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Choi W, Cho YS, Ha YR, Oh JH, Lee H, Kang BS, Kim YW, Koh CY, Lee JH, Jung E, Sohn Y, Kim HB, Kim SJ, Kim H, Suh D, Lee DH, Hong JY, Lee WW. Role of point-of-care ultrasound in critical care and emergency medicine: update and future perspective. Clin Exp Emerg Med 2023; 10:363-381. [PMID: 38225778 PMCID: PMC10790072 DOI: 10.15441/ceem.23.101] [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: 07/29/2023] [Revised: 10/01/2023] [Accepted: 10/05/2023] [Indexed: 01/17/2024] Open
Abstract
Point-of-care ultrasound (POCUS) is a rapidly developing technology that has the potential to revolutionize emergency and critical care medicine. The use of POCUS can improve patient care by providing real-time clinical information. However, appropriate usage and proper training are crucial to ensure patient safety and reliability. This article discusses the various applications of POCUS in emergency and critical care medicine, the importance of training and education, and the future of POCUS in medicine.
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Affiliation(s)
- Wookjin Choi
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Young Soon Cho
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Young Rock Ha
- Department of Intensive Care Medicine, Seongnam Citizens Medical Center, Seongnam, Korea
| | - Je Hyeok Oh
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Heekyung Lee
- Department of Emergency Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Bo Seung Kang
- Department of Emergency Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Yong Won Kim
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Chan Young Koh
- Department of Emergency Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Ji Han Lee
- Department of Emergency Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Euigi Jung
- Department of Emergency Medicine, VHS Medical Center, Seoul, Korea
| | - Youdong Sohn
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Korea
| | - Han Bit Kim
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Su Jin Kim
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hohyun Kim
- Department of Trauma and Surgical Critical Care, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Dongbum Suh
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Hyun Lee
- Department of Intensive Care Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
| | - Ju Young Hong
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Won Woong Lee
- Department of Intensive Care Medicine, Seongnam Citizens Medical Center, Seongnam, Korea
| | - on behalf of the Society Emergency and Critical Care Imaging (SECCI)
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
- Department of Intensive Care Medicine, Seongnam Citizens Medical Center, Seongnam, Korea
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
- Department of Emergency Medicine, Dankook University College of Medicine, Cheonan, Korea
- Department of Emergency Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
- Department of Emergency Medicine, VHS Medical Center, Seoul, Korea
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Korea
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Trauma and Surgical Critical Care, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Intensive Care Medicine, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
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Reardon RF, Chinn E, Plummer D, Laudenbach A, Rowland Fisher A, Smoot W, Lee D, Novik J, Wagner B, Kaczmarczyk C, Moore J, Thompson E, Tschautscher C, Dunphy T, Pahl T, Puskarich MA, Miner JR. Feasibility, utility, and safety of fully incorporating transesophageal echocardiography into emergency medicine practice. Acad Emerg Med 2022; 29:334-343. [PMID: 34644420 PMCID: PMC9298053 DOI: 10.1111/acem.14399] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/10/2021] [Accepted: 09/19/2021] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Transthoracic echocardiography (TTE) is a standard procedure for emergency physicians (EPs). Transesophageal echocardiography (TEE) is known to have great utility in patients who are critically ill or in cardiac arrest and has been used by some EPs with specialized ultrasound (US) training, but it is generally considered outside the reach of the majority of EPs. We surmised that all of our EPs could learn to perform focused TEE (F-TEE), so we trained and credentialed all of the physicians in our group. METHODS We trained 52 EPs to perform and interpret F-TEEs using a 4-h simulator-based course. We kept a database of all F-TEE examinations for quality assurance and continuous quality feedback. Data are reported using descriptive statistics. RESULTS Emergency physicians attempted 557 total F-TEE examinations (median = 10, interquartile range = 5-15) during the 42-month period following training. Clinically relevant images were obtained in 99% of patients. EPs without fellowship or other advanced US training performed the majority of F-TEEs (417, 74.9%) and 94.3% (95% confidence interval [CI] = 91.4%-96.3%) had interpretable images recorded. When TTE and TEE were both performed (n = 410), image quality of TEE was superior in 378 (93.3%, 95% CI = 89.7%-95%). Indications for F-TEE included periarrest states (55.7%), cardiac arrest (32.1%), and shock (12.2%). There was one case of endotracheal tube dislodgement during TEE placement, but this was immediately identified and replaced without complication. CONCLUSION After initiating a mandatory group F-TEE training and credentialing program, we report the largest series to date of EP-performed resuscitative F-TEE. The majority of F-TEE examinations (75%) were performed by EPs without advanced US training beyond residency.
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Affiliation(s)
- Robert F. Reardon
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Elliott Chinn
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Dave Plummer
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Andrew Laudenbach
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Andie Rowland Fisher
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Will Smoot
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Daniel Lee
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Joseph Novik
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Barrett Wagner
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Chris Kaczmarczyk
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Johanna Moore
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Emily Thompson
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Craig Tschautscher
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Teresa Dunphy
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Thomas Pahl
- Glacial Ridge Health SystemGlenwoodMinnesotaUSA
| | - Michael A. Puskarich
- Department of Emergency MedicineHennepin County Medical Center & University of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - James R. Miner
- Department of Emergency MedicineHennepin County Medical Center & University of Minnesota Medical SchoolMinneapolisMinnesotaUSA
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Chan SSW. Emergency Physician use of Ultrasonography to Evaluate Hypotension: A Case Report. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790200900409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In a non-trauma patient, several conditions giving rise to hypotension and cardiovascular collapse can be immediately life-threatening. These include cardiac tamponade, ruptured abdominal aortic aneurysm, pulmonary embolism, and massive acute myocardial infarction. Prompt diagnosis is essential because correct immediate treatment and disposal decisions will affect the outcome. This is a report of a case in which the emergency physician used ultrasonography to evaluate a patient with hypotension, leading to timely intervention. Sonographic diagnosis also guided subsequent disposal and management decisions. This utility of ultrasonography in the emergency department setting is discussed.
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Gratton R, Olaussen A, Hassan M, Thaveenthiran P, Fitzgerald MC, Mitra B. Diagnostic performance of the cardiac FAST in a high-volume Australian trauma centre. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2017. [DOI: 10.5339/jemtac.2017.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background: Cardiac injury is uncommon, but it is important to diagnose, in order to prevent subsequent complications. Extended focused assessment with sonography in trauma (eFAST) allows rapid evaluation of the pericardium and thorax. The objective of this study was to describe cardiac injuries presenting to a major trauma centre and the diagnostic performance of eFAST in detecting haemopericardium as well as broader cardiac injuries. Methods: Data of patients with severe injuries and diagnosed cardiac injuries (Injury Severity Score >12 and AIS 2008 codes for cardiac injuries) were extracted from The Alfred Trauma Registry over a four-year period from July 2010 to June 2014. The initial eFAST results were compared to those of the final diagnosis, which were determined after analysing imaging results and intraoperative findings. Results: Thirty patients who were identified with cardiac injuries met the inclusion criteria. Among these, 22 patients sustained injuries under the scope of eFAST, of which a positive eFAST scan in the pericardium was reported in 13 (59%) patients, while nine (41%) patients had a negative scan. This resulted in a sensitivity of 59% (95% CI: 36.7%–78.5%). The sensitivity of detecting any cardiac injuries was lower at 43.3% (95% CI: 26.0–62.3). Conclusions: The low sensitivities of eFAST for detecting cardiac injuries and haemopericardium demonstrate that a negative result cannot be used in isolation to exclude cardiac injuries. A high index of suspicion for cardiac injury remains essential. Adjunct diagnostic modalities are indicated for the diagnosis of cardiac injury following major trauma.
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Affiliation(s)
| | - Alexander Olaussen
- 2Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
- 3Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- 4Trauma Service, The Alfred Hospital, Melbourne, Australia
- 5National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Mariam Hassan
- 5National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | | | - Mark C. Fitzgerald
- 4Trauma Service, The Alfred Hospital, Melbourne, Australia
- 5National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Biswadev Mitra
- 3Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- 5National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- 6Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
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Schuss- und Stichverletzungen. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0162-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Mok KL. Make it SIMPLE: enhanced shock management by focused cardiac ultrasound. J Intensive Care 2016; 4:51. [PMID: 27529027 PMCID: PMC4983798 DOI: 10.1186/s40560-016-0176-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/12/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Shock is a spectrum of circulatory failure that, if not properly managed, would lead to high mortality. Special diagnostic and treatment strategies are essential to save lives. However, clinical and laboratory findings are always non-specific, resulting in clinical dilemmas. MAIN CONTENT Focused cardiac ultrasound (FoCUS) has emerged as one of the power tools for clinicians to answer simple clinical questions and guide subsequent management in hypotensive patients. This article will review the development and utility of FoCUS in different types of shock. The sonographic features and ultrasound enhanced management of hypotensive patients by a de novo "SIMPLE" approach will be described. Current evidence on FoCUS will also be reviewed. CONCLUSION Focused cardiac ultrasound provides timely and valuable information for the evaluation of shock. It helps to improve the diagnostic accuracy, narrow the possible differential diagnoses, and guide specific management. SIMPLE is an easy-to-remember mnemonic for non-cardiologists or novice clinical sonographers to apply FoCUS and interpret the specific sonographic findings when evaluating patients in shock.
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Affiliation(s)
- Ka Leung Mok
- Accident and Emergency Department, Ruttonjee Hospital, 266 Queen’s Road East, Wanchai, Hong Kong SAR
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Image-based resuscitation of the hypotensive patient with cardiac ultrasound: An evidence-based review. J Trauma Acute Care Surg 2016; 80:511-8. [PMID: 26670112 DOI: 10.1097/ta.0000000000000941] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article is a detailed review of the literature regarding the use of cardiac ultrasound for the resuscitation of hypotensive patients. In addition, figures regarding windows and description of how to perform the test are included.
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Kennedy Hall M, Coffey EC, Herbst M, Liu R, Pare JR, Andrew Taylor R, Thomas S, Moore CL. The "5Es" of emergency physician-performed focused cardiac ultrasound: a protocol for rapid identification of effusion, ejection, equality, exit, and entrance. Acad Emerg Med 2015; 22:583-93. [PMID: 25903585 DOI: 10.1111/acem.12652] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 12/19/2014] [Indexed: 12/18/2022]
Abstract
Emergency physician (EP)-performed focused cardiac ultrasound (EP FOCUS) has been increasingly recognized as a crucial tool to help clinicians diagnose and treat potentially life-threatening conditions. The existing literature demonstrates a variety of EP FOCUS applications and protocols; however, EP FOCUS is not taught, practiced, or interpreted consistently between institutions. Drawing on over 12 years of experience in a large-volume, high-acuity academic emergency department, we have developed a protocol for teaching and performing EP FOCUS known as "The 5Es," where each E represents a specific assessment for immediately relevant clinical information. These include pericardial effusion, qualitative left ventricular ejection, ventricular equality, exit (aortic root diameter), and entrance (inferior vena cava diameter and respirophasic variation). Each of these assessments has been well described in the emergency medicine literature and is within the scope of EP-performed echocardiography. This approach provides a reliable and easily recalled framework for assessing, teaching, and communicating EP FOCUS findings that are essential in caring for the patient in the emergency setting.
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Affiliation(s)
- M. Kennedy Hall
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - E. C. Coffey
- Department of Emergency Medicine; University of Texas Health Science Center San Antonio; San Antonio TX
| | - Meghan Herbst
- Department of Emergency Medicine; Hartford Hospital, University of Connecticut School of Medicine; Hartford CT
| | - Rachel Liu
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Joseph R. Pare
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - R. Andrew Taylor
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Sheeja Thomas
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
| | - Chris L. Moore
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
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Abstract
BACKGROUND Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
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Soubeyrand M, Begin M, Pierrart J, Gagey O, Dumontier C, Guerini H. L’échographie pour le chirurgien de la main (conférence d’enseignement XLVe congrès de la Société française de chirurgie de la main). ACTA ACUST UNITED AC 2011; 30:368-84. [DOI: 10.1016/j.main.2011.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Revised: 08/30/2011] [Accepted: 09/21/2011] [Indexed: 11/28/2022]
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A brief training module improves recognition of echocardiographic wall-motion abnormalities by emergency medicine physicians. Emerg Med Int 2011; 2011:483242. [PMID: 22046540 PMCID: PMC3200256 DOI: 10.1155/2011/483242] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 05/09/2011] [Indexed: 11/29/2022] Open
Abstract
Objective. Wall-motion abnormality on echocardiogram is more sensitive in detecting cardiac ischemia than the electrocardiogram, but the use of bedside echocardiography by emergency physicians (EPs) for this purpose does not appear to be widespread, apparently due to limited data on proficiency of EPs for this task. We sought to determine the effect of a brief training module on the ability of EPs to recognize wall motion abnormalities on echocardiograms. Methods. We developed a brief training and testing module and presented it to EPs. After baseline testing of 15 echocardiograms, we presented the 30-minute training module, and administered a new test of 15 different echocardiograms. Physicians were asked to interpret the wall motion as normal or abnormal. Results. 35 EPs over two separate sessions showed significant improvement recognition of wall-motion abnormalities after the brief training module. Median score on the baseline test was 67%, interquartile range (IQR) 53% to 80%, while the median score on the posttraining test was 87%, IQR 80% to 87%, P < .001, independent of time in practice or prior training. Conclusion. With only brief training on how to recognize wall motion abnormalities on echocardiograms, EPs showed significant improvement in ability to identify wall motion abnormalities.
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Lichte P, Oberbeck R, Binnebösel M, Wildenauer R, Pape HC, Kobbe P. A civilian perspective on ballistic trauma and gunshot injuries. Scand J Trauma Resusc Emerg Med 2010; 18:35. [PMID: 20565804 PMCID: PMC2898680 DOI: 10.1186/1757-7241-18-35] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2009] [Accepted: 06/17/2010] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Gun violence is on the rise in some European countries, however most of the literature on gunshot injuries pertains to military weaponry and is difficult to apply to civilians, due to dissimilarities in wound contamination and wounding potential of firearms and ammunition. Gunshot injuries in civilians have more focal injury patterns and should be considered distinct entities. METHODS A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed. RESULTS Craniocerebral gunshot injuries are often lethal, especially after suicide attempts. The treatment of non space consuming haematomas and the indications for invasive pressure measurement are controversial. Civilian gunshot injuries to the torso mostly intend to kill; however for those patients who do not die at the scene and are hemodynamically stable, insertion of a chest tube is usually the only required procedure for the majority of penetrating chest injuries. In penetrating abdominal injuries there is a trend towards non-operative care, provided that the patient is hemodynamically stable. Spinal gunshots can also often be treated without operation. Gunshot injuries of the extremities are rarely life-threatening but can be associated with severe morbidity.With the exception of craniocerebral, bowel, articular, or severe soft tissue injury, the use of antibiotics is controversial and may depend on the surgeon's preference. CONCLUSION The treatment strategy for patients with gunshot injuries to the torso mostly depends on the hemodynamic status of the patient. Whereas hemodynamically unstable patients require immediate operative measures like thoracotomy or laparotomy, hemodynamically stable patients might be treated with minor surgical procedures (e.g. chest tube) or even conservatively.
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Affiliation(s)
- Philipp Lichte
- Department of Trauma Surgery, University Hospital of the RWTH Aachen, Aachen, Germany.
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Yanagawa Y, Sakamoto T, Okada Y. Hypovolemic shock evaluated by sonographic measurement of the inferior vena cava during resuscitation in trauma patients. ACTA ACUST UNITED AC 2008; 63:1245-8; discussion 1248. [PMID: 18212645 DOI: 10.1097/ta.0b013e318068d72b] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inferior vena cava (IVC) diameter immediately after fluid resuscitation has not yet been investigated in trauma patients with shock on arrival. METHODS Between June 2004 and May 2005, 30 trauma patients with hemorrhagic shock were prospectively investigated. Using ultrasound, we measured maximum anterior-posterior diameter of the IVC just below the diaphragm in the hepatic segment, in the expiratory phase. This was performed on arrival and when systolic blood pressure had been raised to over 90 mm Hg by fluid resuscitation in the emergency room. Subjects were divided into two groups: a transient responder group (n = 17) in which shock recurred after leaving the emergency room and a responder group (n = 13) in which blood pressure remained stable. RESULTS There were no significant differences between the two groups regarding age or gender, or regarding vital signs or IVC diameter on arrival. Average injury severity score in the transient responder group was significantly greater than that in the responder group. After fluid resuscitation, no significant intergroup differences were observed regarding vital signs. However, IVC diameter was significantly smaller in the transient responder group than in the responder group (6.5 +/- 0.5 mm; mean +/- SE vs. 10.7 +/- 0.7 mm, p < 0.05). CONCLUSION In trauma patients, inadequate dilatation of the IVC by fluid resuscitation, might indicate insufficient circulating blood volume despite normalization of blood pressure. In this small study, IVC diameter appeared a better predictor of recurrence of shock than blood pressure, heart rate, or arterial base excess. A larger prospective study is called for to clearly establish the sensitivity and specificity of this method.
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Affiliation(s)
- Youichi Yanagawa
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan.
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Noble VE, Nelson BP, Sutingco AN, Marill KA, Cranmer H. Assessment of knowledge retention and the value of proctored ultrasound exams after the introduction of an emergency ultrasound curriculum. BMC MEDICAL EDUCATION 2007; 7:40. [PMID: 17971234 PMCID: PMC2223143 DOI: 10.1186/1472-6920-7-40] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Accepted: 10/30/2007] [Indexed: 05/25/2023]
Abstract
BACKGROUND Optimal training required for proficiency in bedside ultrasound is unknown. In addition, the value of proctored training is often assumed but has never been quantified. METHODS To compare different training regimens for both attending physicians and first year residents (interns), a prospective study was undertaken to assess knowledge retention six months after an introductory ultrasound course. Eighteen emergency physicians and twelve emergency medicine interns were assessed before and 6 months after an introductory ultrasound course using a standardized, image-based ultrasound test. In addition, the twelve emergency medicine interns were randomized to a group which received additional proctored ultrasound hands-on instruction from qualified faculty or to a control group with no hands-on instruction to determine if proctored exam training impacts ultrasound knowledge. Paired and unpaired estimates of the median shift in test scores between groups were made with the Hodges-Lehmann extension of the Wilcoxon-Mann-Whitney test. RESULTS Six months after the introductory course, test scores (out of a 24 point test) were a median of 2.0 (95% CI 1.0 to 3.0) points higher for residents in the control group, 5.0 (95% CI 3.0 to 6.0) points higher for residents in the proctored group, and 2.5 (95% CI 1.0 to 4.0) points higher for the faculty group. Residents randomized to undergo proctored ultrasound examinations exhibited a higher score improvement than their cohorts who were not with a median difference of 3.0 (95% CI 1.0 to 5.0) points. CONCLUSION We conclude that significant improvement in knowledge persists six months after a standard introductory ultrasound course, and incorporating proctored ultrasound training into an emergency ultrasound curriculum may yield even higher knowledge retention.
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Affiliation(s)
- Vicki E Noble
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, Massachusetts, USA
| | - Bret P Nelson
- Department of Emergency Medicine, Mount Sinai School of Medicine, 1190 Fifth Avenue, NY, New York, USA
| | - A Nicholas Sutingco
- Department of Emergency Medicine, INOVA Fair Oaks Hospital, 3600 Joseph Siewick Drive, Fairfax, Virginia, USA
| | - Keith A Marill
- Department of Emergency Medicine, Brigham and Women's Hospital, 32 Francis St., Boston, Massachusetts, USA
| | - Hilarie Cranmer
- Department of Emergency Medicine, Brigham and Women's Hospital, 32 Francis St., Boston, Massachusetts, USA
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Tayal VS, Nicks BA, Norton HJ. Emergency ultrasound evaluation of symptomatic nontraumatic pleural effusions. Am J Emerg Med 2006; 24:782-6. [PMID: 17098097 DOI: 10.1016/j.ajem.2006.03.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Revised: 03/09/2006] [Accepted: 03/10/2006] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE We hypothesized that thoracic ultrasound (ThorUS) performed by emergency physicians would be a rapid and effective management tool for the evaluation of nontraumatic pleural effusion (PleurEff). METHODS This is a prospective observational study of symptomatic adults presenting to an urban ED with suspicion of PleurEff. ThorUS was performed bilaterally in the upright position. Measurements included treating physician's procedural time requirements, pre- and posttest likelihood of PleurEff, and management changes. RESULTS There were 59 patients who were entered into the study. Investigating physician's actual time to perform ThorUS was 2.19 minutes. After ThorUS, 48 (81%) patients had an increase and 11 (19%) had a reduction in likelihood of PleurEff with average absolute change in likelihood of PleurEff of 34% (P < .02). ThorUS changed management in 41% of cases; thoracentesis occurred most frequently. CONCLUSION ThorUS performed by emergency physicians is a rapid and effective management tool for the evaluation of nontraumatic PleurEff in symptomatic ED patients.
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Affiliation(s)
- Vivek S Tayal
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC 28232, USA.
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Price AS, Leech SJ, Sierzenski PR. Impending cardiac tamponade: A case report highlighting the value of bedside echocardiography. J Emerg Med 2006; 30:415-9. [PMID: 16740452 DOI: 10.1016/j.jemermed.2005.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2004] [Revised: 03/30/2005] [Accepted: 07/26/2005] [Indexed: 11/24/2022]
Abstract
Cardiac tamponade is a life-threatening process that must be diagnosed and treated in a timely fashion. As blood fills the pericardial sac, right ventricular filling is impeded and cardiac output is diminished, ultimately leading to cardiovascular collapse. Fortunately, emergency ultrasonography has improved the way we manage these patients today. In this report, we discuss a patient with hypotension and tachycardia who was found to have a massive loculated posterior pericardial effusion with impending cardiac tamponade. The diagnosis and appropriate treatment of this patient were rapidly ascertained with the use of bedside echocardiography. We review the literature on emergency ultrasonography, and consider the numerous instances in which emergency echocardiography can be life-saving.
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Affiliation(s)
- Ali S Price
- Department of Emergency Medicine, Christiana Care Health System, P.O. Box 6001, Newark, DE 19718, USA
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18
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Chan SSW, Tam MMK, Cheung NK, Man CY, Rainer TH. Ultrasonography of the Internal Jugular Vein in Patients With Dyspnea. Ann Emerg Med 2005; 45:459-60; author reply 460. [PMID: 15795733 DOI: 10.1016/j.annemergmed.2004.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
The use of echocardiography in the ED is well established and continues to gain widespread use in the evaluation of critically ill patients. In certain circumstances such as chest trauma, pericardial effusion, and cardiac arrest,EPs can perform and interpret echocardiographic examinations reliably. In other circumstances such as the diagnosis of acute coronary syndromes, PE,and endocarditis, the EP should be aware of the uses and limitations of echocardiography and obtain appropriate consultation when necessary.Academic- and community-based EPs should seek to incorporate further the use of echocardiography in their respective clinical practices, with special attention given to training and quality assurance. As EPs continue to improve their skills in cardiac ultrasound, their ability to diagnose a wider spectrum of cardiac diseases undoubtedly will grow proportionally.
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Affiliation(s)
- Teriggi J Ciccone
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Affiliated Emergency Medicine Residency Program, One Deaconess Road, West Campus Clinical Center 2, Boston, MA 02115, USA.
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20
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Abstract
Bedside US has an established role in the evaluation of chest trauma patients. Transthoracic echocardiography and TEE can be used to obtain critical information at the bedside for many emergent conditions, including the immediate detection of hemopericardium and acute aortic injury. More recent work has demonstrated that US also can be used to detect hemothoraces and pneumothoraces with accuracy. These diagnostic techniques can improve patient outcome and are within the scope of practice of emergency physicians and trauma surgeons. Physicians caring for trauma patients should be familiar with these techniques.
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21
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Tayal VS, Kline JA. Emergency echocardiography to detect pericardial effusion in patients in PEA and near-PEA states. Resuscitation 2003; 59:315-8. [PMID: 14659600 DOI: 10.1016/s0300-9572(03)00245-4] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Emergency echocardiography (EM echo) has been proposed to assist in decision-making in patients with pulseless electric activity (PEA) or PEA-like states. We observed the value of EM echo by emergency physicians in detecting pericardial effusion in patients in PEA and near PEA states. MATERIALS AND METHODS Observational, prospective series at a Level 1 urban ED of patients with non-traumatic PEA or near PEA states who had EM echoes performed by emergency physicians during an 18-month period. Outcomes of patients with EM echoes were established by review of clinical course, formal echocardiography, radiography, operation or autopsy. RESULTS Twenty patients had EM echo for non-traumatic hemodynamic collapse. Eight of 20 patients (40%) were without cardiac ventricular motion and were refractory to ACLS measures. Twelve of 20 (60%) patients had cardiac kinetic motion observed on echo. Eight of the 12 (67%) patients with cardiac motion had a pericardial effusion observed on EM echo. Formal echocardiography or other imaging studies confirmed all pericardial effusion cases. The following diagnoses were subsequently confirmed in patients with pericardial effusion: one aortic aneurysm, two aortic dissections, two metastatic cancers, one post-dialysis effusion, two minimal effusions. Three patients had tamponade with emergency pericardial drainage or surgery. In two of four patients with cardiac activity without pericardial effusion, EM echo was useful by detecting pacer capture and ROSC, respectively. CONCLUSIONS Emergency echocardiography performed by emergency physicians in patients in PEA or near PEA states can detect pericardial effusions with correctable etiologies versus true PEA with ventricular standstill.
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Affiliation(s)
- Vivek S Tayal
- Department of Emergency Medicine, P.O. Box 32861, Charlotte, NC 28232, USA.
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22
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Yen K, Gorelick MH. Ultrasound applications for the pediatric emergency department: a review of the current literature. Pediatr Emerg Care 2002; 18:226-34. [PMID: 12066016 DOI: 10.1097/00006565-200206000-00020] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kenneth Yen
- Section of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA.
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23
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Blaivas M. Incidence of pericardial effusion in patients presenting to the emergency department with unexplained dyspnea. Acad Emerg Med 2001; 8:1143-6. [PMID: 11733291 DOI: 10.1111/j.1553-2712.2001.tb01130.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the frequency of pericardial effusion in patients presenting to the emergency department (ED) with unexplained, new onset dyspnea. METHODS This prospective observational study took place at an urban community hospital ED with a residency program and an annual census of 65,000 visits. Patients presenting between May 1999 and January 2000 with new-onset dyspnea were eligible if they lacked any pulmonary, infectious, hematological, traumatic, psychiatric, cardiovascular, or neuromuscular explanation for their dyspnea after ED evaluation. Patients received a focused echocardiogram by certified emergency physicians. Data were recorded on standardized data sheets and studies were taped for review. Effusions were categorized as small when the fluid stripe measured less than 10 mm. Moderate-sized effusions measured 10 to 15 mm. Large effusions measured more than 15 mm. RESULTS One hundred three patients were enrolled. Median age was 56 years (IQR 44, 95% CI = 32 to 67). Fourteen patients (13.6%, 95% CI = 8% to 23%) had effusions. Four had large effusions that explained their dyspnea and were admitted to cardiology; two of these effusions were hemorrhagic, and two were viral in origin. Seven patients with small effusions were treated conservatively at home. Three patients had moderate-sized effusions; all were admitted but treated conservatively. CONCLUSIONS While limited by small numbers, these preliminary data suggest that patients with unexplained dyspnea should be checked for pericardial effusion when bedside ED ultrasound is available.
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Affiliation(s)
- M Blaivas
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA.
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24
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25
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Mandavia DP, Hoffner RJ, Mahaney K, Henderson SO. Bedside echocardiography by emergency physicians. Ann Emerg Med 2001; 38:377-82. [PMID: 11574793 DOI: 10.1067/mem.2001.118224] [Citation(s) in RCA: 194] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVE Timely diagnosis of a pericardial effusion is often critical in the emergency medicine setting, and echocardiography provides the only reliable method of diagnosis at the bedside. We attempt to determine the accuracy of bedside echocardiography as performed by emergency physicians to detect pericardial effusions in a variety of high-risk populations. METHODS Emergency patients presenting with high-risk criteria for the diagnosis of pericardial effusion underwent emergency bedside 2-dimensional echocardiography by emergency physicians who were trained in ultrasonography. The presence or absence of a pericardial effusion was determined, and all images were captured on video or as thermal images. All emergency echocardiograms were subsequently reviewed by the Department of Cardiology for the presence of a pericardial effusion. RESULTS During the study period, a total of 515 patients at high risk were enrolled. Of these, 103 patients were ultimately deemed to have a pericardial effusion according to the comparative standard. Emergency physicians detected pericardial effusion with a sensitivity of 96% (95% confidence interval [CI] 90.4% to 98.9%), specificity of 98% (95% CI 95.8% to 99.1%), and overall accuracy of 97.5% (95% CI 95.7% to 98.7%). CONCLUSION Echocardiography performed by emergency physicians is reliable in evaluating for pericardial effusions; this bedside diagnostic tool may be used to examine specific patients at high risk. Emergency departments incorporating bedside ultrasonography should teach focused echocardiography to evaluate the pericardium.
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Affiliation(s)
- D P Mandavia
- Department of Emergency Medicine, Los Angeles County & University of Southern California Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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26
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Hendrickson RG, Dean AJ, Costantino TG. A novel use of ultrasound in pulseless electrical activity: the diagnosis of an acute abdominal aortic aneurysm rupture. J Emerg Med 2001; 21:141-4. [PMID: 11489403 DOI: 10.1016/s0736-4679(01)00362-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We report a case of a patient who presented to the Emergency Department with pulseless electrical activity. A rapid diagnosis of ruptured abdominal aortic aneurysm was made by Emergency Medicine bedside ultrasonography. On arrival, the patient was without palpable pulses and bradycardic. Therapy with epinephrine, fluids, and atropine was initiated. A bedside ultrasound was immediately performed and revealed coordinated cardiac motion with empty ventricles. A rapid search for signs of blood loss in the abdomen revealed a large abdominal aortic aneurysm. Pulses were restored with fluid, blood, and epinephrine and surgical intervention was begun within 30 min of patient arrival.
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Affiliation(s)
- R G Hendrickson
- Department of Emergency Medicine, Medical College of Pennsylvania/Hahnemann University, Philadelphia, Pennsylvania 19129, USA
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27
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Abstract
Because of an outstanding track record for diagnostic accuracy, noninvasive properties, ease of use, and relatively low expense, echocardiography has become a leading technique in the evaluation of cardiac disorders. In the three decades since echocardiography entered the ranks of standard cardiac diagnostic tools, refinements and technological advances have progressively increased its usefulness. One of the most noteworthy advancements has been the development of ultrasound contrast agents, which investigators are avidly seeking to apply to a broad spectrum of clinical settings and issues.
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Affiliation(s)
- A N DeMaria
- University of California at San Diego Medical Center 92103-8411, USA
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28
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Abstract
In an attempt to provide comprehensive and timely patient care, emergency physicians have begun to use ultrasonography to perform and interpret goal-oriented examinations. Reducing time to diagnosis can potentially have a major impact on the treatment of patients with ruptured ectopic pregnancy, leaking aortic aneurysm, and cardiac tamponade, who require time-sensitive surgical intervention. A review of three cases reveals how ultrasonography performed by emergency physicians can rapidly provide valuable diagnostic information and expedite patient care in three different clinical scenarios.
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Affiliation(s)
- B Durham
- Department of Emergency Medicine, Martin Luther King Trauma and Medical Center, Los Angeles, CA 90059, USA
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Schlager D, Lazzareschi G, Whitten D, Sanders AB. A prospective study of ultrasonography in the ED by emergency physicians. Am J Emerg Med 1994; 12:185-9. [PMID: 8161394 DOI: 10.1016/0735-6757(94)90244-5] [Citation(s) in RCA: 109] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The objective of this study was to examine the use of limited, goal-directed, two-dimensional ultrasound studies performed by emergency physicians and to assess the frequency, variety, and accuracy of their readings. A 1-year prospective study was performed by using an emergency department (ED) ultrasound machine with a 3.5-mHz mechanical oscillating sector transducer and a 5.0-mHz vaginal transducer. In a series of proctoring sessions, radiologists trained emergency physicians to do limited, goal-directed ultrasonography. Laser print ultrasonograms were collected from all ED ultrasound examinations performed during a 1-year period and were compared with either formal ultrasonograms performed in the radiology department, the patient's hospital record, or both. Sensitivity, specificity, and positive predictive value (PPV), as well as negative predictive values (NPV), were calculated. The setting was a 104-bed community hospital with an ED volume of 25,000 patients annually, and patients whom the emergency physician believed needed ultrasound studies in the ED were entered. ED ultrasonography was performed in 167 patients by 14 physicians during a 1-year period. For 132 patients who completed formal follow-up, the overall diagnostic accuracy of interpretations of ED ultrasonograms yielded a sensitivity of .95, specificity of .98, PPV of .99, and NPV of .89. Eleven categories of ultrasound use were reported. The three studies most commonly performed were for gallbladder disease (53%), intrauterine pregnancy (28%), and abdominal aortic aneurysms (7%). Accuracy of ED gallbladder ultrasonograms for 65 patients showed a sensitivity of .86, specificity of .97, PPV of .97, and NPV of .85.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D Schlager
- Department of Emergency Medicine, Kaiser Permanente Medical Center, Santa Rosa, CA
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Schiavone WA, Ghumrawi BK, Catalano DR, Haver DW, Pipitone AJ, L'Hommedieu RH, Keyser PH, Tsai AR. The use of echocardiography in the emergency management of nonpenetrating traumatic cardiac rupture. Ann Emerg Med 1991; 20:1248-50. [PMID: 1952316 DOI: 10.1016/s0196-0644(05)81483-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Three young adults, all drivers involved in three separate motor vehicle accidents that occurred in Portage County, Ohio, during a three-week period, sustained blunt, nonpenetrating chest trauma that resulted in right atrial rupture and cardiac tamponade. On arrival in the emergency department, all were hypotensive and complained of chest pain; only one had jugular venous distension and upper body cyanosis. All had normal chest radiographs, and one had ECG ST elevation. Echocardiography showed a moderate-sized pericardial effusion and signs of cardiac tamponade in all three. Two of the three survived emergency thoracotomy and repair of the right atrial rupture. These cases demonstrate the importance of echocardiography in diagnosing cardiac tamponade as the classic signs are not always present.
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Affiliation(s)
- W A Schiavone
- Department of Medicine, Robinson Memorial Hospital, Ravenna, Ohio 44266-1204
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