satoshi Yamaga
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Radiation Disaster Medicine, Research Institute for Radiation Biology and MedicineHiroshima UniversityHiroshimaJapan
| | - Satomi Senoo
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineSaiseikai Yokohamashi Tobu HospitalYokohamaJapan
| | - Akio Kimura
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical CareCenter Hospital of the National Center for Global Health and MedicineTokyoJapan
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Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med 2023; 82:e115-e155. [PMID: 37596025 DOI: 10.1016/j.annemergmed.2023.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 08/20/2023]
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Kongkatong M, Ottenhoff J, Thom C, Han D. Focused Ultrasonography in Cardiac Arrest. Emerg Med Clin North Am 2023; 41:633-675. [PMID: 37391255 DOI: 10.1016/j.emc.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting.
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Affiliation(s)
- Matthew Kongkatong
- Department of Emergency Medicine, University of Virginia Health, 1215 Lee Street, Charlottesville, VA 22908, USA.
| | - Jakob Ottenhoff
- Department of Emergency Medicine, University of Virginia Health, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - Christopher Thom
- Department of Emergency Medicine, University of Virginia Health, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - David Han
- Department of Emergency Medicine, University of Virginia Health, 1215 Lee Street, Charlottesville, VA 22908, USA
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Adhikari S, Leo M, Liu R, Johnston M, Keehbauch J, Barton M, Kendall J. The 2023 Core Content of advanced emergency medicine ultrasonography. J Am Coll Emerg Physicians Open 2023; 4:e13015. [PMID: 37564703 PMCID: PMC10411060 DOI: 10.1002/emp2.13015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
In February 2023, the American Board of Emergency Medicine (ABEM) approved modifications to the Advanced Emergency Medicine Ultrasonography (AEMUS) Core Content, which defines the areas of knowledge considered essential for the practice of AEMUS. This manuscript serves as a revision of the AEMUS Core Content originally published in 2014. The revision of the Core Content for AEMUS training aims to establish standardized education and qualifications necessary for AEMUS fellowship program leadership, clinical application, administration, quality improvement, and research. The Core Content provides the organizational framework and serves as the basis for the development of content for the Focused Practice Examination (FPE) administered by ABEM. AEMUS fellowship directors may reference the Core Content when designing AEMUS fellowship curricula to help prepare graduates for the autonomous practice of AEMUS and the FPE. In this article, an updated revision of the previously published AEMUS Core Content is detailed, and the entire development of the Core Content is presented.
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Affiliation(s)
- Srikar Adhikari
- Department of Emergency MedicineUniversity of ArizonaTucsonArizonaUSA
| | - Megan Leo
- Department of Emergency MedicineBoston Medical CenterBostonMassachussetsUSA
| | - Rachel Liu
- Department of Emergency MedicineYale UniversityNew HavenConnecticutUSA
| | - Mary Johnston
- American Board of Emergency MedicineEast LansingMichiganUSA
| | | | - Melissa Barton
- American Board of Emergency MedicineEast LansingMichiganUSA
| | - John Kendall
- Department of Emergency MedicineDenver Health Medical CenterDenverColoradoUSA
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Bracey A, Massey L, Pellet A, Thode HC, Holman TR, Singer A, McClure M, Secko M. FOCUS accurately detects wall motion abnormalities in patients with ACS, A retrospective study. Am J Emerg Med 2023; 69:17-22. [PMID: 37037160 DOI: 10.1016/j.ajem.2023.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 03/07/2023] [Accepted: 03/28/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Chest pain is a common presentation to the Emergency Department (ED) with roughly 6 million visits a year. The primary diagnostic modality for the identification of acute coronary syndrome (ACS) is the electrocardiogram (ECG), which is used to screen for electrocardiographic findings representing acute coronary occlusion. It is known that the ischemia generated by an acutely occluded coronary vessel generates a wall motion abnormality which can be visualized by echocardiogram; however, emergency physician-performed focused cardiac ultrasound (FOCUS) currently does not have a formal role in the diagnosis of OMI within the emergency department. PURPOSE We sought to define the characteristics of FOCUS performed by emergency physicians of variable training levels in the identification of RWMA in patients presenting to the emergency department with high suspicion for ACS before undergoing cardiac catheterization or formal echocardiography. We also explored whether RWMA was associated with OMI in these patients. METHODS We performed a structured, retrospective review of adult patients presenting to a large, academic, tertiary care center with suspected ACS from July 1st, 2019, and October 24th, 2020. Patients were included if they underwent FOCUS in the ED during the time-period above for suspected ACS looking for RWMA and FOCUS images were stored and reviewable in our middleware software. The primary outcome was the accuracy, sensitivity, and specificity of FOCUS compared to formal echocardiography for the detection of RWMA. Secondary outcomes were sensitivity of FOCUS compared to formal echocardiography for detection of RWMA in patients with and without cardiac catheterization proven OMI and sensitivity and specificity of FOCUS operators based on training. RESULTS FOCUS for RWMA performed by emergency physicians had a sensitivity of 94% (95% CI, 82-98), specificity 35% (95% CI, 15-61), and overall accuracy of 78% (95% CI, 66-87). Of all subjects, 82% underwent urgent or emergency coronary angiography, of which 71% had OMI at the time of coronary angiography of the procedure. FOCUS identified RWMA in 87% of patients with coronary angiography proven OMI. Residents (PGY-1 - PGY-3) (n = 31) were able to detect RWMA with a sensitivity of 86% (95% CI, 64-96), a specificity of 56% (95% CI, 23-85%), and an accuracy of 77 (95% CI, 58-90%). Emergency ultrasound fellows and attendings (n = 34) were able to detect RWMA with a sensitivity of 85% (95% CI, 64-95%), a specificity of 75% (95% CI, 36-96%), and an accuracy of 82% (95% CI, 65-93%). CONCLUSIONS Our retrospective study concludes FOCUS performed by emergency physicians may be used to detect RWMA in patients with high concern for acute coronary syndrome. This may have its greatest utility in patients presenting without STEMI where the ECG is felt to be equivocal, but the clinician has high concern for OMI, in which the presence of RWMA might result in emergent cath lab activation, though this requires further study. The presence of RWMA in such cases may help to rule in OMI as a cause; however, the absence of RWMA should exclude OMI. Further research is necessary to confirm these findings.
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Xu C, Melendez A, Nguyen T, Ellenberg J, Anand A, Delgado J, Herbst MK. Point-of-care ultrasound may expedite diagnosis and revascularization of occult occlusive myocardial infarction. Am J Emerg Med 2022; 58:186-191. [PMID: 35700615 DOI: 10.1016/j.ajem.2022.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/06/2022] [Accepted: 06/01/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Electrocardiographically occult occlusive myocardial infarction (OOMI), defined as coronary artery occlusion requiring revascularization without ST-segment elevation on electrocardiogram (ECG), is associated with delayed diagnosis resulting in higher morbidity. Left ventricular (LV) wall motion abnormalities (WMA) appreciated on echocardiography can expedite OOMI diagnosis. We sought to determine whether point-of-care ultrasound (PoCUS) demonstrating WMA expedites revascularization time when performed on emergency department patients being evaluated for OOMI. METHODS This was a single-site retrospective cohort study over a 38-month period. All admitted adult ED patients ≥35 years of age evaluated by the emergency physician with PoCUS for LV function, an ECG, and a standard troponin I biomarker assay were included. Patients with ST-segment elevation myocardial infarction (STEMI), prior LV dysfunction, fever ≥100.4 °F, or hypotension were excluded. A structured chart abstraction was performed for relevant demographic and clinical characteristics. RESULTS We screened 1561 ED patients who underwent cardiac PoCUS for eligibility: 874 met exclusion criteria, 453 were discharged, and 234 were included in the analysis. Twenty-three patients had coronary interventions, of which 14 had WMA. PoCUS was performed 36 min (IQR -9-68) before troponin resulted (n = 234) and 39 min (IQR -23-96) before the first troponin elevation (n = 85). Twenty of the 23 patients diagnosed with OOMI had elevated troponins prior to catheterization with time from PoCUS to first troponin elevation of 43 min (IQR 9-263). Of these patients, 11 had WMA identified on PoCUS, and the WMA was appreciated 47 min (IQR 26-255) prior to troponin elevation. The time from ED arrival to revascularization was 673 min (IQR 251-2158); 432 min (IQR 209-1300) among patients with WMA (n = 14) compared with 2158 min (IQR 552-3390) for those without WMA (n = 9). CONCLUSION Cardiac PoCUS may identify OOMI earlier than standard evaluation and may expedite definitive management.
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Affiliation(s)
- Curtis Xu
- University of Connecticut School of Medicine, Department of Emergency Medicine, Farmington, CT, United States of America
| | - Andrew Melendez
- University of Connecticut School of Medicine, Department of Emergency Medicine, Farmington, CT, United States of America
| | - Thuy Nguyen
- University of Connecticut School of Medicine, Department of Emergency Medicine, Farmington, CT, United States of America
| | - Justin Ellenberg
- University of Connecticut School of Medicine, Department of Emergency Medicine, Farmington, CT, United States of America
| | - Ambika Anand
- University of Connecticut School of Medicine, Department of Emergency Medicine, Farmington, CT, United States of America
| | - João Delgado
- Hartford Hospital, Department of Emergency Medicine, Hartford, CT, United States of America
| | - Meghan Kelly Herbst
- University of Connecticut School of Medicine, Department of Emergency Medicine, Farmington, CT, United States of America.
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Sağlam C, Ünlüer EE, Yamanoğlu NGÇ, Kara PH, Ediboğlu E, Bektaşlı R, Tandon S, Gönüllü H. Accuracy of Emergency Physicians for Detection of Regional Wall Motion Abnormalities in Patients With Chest Pain Without ST-Elevation Myocardial Infarction. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1335-1342. [PMID: 32969533 DOI: 10.1002/jum.15513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/02/2020] [Accepted: 08/29/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Our aim was to evaluate the accuracy of emergency physicians (EPs) in the detection of regional wall motion abnormalities (RWMAs) using focused cardiac ultrasound (FOCUS) in patients suspected of non-having ST-elevation myocardial infarction. METHODS We prospectively enrolled patients with chest pain. Three EPs underwent didactics and hands-on-training, of 3 hours each, by an experienced cardiologist, on detecting RWMAs using 2-dimensional echocardiography. They performed a FOCUS examination to evaluate for RWMAs and recorded the echo images. Our reference standard for the detection of RWMAs was accepted as a blinded cardiologist review of the prerecorded video clips. We calculated the corrected sample size and inter-rater agreement between the EPs (82 and 0.83, respectively). The analysis of the study was performed on 89 patients. RESULTS Eighty-nine patients with chest pain were screened. Emergency physicians demonstrated the detection of RWMAs with good sensitivity and even excellent specificity: 76.9% (95% confidence interval [CI], 56.4%- 91.0%) and 92.1% (95% CI, 82.4%-97.4%), respectively. The accuracy of FOCUS was 87.6% (95% CI, 79.0%-93.7%). The area under the curve from a receiver operating characteristic curve analysis, which evaluated the EPs' rate of detecting the presence or absence of RWMAs, was 0.845 (95% CI, 0.753-0.913). CONCLUSIONS Our study results suggest that EPs with training in bedside echocardiography can accurately rule in patients with RWMAs in suspected non-ST-elevation myocardial infarction cases.
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Affiliation(s)
- Caner Sağlam
- Clinics of Emergency Medicine, Health Science University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Erden Erol Ünlüer
- Clinics of Emergency Medicine, Health Science University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Nalan Gökçe Çelebi Yamanoğlu
- Clinics of Emergency Medicine, Health Science University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Pınar Hanife Kara
- Clinics of Emergency Medicine, Health Science University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Emek Ediboğlu
- Cardiology, Health Science University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Rami Bektaşlı
- Clinics of Emergency Medicine, Health Science University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Shikha Tandon
- Clinic of Emergency Medicine, Fortis Hospital, Mohali, India
| | - Hayriye Gönüllü
- Clinics of Emergency Medicine, Health Science University, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
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Barnicle R, Bracey A, Secko M. Early Identification of Takotsubo syndrome in the emergency department using point-of-care echocardiography: A case series. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:413-419. [PMID: 32924171 DOI: 10.1002/jcu.22918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/23/2020] [Accepted: 09/03/2020] [Indexed: 06/11/2023]
Abstract
Takotsubo syndrome (TS) is an incompletely understood, transient dysfunction of the left ventricle. While acute coronary syndrome must be at the forefront of the differential diagnosis and ruled out appropriately, the possibility of TS can be identified early with point-of-care ultrasonography. The formal diagnostic criteria for TS rely on invasive diagnostic procedures and resolution of symptoms, typically relegating it to a diagnosis of exclusion. However, the acute complications are potentially lethal, and rapid identification is therefore beneficial because these patients can be risk-stratified to higher levels of care. Our case series of three patients, each with early suspected and subsequently confirmed TS, explores how early emergency department ultrasonography can suggest the diagnosis during the emergent workup, and potentially influence disposition decisions, subsequent interventions, and possibly even outcomes.
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Affiliation(s)
- Ryan Barnicle
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Alexander Bracey
- Department of Emergency Medicine, Albany Medical Center, Albany, New York, USA
| | - Michael Secko
- Division Chief, Emergency and Clinical Ultrasound, Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
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Siew KSW, Ng KF, Othman N, Lee CY. Unusual cause of heart failure in the young, the intracardiac mass: Diagnostic dilemmas solved by echocardiography. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/20101058211011204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Primary cardiac tumor remains exceedingly rare, accounting for 0.5 cases per million of the population annually. We report a case of cardiac tumor, which was initially misdiagnosed as heart failure secondary to acute coronary syndrome. The diagnosis was revised later after routine echocardiography in the ward. A 39-year-old gentleman who presented to the emergency department with cardiac failure and ischemic changes on the electrocardiogram was initially worked-up for acute coronary syndrome. However, echocardiography was performed later in the ward to evaluate the cardiac ejection fraction, revealing a massive left atrial mass measuring 6 cm × 4 cm. Severe mitral regurgitation was noted through the echocardiogram owing to the mass prolapse into the mitral annulus. The initial presentation of cardiac tumors can be ambiguous. Studies have shown that echocardiography as the noninvasive cardiac imaging approach remains the gold standard of diagnostic tool. Hence, echocardiography should be performed as a routine assessment of cardiac failure. Meanwhile, the incorporation of point of care ultrasound in the available center may assist the physician to diagnose accurately in the emergency department setting by excluding other potential differential diagnoses. Delay in diagnosis and initiation of treatment may result in progression to chronic heart failure and dangerous complication, i.e. hemodynamic sequelae and systemic embolism of the clot. In our experience, we managed to reach an accurate diagnosis, timely referral and appropriate intervention despite the lack of point of care ultrasound.
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Affiliation(s)
| | - Kim Fong Ng
- Department of Cardiology, Hospital Sultanah Aminah, Malaysia
| | - Norliza Othman
- Department of Radiology, Hospital Sultanah Aminah, Malaysia
| | - Chuey Yan Lee
- Department of Cardiology, Hospital Sultanah Aminah, Malaysia
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Bautz B, Schneider JI. High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update). Emerg Med Clin North Am 2020; 38:453-498. [PMID: 32336336 DOI: 10.1016/j.emc.2020.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.
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Affiliation(s)
- Benjamin Bautz
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Jeffrey I Schneider
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA; Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA.
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Sorensen B, Hunskaar S. Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. Ultrasound J 2019; 11:31. [PMID: 31749019 PMCID: PMC6868077 DOI: 10.1186/s13089-019-0145-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/21/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services. METHODS Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound. RESULTS On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies. CONCLUSION Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.
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Affiliation(s)
- Bjarte Sorensen
- Hjelmeland General Practice Surgery, Prestagarden 13, 4130, Hjelmeland, Norway.
| | - Steinar Hunskaar
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre AS, Bergen, Norway
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