Emergency and Critical Care Imaging

Patient satisfaction using handheld ultrasound at emergency department in Jordan University Hospital

INTRODUCTION

The use of portable ultrasound equipment in emergency medicine has shown the capacity to greatly improve patient care in the swiftly changing field. This research evaluates the influence of the Butterfly POCUS device on patient contentment in the Emergency Department at Jordan University Hospital.

MATERIALS AND METHODS

We conducted a cross-sectional survey of 98 patients to examine their satisfaction levels after undergoing an ultrasound examination. We then evaluated these levels in relation to demographic and clinical characteristics.

RESULTS

Seventy eight percent of the patients expressed a high level of satisfaction with their evaluation. This satisfaction level was consistent across all patient demographics, with no notable differences. Significantly, there was a clear correlation between greater satisfaction levels and higher first pain ratings, indicating that the technology effectively addresses patient concerns and enhances the diagnostic experience.

CONCLUSION

The findings of our study support the wider use of portable ultrasound technology in emergency care settings, emphasizing its ability to greatly enhance patient satisfaction and outcomes. Further investigation should include multicenter trials to authenticate these results and investigate the long-term effects on clinical practice.

Utility of bone suppression imaging for the detection of pneumonia on chest radiographs

INTRODUCTION

Chest X-rays (CXR) are routinely used to diagnose lung and heart conditions. AI based Bone suppression imaging (BSI) aims to enhance accuracy in identifying chest anomalies by eliminating bony structures such as the ribs, clavicles, and scapula from CXRs. The aim of this retrospective study was to assess the clinical value of BSI in detecting pneumonia.

METHODS

Ninety-nine emergency patients with suspected pneumonia underwent erect postero-anterior CXRs. The BSI processing system was used to generate corresponding bone-suppressed images for the 99 radiographs. Each patient had undergone a computed tomography (CT) examination within 48 h, considered the standard of reference. Two blinded readers separately analyzed images, indicating confidence levels regarding signs of pneumonia for each lung separated in three fields, first with standard images, then with BSI. Sensitivity, specificity, predictive values, and readers' certitude were calculated, and inter-reader agreement was evaluated with the kappa statistic.

RESULTS

Out of the 99 included cases, 39 cases of pneumonia were diagnosed (39.4%). Of the remaining 60 patients, 14 presented only pleural effusions (14.1%). BSI images led to a significant increase in false positives (+251%) and significantly affected one reader's diagnosis and certitude, decreasing accuracy (up to 17%) and specificity (up to 14%). Sensitivity increased by 66% with BSI. Inter-reader agreement ranged from weak to moderate (0.113-0.53) and did not improve with BSI. For both readers, BSI images were read with significantly lesser certitude than standard images.

CONCLUSION

BSI did not add clinical value in pneumonia detection on CXR due to a significant increase in false positive results and a decrease one readers' certitude.

IMPLICATION FOR PRACTICE

The study emphasizes the importance of proper clinical training before implementing new post-processing and artificial intelligence (AI) tools in clinical practice.

Lung segment anything model (LuSAM): a decoupled prompt-integrated framework for automated lung segmentation on chest x-Ray images

Accurate lung segmentation in chest x-ray images plays a pivotal role in early disease detection and clinical decision-making. In this study, we introduce an innovative approach to enhance the precision of lung segmentation using the Segment Anything Model (SAM). Despite its versatility, SAM faces the challenge of prompt decoupling, often resulting in misclassifications, especially with intricate structures like the clavicle. Our research focuses on the integration of spatial attention mechanisms within SAM. This approach enables the model to concentrate specifically on the lung region, fostering adaptability to image variations and reducing the likelihood of false positives. This work has the potential to significantly advance lung segmentation, improving the identification and quantification of lung anomalies across diverse clinical contexts.

Point-of-care ultrasound induced changes in management of unselected patients in the emergency department - a prospective single-blinded observational trial

Background

Point-of-Care ultrasound (POCUS) changes the management in specific groups of patients in the Emergency Department (ED). It seems intuitive that POCUS holds an unexploited potential on a wide variety of patients. However, little is known about the effect of ultrasound on the broad spectrum of unselected patients in the ED. This study aimed to identify the effect on the clinical management if POCUS was applied on unselected patients. Secondarily the study aimed to identify predictors of ultrasound changing management.

Methods

This study was a blinded observational single center trial. A basic whole body POCUS protocol was performed in extension to the physical examination. The blinded treating physicians were interviewed about the presumptive diagnosis and plan for the patient. Subsequently the physicians were unblinded to the POCUS results and asked to choose between five options regarding the benefit from POCUS results.

Results

A total of 403 patients were enrolled in this study. The treating physicians regarded POCUS examinations influence on the diagnostic workup or treatment as following: 1) No new information: 249 (61.8%), 2) No further action: 45 (11.2%), 3) Further diagnostic workup needed: 52 (12.9%), 4) Presumptive diagnosis confirmed 38 (9.4%), and 5) Immediate treatment needed: 19 (4.7%). Predictors of beneficial ultrasound were: (a) triage > 1, (b) patient comorbidities (cardiac disease, hypertension or lung disease), or (c) patients presenting with abdominal pain, dyspnea, or syncope.

Conclusion

POCUS was found to be potentially beneficial in 27.0% of all patients. High triage score, known cardiac disease, hypertension, pulmonary diseases, a clinical presentation with abdominal pain, dyspnea, or syncope are predictors of this. Future research should focus on patient-important outcomes when applying POCUS on these patients.

Trial registration

The trail was registered prior to patient inclusion with the Danish Data Protection Agency (https://www.datatilsynet.dk/ Case no: 1–16–02-603-14) and Clinical Trials (www.clinicaltrials.gov/ Protocol ID: DNVK1305018).

Impact of point-of-care ultrasound on clinical decision-making at an urban emergency department in Tanzania

BACKGROUND

Point of care ultrasound (PoCUS) is an efficient, inexpensive, safe, and portable imaging modality that can be particularly useful in resource-limited settings. However, its impact on clinical decision making in such settings has not been well studied. The objective of this study is to describe the utilization and impact of PoCUS on clinical decision making at an urban emergency department in Dar es Salaam, Tanzania.

METHODS

This was a prospective descriptive cross-sectional study of patients receiving PoCUS at Muhimbili National Hospital's Emergency Medical Department (MNH EMD). Data on PoCUS studies during a period of 10 months at MNH EMD was collected on consecutive patients during periods when research assistants were available. Data collected included patient age and sex, indications for ultrasound, findings, interpretations, and provider-reported diagnostic impression and disposition plan before and after PoCUS. Descriptive statistics, including medians and interquartile ranges, and counts and percentages, are reported. Pearson chi squared tests and p-values were used to evaluate categorical data for significant differences.

RESULTS

PoCUS data was collected for 986 studies performed on 784 patients. Median patient age was 32 years; 56% of patients were male. Top indications for PoCUS included trauma, respiratory presentations, and abdomino-pelvic pain. The most frequent study types performed were eFAST, cardiac, and obstetric or gynaecologic studies. Overall, clinicians reported that the use of PoCUS changed either diagnostic impression or disposition plan in 29% of all cases. Rates of change in diagnostic impression or disposition plan increased to 45% in patients for whom more than one PoCUS study type was performed.

CONCLUSIONS

In resource-limited emergency care settings, PoCUS can be utilized for a wide range of indications and has substantial impact on clinical decision making, especially when more than one study type is performed.

Which method is best for an early accurate diagnosis of acute heart failure? Comparison between lung ultrasound, chest X-ray and NT pro-BNP performance: a prospective study

Acute heart failure is a common condition among adults presenting with dyspnea in the Emergency Department (ED), still the diagnosis is challenging as objective standardized criteria are lacking. First line work-up, other then clinical findings, is nowadays made with lung ultrasound imaging study, chest X-ray study and brain natriuretic peptide (BNP) level determination; however, it is not clear which is the best diagnostic test to be used and whether there is any real benefit for clinical judgement. We set up this study to compare the performances of these three diagnostic tools; furthermore, we combined them to find the best possible approach to dyspneic patients. This is a prospective observational study based in the ED. We enrolled adults presenting with dyspnea not trauma-related, they underwent lung ultrasound, and chest X-ray studies, and NT pro-BNP level determination. Then we compared the results with the diagnosis of acute heart failure established by an independent panel of experts. 236 patients were enrolled in the study. We find sensitivity and specificity for lung ultrasound of 57.73 and 87.97 %, for chest X-ray 74.49 and 86.26 %, for NT pro-BNP 97.59 and 27.56 %, respectively. Combining together the chest X-ray and lung ultrasound, we find the best overall performance with 84.69 % sensitivity, 77.69 % specificity and 87.07 % negative predictive value. From our results, we could not identify the "best test" to diagnose acute heart failure in an emergency setting, although we could suggest that a stepwise workup combining chest X-ray and lung ultrasound at first, then for those negative, a determination of NT pro-BNP assay would be a reasonable approach to the dyspneic patient.

Bedside ultrasound training at Muhimbili National Hospital in Dar es Salaam, Tanzania and Hospital San Carlos in Chiapas, Mexico

INTRODUCTION

In resource-rich settings, bedside ultrasound has rapidly evolved to be a crucial part of emergency centre practice and a growing part of critical care practice. This portable and affordable technology may be even more valuable in resource-limited environments where other imaging modalities are inaccessible, but the optimal amount of training required to achieve competency in bedside ultrasound is largely unknown. We sought to evaluate the feasibility of implementation of a mixed-modality bedside ultrasound training course for emergency and generalist acute care physicians in limited resource settings, and to provide a description of our core course components, including specific performance goals, to facilitate implementation of similar initiatives.

METHODS

We conducted a standardised training course at two distinct sites-one large, urban tertiary hospital in Tanzania with a dedicated Emergency Centre, and one small, rural, hospital in southern Mexico with a general, acute intake area. We report on pre-training ultrasound use at both sites, as well as pre- and post-training views on most useful indications.

RESULTS

Overall, participants were very satisfied with the course, although approximately one-third of the providers at both sites would have preferred more hands-on training. All participants passed a standardised exam requiring image acquisition and interpretation.

DISCUSSION

Introducing bedside ultrasound training in two distinct resource-limited settings was feasible and well-received. After a brief intensive period of training, participants successfully passed a comprehensive examination, including demonstration of standardised image acquisition and accurate interpretation of normal and abnormal studies.

Estimated effect of an integrated approach to suspected deep venous thrombosis using limited-compression ultrasound

OBJECTIVES

Deep vein thrombosis (DVT) is both common and serious, yet the desire to never miss the diagnosis, coupled with the low specificity of D-dimer testing, results in high imaging rates, return visits, and empirical anticoagulation. The objective of this study was to evaluate a new approach incorporating bedside limited-compression ultrasound (LC US) by emergency physicians (EPs) into the workup strategy for DVT.

METHODS

This was a cross-sectional observational study of emergency department (ED) patients with suspected DVT. Patients on anticoagulants; those with chronic DVT, leg cast, or amputation; or when the results of comprehensive imaging were already known were excluded. All patients were treated in the usual fashion based on the protocol in use at the center, including comprehensive imaging based on the modified Wells score and serum D-dimer testing. Seventeen physicians were trained and performed LC US in all subjects. The authors identified a priori an alternate workup strategy in which DVT would be ruled out in "DVT unlikely" (Wells score < 2) patients if the LC US was negative and in "DVT likely" (Wells score ≥ 2) patients if both the LC US and the D-dimer were negative. The criterion standard was based on comprehensive imaging interpreted by radiologists blinded to LC US findings and by structured medical record review at 6 months in patients without comprehensive imaging.

RESULTS

A total of 227 patients were enrolled (47% DVT likely), of whom 24 had DVT. The LC US was positive in 27 cases (21 actually DVT positive), indeterminate in 28 (one DVT positive), and negative in 172 (two DVT positive). Of 130 patients deemed DVT negative by the new strategy, one had confirmed DVT (miss rate = 0.8%; 95% confidence interval [CI] = 0.1% to 4.0%), but this patient had been misclassified by the treating physician as low risk by Wells criteria. The stand-alone sensitivity and specificity of LC US were 91% (95% CI = 70% to 98%) and 97% (95% CI = 92% to 99%), respectively. Incorporating LC US into the diagnostic approach would have reduced the rate of comprehensive imaging from 70% to 43%, D-dimer testing from 100% to 33%, and the mean time to diagnostic certainty by 5.0 hours and avoided 24 (11%) return visits for imaging and 10 (4.4%) cases of unnecessary anticoagulation. In 19% of cases, the treating and scanning physician disagreed whether the patient was DVT likely or DVT unlikely based on Wells score (κ = 0.62; 95% CI = 0.48 to 0.77).

CONCLUSIONS

Limited-compression US holds promise as one component of the diagnostic approach to DVT, but should not be used as a stand-alone test due to imperfect sensitivity. Tradeoffs in diagnostic efficiency for the sake of perfect sensitivity remain a difficult issue collectively in emergency medicine (EM), but need to be scrutinized carefully in light of the costs of overinvestigation, delays in diagnosis, and risks of empirical anticoagulation.

Revisiting signs, strengths and weaknesses of Standard Chest Radiography in patients of Acute Dyspnea in the Emergency Department

Dyspnoea, defined as an uncomfortable awareness of breathing, together with thoracic pain are two of the most frequent symptoms of presentation of thoracic diseases in the Emergency Department (ED). Causes of dyspnoea are various and involve not only cardiovascular and respiratory systems. In the emergency setting, thoracic imaging by standard chest X-ray (CXR) plays a crucial role in the diagnostic process, because it is of fast execution and relatively not expensive. Although radiologists are responsible for the final reading of chest radiographs, very often the clinicians, and in particular the emergency physicians, are alone in the emergency room facing this task. In literature many studies have demonstrated how important and essential is an accurate direct interpretation by the clinician without the need of an immediate reading by the radiologist. Moreover, the sensitivity of CXR is much impaired when the study is performed at bedside by portable machines, particularly in the diagnosis of some important causes of acute dyspnoea, such as pulmonary embolism, pneumothorax, and pulmonary edema. In these cases, a high inter-observer variability of bedside CXR reading limits the diagnostic usefulness of the methodology and complicates the differential diagnosis. The aim of this review is to analyze the radiologic signs and the correct use of CXR in the most important conditions that cause cardiac and pulmonary dyspnoea, as acute exacerbation of chronic obstructive pulmonary disease, acute pulmonary oedema, acute pulmonary trombo-embolism, pneumothorax and pleural effusion, and to focus indications and limitations of this diagnostic tool.

Clinical application of transthoracic ultrasonography in inpatients with pneumonia

PURPOSE

The aim of this study was to investigate the clinical applicability of transthoracic ultrasound (TUS) in the diagnosis and follow-up of community acquired pneumonia (CAP).

METHODS

We designed a pilot study in 15 patients and subsequently investigated 342 patients (206 men and 136 women) consecutively admitted to our Department from September 2005 to November 2009 because of radiographically diagnosed CAP. All patients underwent standard chest radiography, and consequently TUS. Follow-up TUS were performed at 4th and 8-10th day, in most patients.

RESULTS

Concerning the reproducibility of TUS method, no reader's bias was present (P=0·18), overall variability and between-subject variability (inter-reader agreement) did not show any difference between readers (P = 0·62 and P = 0·32 respectively), and estimated within-subject variabilities (intra-reader agreement) suggested a very high repeatability of the method (P ∼ 1). Of 342 patients with Rx diagnosis of CAP, in 314 patients (92% of cases) a pulmonary consolidation was also detected using TUS, whose ultrasonographic patterns were studied. Pleural effusion was detected in 120/342 (35%) patients using ultrasound and in 111/342 (32%) patients using chest radiography. Overall dimensional changes of the lung consolidated areas assessed with TUS method showed highly significant results. (1st day mean ± SD: 66·34 ± 19·25; 4th day: 39·92 ± 14·61; 8-10th day: 7·41 ± 1·50; P < 0·0001).

CONCLUSIONS

TUS is easily reproducible and we proved it to be a useful complementary diagnostic tool for the diagnosis and the follow-up of CAP.

Use of echocardiography and modalities of patient monitoring of trauma patients

PURPOSE OF REVIEW

Trauma patients require evaluation of the anatomic structure as well as the hemodynamic profile of the heart to improve effectiveness of resuscitation. They are prone to hemodynamic instability and must be monitored with various modalities to detect deterioration early. Newer, less invasive ultrasound technologies are replacing familiar 'gold standard' modalities of the past. This article reviews the indications, roles, imaging approaches, and limitations of modern echocardiography. A brief review of other ICU monitoring modalities is also presented.

RECENT FINDINGS

Echocardiography has emerged as a first-line diagnostic tool for assessment of trauma patients, especially those with hemodynamic compromise. It yields crucial information about structural damage as well as the hemodynamic profile and can be performed through either the transesophageal or transthoracic route. Quick and systematic use of echocardiography for diagnosis and management of critically injured patients may lead to improved outcomes.

SUMMARY

Echocardiography plays an important role in the trauma bay for diagnosis of thoracic injury and at the bedside in the ICU for evaluation of the hemodynamic profile.