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Lee MS, Sweetnam-Holmes D, Soffer GP, Harel-Sterling M. Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine. Curr Opin Pediatr 2024; 36:256-265. [PMID: 38411588 DOI: 10.1097/mop.0000000000001340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care. RECENT FINDINGS POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care. SUMMARY POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.
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Affiliation(s)
- Michelle Sin Lee
- Pediatric Emergency Medicine, Hospital for Sick Children, Assistant Professor, University of Toronto, Toronto, ON, Canada
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2
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Park Y, Han J, Leikin S, Díaz-Gómez JL. Essential Point-of-Care Ultrasound Insights for 2024. Semin Ultrasound CT MR 2024; 45:22-28. [PMID: 38081554 DOI: 10.1053/j.sult.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
To assess point-of-care ultrasound (POCUS) in 2024, we should start by defining its expanded scope and integration into general and specialty practice. Clinicians should abide by the evolving evidence for POCUS utilization and patient outcomes different from mortality and morbidity, especially as there are notable advancements in handheld ultrasound technology with a clear shift from capability to portability. To reduce diagnostic errors, POCUS practitioners need a holistic framework that accounts for known and new applications. Defining the POCUS scope of practices, proper training, and innovation, like artificial intelligence, can play a bigger role in mitigating diagnostic errors as we move forward.
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Affiliation(s)
- Yangseon Park
- Division of Cardiovascular Anesthesia and Critical Care Medicine, Department of Anesthesia, Baylor College of Medicine, Texas Heart Institute at Baylor St. Luke's Medical Center, Houston, TX
| | | | - Scott Leikin
- Division of Cardiovascular Anesthesia and Critical Care Medicine, Department of Anesthesia, Baylor College of Medicine, Texas Heart Institute at Baylor St. Luke's Medical Center, Houston, TX
| | - José L Díaz-Gómez
- Division of Cardiovascular Anesthesia and Critical Care Medicine, Department of Anesthesia, Baylor College of Medicine, Texas Heart Institute at Baylor St. Luke's Medical Center, Houston, TX.
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Rahmani E, Fayyazishishavan E, Afzalian A, Varshochi S, Amani-Beni R, Ahadiat SA, Moshtaghi Z, Shafagh SG, Khorram R, Asadollahzade E, Atbaei R, Kahrizi MS, Rahbari A, Baharlouie N, Mostanbet F, Amirabadiquchani B, Kiani M, memarizadeh M, Keshtkar Rajabi S, Barati R, Hajinouri H, Najafi S, Abdollahi Z, Dadashzadehasl N, Moghadam Fard A, Afshar M, Abedi A, Saeidi S, Mansourirad A, Emami Shahrezaei P, Shah Hosseini S, Rostami Ghotbabadi Z, Vafadar R, Roohinezhad R, Ghalamkarpour N, Farrokhi M. Point-Of-Care Ultrasonography for Identification of Skin and Soft Tissue Abscess in Adult and Pediatric Patients; a Systematic Review and Meta-Analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e49. [PMID: 37609534 PMCID: PMC10440756 DOI: 10.22037/aaem.v11i1.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Introduction Differentiating the soft tissue abscess from other types of skin and soft tissue infections (SSTIs) poses a particular challenge because they have similar physical evaluation findings, but each disease has a different course, outcome, and treatment. This meta-analysis aimed to investigate the diagnostic accuracy of point-of-care ultrasonography for diagnosis of soft tissue abscess in the emergency departments. Methods A comprehensive literature search of MEDLINE, Scopus, Web of Science, Embase, and Google Scholar, from inception to January 2023, was conducted to identify relevant studies investigating the diagnostic performance of point-of-care ultrasonography for identification of abscess. Methodological quality of the included studies was assessed using a revised tool for the quality assessment of diagnostic accuracy studies (QUADAS-2). Results The pooled estimates of diagnostic parameters of ultrasonography for diagnosis of abscess were as follows: sensitivity, 0.93 (95% CI: 0.92-0.94); specificity, 0.87 (95% CI: 0.85-0.89), and the area under the summary receiver-operating characteristic (SROC), 0.95. The pooled sensitivity, specificity, and area under the SROC of studies in adult patients were 0.98 (95% CI: 0.92-1), 0.92 (95% CI: 0.86-0.95), and 0.99, respectively. The pooled sensitivity, specificity, and area under the SROC of studies in pediatric patients were 0.9 (95% CI: 0.87-0.92), 0.78 (95% CI: 0.73-0.82), and 0.91, respectively. Conclusion Our meta-analysis demonstrated that the point-of-care ultrasonography has excellent diagnostic value for the abscess in the emergency department. Furthermore, we found that the diagnostic performance of point-of-care ultrasonography for diagnosis of abscess was higher for adult cases than for pediatric patients.
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Affiliation(s)
- Erfan Rahmani
- Graduated, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Fayyazishishavan
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA
| | - Arian Afzalian
- Graduated, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sanaz Varshochi
- Graduated, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Amani-Beni
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Zeynab Moshtaghi
- Graduated, Faculty of Nursing, Bushehr University of Medical Sciences, Bushehr, Iran
| | | | - Roya Khorram
- Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elnaz Asadollahzade
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Raihaneh Atbaei
- School of Medicine, Jahrom University of Medical Sciences, Jahrom, Iran
| | | | | | - Negar Baharlouie
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | | | - Moein Kiani
- School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | | | - Shahin Keshtkar Rajabi
- Firoozabadi hospital clinical research development unit (FHCRDU), Department of internal medicine, school of medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Reza Barati
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Shahrzad Najafi
- Graduated, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeynab Abdollahi
- Department of Radiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nahid Dadashzadehasl
- Legal Medicine Research Center, Iranian Legal Medicine Organization, Tehran, Iran
| | | | - Mozhgan Afshar
- University of Psychology Sciences, South Azad Tehran, Iran
| | - Atefeh Abedi
- Dental and Periodontal Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sara Saeidi
- Students Research Committee, Faculty of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Adeleh Mansourirad
- Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, USA
| | | | | | | | - Reza Vafadar
- Department of Orthopedic Surgery, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Nogol Ghalamkarpour
- Department of Clinical Laboratory Sciences, School of Allied Medicine, Student Research Committee, Lorestan University of Medical Sciences, Khorramabad, Iran
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de Borja C, Watkins R, Woolridge T. Common Ultrasound Applications for Pediatric Musculoskeletal Conditions. Curr Rev Musculoskelet Med 2022; 15:447-455. [PMID: 35932426 PMCID: PMC9789252 DOI: 10.1007/s12178-022-09788-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW To discuss the use of ultrasound for diagnosis and management of common pediatric musculoskeletal conditions through a case-based approach. RECENT FINDINGS Ultrasound is an essential diagnostic modality in the early detection of developmental dysplasia of the hips and can be used as early as 6 weeks of age when the ossific nucleus has not developed yet. Ultrasound is helpful in diagnosing traumatic injuries such as fractures and intramuscular hematomas, can visualize fracture healing at early stages, and can also be used to guide aspiration of hematomas that can help with decreasing pain and faster recovery. Ultrasound is superior to radiographs in evaluating joint effusions and soft tissue infections or masses and is better tolerated by children compared to other imaging modalities such as magnetic resonance imaging (MRI). Ultrasound is an easily accessible, affordable, non-invasive, and radiation-free imaging modality that is well tolerated by children and their families. It can aid in the diagnosis and management of a wide variety of musculoskeletal conditions including developmental, traumatic, and infectious etiologies, as well as in the evaluation of superficial soft tissue masses.
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Affiliation(s)
- Celina de Borja
- Division of Pediatric Orthopaedics, Department of Orthopaedic Surgery, University of California, San Francisco, 1825 4th Street – 5th Floor, San Francisco, CA 94158 USA
| | - Rhonda Watkins
- Division of Pediatric Orthopaedics, Department of Orthopaedic Surgery, University of California, San Francisco, 1825 4th Street – 5th Floor, San Francisco, CA 94158 USA
| | - Tiana Woolridge
- Department of Pediatrics, University of California, San Francisco, San Francisco, USA
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Dubey J, Shian B. Point-of-Care Ultrasound for Musculoskeletal Injection and Clinical Evaluation. Prim Care 2022; 49:163-189. [DOI: 10.1016/j.pop.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Thakrar DB, Sultan MJ. Cellulitis: diagnosis and differentiation. J Wound Care 2021; 30:958-965. [PMID: 34881996 DOI: 10.12968/jowc.2021.30.12.958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Dixa B Thakrar
- General Surgery Trainee, Imperial College Healthcare NHS Trust, Department of General Surgery, London, UK
| | - Muhammad J Sultan
- Locum Consultant Vascular Surgeon, Hull Royal Infirmary; Senior Honorary Clinical Lecturer, University of Hull, UK
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Shaahinfar A, Ghazi-Askar ZM. Procedural Applications of Point-of-Care Ultrasound in Pediatric Emergency Medicine. Emerg Med Clin North Am 2021; 39:529-554. [PMID: 34215401 DOI: 10.1016/j.emc.2021.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.
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Affiliation(s)
- Ashkon Shaahinfar
- Division of Emergency Medicine, UCSF Benioff Children's Hospital Oakland, Trailer 3, 747 52nd Street, Oakland, CA 94609, USA; Department of Emergency Medicine, UCSF School of Medicine, 550 16th Street, MH5552, San Francisco, CA, USA.
| | - Zahra M Ghazi-Askar
- Department of Emergency Medicine, Stanford School of Medicine, 300 Pasteur Drive, Room M121, Alway Building MC 5768, Stanford, CA 94305, USA
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Pediatric Subcutaneous Abscess: Still a Clinical Exam-Based Diagnosis and Treatment. CHILDREN-BASEL 2021; 8:children8050392. [PMID: 34068855 PMCID: PMC8153592 DOI: 10.3390/children8050392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 11/17/2022]
Abstract
Subcutaneous abscesses occur frequently in the pediatric population, yet there is great variability in the approach to diagnosis and management, partly due to opposing recommendations in the current literature and the lack of a standardized protocol for diagnosis and management among pediatric medical centers. This has led to inconsistencies by the providers, as well as the hospital clinical pathways, with regards to the appropriate management of subcutaneous abscesses. We hypothesize that the current variability in diagnostic work-up and management contributes to the wide use of unnecessary imaging and therapeutics without altering the overall outcomes. We performed a retrospective chart review that compared 200 encounters for patients < 18 years of age with a diagnosis of subcutaneous abscess at a single large tertiary pediatric institution. Our results showed that only 13.6% of wound cultures obtained led to a change in the antibiotic regimen and that blood cultures were positive in only 2.1% of cases. There was no difference in the incision and drainage performed based on ultrasound findings in the presence of fluctuance on physical exam. Patients presenting with fever were more likely to be admitted to the hospital for further care than those without fever. Our results showed no difference in outcome after incision and drainage for abscesses packed with gauze versus those left to drain via a vessel loop drain. There was no difference in recurrence in patients discharged with oral antibiotics versus without oral antibiotic treatment. Our data indicate that many of the diagnostic studies used for the management of a subcutaneous abscess have little to no effect on the outcome. Subcutaneous abscesses are a common pediatric complaint, and this study could help healthcare providers utilize more effective and efficient management strategies for skin and soft tissue infections.
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Shah N, Buice J, Shields A, Pruitt C. Does Point-of-Care Ultrasound Affect Outcomes in Pediatric Patients with Skin and Soft Tissue Infections? South Med J 2021; 113:645-650. [PMID: 33263136 DOI: 10.14423/smj.0000000000001185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE There is increasing evidence for the use of point-of-care ultrasound (POCUS) in pediatric patients with skin and soft tissue infections (SSTI), but there is a lack of sufficient data on its impact on SSTI outcomes. The objective of this study was to determine whether POCUS use is associated with fewer complications after discharge from the pediatric emergency department. METHODS This was a prospective cohort study in patients presenting to the emergency department with SSTI between the ages of 2 months and 19 years old. Adverse outcomes included hospitalization after discharge, change in antibiotics, subsequent procedures, or reevaluation by a medical professional. Outcome information was obtained 1 week later. Descriptive statistics and χ2 tests were used. RESULTS Of 456 patients screened, 250 were enrolled. POCUS was performed on 113 (45%) patients. The median age was 5 years, with more females in the non-POCUS group compared with the POCUS group (58% vs. 52%). Cellulitis without abscess was more commonly diagnosed in the POCUS group than in the non-POCUS group (26% vs 14%, P = 0.02.) The patients in the non-POCUS group were more likely to undergo incision and drainage than those in the POCUS group (62% vs 45%, P = 0.008). Overall, a greater number of patients in the POCUS group did not undergo any procedure (45% vs 27%, P = 0.003). The outcomes at 1 week did not differ significantly between the two groups. CONCLUSIONS POCUS use may lead to fewer procedures, but it does not lead to significantly better outcomes. Large randomized controlled trials are needed to confirm or refute our findings.
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Affiliation(s)
- Nipam Shah
- From Pediatrics, Division of Pediatric Emergency Medicine, and the School of Medicine, University of Alabama at Birmingham, Birmingham
| | - Jonathan Buice
- From Pediatrics, Division of Pediatric Emergency Medicine, and the School of Medicine, University of Alabama at Birmingham, Birmingham
| | - Ashlyn Shields
- From Pediatrics, Division of Pediatric Emergency Medicine, and the School of Medicine, University of Alabama at Birmingham, Birmingham
| | - Christopher Pruitt
- From Pediatrics, Division of Pediatric Emergency Medicine, and the School of Medicine, University of Alabama at Birmingham, Birmingham
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Menegas S, Moayedi S, Torres M. Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians. J Emerg Med 2020; 60:310-320. [PMID: 33298356 DOI: 10.1016/j.jemermed.2020.10.043] [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: 08/03/2020] [Revised: 10/02/2020] [Accepted: 10/19/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Abscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses. OBJECTIVE This review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department. DISCUSSION Ultrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative. CONCLUSIONS This review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.
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Affiliation(s)
- Samantha Menegas
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Siamak Moayedi
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mercedes Torres
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Point-of-Care Ultrasound Used to Distinguish Between Superficial Skin Abscess and Deep Mediastinal Abscess: A Case Report. J Emerg Med 2020; 60:e23-e25. [PMID: 33262009 DOI: 10.1016/j.jemermed.2020.10.015] [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: 07/30/2020] [Revised: 09/25/2020] [Accepted: 10/04/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Skin and soft tissue infections (SSTIs) are an increasingly common complaint in the emergency department (ED), but physical examination does not reliably identify abscesses or accurately determine which skin lesions require incision and drainage. Point-of-care ultrasound (POCUS) improves management of soft tissue skin infections by detecting occult abscess, preventing unnecessary procedures, and identifying more complex disease requiring further imaging. CASE REPORT Here, we report a case in which POCUS drastically changed the management of what initially appeared to be an uncomplicated superficial skin abscess but was actually a much more serious mediastinal infection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case underscores the importance and utility of POCUS to enhance the physical examination in suspected SSTIs. Because POCUS is easy, accurate, low risk, and can change management, we recommend its consideration as a standard component of the ED work up for SSTIs.
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Ray JW, Gende AM, Hall MM, Coe I, Situ-LaCasse E, Waterbrook A. Ultrasound in Trauma and Other Acute Conditions in Sports, Part II. Curr Sports Med Rep 2020; 19:546-551. [DOI: 10.1249/jsr.0000000000000788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Gottlieb M, Avila J, Chottiner M, Peksa GD. Point-of-Care Ultrasonography for the Diagnosis of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-analysis. Ann Emerg Med 2020; 76:67-77. [DOI: 10.1016/j.annemergmed.2020.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 12/13/2019] [Accepted: 12/31/2019] [Indexed: 02/01/2023]
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Lam SHF, Alade K, Brennan J, Castillo EM, Doniger SJ, Levine MC, Nadolski A, Rabiner JE, Shah V, Sivitz A, Medak AJ. Interpretation Accuracy and Interrater Agreement of Pediatric Skin and Soft Tissue Point-of-Care Ultrasound Images among Residents and Faculty. J Emerg Med 2020; 58:457-463. [PMID: 31843323 DOI: 10.1016/j.jemermed.2019.10.028] [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: 06/18/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) is commonly used to facilitate care in the emergency department. Acquired images are often reviewed by local experts for educational and quality assurance purposes. However, no published study has examined the accuracy and reliability of POCUS image interpretation by multiple reviewers. OBJECTIVES We studied the accuracy and interrater agreement among expert and trainee reviewers of prerecorded pediatric skin and soft tissue (SST) POCUS images. METHODS POCUS faculty and emergency medicine (EM) residents blindly reviewed deidentified pediatric SST POCUS images and indicated whether a drainable fluid collection was present, absent, or indeterminate. This was then compared with the gold standard based on discharge diagnoses and telephone follow-up. Images rated as indeterminate were excluded from the initial analysis. Sensitivity analysis assuming indeterminate answers were inaccurate was subsequently conducted. RESULTS In phase 1, 6 pediatric EM POCUS directors reviewed 168 images. The overall accuracy was 79.7% (range 66.1-86.0%). The mean Cohen's kappa was 0.58 (range 0.24-0.84). Sensitivity analysis yielded an overall accuracy of 71.3% (range 56.5-76.9%) and a Cohen's kappa of 0.43 (range 0.20-0.59). In phase 2, 6 general EM POCUS faculty and 20 EM residents reviewed 120 images. The overall accuracy among residents was 72.2% (range 51.4-84.7%) and among faculty was 83.6% (range 77.9-88.8%). Sensitivity analysis yielded an overall resident accuracy of 63.0% (range 49.5-80.7) and an overall faculty accuracy of 73.9% (range 67.0-79.8%). Fleiss' kappa was 0.322 for residents and 0.461 for faculty. CONCLUSIONS We found moderate accuracy and fair to good interrater agreement among POCUS faculty and EM residents reviewing pediatric SST POCUS images.
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Affiliation(s)
- Samuel H F Lam
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Kiyetta Alade
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine/Texas Children''s Hospital, Houston, Texas
| | - Jesse Brennan
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Edward M Castillo
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Stephanie J Doniger
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, CHOC Children's of Orange, Orange, California
| | - Marla C Levine
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Dell Children's Medical Center of Central Texas, Austin, Texas
| | - Adam Nadolski
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Joni E Rabiner
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University Medical Center/New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
| | - Virag Shah
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
| | - Adam Sivitz
- Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Anthony J Medak
- Department of Emergency Medicine, University of California at San Diego Medical Center, San Diego, California
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Kinnear B, Kelleher M, Chorny V. Clinical Progress Note: Point-of-Care Ultrasound for the Pediatric Hospitalist. J Hosp Med 2020; 15:170-172. [PMID: 31891559 DOI: 10.12788/jhm.3325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/30/2019] [Accepted: 09/04/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Benjamin Kinnear
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Matthew Kelleher
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Valeriy Chorny
- Department of Pediatrics, SUNY Downstate and Kings County Hospital Center, Brooklyn, New York
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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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Mower WR, Crisp JG, Krishnadasan A, Moran GJ, Abrahamian FM, Lovecchio F, Karras DJ, Steele MT, Rothman RE, Talan DA. Effect of Initial Bedside Ultrasonography on Emergency Department Skin and Soft Tissue Infection Management. Ann Emerg Med 2019; 74:372-380. [PMID: 30926187 DOI: 10.1016/j.annemergmed.2019.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/23/2019] [Accepted: 02/01/2019] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE We examine the utility of emergency department (ED) ultrasonography in treatment of skin and soft tissue infections. METHODS We enrolled ED patients with skin and soft tissue infections and surveyed clinicians in regard to their pre-ultrasonography certainty about the presence or absence of an abscess, their planned management, post-ultrasonography findings, and actual management. We determined sensitivity and specificity of ultrasonography and clinical evaluation, and assessed appropriateness of management changes based on initial clinical assessment and outcomes through 1-week follow-up. RESULTS Among 1,216 patients, clinicians were uncertain of abscess presence in 105 cases (8.6%) and certain for 1,111 cases (91.4%). Based on surgical exploration and follow-up through 1 week, sensitivity and specificity for abscess detection by clinical evaluation were 90.3% and 97.7%, and by ultrasonography were 94.0% and 94.1%, respectively. Among 1,111 cases for which the clinician was certain, sensitivity and specificity of clinical evaluation were 96.6% and 97.3% compared with ultrasonographic evaluation sensitivity and specificity of 95.7% and 96.2%, respectively. Of 105 uncertain cases, sensitivity and specificity of ultrasonography were 68.5% and 80.4%. Ultrasonography changed management in 13 of 1,111 certain cases (1.2%), appropriately in 10 of 13 (76.9%) and inappropriately in 3 of 13 (23.1%). Of 105 uncertain cases, ultrasonography changed management in 25 (23.8%), appropriately in 21 of 25 (84.0%) and inappropriately in 4 of 25 (16.0%). CONCLUSION Ultrasonography rarely changed management when clinicians were certain about the presence or absence of an abscess. When they were uncertain, ultrasonography changed drainage decisions in approximately one quarter of cases, of which most (84%) were appropriate.
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Affiliation(s)
- William R Mower
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA.
| | - Jonathan G Crisp
- UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA; Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA
| | - Anusha Krishnadasan
- Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA
| | - Gregory J Moran
- Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA
| | - Fredrick M Abrahamian
- Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA
| | - Frank Lovecchio
- Department of Emergency Medicine, Maricopa Medical Center, University of Arizona and Mayo Graduate School of Medicine, Phoenix, AZ
| | - David J Karras
- Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Mark T Steele
- Department of Emergency Medicine, Truman Medical Center, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins Medical Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - David A Talan
- Department of Emergency Medicine and Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA
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