Emergency Department Targeted Ultrasound Interest Group. Emergency Department Targeted Ultrasound: 2006 Update

Point of care ultrasound training in Canadian emergency medicine residency programs

OBJECTIVES

Point of care ultrasound (POCUS) has been endorsed as an important clinical tool by the Canadian Association of Emergency Physicians (CAEP) and is a training objective of emergency medicine (EM) residency programs accredited by both the Royal College of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada (CFPC). Our objectives are to describe the national state of POCUS training in RCPSC-EM and CFPC-EM residency programs and to evaluate the implementation of the CAEP core POCUS curriculum in these programs.

METHODS

This was an online survey study of all POCUS education leads for both RCPSC-EM and CFPC-EM programs. The survey queried participants on program demographics, description of POCUS training, methods of POCUS assessment, and implementation of the CAEP core POCUS curriculum.

RESULTS

The response rate was 100% (39/39). All RCPSC-EM and CFPC-EM programs provide POCUS training for their residents, and 100% of RCPSC-EM programs and 91% (20/22) of CFPC-EM programs have a POCUS lead. All programs provide POCUS training for their residents, but there is variability in how POCUS is introduced to residents, ongoing POCUS instruction provided throughout residency, and POCUS assessment. Only 47% (8/17) of RCPSC-EM and 32% (7/22) of CFPC-EM programs have a quality assurance process for the use of POCUS by their residents. POCUS leads believe their residents are proficient in the CAEP core POCUS applications by the end of training except for advanced cardiac and thoracic ultrasound.

CONCLUSIONS

POCUS training in Canadian EM programs is prevalent, but there is variability in support for POCUS leads, delivery of training, determination of proficiency, and presence of quality assurance. While almost all programs deliver POCUS education aligning with the CAEP core POCUS curriculum position statement, more support is required both locally and nationally for sharing best practices for POCUS education.

Do combined ultrasound and electrocardiogram-rhythm findings predict survival in emergency department cardiac arrest patients? The Second Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED2) study

Objectives

Point-of-care ultrasound (POCUS) is used increasingly during resuscitation. The aim of this study was to assess whether combining POCUS and electrocardiogram (ECG) rhythm findings better predicts outcomes during cardiopulmonary resuscitation in the emergency department (ED).

Methods

We completed a health records review on ED cardiac arrest patients who underwent POCUS. Primary outcome measurements included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge.

Results

POCUS was performed on 180 patients; 45 patients (25.0%; 19.2%–31.8%) demonstrated cardiac activity on initial ECG, and 21 (11.7%; 7.7%–17.2%) had cardiac activity on initial POCUS; 47 patients (26.1%; 20.2%–33.0%) achieved ROSC, 18 (10.0%; 6.3%–15.3%) survived to admission, and 3 (1.7%; 0.3%–5.0%) survived to hospital discharge. As a predictor of failure to achieve ROSC, ECG had a sensitivity of 82.7% (95% CI 75.2%–88.7%) and a specificity of 46.8% (32.1%–61.9%). Overall, POCUS had a higher sensitivity of 96.2% (91.4%–98.8%) but a similar specificity of 34.0% (20.9%–49.3%). In patients with ECG-asystole, POCUS had a sensitivity of 98.18% (93.59%–99.78%) and a specificity of 16.00% (4.54%–36.08%). In patients with pulseless electrical activity, POCUS had a sensitivity of 86.96% (66.41%–97.22%) and a specificity of 54.55% (32.21%–75.61%). Similar patterns were seen for survival to admission and discharge. Only 0.8% (0.0–4.7%) of patients with ECG-asystole and standstill on POCUS survived to hospital discharge.

Conclusion

The absence of cardiac activity on POCUS, or on both ECG and POCUS together, better predicts negative outcomes in cardiac arrest than ECG alone. No test reliably predicted survival.

The core emergency ultrasound curriculum project: A report from the Curriculum Working Group of the CAEP Emergency Ultrasound Committee

Emergency ultrasound (EUS) is now widely considered to be a "skill integral to the practice of emergency medicine." 1 The Canadian Association of Emergency Physicians (CAEP) initially issued a position statement in 1999 supporting the availability of focused ultrasound 24 hours per day in the emergency department (ED). 2.

Barriers to point-of-care ultrasound use in rural emergency departments

Over the past few decades, point-of-care ultrasound (PoCUS) has come to play a major role in the practice of emergency medicine. Despite its numerous benefits, there has been a slow uptake of PoCUS use in rural emergency departments. Surveys conducted across Canada and the United States have identified a lack of equipment, training, funding, quality assurance, and an inability to maintain skills as major barriers to PoCUS use. Potential solutions include expanding residency training in ultrasound skills, extending funding for PoCUS training to rural physicians in practice, moving PoCUS training courses to rural sites, and creating telesonography training for rural physicians. With these barriers identified and solutions proposed, corrective measures must be taken so that the benefits of PoCUS are extended to patients in rural Canada where, arguably, it has the greatest potential for benefit when access to advanced imaging is not readily available.

A majority of rural emergency departments in the province of Quebec use point-of-care ultrasound: a cross-sectional survey

BACKGROUND

Point-of-care ultrasound (POCUS) can be used to provide rapid answers to specific and potentially life-threatening clinical questions, and to improve the safety of procedures. The rate of POCUS access and use in Canada is unclear. The objective of this study was to examine access to POCUS and potential barriers/facilitators to its use among rural physicians in Quebec.

METHODS

This descriptive cross-sectional study used an online survey. The 30-item questionnaire is an adapted and translated version of a questionnaire used in a prior survey conducted in rural Ontario, Canada. The questionnaire was pre-tested for clarity and relevance. The survey was sent to non-locum physicians working either full- or part-time in rural emergency departments (EDs) (n = 206). All EDs were located in rural and small towns and provided 24/7 medical coverage with acute care hospitalization beds.

RESULTS

In total, 108 surveys were completed (participation rate = 52.4%). Of the individuals who completed surveys, ninety-three percent were family physicians, and seven percent had Canadian College of Family Physicians - Emergency Medicine (CCFP-EM) certification. The median number of years of practice was seven. A bedside ultrasound device was available in 95% of rural EDs; 75.9% of physicians reported using POCUS on a regular basis. The most common indications for POCUS use were to rule out abdominal aortic aneurysm (70.4%) and to evaluate presence of free fluid in trauma and intrauterine pregnancy (60%). The most common reason (73%) for not using POCUS was limited access to POCUS training programs. Over 40% of POCUS users received training in POCUS during medical school or residency. Sixty-four percent received training from the Canadian Emergency Ultrasound Society, 13% received training from the Canadian Association of Emergency Physicians, and 23% were trained in another course. Finally, 95% of respondents reported that POCUS skills are essential for rural ED practice.

CONCLUSIONS

POCUS use in rural EDs in the province of Quebec appears to be relatively widespread. Access to training programs is a barrier to greater use.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Basic concepts in the use of thoracic and lung ultrasound

PURPOSE OF REVIEW

Recent advances were made in the field of point-of-care ultrasound (POCUS). Thoracic and lung ultrasound have become a rapid and accurate method of diagnosis of hypoxic diseases. The purpose of this article is to review the recent literature on POCUS, emphasizing on its use in the operating room.

RECENT FINDINGS

Many international critical care societies published guidelines on the use of ultrasound in the installation of central venous access. More recently, evidenced-based guidelines on the use of POC lung ultrasound were published. Lung ultrasound has shown its superiority over conventional chest radiography in the diagnosis of many disorders of significant importance in anesthesiology, particularly the pneumothorax.

SUMMARY

POC thoracic and lung ultrasound is used in many critical medicine fields. The aim of this review is to describe the basic lung ultrasound technique and the knowledge required in order to diagnose and treat the hypoxic patient. Emphasis is on disorder such as pleural effusion, alveolar interstitial disease, as well as pneumothorax, which is of particular importance in the field of anesthesiology.

Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review

OBJECTIVES

The objective was to determine if focused transthoracic echocardiography (echo) can be used during resuscitation to predict the outcome of cardiac arrest.

METHODS

A literature search of diagnostic accuracy studies was conducted using MEDLINE via PubMed, EMBASE, CINAHL, and Cochrane Library databases. A hand search of references was performed and experts in the field were contacted. Studies were included for further appraisal and analysis only if the selection criteria and reference standards were met. The eligible studies were appraised and scored by two independent reviewers using a modified quality assessment tool for diagnostic accuracy studies (QUADAS) to select the papers included in the meta-analysis.

RESULTS

The initial search returned 2,538 unique papers, 11 of which were determined to be relevant after screening criteria were applied by two independent researchers. One additional study was identified after the initial search, totaling 12 studies to be included in our final analysis. The total number of patients in these studies was 568, all of whom had echo during resuscitation efforts to determine the presence or absence of kinetic cardiac activity and were followed up to determine return of spontaneous circulation (ROSC). Meta-analysis of the data showed that as a predictor of ROSC during cardiac arrest, echo had a pooled sensitivity of 91.6% (95% confidence interval [CI] = 84.6% to 96.1%), and specificity was 80.0% (95% CI = 76.1% to 83.6%). The positive likelihood ratio for ROSC was 4.26 (95% CI = 2.63 to 6.92), and negative likelihood ratio was 0.18 (95% CI = 0.10 to 0.31). Heterogeneity of the results (sensitivity) was nonsignificant (Cochran's Q: χ(2)  = 10.63, p = 0.16, and I(2)  = 34.1%).

CONCLUSIONS

  Echocardiography performed during cardiac arrest that demonstrates an absence of cardiac activity harbors a significantly lower (but not zero) likelihood that a patient will experience ROSC. In selected patients with a higher likelihood of survival from cardiac arrest at presentation, based on established predictors of survival, echo should not be the sole basis for the decision to cease resuscitative efforts. Echo should continue to be used only as an adjunct to clinical assessment in predicting the outcome of resuscitation for cardiac arrest.

The current state of ultrasound training in canadian emergency medicine programs: perspectives from program directors

OBJECTIVES

There is a paucity of data about emergency ultrasound (EUS) training in emergency medicine (EM) residency programs accredited by the Royal College of Physicians and Surgeons of Canada (Royal College) and the College of Family Physicians of Canada (CFPC). Historically the progress of EUS in Canada has been different from that in the United States. We describe the current state of EUS training in both Royal College and CFPC-EM programs.

METHODS

All Royal College EM program directors and all CFPC-EM program directors were invited to participate in a website-based survey. Main outcome measures were characteristics of currently offered EUS training.

RESULTS

The response rate of the survey was 100% (30/30). EUS is part of the formal residency curriculum in 100% (13/13) of Royal College EM programs and in 88% (15/17) of CFPC-EM programs. EM resident rotations in ultrasound (US) are provided by 77% (10/13) of Royal College programs but only 47% (8/17) of CFPC-EM programs. There are specific requirements for numbers of EUS exams to be completed by graduation in 77% (10/13) of Royal College programs and 47% (8/17) of CFPC-EM programs. EM faculty and residents make clinical decisions and patient dispositions based on their EUS interpretation without a consultative study by radiology in 100% (13/13) of Royal College programs and 88% (15/17) of CFPC-EM programs. However, 69% (9/13) of Royal College programs and 53% (9/17) of CFPC-EM programs have no formal quality assurance program in place.

CONCLUSIONS

EUS training in Canadian EM programs is prevalent, but there are considerable discrepancies among residency programs in scope of training, curricula, determination of proficiency, and quality assurance. These findings suggest variability in both the level and the quality of EUS training in Canada.