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Zaki HA, Albaroudi B, Shaban EE, Elgassim M, Almarri ND, Basharat K, Shaban A. Deep venous thrombosis (DVT) diagnostics: gleaning insights from point-of-care ultrasound (PoCUS) techniques in emergencies: a systematic review and meta-analysis. Ultrasound J 2024; 16:37. [PMID: 39080184 PMCID: PMC11289207 DOI: 10.1186/s13089-024-00378-1] [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: 10/13/2023] [Accepted: 05/06/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND The assessment of deep venous thrombosis (DVT) is clinically difficult diagnosis. The "gold standard test" for DVT diagnosis is venography; however, various point-of-care ultrasound (POCUS) protocols have been suggested for DVT evaluation in the emergency department. AIMS This review evaluated the role of different POCUS protocols in diagnosing DVT in the emergency department. METHODS A systematic review and meta-analysis was conducted based of PRISMA guideline and registered on PROSEPRO (CRD42023398871). An electronic database search in Embase, PubMed, ScienceDirect, and Google scholar and a manual search were performed to identify eligible studies till February 2023. Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was used to assess the risk of bias in included studies. Quantitative analysis was carried out using STATA 16 and Review Manager software (RevMan 5.4.1). Sensitivity, specificity of POCUS protocols for DVT diagnosis compared to reference standard test was calculated. RESULTS Heterogeneity was identified between 26 included studies for review. The pooled sensitivity, specificity, PPV, and NPV for the 2-point POCUS protocol were 92.32% (95% CI: 87.58-97.06), 96.86% (95% CI: 95.09-98.64), 88.41% (95% CI: 82.24-94.58) and 97.25% (95% CI: 95.51-98.99), respectively. Similarly, the pooled sensitivity, specificity, PPV, and NPV for 3-point POCUS were 89.15% (95% CI: 83.24-95.07), 92.71% (95% CI: 89.59-95.83), 81.27% (95% CI: 73.79-88.75), and 95.47% (95% CI: 92.93-98). The data pooled for complete compression ultrasound, and whole-leg duplex ultrasound also resulted in a sensitivity and specificity of 100% (95% CI: 98.21-100) and 97.05% (95% CI: 92.25-100), respectively. On the other hand, the time from triage to DVT diagnosis was significantly shorter for emergency physician-performed POCUS than diagnostic tests performed by radiologists. CONCLUSION The diagnostic performance of POCUS protocols performed by emergency physicians was excellent. Combined with the significant reduction in time to diagnosis. POCUS can be used as the first-line imaging tool for DVT diagnosis in the emergency department. We also recommended that attending emergency physicians with POCUS training are present during DVT diagnosis to improve diagnostic performance even though high diagnostic performance is observed even with the minimum training.
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Affiliation(s)
- Hany A Zaki
- Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Bilal Albaroudi
- Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar.
| | - Eman E Shaban
- Department of Cardiology, Al Jufairi Diagnosis and Treatment, MOH, Doha, Qatar
| | - Mohamed Elgassim
- Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Nood Dhafi Almarri
- Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Kaleem Basharat
- Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Shaban
- Department of Internal Medicine, Mansoura General Hospital, Mansoura, Egypt
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Popat A, Harikrishnan S, Seby N, Sen U, Patel SK, Mittal L, Patel M, Vundi C, Patel Y, Babita, Kumar A, Nakrani AA, Patel M, Yadav S. Utilization of Point-of-Care Ultrasound as an Imaging Modality in the Emergency Department: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e52371. [PMID: 38694948 PMCID: PMC11062642 DOI: 10.7759/cureus.52371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 05/04/2024] Open
Abstract
Point-of-care ultrasound (POCUS) is an imaging modality that has become a fundamental part of clinical care provided in the emergency department (ED). The applications of this tool in the ED have ranged from resuscitation, diagnosis, and therapeutic to procedure guidance. This review aims to summarize the evidence on the use of POCUS for diagnosis and procedure guidance. To achieve this, CrossRef, PubMed, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched for studies published between January 2000 and November 2023. Additionally, the risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 (for studies on the diagnostic role of POCUS) and Cochrane Risk of Bias tool (for studies on the use of POCUS for procedure guidance). Furthermore, diagnostic accuracy outcomes were pooled using STATA 16 software (StatCorp., College Station, TX, USA), while outcomes related to procedure guidance were pooled using the Review Manager software. The study included 81 articles (74 evaluating the diagnostic application of POCUS and seven evaluating the use of POCUS in guiding clinical procedures). In our findings sensitivities and specificities for various conditions were as follows: appendicitis, 65% and 89%; hydronephrosis, 82% and 74%; small bowel obstruction, 93% and 82%; cholecystitis, 75% and 96%; retinal detachment, 94% and 91%; abscess, 95% and 85%; foreign bodies, 67% and 97%; clavicle fractures, 93% and 94%; distal forearm fractures, 97% and 94%; metacarpal fractures, 94% and 92%; skull fractures, 91% and 97%; and pleural effusion, 91% and 97%. A subgroup analysis of data from 11 studies also showed that the two-point POCUS has a sensitivity and specificity of 89% and 96%, while the three-point POCUS is 87% sensitive and 92% specific in the diagnosis of deep vein thrombosis. In addition, the analyses showed that ultrasound guidance significantly increases the overall success rate of peripheral venous access (p = 0.02) and significantly reduces the number of skin punctures (p = 0.01) compared to conventional methods. In conclusion, POCUS can be used in the ED to diagnose a wide range of clinical conditions accurately. Furthermore, it can be used to guide peripheral venous access and central venous catheter insertion.
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Affiliation(s)
- Apurva Popat
- Internal Medicine, Marshfield Clinic Health System, Marshfield, USA
| | | | - Niran Seby
- Internal Medicine, Tbilisi State Medical University, Tbilisi, GEO
| | - Udvas Sen
- Internal Medicine, Agartala Government Medical College, Agartala, IND
| | - Sagar K Patel
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Bhuj, IND
| | - Lakshay Mittal
- Internal Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Mitkumar Patel
- Internal Medicine, Mahatma Gandhi Mission (MGM) Medical College, Navi Mumbai, IND
| | - Charitha Vundi
- Internal Medicine, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, IND
| | - Yashasvi Patel
- Internal Medicine, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Babita
- Internal Medicine, Uzhhorod National University, Uzhhorod, UKR
| | - Ashish Kumar
- General Practice, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Ahmedabad, IND
| | - Akash A Nakrani
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Surat, IND
| | - Mahir Patel
- Medical School, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Sweta Yadav
- Internal Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Ahmedabad, IND
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Jarman RD, McDermott C, Colclough A, Bøtker M, Knudsen L, Harris T, Albaroudi B, Albaroudi O, Haddad M, Darke R, Berry E, Breslin T, Fitzpatrick G, Flanagan L, Olusanya O, Craver D, Omar A, Simpson T, Cherian N, Dore M, Prosen G, Kay S, Villén-Villegas T, Gargani L, Carley S, Woo M, Dupriez F, Hussain A, Via G, Connolly JA, Peck M, Melniker L, Walden A, Attard Biancardi MA, Żmijewska-Kaczor O, Lalande E, Geukens P, McLaughlin R, Olszynski P, Hoffmann B, Chin E, Muhr C, Kim DJ, Mercieca A, Shukla D, Hayward S, Smith M, Gaspari R, Smallwood N, Pes P, Tavazzi G, Corradi F, Lambert M, Morris C, Trauer M, Baker K, Bystrzycki A, Goudie A, Liu R, Rudd L, Dietrich CF, Jenssen C, Sidhu PS. EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) LONG VERSION. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:e1-e24. [PMID: 36228631 DOI: 10.1055/a-1882-5615] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
AIMS To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS). METHODS We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.
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Affiliation(s)
- Robert David Jarman
- Emergency Department, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
- School of Health and Life Sciences, Teesside University, Middlesbrough, United Kingdom of Great Britain and Northern Ireland
| | - Cian McDermott
- Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Anna Colclough
- Emergency Medicine, University Hospital Lewisham, London, United Kingdom of Great Britain and Northern Ireland
| | - Morten Bøtker
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Viborg, Denmark
| | - Lars Knudsen
- Department of Anaesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Tim Harris
- Emergency Medicine, Queen Mary University of London, United Kingdom of Great Britain and Northern Ireland
- Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Omar Albaroudi
- Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Mahmoud Haddad
- Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Robert Darke
- Emergency Medicine and Intensive Care Medicine, Health Education England North East, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Edward Berry
- Emergency Medicine, Torbay Hospital, Torquay, United Kingdom of Great Britain and Northern Ireland
| | - Tomas Breslin
- Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Ireland
| | | | - Leah Flanagan
- Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Olusegun Olusanya
- Intensive Care Medicine, University College Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Dominic Craver
- Emergency Medicine, The Royal London Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Adhnan Omar
- Respiratory Medicine, University Hospital Lewisham, London, United Kingdom of Great Britain and Northern Ireland
| | - Thomas Simpson
- Respiratory Medicine, Lewisham and Greenwich NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Nishant Cherian
- Emergency Medicine, The Alfred Emergency & Trauma Centre, Melbourne, Australia
- School of Health and Life Sciences, Teesside University, Middlesbrough, United Kingdom of Great Britain and Northern Ireland
| | - Martin Dore
- Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom of Great Britain and Northern Ireland
| | - Gregor Prosen
- Center for Emergency Medicine, University Medical Centre Maribor, Slovenia
| | - Sharon Kay
- Cardiac Physiology and Echocardiography, The University of Sydney, Australia
| | | | - Luna Gargani
- Cardiology, Institute of Clinical Physiology National Research Council, Pisa, Italy
| | - Simon Carley
- Emergency Medicine, Manchester University NHS Foundation Trust, Manchester, United Kingdom of Great Britain and Northern Ireland
- Emergency Medicine, Manchester Metropolitan University, Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Michael Woo
- Emergency Medicine, University of Ottawa, Canada
- Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Florence Dupriez
- Emergency Medicine, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Arif Hussain
- Cardiac Critical Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Gabriele Via
- Anesthesiology, Intensive Care and Pain Medicine, Istituto Cardiocentro Ticino Ente Ospedaliero Cantonale, Lugano, Switzerland, Pavia, Italy
| | - James Anthony Connolly
- Emergency Medicine, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Marcus Peck
- Anaesthesia and Intensive Care, Frimley Park Hospital NHS Trust, Frimley, United Kingdom of Great Britain and Northern Ireland
| | - Larry Melniker
- Emergency Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, United States
| | - Andrew Walden
- Acute and Intensive Care Medicine, Royal Berkshire Hospital, Reading, United Kingdom of Great Britain and Northern Ireland
- Acute Medicine and Intensive Care Medicine, University of Oxford, United Kingdom of Great Britain and Northern Ireland
| | | | - Olga Żmijewska-Kaczor
- Emergency Medicine, Royal Cornwall Hospital, Truro, United Kingdom of Great Britain and Northern Ireland
| | - Elizabeth Lalande
- Emergency Medicine, Centre Hospitalier de l'Université Laval, Sainte-Foy, Canada
| | - Paul Geukens
- Intensive Care Medicine, Hopital de Jolimont, Haine-Saint-Paul, Belgium
| | - Russell McLaughlin
- Emergency Medicine, Royal Victoria Hospital, Belfast, United Kingdom of Great Britain and Northern Ireland
- Medical Director, Northern Ireland Ambulance Service, Belfast, United Kingdom of Great Britain and Northern Ireland
| | - Paul Olszynski
- Emergency Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Beatrice Hoffmann
- Emergency Department, Harvard Medical School Department of Emergency Medicine Beth Israel Deaconess Medical Center, Boston, United States
| | - Eric Chin
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, United States
| | - Christopher Muhr
- Emergency Medicine and Internal Medicine, Capio Sankt Gorans Sjukhus, Stockholm, Sweden
| | - Daniel J Kim
- Emergency Medicine, The University of British Columbia, Vancouver, Canada
- Emergency Medicine, Vancouver General Hospital, Vancouver, Canada
| | | | | | - Simon Hayward
- Physiotherapy, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom of Great Britain and Northern Ireland
| | - Michael Smith
- School of Healthcare Sciences, Cardiff University College of Biomedical and Life Sciences, Cardiff, United Kingdom of Great Britain and Northern Ireland
| | - Romolo Gaspari
- Emergency Medicine, UMass Memorial Medical Center, Worcester, United States
- Emergency Medicine, UMass Medical School, Worcester, United States
| | - Nick Smallwood
- Acute Medicine, East Surrey Hospital, Redhill, United Kingdom of Great Britain and Northern Ireland
| | - Philippe Pes
- Emergency Medicine, University Hospital Centre Nantes, France
| | - Guido Tavazzi
- Anesthesia and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, Università degli Studi di Pavia Facoltà di Medicina e Chirurgia, Pavia, Italy
| | - Francesco Corradi
- Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Italy
| | - Michael Lambert
- Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, United States
| | - Craig Morris
- Intensive Care, Royal Derby Hospital, Derby, United Kingdom of Great Britain and Northern Ireland
| | - Michael Trauer
- Emergency Medicine, St Thomas' Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Kylie Baker
- Emergency Medicine, Ipswich Hospital, Ipswich, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Australia
| | - Adam Bystrzycki
- Emergency Medicine, The Alfred Emergency & Trauma Centre, Melbourne, Australia
- Department of Epidemiology & Preventive Medicine, Monash University, Clayton, Australia
| | - Adrian Goudie
- Emergency Medicine, Fiona Stanley Hospital, Murdoch, Australia
| | - Rachel Liu
- Emergency Medicine, Yale School of Medicine, New Haven, United States
| | - Lynne Rudd
- General Secretary, European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), London, United Kingdom of Great Britain and Northern Ireland
| | - Christoph F Dietrich
- Department Allgemeine Innere Medizin, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland
| | - Christian Jenssen
- Klinik für Innere Medizin, Krankenhaus Märkisch Oderland Strausberg/ Wriezen, Germany
| | - Paul S Sidhu
- Radiology, King's College London, United Kingdom of Great Britain and Northern Ireland
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Cardiac and vascular point-of-care ultrasound: current situation, problems, and future prospects. J Med Ultrason (2001) 2022; 49:601-608. [PMID: 34997377 PMCID: PMC8741534 DOI: 10.1007/s10396-021-01166-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/21/2021] [Indexed: 11/15/2022]
Abstract
Although clinical application of ultrasound to the heart has a history of about 80 years, its big turning point was the emergence of a portable ultrasound diagnostic machine. As a result, the place, where echocardiography is performed widely spread outside the examination room, and the people who perform echocardiography have also greatly increased. Emergency physicians, anesthesiologists, and primary care physicians became interested in echocardiography and started using it. Such ultrasound examinations performed by a doctor for assessment of disease condition, management, or guidance of treatment at bedside has been called point-of-care ultrasound (POCUS). Cardiac POCUS is divided into a focused cardiac ultrasound examination (FoCUS) and limited echocardiography. The former is performed by non-experts in echocardiography, such as emergency physicians and anesthesiologists, whereas the latter is usually performed by cardiologists who are experts in echocardiography. FoCUS has an established protocol and evaluation method, and evidence to prove its effectiveness is accumulating. In addition, the COVID-19 outbreak reaffirmed the importance of POCUS. Although FoCUS is becoming popular in Japan, an educational program has not been established, and discussion on how to educate medical students and residents will be necessary. Even if POCUS in cardiovascular medicine becomes widespread, auscultation will still be necessary. Rather, adding cardiac and vascular POCUS to inspection, palpation, and auscultation in the flow of physical examinations will benefit patients greatly.
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Agreement between emergency physicians and radiologists for the diagnosis of deep venous thrombosis with compression ultrasound: a prospective study. Eur J Emerg Med 2021; 28:25-28. [PMID: 32657823 DOI: 10.1097/mej.0000000000000728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The time factor in diagnosis and management of a deep vein thrombosis of the lower extremities (LE DVT) is of increasing importance in the era of crowding of emergency departments (ED). Current techniques used to detect LE DVT include a two-point regional compression ultrasound (rCUS), yet assessments are usually performed only during office hours. Outside office hours ultrasonography is postponed and low molecular weight heparin (LMWH) prescribed. OBJECTIVES Primary outcome of the study was to assess the level of agreement in rCUS for LE DVT when performed by Dutch emergency physicians compared to rCUS by a radiologist. Secondary outcome was time to diagnosis. METHOD We performed a single-blind cohort study. All consecutive patients aged 18 years and older attending the ED with clinical suspicion of LE DVT were considered eligible for study enrolment. rCUS was ordered at the radiology department; subsequently, the bedside rCUS examination was also performed in the ED by the emergency physicians or ED residents. RESULTS A total of 138 patients were included, of whom 28 patients were diagnosed with DVT by a radiologist. Emergency physicians and radiologists showed comparable agreement [absolute agreement 94% (P < 0.001), Cohen's Kappa 0.87]. Emergency physicians decreased overall time to diagnosis by 01:04 h, ED residents showed comparable results. During out-of-office hours, time benefit was 16:39 h on weekdays and 18:40 h during weekends. CONCLUSION Emergency physicians show comparable agreement in diagnosing LE DVT using rCUS when compared to radiologists. Average time benefit is over an hour, thereby reducing unnecessary waiting and improving time to disposition. ED residents demonstrated similar results in both agreement and time-saving.
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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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Canakci ME, Acar N, Bilgin M, Kuas C. Diagnostic value of point-of-care ultrasound in deep vein thrombosis in the emergency department. JOURNAL OF CLINICAL ULTRASOUND : JCU 2020; 48:527-531. [PMID: 32643227 DOI: 10.1002/jcu.22892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE Point-of-care ultrasound (POCUS) has been demonstrated as one of the primary diagnostic tools for deep vein thrombosis (DVT) screening in the emergency department, but there are quite different results in the literature regarding its diagnostic value. The aim of this study is to assess the diagnostic value of POCUS in DVT diagnosis. METHODS Patients with a clinical suspicion of DVT who underwent POCUS and were monitored by the radiology department via ultrasonography (US) or venography for DVT were retrospectively examined. POCUS examination for DVT was performed in the femoral and popliteal regions by a two-point compression technique. The inclusion criteria were age >18 years and patients with both a POCUS report and venography or US examinations performed by the radiology department (RUS) and reported by the radiology clinic. RUS and venography were considered as the gold standards. RESULTS The study included 266 patients. POCUS had a sensitivity of 93% (95% CI: 84-98) and specificity of 93% (95% CI: 89-96). Its positive likelihood ratio (LR+ ) was 14 (95% CI: 8-24), and its negative likelihood ratio (LR- ) was 0.08 (95% CI: 0.03-0.19). POCUS also had a positive predictive value (PPV) of 83% (95% CI: 74-89) and a negative predictive value (NPV) of 97% (95% CI: 94-99). CONCLUSIONS Our study verifies that POCUS has high specificity and sensitivity for the examination of the popliteal and femoral veins by an emergency physician to evaluate patients with a preliminary diagnosis of DVT.
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Affiliation(s)
- Mustafa Emin Canakci
- Emergency Department, Eskisehir Osmangazi University School of Medicine, Eskisehir, Turkey
| | - Nurdan Acar
- Emergency Department, Eskisehir Osmangazi University School of Medicine, Eskisehir, Turkey
| | - Muzaffer Bilgin
- Biostatistics Department, Eskisehir Osmangazi University School of Medicine, Eskisehir, Turkey
| | - Caglar Kuas
- Emergency Department, Yildirim Beyazit University Yenimahalle Training And Research Hospital, Ankara, Turkey
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Dehbozorgi A, Damghani F, Mousavi-Roknabadi RS, Sharifi M, Sajjadi SM, Hosseini-Marvast SR. Accuracy of three-point compression ultrasound for the diagnosis of proximal deep-vein thrombosis in emergency department. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:80. [PMID: 31620179 PMCID: PMC6788177 DOI: 10.4103/jrms.jrms_1057_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/05/2019] [Accepted: 06/03/2019] [Indexed: 11/08/2022]
Abstract
Background: This study aimed to assess the accuracy of three-point compression ultrasonography (3PCUS) performed for the diagnosis of proximal deep-vein thrombosis (DVT) in Emergency Department (ED) compared with the results of duplex US (DUS) (whole-leg compression ultrasound). Materials and Methods: The current prospective cross-sectional study with diagnostic test assessment was conducted on adult patients who were referred to the ED of a general teaching hospital in Shiraz, southern part of Iran (September 2016–May 2017), suspected of lower-extremity DVT, using a convenience sampling. The results of 3PCUS performed by ED residents were compared with the results of DUS performed by the radiology residents, which was considered as a criterion standard. Results: A total of 240 patients were enrolled, with a mean (standard deviation) age of 59.46 (16.58). 3PCUS has a sensitivity and a specificity of 100% (95% confidence interval [CI], 96.55%–100%) and 93.33% (95% CI, 87.72%–96.91%), respectively, in comparison with DUS (whole-leg compression ultrasound). Negative predictive value and positive predictive value were 100% and 92.11% (95% CI, 86.12%–95.64%), respectively, with an accuracy of 96.25% (95% CI, 93%–98.27%). Conclusion: The results of this study showed that 3PCUS of the lower extremities with a portable US machine, performed by the ED's residents, can accurately identify the presence or absence of lower-extremity DVT.
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Affiliation(s)
- Afsaneh Dehbozorgi
- Department of Emergency Medicine, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Damghani
- Department of Emergency Medicine, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mehrdad Sharifi
- Department of Emergency Medicine, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Mahmoudreza Sajjadi
- Department of Emergency Medicine, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Jahanian F, Khatir IG, Bani-Mostafavi ES, Moradi S, Aghamalaki FH. Diagnostic Accuracy of a Three-point Compression Ultrasonography Performed by Emergency Medicine Resident for the Diagnosis of Deep Vein Thrombosis: a Prospective Diagnostic Study. Acta Inform Med 2019; 27:119-122. [PMID: 31452570 PMCID: PMC6688293 DOI: 10.5455/aim.2019.27.119-122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction: Deep vein thrombosis (DVT) is a common cause of admission to the emergency departments (ED). Doppler ultrasonography of the entire lower limb is the first-line imaging modality. But most EDs do not access to full-time radiologists which can lead to delayed diagnosis. Aim: The aim of this study was to evaluate the diagnostic accuracy of three-point compression ultrasonography performed by emergency medicine resident for diagnosis of DVT. Methods: This prospective diagnostic study was carried out at Imam Khomeini Hospital in Sari from March 2018 to November 2018. For all patients with suspected lower extremity DVT, first bedside 3-point compression ultrasound were performed by a third year emergency medicine resident at ED. Then Doppler ultrasonography were performed by a radiologist in the radiology department, as a reference test. Sensitivity, specificity, and positive predictive value of the three-point compression ultrasound performed by emergency medicine resident was calculated. Results: Of the 72 patients enrolled in our study, 50% of the patients were male, with an average age of 36±19 years. The mean of patient admission time to perform ultrasonography by an emergency medicine resident and radiologist were 14.05±19 and 216±140.1 minutes, respectively. The two groups had a statistically significant difference (P<0.0001). In ultrasonography performed by emergency medicine resident and doper ultrasonography by radiologist, 91.67% and 36.1% of patients were diagnosed with DVT, respectively. Although the ultrasonography performed by emergency medicine resident has a relatively low sensitivity (53.8%), it has a good specificity (85.7%). The positive and negative predictive value was 70 and 75%, respectively. Conclusion: Although the results of this study indicate insufficient sensitivity of bedside three-point compression ultrasound performed by emergency medicine resident in diagnosis of lower limb DVT, the specificity, positive and negative predictive values and positive likelihood ratio were almost appropriate.
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Affiliation(s)
- Fatemeh Jahanian
- Department of Emergency Medicine, Diabetes Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Iraj Goli Khatir
- Department of Emergency Medicine, Orthopedic Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Siavash Moradi
- Department of Community Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Hosseini Aghamalaki
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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10
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Kea B, Hall MK, Wang R. Recognising bias in studies of diagnostic tests part 2: interpreting and verifying the index test. Emerg Med J 2019; 36:501-505. [PMID: 31221671 DOI: 10.1136/emermed-2019-208447] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 03/27/2019] [Accepted: 04/02/2019] [Indexed: 11/04/2022]
Abstract
Multiple pitfalls can occur with the conduct and analysis of a study of diagnostic tests, resulting in biased accuracy. Our conceptual model includes three stages: patient selection, interpretation of the index test and disease verification. In part 2, we focus on (1) Interpretation bias (or workup bias): where the classification of an indeterminate index test result can bias the accuracy of a test or how lack of blinding can bias a subjective test result, and (2) Disease verification bias: where the index test result is incorporated into the gold standard or when the gold standard is applied only to a select population as the gold standard is an invasive test. In an example with age-adjusted D-dimer for pulmonary embolism, differential verification bias was a limitation due to the use of two gold standards-CT for a high-risk population and follow-up for symptoms in a low-risk population. However, there are circumstances when certain choices in study design are unavoidable, and result in biased test characteristics. In this case, the informed reader will better judge the quality of a study by recognising the potential biases and limitations by being methodical in their approach to understanding the methods, and in turn, better apply studies of diagnostic tests into their clinical practice.
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Affiliation(s)
- Bory Kea
- Emergency Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - M Kennedy Hall
- Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Ralph Wang
- Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
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11
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Lee JH, Lee SH, Yun SJ. Comparison of 2-point and 3-point point-of-care ultrasound techniques for deep vein thrombosis at the emergency department: A meta-analysis. Medicine (Baltimore) 2019; 98:e15791. [PMID: 31145304 PMCID: PMC6709014 DOI: 10.1097/md.0000000000015791] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND To our knowledge, so far, no studies have comprehensively examined the performance of 2-point and 3-point point-of-care compression ultrasound (POCUS) in the diagnosis of lower extremity deep vein thrombosis (DVT). The aim of this meta-analysis was to compare the performance of 2-point and 3-point POCUS techniques for the diagnosis of DVT and evaluate the false-negative rate of each POCUS method. METHODS A computerized search of the PubMed, EMBASE, and Cochrane library databases was performed to identify relevant original articles. Bivariate modeling and hierarchical summary receiver operating characteristic modeling were performed to compare the diagnostic performance of 2-point and 3-point POCUS. The pooled proportions of the false-negative rate for each POCUS method were assessed using a DerSimonian-Laird random-effects model. Meta-regression analyses were performed according to the patient and study characteristics. RESULTS Seventeen studies from 16 original articles were included (2-point, 1337 patients in 9 studies; 3-point, 1035 patients in 8 studies). Overall, 2-point POCUS had similar pooled sensitivity [0.91; 95% confidence interval (95% CI), 0.68-0.98; P = .86) and specificity (0.98; 95% CI, 0.96-0.99; P = .60) as 3-point POCUS (sensitivity, 0.90; 95% CI, 0.83-0.95 and specificity, 0.95; 95% CI, 0.83-0.99). The false-negative rates of 2-point (4.0%) and 3-point POCUS (4.1%) were almost similar. Meta-regression analysis showed that high sensitivity and specificity tended to be associated with an initial POCUS performer (including attending emergency physician > only resident) and separate POCUS training for DVT (trained > not reported), respectively. CONCLUSION Both 2-point and 3-point POCUS techniques showed excellent performance for the diagnosis of DVT. We recommend that POCUS-trained attending emergency physicians perform the initial 2-point POCUS to effectively and accurately diagnose DVT.
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Affiliation(s)
- Ju Hyung Lee
- Department of Medical Service, 8311 unit, the Republic of Korea Air Force, Chungcheongnam-do
| | - Sun Hwa Lee
- Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine
| | - Seong Jong Yun
- Department of Radiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Republic of Korea
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Hagiwara Y, Sasaki R, Shimizu T, Soga K, Hatada C, Miyauchi M, Okamura T, Sakurai M, Akiyama H, Hasegawa Y. The utility of superb microvascular imaging for the detection of deep vein thrombosis. J Med Ultrason (2001) 2018; 45:665-669. [PMID: 29774429 DOI: 10.1007/s10396-018-0883-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/06/2018] [Indexed: 12/12/2022]
Abstract
Superb microvascular imaging (SMI) reduces motion artifacts significantly and allows visualization of low-velocity blood flow in vessels; thus, thrombi are clearly demonstrated compared to conventional B-mode and color Doppler imaging. Ultrasonographic images of the lower extremities of a 69-year-old woman with acute ischemic stroke complicated with deep vein thrombosis (DVT) are presented. Because SMI allows visualization of low-velocity blood flow, echo contrast between the thrombus and the surrounding flow makes it possible to clearly visualize the thrombus. SMI is a useful method to evaluate DVT, especially early after thrombus formation when it is difficult to delineate size and length because of echolucency.
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Affiliation(s)
- Yuta Hagiwara
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.
- Department of Neurology, St. Marianna University School of Medicine, Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-8511, Japan.
| | - Rie Sasaki
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takahiro Shimizu
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kaima Soga
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Chihiro Hatada
- Ultrasound Examination Center, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Motoki Miyauchi
- Ultrasound Examination Center, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Takanori Okamura
- Ultrasound Examination Center, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Masaru Sakurai
- Ultrasound Examination Center, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Hisanao Akiyama
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yasuhiro Hasegawa
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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Pujol S, Laurent J, Markarian T, Claret PG, Lefrant JY, Roger C, Muller L, de La Coussaye JE, Perez-Martin A, Bobbia X. Compression with a pocket-sized ultrasound device to diagnose proximal deep vein thrombosis. Am J Emerg Med 2018; 36:1262-1264. [PMID: 29653786 DOI: 10.1016/j.ajem.2018.03.076] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Compression ultrasonography (CUS) is a validated technique for the diagnosis of deep venous thrombosis (DVT), but has never been studied with pocket-sized ultrasound device (PUD). The main objective of this study was to assess the diagnostic performance of CUS made by emergency physicians (EPs) using a PUD. MATERIALS This was a prospective, diagnostic test assessment, single-center study. Patients underwent VCU performed by a trained EP with PUD (CUS-PUD) for searching proximal DVT (PDVT) and were then seen by an expert vascular physician who blindly performed a duplex venous ultrasound, which was the criterion standard. CUS-PUD's diagnostic performance was evaluated by sensitivity (Se), specificity (Sp), and positive and negative predictive values (PPV and NPV). RESULTS The sample included 57 patients of whom 56 were analyzed. Eleven (20%) PDVT were diagnosed with CUS-PUD: 7 (64%) femoral and 4 (36%) popliteal. The CUS-PUD's Se was 100% [72%; 100%], Sp 100% [92%; 100%]. The PPV was 100% [74%; 100%], and the NPV was 100% [90%; 100%]. CONCLUSION CUS-PUD performed with a pocket-sized ultrasound appears to be feasible in emergency practice for the diagnosis of proximal DVT. A study with a larger sample size will have to describe the accuracy.
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Affiliation(s)
- Sarah Pujol
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, place du Pr Debré, 30029 Nîmes, France.
| | - Jeremy Laurent
- Department of Vascular Medicine and Laboratory, CHU de Nîmes, hôpital Caremeau, place du Pr-Debré, 30029 Nîmes cedex 9, France.
| | - Thibaut Markarian
- Emergency Department, Timone 2 Hospital, Aix-Marseille University, Marseille, France.
| | - Pierre-Géraud Claret
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, place du Pr Debré, 30029 Nîmes, France.
| | - Jean Yves Lefrant
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, place du Pr Debré, 30029 Nîmes, France.
| | - Claire Roger
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, place du Pr Debré, 30029 Nîmes, France.
| | - Laurent Muller
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, place du Pr Debré, 30029 Nîmes, France.
| | - Jean Emmanuel de La Coussaye
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, place du Pr Debré, 30029 Nîmes, France.
| | - Antonia Perez-Martin
- Department of Vascular Medicine and Laboratory, CHU de Nîmes, hôpital Caremeau, place du Pr-Debré, 30029 Nîmes cedex 9, France.
| | - Xavier Bobbia
- Department of Anesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, place du Pr Debré, 30029 Nîmes, France; Emergency Department, Timone 2 Hospital, Aix-Marseille University, Marseille, France.
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Seyedhosseini J, Fadavi A, Vahidi E, Saeedi M, Momeni M. Impact of point-of-care ultrasound on disposition time of patients presenting with lower extremity deep vein thrombosis, done by emergency physicians. Turk J Emerg Med 2017; 18:20-24. [PMID: 29942878 PMCID: PMC6009805 DOI: 10.1016/j.tjem.2017.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 11/23/2017] [Accepted: 12/12/2017] [Indexed: 11/24/2022] Open
Abstract
Background Point-of-care venous compression ultrasound (VCU) is highly accurate in deep vein thrombosis (DVT) diagnosis; however, waiting to perform this exam by radiologists, may cause delay in patients' disposition. Objective To compare the effect of point-of-care VCU on patients' disposition time, done by emergency physician versus radiologists. Methods A total of 50 patients suspected of having lower extremity DVT, were randomized into 2 equal groups and they underwent a point-of-care VCU performed either by an emergency physician (emergency medicine (EM) group) or a radiologist (radiology group). The mean time of patients' disposition and management were compared between the two groups. Results The EM group consisted of 16 males and 9 females while the radiology group consisted of 13 males and 12 females. The median time elapsed from triage to performing ultrasonography and the median time elapsed from triage to final disposition were significantly lower in the EM group than those in the radiology group (50 min vs. 142 min, and 69 min vs. 260 min, respectively; p < .001). The final diagnosis was confirmed to be DVT in 14 patients (56%) in the EM group and in 17 patients (68%) in the radiology group (p = .38). There was no false positive or negative diagnosis. Conclusions Performing VCU in patients suspected of having DVT by a trained emergency physician could significantly reduce the time of patients' disposition in the emergency setting.
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Affiliation(s)
- Javad Seyedhosseini
- Tehran University of Medical Sciences, Shariati Hospital, Emergency Medicine Research Center, Iran
| | - Arash Fadavi
- Kermanshah University of Medical Sciences, Emergency Medicine Research Center, Iran
| | - Elnaz Vahidi
- Tehran University of Medical Sciences, Shariati Hospital, Emergency Medicine Research Center, Iran
| | - Morteza Saeedi
- Tehran University of Medical Sciences, Shariati Hospital, Emergency Medicine Department, Iran
| | - Mehdi Momeni
- Tehran University of Medical Sciences, Shariati Hospital, Emergency Medicine Department, Iran
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15
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Hung KKC, Graham CA, Yim WT, Yam ESF, Cheung NK, Rainer TH. Management of Suspected Deep Venous Thrombosis in an Emergency Medicine Ward in Hong Kong. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791101800103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Clinical signs and symptoms can vary for patients with deep venous thrombosis (DVT). DVT is an important diagnosis to recognise as it can lead to proximal embolism into the pulmonary circulation resulting in sudden collapse and death. The objective of this study is to describe the management of patients with suspected DVT in the emergency medicine ward (EMW) setting in Hong Kong using a standardised clinical pathway. Methods A retrospective review was conducted for patients with suspected DVT admitted to the EMW from April to December 2008 using a standardised protocol. The use of a clinical prediction rule and diagnostic tests (including the modified Well's score, D-dimer and ultrasound examination) and outcomes (including the length of stay and secondary admission rate) were investigated. Results A total of 100 patients with suspected DVT were admitted to the EMW in the nine-month study period. DVT was confirmed in 30% using ultrasonography. Fifty-two percent of patients were in the high-risk category according to the modified Well's score. Seventy-six percent of patients had positive D-dimer results. Ten percent of patients were safely discharged without an ultrasound examination. Mean length of stay in the EMW was 1.99 days. Thirteen percent of patients required second admission to other specialties. Conclusions This study suggests that a standardised clinical pathway based in the EMW can be used for patients with suspected DVT to reduce hospital admission.
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16
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Pomero F, Borretta V, Bonzini M, Melchio R, Douketis JD, Fenoglio LM, Dentali F. Accuracy of emergency physician–performed ultrasonography in the diagnosis of deep-vein thrombosis. Thromb Haemost 2017; 109:137-45. [DOI: 10.1160/th12-07-0473] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 09/14/2012] [Indexed: 11/05/2022]
Abstract
SummaryDuplex ultrasound is the first-line diagnostic test for detecting lower limb deep-vein thrombosis (DVT) but it is time consuming, requires patient transport, and cannot be interpreted by most physicians. The accuracy of emergency physician–performed ultrasound (EPPU) for the diagnosis of DVT, when performed at the bedside, is unclear. We did a systematic review and meta-analysis of the literature, aiming to provide reliable data on the accuracy of EPPU in the diagnosis of DVT. The MEDLINE and EMBASE databases (up to August 2012) were systematically searched for studies evaluating the accuracy of EPPU compared to either colour-flow duplex ultrasound performed by a radiology department or vascular laboratory, or to angiography, in the diagnosis of DVT. Weighted mean sensitivity and specificity and associated 95% confidence intervals (CIs) were calculated using a bivariate random-effects regression approach. There were 16 studies included, with 2,379 patients. The pooled prevalence of DVT was 23.1% (498 in 2,379 patients), ranging from 7.4% to 47.3%. Using the bivariate approach, the weighted mean sensitivity of EPPU compared to the reference imaging test was 96.1% (95%CI 90.6–98.5%), and with a weighted mean specificity of 96.8% (95%CI:94.6–98.1%). Our findings suggest that EPPU may be useful in the management of patients with suspected DVT. Future prospective studies are warranted to confirm these findings.
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Abstract
Though the use of point-of-care ultrasound (POCUS) has increased over the last decade, formal hospital credentialing for POCUS may still be a challenge for hospitalists. This document details the Hospital Medicine Department Ultrasound Credentialing Policy from Regions Hospital, which is part of the HealthPartners organization in Saint Paul, Minnesota. National organizations from internal medicine and hospital medicine (HM) have not published recommended guidelines for POCUS credentialing. Revised guidelines for POCUS have been published by the American College of Emergency Physicians, though these are not likely intended to guide hospitalists when working with credentialing committees and medical boards. This document describes the scope of ultrasound in HM and our training, credentialing, and quality assurance program. This report is intended to be used as a guide for hospitalists as they work with their own credentialing committees and will require modification for each institution. However, the overall process described here should assist in the establishment of POCUS at various institutions.
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Affiliation(s)
- Benji K Mathews
- Department of Hospital Medicine, HealthPartners, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Michael Zwank
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, Regions Hospital, St. Paul, Minnesota, USA
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Laher AE, Watermeyer MJ, Buchanan SK, Dippenaar N, Simo NCT, Motara F, Moolla M. A review of hemodynamic monitoring techniques, methods and devices for the emergency physician. Am J Emerg Med 2017; 35:1335-1347. [PMID: 28366285 DOI: 10.1016/j.ajem.2017.03.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 03/15/2017] [Accepted: 03/16/2017] [Indexed: 02/07/2023] Open
Abstract
The emergency department (ED) is frequently the doorway to the intensive care unit (ICU) for a significant number of critically ill patients presenting to the hospital. Hemodynamic monitoring (HDM) which is a key component in the effective management of the critically ill patient presenting to the ED, is primarily concerned with assessing the performance of the cardiovascular system and determining the correct therapeutic intervention to optimise end-organ oxygen delivery. The spectrum of hemodynamic monitoring ranges from simple clinical assessment and routine bedside monitoring to point of care ultrasonography and various invasive monitoring devices. The clinician must be aware of the range of available techniques, methods, interventions and technological advances as well as possess a sound approach to basic hemodynamic monitoring prior to selecting the optimal modality. This article comprises an in depth discussion of an approach to hemodynamic monitoring techniques and principles as well as methods of predicting fluid responsiveness as it applies to the ED clinician. We review the role, applicability and validity of various methods and techniques that include; clinical assessment, passive leg raising, blood pressure, finger based monitoring devices, the mini-fluid challenge, the end-expiratory occlusion test, central venous pressure monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other modern invasive hemodynamic monitoring devices.
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Affiliation(s)
- Abdullah E Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, South Africa.
| | - Matthew J Watermeyer
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Sean K Buchanan
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Nicole Dippenaar
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | | | - Feroza Motara
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Muhammed Moolla
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, South Africa; Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, South Africa
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Schroeder M, Shorette A, Singh S, Budhram G. Phelgmasia Cerulea Dolens Diagnosed by Point-of-Care Ultrasound. Clin Pract Cases Emerg Med 2017; 1:104-107. [PMID: 29849409 PMCID: PMC5965407 DOI: 10.5811/cpcem.2016.12.32716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/11/2016] [Accepted: 12/13/2016] [Indexed: 11/11/2022] Open
Abstract
Phlegmasia cerulea dolens (PCD) is a rare entity that is associated with significant morbidity and mortality, including limb ischemia and pulmonary embolism. Point-of-care ultrasound (POCUS) can expedite the diagnosis, leading to earlier life- and limb-saving treatment. Although primarily used for assessing for the presence of deep venous thrombosis, in the appropriate clinical setting POCUS can also be used to diagnosis PCD as well as to distinguish between venous and arterial occlusion, which can lead to a difference in management. We present a case of phlegmasia cerulea dolens after mild trauma in a patient with an underlying hypercoagulability disorder diagnosed by an emergency physician using POCUS, which expedited treatment with catheter-directed thrombolytic therapy.
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Affiliation(s)
- Michele Schroeder
- University of Massachusetts Medical School-Baystate Health Springfield Campus, Baystate Medical Center, Department of Emergency Medicine, Springfield, Massachusetts
| | - Amanda Shorette
- University of Massachusetts Medical School-Baystate Health Springfield Campus, Baystate Medical Center, Department of Emergency Medicine, Springfield, Massachusetts
| | - Sukhdeep Singh
- University of Massachusetts Medical School-Baystate Health Springfield Campus, Baystate Medical Center, Department of Emergency Medicine, Springfield, Massachusetts
| | - Gavin Budhram
- University of Massachusetts Medical School-Baystate Health Springfield Campus, Baystate Medical Center, Department of Emergency Medicine, Springfield, Massachusetts
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Bhagra A, Tierney DM, Sekiguchi H, Soni NJ. Point-of-Care Ultrasonography for Primary Care Physicians and General Internists. Mayo Clin Proc 2016; 91:1811-1827. [PMID: 27825617 DOI: 10.1016/j.mayocp.2016.08.023] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/02/2016] [Accepted: 08/17/2016] [Indexed: 12/12/2022]
Abstract
Point-of-care ultrasonography (POCUS) is a safe and rapidly evolving diagnostic modality that is now utilized by health care professionals from nearly all specialties. Technological advances have improved the portability of equipment, enabling ultrasound imaging to be executed at the bedside and thereby allowing internists to make timely diagnoses and perform ultrasound-guided procedures. We reviewed the literature on the POCUS applications most relevant to the practice of internal medicine. The use of POCUS can immediately narrow differential diagnoses by building on the clinical information revealed by the traditional physical examination and refining clinical decision making for further management. We describe 2 common patient scenarios (heart failure and sepsis) to highlight the impact of POCUS performed by internists on efficiency, diagnostic accuracy, resource utilization, and radiation exposure. Using POCUS to guide procedures has been found to reduce procedure-related complications, along with costs and lengths of stay associated with these complications. Despite several undisputed advantages of POCUS, barriers to implementation must be considered. Most importantly, the utility of POCUS depends on the experience and skills of the operator, which are affected by the availability of training and the cost of ultrasound devices. Additional system barriers include availability of templates for documentation, electronic storage for image archiving, and policies and procedures for quality assurance and billing. Integration of POCUS into the practice of internal medicine is an inevitable change that will empower internists to improve the care of their patients at the bedside.
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Affiliation(s)
- Anjali Bhagra
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - David M Tierney
- Abbott Northwestern Hospital, Medical Education Department, Minneapolis, MN
| | - Hiroshi Sekiguchi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nilam J Soni
- Section of Hospital Medicine, South Texas Veterans Health Care System and Division of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center, San Antonio, TX
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Mulcare MR, Lee RW, Pologe JI, Clark S, Borda T, Sohn Y, Sacco DL, Riley DC. Interrater reliability of emergency physician-performed ultrasonography for diagnosing femoral, popliteal, and great saphenous vein thromboses compared to the criterion standard study by radiology. JOURNAL OF CLINICAL ULTRASOUND : JCU 2016; 44:360-367. [PMID: 26890934 DOI: 10.1002/jcu.22338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/12/2016] [Accepted: 01/13/2016] [Indexed: 06/05/2023]
Abstract
PURPOSE To assess the interrater reliability and test characteristics of lower limb sonographic examination for the diagnosis of deep venous and proximal great saphenous vein thrombosis when performed by Emergency Physicians (EPs) as compared to that by the Department of Radiology (Radiology). The secondary objective was to assess the effects of patient body mass index and EP satisfaction with bedside ultrasound on sensitivity and specificity. METHODS A prospective study was conducted for patients with clinical suspicion for lower extremity thrombus. EPs evaluated for venous thrombosis in the common femoral vein, femoral vein of the thigh, popliteal vein, and proximal great saphenous vein. Subsequently, all patients received ultrasounds by Radiology, the criterion standard. RESULTS One hundred ninety-seven patients (257 individual legs) were evaluated. There was 90-95% agreement between EP and Radiology, moderate kappa agreement for common femoral vein, and femoral vein of the thigh and fair kappa agreement for great saphenous vein and popliteal vein. The sensitivity and specificity of EP ultrasounds compared with criterion standard were lower than previously reported. There was no trend in patient body mass index or provider satisfaction influencing the test characteristics. CONCLUSIONS Our study suggests that point-of-care sonography should not replace Radiology-performed scans. The required amount of training for EPs to be competent in this examination needs further investigation. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:360-367, 2016.
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Affiliation(s)
- Mary R Mulcare
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York
- Emergency Medicine Residency, New York-Presbyterian Hospital, New York, New York
| | - Randall W Lee
- Division of Emergency Medicine, Columbia University Medical Center, New York, New York
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Jonas I Pologe
- Division of Emergency Medicine, Columbia University Medical Center, New York, New York
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Sunday Clark
- Division of Emergency Medicine, Weill Cornell Medical College, New York, New York
- Emergency Medicine Residency, New York-Presbyterian Hospital, New York, New York
| | - Tomas Borda
- Department of Family Medicine, The Brooklyn Hospital Center, Brooklyn, New York
| | - Youdong Sohn
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Gyeonggi-do, South Korea
| | - Dana L Sacco
- Emergency Medicine Residency, New York-Presbyterian Hospital, New York, New York
- Division of Emergency Medicine, Columbia University Medical Center, New York, New York
| | - David C Riley
- Emergency Medicine Residency, New York-Presbyterian Hospital, New York, New York
- Division of Emergency Medicine, Columbia University Medical Center, New York, New York
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Zitek T, Baydoun J, Yepez S, Forred W, Slattery DE. Mistakes and Pitfalls Associated with Two-Point Compression Ultrasound for Deep Vein Thrombosis. West J Emerg Med 2016; 17:201-8. [PMID: 26973753 PMCID: PMC4786247 DOI: 10.5811/westjem.2016.1.29335] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/04/2016] [Accepted: 01/10/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction Two-point compression ultrasound is purportedly a simple and accurate means to diagnose proximal lower extremity deep vein thrombosis (DVT), but the pitfalls of this technique have not been fully elucidated. The objective of this study is to determine the accuracy of emergency medicine resident-performed two-point compression ultrasound, and to determine what technical errors are commonly made by novice ultrasonographers using this technique. Methods This was a prospective diagnostic test assessment of a convenience sample of adult emergency department (ED) patients suspected of having a lower extremity DVT. After brief training on the technique, residents performed two-point compression ultrasounds on enrolled patients. Subsequently a radiology department ultrasound was performed and used as the gold standard. Residents were instructed to save videos of their ultrasounds for technical analysis. Results Overall, 288 two-point compression ultrasound studies were performed. There were 28 cases that were deemed to be positive for DVT by radiology ultrasound. Among these 28, 16 were identified by the residents with two-point compression. Among the 260 cases deemed to be negative for DVT by radiology ultrasound, 10 were thought to be positive by the residents using two-point compression. This led to a sensitivity of 57.1% (95% CI [38.8–75.5]) and a specificity of 96.1% (95% CI [93.8–98.5]) for resident-performed two-point compression ultrasound. This corresponds to a positive predictive value of 61.5% (95% CI [42.8–80.2]) and a negative predictive value of 95.4% (95% CI [92.9–98.0]). The positive likelihood ratio is 14.9 (95% CI [7.5–29.5]) and the negative likelihood ratio is 0.45 (95% CI [0.29–0.68]). Video analysis revealed that in four cases the resident did not identify a DVT because the thrombus was isolated to the superior femoral vein (SFV), which is not evaluated by two-point compression. Moreover, the video analysis revealed that the most common mistake made by the residents was inadequate visualization of the popliteal vein. Conclusion Two-point compression ultrasound does not identify isolated SFV thrombi, which reduces its sensitivity. Moreover, this technique may be more difficult than previously reported, in part because novice ultrasonographers have difficulty properly assessing the popliteal vein.
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Affiliation(s)
- Tony Zitek
- University of Nevada School of Medicine, Department of Emergency Medicine, Reno, Nevada; University Medical Center of Southern Nevada, Department of Emergency Medicine, Las Vegas, Nevada
| | - Jamie Baydoun
- University of Nevada School of Medicine, Department of Emergency Medicine, Reno, Nevada; University Medical Center of Southern Nevada, Department of Emergency Medicine, Las Vegas, Nevada
| | - Salvador Yepez
- University Medical Center of Southern Nevada, Department of Emergency Medicine, Las Vegas, Nevada
| | - Wesley Forred
- University Medical Center of Southern Nevada, Department of Emergency Medicine, Las Vegas, Nevada
| | - David E Slattery
- University of Nevada School of Medicine, Department of Emergency Medicine, Reno, Nevada; University Medical Center of Southern Nevada, Department of Emergency Medicine, Las Vegas, Nevada
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Day J, Davis J, Riesenberg LA, Heil D, Berg K, Davis R, Berg D. Integrating Sonography Training Into Undergraduate Medical Education: A Study of the Previous Exposure of One Institution's Incoming Residents. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1253-7. [PMID: 26112628 DOI: 10.7863/ultra.34.7.1253] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Sonography is a crucial and versatile tool within the field of medicine. Recent advancements in technology have led to increased use of point-of-care sonography. We designed a survey to assess prior point-of-care sonography training among incoming interns at an academic teaching hospital. METHODS In 2012 and 2013, we surveyed incoming interns (n = 154 and 145, respectively) regarding point-of-care sonography training received during medical school. The survey questions included formal didactic sessions, bedside instruction, and the use of simulation technology. RESULTS One-fourth (26.3% in 2012 and 23.4% in 2013) of responding interns reported having never done an ultrasound scan at the bedside. In 2012 and 2013, 55.0% and 55.6% of respondents reported never having done an ultrasound scan in a simulation center, respectively. Interns agreed that sonography education should be provided during medical school. On average, interns disagreed with the statement that sonography should be taught in residency only. There was no significant difference in the sex or general previous experience with sonography across both intern classes. CONCLUSIONS Point-of-care sonography is inconsistently taught in medical school. The interns in our study also thought that sonography education should begin in medical school, and sonography should be taught by using simulation and at the bedside.
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Affiliation(s)
- James Day
- Rector Clinical Skills and Simulation Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania USA (Ja.D., Jo.D., D.H., K.B., D.B.); and Medical Education Outcomes and Research, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama USA (L.A.R., R.D.)
| | - Joshua Davis
- Rector Clinical Skills and Simulation Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania USA (Ja.D., Jo.D., D.H., K.B., D.B.); and Medical Education Outcomes and Research, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama USA (L.A.R., R.D.)
| | - Lee Ann Riesenberg
- Rector Clinical Skills and Simulation Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania USA (Ja.D., Jo.D., D.H., K.B., D.B.); and Medical Education Outcomes and Research, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama USA (L.A.R., R.D.).
| | - Daniel Heil
- Rector Clinical Skills and Simulation Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania USA (Ja.D., Jo.D., D.H., K.B., D.B.); and Medical Education Outcomes and Research, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama USA (L.A.R., R.D.)
| | - Katherine Berg
- Rector Clinical Skills and Simulation Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania USA (Ja.D., Jo.D., D.H., K.B., D.B.); and Medical Education Outcomes and Research, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama USA (L.A.R., R.D.)
| | - Robyn Davis
- Rector Clinical Skills and Simulation Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania USA (Ja.D., Jo.D., D.H., K.B., D.B.); and Medical Education Outcomes and Research, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama USA (L.A.R., R.D.)
| | - Dale Berg
- Rector Clinical Skills and Simulation Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania USA (Ja.D., Jo.D., D.H., K.B., D.B.); and Medical Education Outcomes and Research, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama USA (L.A.R., R.D.)
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What Is the Accuracy of Emergency Physician–Performed Ultrasonography for Deep Venous Thrombosis? Ann Emerg Med 2015; 65:699-701. [DOI: 10.1016/j.annemergmed.2014.06.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 06/23/2014] [Accepted: 06/27/2014] [Indexed: 11/20/2022]
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Resident performed two-point compression ultrasound is inadequate for diagnosis of deep vein thrombosis in the critically III. J Thromb Thrombolysis 2015; 37:298-302. [PMID: 23722715 DOI: 10.1007/s11239-013-0945-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Doppler ultrasonography is a standard in diagnosis of deep vein thrombosis (DVT) but is often delayed. Clinician-performed focused vascular sonography (FVS) has proven to accurately diagnose DVT in the ambulatory and emergency room settings. Whether trained medical residents can perform quality FVS in the critically ill is unknown. Medical residents were trained in a 2-hour module in FVS assessing for complete compressibility of common femoral and popliteal veins. Residents imaged consecutive medical ICU and intermediate care patients awaiting comprehensive, sonographer-performed and radiologist-interpreted examinations. Sensitivity, specificity, positive and negative predictive values of the focused examination were calculated against the comprehensive study. Fleiss Kappa (κ), the degree of agreement between resident and radiologist, was calculated. Time savings was measured. Nineteen residents performed 143 studies on 75 patients. Twelve patients had above-the-knee DVTs, a prevalence of 16 %. All 6 common femoral and 7 of 9 popliteal vein DVTs were identified. None of 6 isolated superficial femoral DVTs were identified. Sensitivity for above-the-knee DVT was 63 %, specificity 97 %. Sensitivity for common femoral and popliteal DVT was 86 %, specificity 97 %. Residents showed substantial agreement with radiologists for diagnosis of DVT (κ = 0.70, SE 0.114, p < 0.001).Time from order of a formal ultrasound to a radiologist's read averaged 14.7 h. The two-point compression ultrasound method demonstrated insufficient sensitivity in a cohort of critically ill medical patients due to a high-incidence of superficial femoral DVT. However, residents demonstrated substantial agreement with radiologists for the diagnosis of clinically relevant DVT after a 2-hour course. FVS should include the superficial femoral vein and is associated with a significant time savings.
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Poley RA, Newbigging JL, Sivilotti ML. Estimated effect of an integrated approach to suspected deep venous thrombosis using limited-compression ultrasound. Acad Emerg Med 2014; 21:971-80. [PMID: 25269577 DOI: 10.1111/acem.12459] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/18/2014] [Accepted: 05/06/2014] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Rachel A. Poley
- The Department of Emergency Medicine; Queen's University; Kingston Ontario Canada
- The Department of Emergency Medicine; Saint Michael's Hospital; Toronto Ontario Canada
| | - Joseph L. Newbigging
- The Department of Emergency Medicine; Queen's University; Kingston Ontario Canada
| | - Marco L.A. Sivilotti
- The Department of Emergency Medicine; Queen's University; Kingston Ontario Canada
- The Department of Pharmacology and Toxicology; Queen's University; Kingston Ontario Canada
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Cook T, Nolting L, Barr C, Hunt P. Diagnostic ultrasonography for peripheral vascular emergencies. Crit Care Clin 2014; 30:185-206, v. [PMID: 24606773 DOI: 10.1016/j.ccc.2013.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Over the past decade, emergency and critical care physicians have been empowered with the ability to use bedside ultrasonography to assist in the evaluation and management of a variety of emergent conditions. Today a single health care provider at the bedside with Duplex ultrasound technology can evaluate peripheral vascular calamities that once required significant time and a variety of health care personnel for the diagnosis. This article highlights peripheral thromboembolic disease, aneurysm, pseudoaneurysm, and arterial occlusion in the acute care setting.
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Affiliation(s)
- Thomas Cook
- Department of Emergency Medicine, Palmetto Health Richland, 14 Medical Park, Suite 350, Columbia, SC 29203, USA
| | - Laura Nolting
- Department of Emergency Medicine, Palmetto Health Richland, 14 Medical Park, Suite 350, Columbia, SC 29203, USA.
| | - Caleb Barr
- Department of Emergency Medicine, Palmetto Health Richland, 14 Medical Park, Suite 350, Columbia, SC 29203, USA
| | - Patrick Hunt
- Department of Emergency Medicine, Palmetto Health Richland, 14 Medical Park, Suite 350, Columbia, SC 29203, USA
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Crowhurst TD, Dunn RJ. Sensitivity and specificity of three-point compression ultrasonography performed by emergency physicians for proximal lower extremity deep venous thrombosis. Emerg Med Australas 2013; 25:588-96. [DOI: 10.1111/1742-6723.12155] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas D Crowhurst
- School of Medicine; Faculty of Health Sciences; University of Adelaide; Adelaide South Australia Australia
| | - Robert J Dunn
- Discipline of Acute Care Medicine; School of Medicine; Faculty of Health Sciences; University of Adelaide; Adelaide South Australia Australia
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Tools for the Clinician: The Essentials of Bedside (ED or ICU) Ultrasound for Deep Vein Thrombosis. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-013-0016-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Torres-Macho J, Antón-Santos JM, García-Gutierrez I, de Castro-García M, Gámez-Díez S, de la Torre PG, Latorre-Barcenilla G, Majo-Carbajo Y, Reparaz-González JC, de Casasola GG. Initial accuracy of bedside ultrasound performed by emergency physicians for multiple indications after a short training period. Am J Emerg Med 2012; 30:1943-9. [PMID: 22795427 DOI: 10.1016/j.ajem.2012.04.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 04/09/2012] [Accepted: 04/11/2012] [Indexed: 02/06/2023] Open
Abstract
PURPOSES Emergency physician-performed ultrasonography holds promise as a rapid and accurate method to diagnose multiple diseases in the emergency department (ED). Our objective was to assess the initial diagnostic accuracy (first 55 explorations) of emergency physician-performed ultrasonography for multiple categories of ultrasound use after a short training period. BASIC PROCEDURES This was a prospective observational study conducted at an urban ED from June 2010 to March 2011 in patients with suspected cholecystitis, hydronephrosis, deep vein thrombosis, and different cardiovascular problems. Five physicians had a 10-hour training session before enrolling patients. The test characteristics of bedside ultrasonography were determined with the final radiologist/cardiologist interpretation. MAIN FINDINGS A total of 275 ultrasonographic examinations were performed (78 abdominal explorations, 80 renal explorations, 76 2-point compression ultrasonographic examinations in patients with suspected deep vein thrombosis, and 41 echocardiograms in patients with different acute cardiovascular problems). Radiologists/cardiologists detected 28 cases of cholecystitis, 26 cases of deep vein thrombosis, 49 cases of hydronephrosis, and 15 cases of significant cardiovascular alterations. The overall diagnostic accuracy of ED ultrasonograms yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 92.6% (95% confidence interval [CI], 90%-99%), 89% (95% CI, 84%-94%), 86.2 % (95% CI, 82%-93%), and 94.2% (95% CI, 92%-99%), respectively. Nineteen (6.9%) false-positive results and 6 false-negative results (2.1%) were obtained. PRINCIPAL CONCLUSIONS Emergency physicians in our institution attained reasonably high initial accuracy in the performance of ultrasonography for a variety of clinical problems after a 10-hour training period.
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Affiliation(s)
- Juan Torres-Macho
- Emergency Department, Hospital Infanta Cristina, Parla, Madrid, Spain.
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van Zyl Smit N, Govind A, Sharma D. Early diagnosis of iliofemoral DVT in pregnancy in the emergency department. BMJ Case Rep 2012; 2012:bcr.02.2012.5719. [PMID: 22693324 DOI: 10.1136/bcr.02.2012.5719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The case of a 26-year-old woman who was 23 weeks pregnant is described; the patient presented, on a weekend, to the emergency department (ED) with left groin pain. There were few clinical signs of deep venous thrombosis (DVT) but ED ultrasound (US) showed a left external iliac vein thrombus. This is a new technique in the ED. Not only does this case show the importance of using this technique in the ED, but it also shows the importance of correct training in how to examine for thrombus in the external iliac vein in the pregnant patient. The patient was admitted to the hospital and started on low-molecular-weight heparin. A formal radiology department US performed the next week confirmed the diagnosis of DVT.
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Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam 2012: Rapid Ultrasound in Shock in the Evaluation of the Critically Ill Patient. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.cult.2011.12.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Barillari A, Barillari G, Pasca S. Extended Compression Ultrasound Performed by Emergency Physicians: A Modified Compression Ultrasound Examination to Detect Superficial and Deep Lower Limb Thromboses in the Emergency Department. J Med Ultrasound 2011. [DOI: 10.1016/j.jmu.2011.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Ward MJ, Sodickson A, Diercks DB, Raja AS. Cost-effectiveness of lower extremity compression ultrasound in emergency department patients with a high risk of hemodynamically stable pulmonary embolism. Acad Emerg Med 2011; 18:22-31. [PMID: 21414059 DOI: 10.1111/j.1553-2712.2010.00957.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Computed tomography angiograms (CTAs) for patients with suspected pulmonary embolism (PE) are being ordered with increasing frequency from the emergency department (ED). Strategies are needed to safely decrease the utilization of CTs to control rising health care costs and minimize the associated risks of anaphylaxis, contrast-induced nephropathy, and radiation-induced carcinogenesis. The use of compression ultrasonography (US) to identify deep vein thromboses (DVTs) in hemodynamically stable patients with signs and symptoms suggestive of PE is highly specific for the diagnosis of PE and may represent a cost-effective alternative to CT imaging. OBJECTIVES The objective was to analyze the cost-effectiveness of a selective CT strategy incorporating the use of compression US to diagnose and treat DVT in patients with a high pretest probability of PE. METHODS The authors constructed a decision analytic model to evaluate the scenario of an otherwise healthy 59-year-old female in whom PE was being considered as a diagnosis. Two strategies were used. The selective CT strategy began with a screening compression US. Negative studies were followed up with a CTA, while patients with positive studies identifying a DVT were treated as though they had a PE and were anticoagulated. The universal CT strategy used CTA as the initial test, and anticoagulation was based on the CT result. Costs were estimated from the 2009 Medicare data for hospital reimbursement, and professional fees were obtained from the 2009 National Physician Fee Schedule. Clinical probabilities were obtained from existing published data, and sensitivity analyses were performed across plausible ranges for all clinical variables. RESULTS In the base case, the selective CT strategy cost $1,457.70 less than the universal CT strategy and resulted in a gain of 0.0213 quality-adjusted life-years (QALYs). Sensitivity analyses confirm that the selective CT strategy is dominant above both a pretest probability for PE of 8.3% and a compression US specificity of 87.4%. CONCLUSIONS A selective CT strategy using compression US is cost-effective for patients provided they have a high pretest probability of PE. This may reduce the need for, and decrease the adverse events associated with, CTAs.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA.
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Tsao JH, Tseng CY, Chuang JL, Chen YC, Huang HH, Chou YH, Tiu CM, Yen DHT. Non-compressibility ratio of sonography in deep venous thrombosis. J Chin Med Assoc 2010; 73:563-7. [PMID: 21093823 DOI: 10.1016/s1726-4901(10)70124-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 07/08/2010] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The risk of post-thrombotic syndrome and pulmonary embolism can be increased if there is failure to diagnose deep venous thrombosis (DVT) promptly. Emergency physicians (EPs) need a quick and readily available test to diagnose, treat and help them decide whether to discharge or admit DVT patients in a timely manner. The aim of this study was to investigate the value of the non-compressibility ratio of thrombosed veins in DVT patients, and give EPs an objective value to aid them in their decision-making with regard to DVT patients in the emergency department. METHODS We reviewed 34 adult patients with DVT diagnosed by sonography in an emergency department. Medical records including demographic data and sonography results were retrospectively reviewed and analyzed. RESULTS Mean age was 72.9 ± 16.5 years. Group I comprised 14 patients (41.2%) who had DVT in the popliteal and femoral veins. Group II comprised 8 patients (23.5%) who had DVT isolated to the popliteal vein and 12 patients (35.3%) who had DVT isolated to the femoral vein. Group I had a significantly higher non-compressibility ratio than Group II (93.4 ± 6.2% vs. 80.1 ± 19.2%, p < 0.05). The area under the receiver operating characteristic curve of the non-compressibility ratio between discriminating groups was 0.711 (95% confidence interval, 0.527-0.854; p < 0.05). The clinical prognostic score of Group I was significantly higher than that of Group II (6.2 ± 1.8 vs. 4.1 ± 2.6, p < 0.05). There was a significant positive correlation between the non-compressibility ratio of the thrombosed vein and the clinical prognostic score (p = 0.001). CONCLUSION The non-compressibility ratio of the thrombosed vein provides EPs with an objective test to evaluate the severity of DVT and to admit patients for consideration of adverse outcomes.
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Affiliation(s)
- Jian-Hsiung Tsao
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Abstract
Hand-carried ultrasound (HCU) is a burgeoning technology at a critical point in its development as a general diagnostic technique. Despite the known safety and accuracy of ultrasound in radiology and echocardiography, the use of HCU to augment physical diagnosis by all physicians has yet unrealized potential. In order to incorporate ultrasound into a diagnostic model of routine bedside application, simple imaging and training protocols must first be derived and validated. Simplified cardiac ultrasound exams have already been validated to detect evidence-based targets such as subclinical atherosclerosis, heart failure, and elevated central venous pressures. However, for general examination of the acutely ill patient, it is the internist-hospitalist who should derive a full-body ultrasound examination, balancing training requirements with the numerous clinical applications potentially available. As the hospital's leading diagnostician with ultrasound expertise available in-house, the hospitalist could develop HCU so as to triage and refer more appropriately and limit unnecessary testing and hospital stays. Active involvement by hospitalists now in the planning of outcome, validation, and training studies, will be invaluable in the formation of an "ultrasound-assisted" physical examination in the future and will promote competent, cost-effective applications of HCU within general medical practice.
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Affiliation(s)
- Bruce J Kimura
- Departments of Cardiology, Internal Medicine, and Graduate Medical Education, Scripps Mercy Hospital, San Diego, California, USA.
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Shiver SA, Lyon M, Blaivas M, Adhikari S. Prospective comparison of emergency physician–performed venous ultrasound and CT venography for deep venous thrombosis. Am J Emerg Med 2010; 28:354-8. [DOI: 10.1016/j.ajem.2009.01.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2008] [Revised: 01/07/2009] [Accepted: 01/08/2009] [Indexed: 10/19/2022] Open
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Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am 2010; 28:29-56, vii. [PMID: 19945597 DOI: 10.1016/j.emc.2009.09.010] [Citation(s) in RCA: 361] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The RUSH exam (Rapid Ultrasound in SHock examination), presented in this article, represents a comprehensive algorithm for the integration of bedside ultrasound into the care of the patient in shock. By focusing on a stepwise evaluation of the shock patient defined here as "Pump, Tank, and Pipes," clinicians will gain crucial anatomic and physiologic data to better care for these patients.
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Affiliation(s)
- Phillips Perera
- New York Presbyterian Hospital, Columbia University Medical Center, Division of Emergency Medicine, 622 West 168th Street, New York, NY 10032, USA.
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Abstract
This article focuses on the clinical presentation, diagnosis, and management of veno-thromboembolism, including deep venous thrombosis (DVT) and pulmonary embolism (PE), from the perspective of the emergency physician. The discussion is divided into two sections: DVT and PE. Because veno-thromboembolism is a continuum, certain aspects, such as background, incidence, the use of D dimer, and anticoagulation of both DVT and PE, are discussed together. Heavier emphasis is placed on topics germane to the emergency physician, and considerations for special populations are reviewed.
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Affiliation(s)
- J Matthew Fields
- Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Ground Ravdin Building, Philadelphia, PA 19104, USA
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40
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Burnside PR, Brown MD, Kline JA. Systematic review of emergency physician-performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med 2008; 15:493-8. [PMID: 18616433 DOI: 10.1111/j.1553-2712.2008.00101.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The authors performed a systematic review to evaluate published literature on diagnostic performance of emergency physician-performed ultrasonography (EPPU) for the diagnosis and exclusion of deep venous thrombosis (DVT). METHODS Structured search criteria were used to query MEDLINE and EMBASE, followed by a hand search of published bibliographies. Relevance and inclusion criteria required prospective investigation of emergency department (ED) outpatients with suspected DVT; diagnostic evaluations had to consist of EPPU followed by criterion standard (radiology-performed) imaging. Two authors independently extracted data from included studies; study quality was assessed utilizing a validated tool for quality assessment of diagnostic accuracy studies (QUADAS). Pooled data were analyzed using an unweighted summary receiver-operating-characteristic (SROC) curve; sensitivity and specificity were estimated using a random effects model. RESULTS The initial search yielded 1,162 publications. Relevance screening and selection yielded six articles including 936 patients. Four of the six studies reported adequate blinding but a number of other methodologic flaws were identified. A random effects model yielded an overall sensitivity of 0.95 (95% confidence interval [CI] = 0.87 to 0.99) and specificity of 0.96 (95% CI = 0.87 to 0.99). CONCLUSIONS Systematic review of six studies suggests that EPPU may be accurate for the diagnosis of DVT compared with radiology-performed ultrasound (US). However, given the methodologic limitations identified among the primary studies, the estimates of diagnostic test performance may be overly optimistic. Further research into EPPU for suspected DVT is needed before it can be adopted into routine clinical practice.
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Affiliation(s)
- Patrick R Burnside
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
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Guerrero J, Salcudean SE, McEwen JA, Masri BA, Nicolaou S. Real-time vessel segmentation and tracking for ultrasound imaging applications. IEEE TRANSACTIONS ON MEDICAL IMAGING 2007; 26:1079-90. [PMID: 17695128 DOI: 10.1109/tmi.2007.899180] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
A method for vessel segmentation and tracking in ultrasound images using Kalman filters is presented. A modified Star-Kalman algorithm is used to determine vessel contours and ellipse parameters using an extended Kalman filter with an elliptical model. The parameters can be used to easily calculate the transverse vessel area which is of clinical use. A temporal Kalman filter is used for tracking the vessel center over several frames, using location measurements from a handheld sensorized ultrasound probe. The segmentation and tracking have been implemented in real-time and validated using simulated ultrasound data with known features and real data, for which expert segmentation was performed. Results indicate that mean errors between segmented contours and expert tracings are on the order of 1%-2% of the maximum feature dimension, and that the transverse cross-sectional vessel area as computed from estimated ellipse parameters a, b as determined by our algorithm is within 10% of that determined by experts. The location of the vessel center was tracked accurately for a range of speeds from 1.4 to 11.2 mm/s.
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Affiliation(s)
- Julian Guerrero
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
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42
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Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: The evolution of a new imaging paradigm. Crit Care Med 2007; 35:S126-30. [PMID: 17446770 DOI: 10.1097/01.ccm.0000260623.38982.83] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The tradition of clinical ultrasound in the hands of physicians who provide critical care to the most acutely ill patients stretches back into the 1980s and is rich with experiences from surgical, emergency medicine, and other practices. Now, as critical care ultrasound explodes around the world, it is important to realize the path its development has taken and learn from trials and tribulations of early practitioners in the field. The development and battles for the right to use ultrasound at the patient's bedside for >20 yrs is described in relation to its emergency medicine and surgical origins. Approaches to education, scanning, documentation, and organization at the national and regional levels are described.
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Affiliation(s)
- John L Kendall
- Emergency Ultrasound, Denver Health Medical Center, Denver, CO, USA.
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Magazzini S, Vanni S, Toccafondi S, Paladini B, Zanobetti M, Giannazzo G, Federico R, Grifoni S. Duplex ultrasound in the emergency department for the diagnostic management of clinically suspected deep vein thrombosis. Acad Emerg Med 2007; 14:216-20. [PMID: 17264203 DOI: 10.1197/j.aem.2006.08.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To evaluate the accuracy and safety of an emergency duplex ultrasound (EDUS) evaluation performed by emergency physicians in the emergency department. METHODS Consecutive adult patients suspected of having their first episode of deep vein thrombosis (DVT) presenting to the emergency department were included in the study. All examinations were performed by emergency physicians trained with a 30-hour ultrasound course. Based on EDUS findings, patients were classified into one of three groups: normal, abnormal, and uncertain. Patients with abnormal and uncertain findings were initially treated as having a DVT. Patients with normal EDUS findings were discharged from the emergency department without anticoagulant therapy. A formal duplex ultrasound evaluation was repeated by a radiologist in all patients within 24-48 hours. Patients with normal findings on duplex ultrasound evaluation were followed up for symptomatic venous thromboembolism for up to one month. RESULTS A total of 399 patients were studied. The EDUS findings were normal in 301 (75%), abnormal in 90 (23%), and uncertain in eight (2%). All abnormal test results were confirmed by the formal duplex ultrasound evaluation, and three patients (0.8%) with uncertain findings on EDUS examination were subsequently diagnosed as having a distal DVT (positive predictive value, 95% [95% confidence interval, 92% to 95%]; negative predictive value, 100% [95% confidence interval = 99% to 100%]). No patients with normal findings on EDUS examination died or experienced venous thromboembolism at the one-month follow-up. CONCLUSIONS EDUS examination yielded a high negative predictive value and good positive predictive value, allowing rapid discharge and avoiding improper anticoagulant treatment.
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Affiliation(s)
- Simone Magazzini
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Jacoby J, Cesta M, Axelband J, Melanson S, Heller M, Reed J. Can emergency medicine residents detect acute deep venous thrombosis with a limited, two-site ultrasound examination? J Emerg Med 2007; 32:197-200. [PMID: 17307633 DOI: 10.1016/j.jemermed.2006.06.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Revised: 01/04/2006] [Accepted: 06/30/2006] [Indexed: 11/24/2022]
Abstract
The purpose of this prospective clinical study was to determine the ability of Emergency Medicine (EM) residents to accurately detect acute deep venous thrombosis (aDVT) after training in a limited, two-site examination. Six residents received a 90-min session consisting of a lecture and a hands-on component. Each resident then performed the examination on symptomatic extremities referred to the vascular laboratory of a community teaching hospital. The examination was limited to the femoral and popliteal sites and was considered normal when the vein completely compressed. A formal examination was completed by the vascular technician (who was blinded to the resident's results) within 30 min of the resident examination. Of the 121 symptomatic extremities, vascular technicians detected nine cases of aDVT in the target area (7% prevalence); resident examinations revealed eight of these (sensitivity 89%). EM residents can perform a limited duplex examination with considerable but not perfect accuracy after receiving very limited instruction.
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Affiliation(s)
- Jeanne Jacoby
- Emergency Medicine Residency Program, St. Luke's Hospital, Bethlehem, Pennsylvania 18015, USA
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Haeusler JMC, Tobler B, Arnet B, Huesler J, Zimmermann H. Pilot study on the comprehensive economic costs of major trauma: Consequential costs are well in excess of medical costs. ACTA ACUST UNITED AC 2006; 61:723-31. [PMID: 16967014 DOI: 10.1097/01.ta.0000210453.70742.7f] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trauma care is expensive. However, reliable data on the exact lifelong costs incurred by a major trauma patient are lacking. Discussion usually focuses on direct medical costs--underestimating consequential costs resulting from absence from work and permanent disability. METHODS Direct medical costs and consequential costs of 63 major trauma survivors (ISS >13) at a Swiss trauma center from 1995 to 1996 were assessed 5 years posttrauma. The following cost evaluation methods were used: correction cost method (direct cost of restoring an original state), human capital method (indirect cost of lost productivity), contingent valuation method (human cost as the lost quality of life), and macroeconomic estimates. RESULTS Mean ISS (Injury Severity Score) was 26.8 +/- 9.5 (mean +/- SD). In all, 22 patients (35%) were disabled, causing discounted average lifelong total costs of USD 1,293,800, compared with 41 patients (65%) who recovered without any disabilities with incurred costs of USD 147,200 (average of both groups USD 547,800). Two thirds of these costs were attributable to a loss of production whereas only one third was a result of the cost of correction. Primary hospital treatment (USD 27,800 +/- 37,800) was only a minor fraction of the total cost--less than the estimated cost of police and the judiciary. Loss of quality of life led to considerable intangible human costs similar to real costs. CONCLUSIONS Trauma costs are commonly underestimated. Direct medical costs make up only a small part of the total costs. Consequential costs, such as lost productivity, are well in excess of the usual medical costs. Mere cost averages give a false estimate of the costs incurred by patients with/without disabilities.
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Guerrero J, Salcudean SE, McEwen JA, Masri BA, Nicolaou S. System for deep venous thrombosis detection using objective compression measures. IEEE Trans Biomed Eng 2006; 53:845-54. [PMID: 16686407 DOI: 10.1109/tbme.2005.863878] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A system for objective vessel compression assessment for deep venous thrombosis characterization using ultrasound image data and a sensorized ultrasound probe is presented. Two new objective measures calculated from applied force and transverse vessel area are also presented and used to describe vessel compressibility. A modified star-Kalman algorithm is used for feature detection in acquired ultrasound images, and objective measures of vessel compressibility are calculated from the detected features and acquired force and location data from the sensorized probe. A three-dimensional shape model of the examined vessel that includes compressibility measures mapped as colors to its surface is presented on the user interface, as well as a virtual representation of the image plane. The compressibility measures were validated using expert segmentation of healthy and diseased vessels and compared using paired t-tests, which showed a significant difference between healthy and diseased cases for both measures. 100% sensitivity and specificity were obtained for both measures. The system was implemented in real-time (16 Hz) and evaluated using a tissue phantom and on healthy human subjects. Sensitivity was 100% and 60%, while specificity was 97% for both measures when implemented. The initial results for the system and its components are promising.
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Affiliation(s)
- Julian Guerrero
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC, Canada.
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Kimura BJ, DeMaria AN. Technology Insight: hand-carried ultrasound cardiac assessment—evolution, not revolution. ACTA ACUST UNITED AC 2005; 2:217-23; quiz 224. [PMID: 16265486 DOI: 10.1038/ncpcardio0154] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Accepted: 02/25/2005] [Indexed: 11/09/2022]
Abstract
Hand-carried ultrasound devices can enhance the art of bedside physical examination by increasing diagnostic accuracy, detecting disease at an earlier stage, and improving triage and referral of patients. Although limitations of device cost and portability can be overcome with technologic advances, the shortage of standardized imaging and training opportunities now needs to be addressed to move the technique forward. Cardiologists are the best-qualified subspecialists to design and teach a simplified training program for bedside use of hand-carried ultrasound devices to assess the cardiovascular system.
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Affiliation(s)
- Bruce J Kimura
- Department of Cardiology, Scripps Mercy Hospital and UCSD Cardiovascular Center at the University of California, San Diego, CA 92103, USA.
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Kendall JL, Blaivas M, Hoffenberg S, Fox JC. History of emergency ultrasound. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2004; 23:1130-1135. [PMID: 15284475 DOI: 10.7863/jum.2004.23.8.1130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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Abstract
The ultrasound diagnosis of deep venous thrombosis by an emergency physician is occurring with increased frequency. The examination is simple to perform and, when combined with a clinical pretest probability or D-dimer, can aid in the rapid disposition ofa patient with lower extremity pain and swelling. The technique and findings of the limited lower extremity ultrasound and the data to support its use in the emergency department are discussed.
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Affiliation(s)
- Jason A Tracy
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Affiliated Emergency Medicine Residency, Harvard Medical School, West Clinical Center 2, One Deaconess Road, Boston, MA 02215, USA
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Blaivas M, Brannam L, Theodoro D. Ultrasound image quality comparison between an inexpensive handheld emergency department (ED) ultrasound machine and a large mobile ED ultrasound system. Acad Emerg Med 2004; 11:778-81. [PMID: 15231471 DOI: 10.1197/j.aem.2003.12.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
UNLABELLED Questions have been raised regarding image quality (IQ) provided by portable ultrasound (US) machines. OBJECTIVES To determine if a difference exists between images obtained with a common portable US machine and those obtained with a more expensive, larger US machine when comparing typical views used by emergency physicians. METHODS The authors performed a cross-sectional, blinded comparison of images from similar sonographic windows obtained on healthy models using a SonoSite 180 Plus and a General Electric (GE) 400 US machine. Both machines were optimized by company representatives. Images obtained included typical abdominal and vascular applications using the abdominal and linear transducers on each machine. All images were printed on identical high-resolution printers and then digitized using a bitmap format at 300 dots-per-inch resolution (RES). Images were then cropped, masked, and placed into random order comparing each view per model by a commercial Web design company (loracs.com). Three credentialed emergency physician sonologists, blinded to machine type, rated each image pair for RES, detail (DET), and total IQ as previously defined in the literature using a ten-point Likert scale; 10 was the best rating for each category. Paired t-test, 95% confidence intervals (95% CIs), and interobserver correlation were calculated. RESULTS A total of 49 image pairs were evaluated. Mean GE 400 RES, DET, and IQ scores were 6.8, 6.8, and 6.6, respectively. Corresponding SonoSite means were 6.3, 6.3, and 6.0, respectively. The difference of 0.5 (95% CI = 0.13 to 1.1) for DET was not statistically significant (p = 0.06). The differences of 0.5 (95% CI = 0.1 to 1.1) and 0.6 (95% CI = 0.2 to 1.2) for RES and IQ were statistically significant, with p = 0.01 and 0.01. There was good interobserver agreement (kappa = 0.71; 95% CI = 0.67 to 0.78). CONCLUSIONS A statistically significant difference was seen between GE 400 and SonoSite in IQ and RES, but not DET.
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Affiliation(s)
- Michael Blaivas
- Department of Emergency Medicine, Medical College of Georgia, Augusta, GA 30912-4007, USA.
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